ER visits increasing for elderly patients: study

28 JUNE 2008The number of emergency department visits by elderly individuals is increasing and is probably going to continue to increase as the population ages, according to a report published in the latest issue of the Annals of Emergency Medicine.
"In 2005, the Centers for Disease Control and Prevention reported increasing emergency department (ED) visit rates per 100 people," Dr. Mary Pat McKay and colleagues from the George Washington University, Washington, DC, write.
"The greatest increase in visit rate was among individuals 65 years and older," they note, adding that because older patients have longer ED stays, are more likely to be admitted, and represent a growing segment of the population, "this finding could have a significant negative effect on ED crowding."
Using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), the researchers analyzed ED visits by subjects older than 65 years during the years 1993 to 2003. They used annual census data to compute visit rates per 100 persons.
The rate of ED visits for subjects 65 to 74 years increased by 34 percent during the study period. Among black subjects, the visit rate increased by 90 percent to 77 visits per 100 persons per year. The rate for white subjects increased by 26 percent to 36 visits per 100 persons per year.
The researchers classified the ED patients' primary diagnostic codes into four categories: injury, acute non-injury, exacerbation of chronic condition, and "other" (including such ill-defined problems as weakness, dizziness, etc.).
According to their report, 93 percent of the increase in ED visits was for diagnoses that fell into the "other/undefined" category. There was an increase of 44 percent in the number of visits at which three or more medications were administered.
No significant change was observed in the admission rate during the study period.
"If trends continue, the effects on ED and hospital crowding could be catastrophic, and planning should begin now," McKay and colleagues conclude.
SOURCE: Annals of Emergency Medicine, June 2008.

High-Normal Albumin Excretion Predicts Hypertension Risk

By Charles Bankhead
BOSTON, 27 JUNE 2008 -- Albumin excretion at the upper end of the normal range significantly increases the risk of hypertension in otherwise low-risk women, according to new analyses of the Nurses' Health Study.
A high-normal albumin/creatinine ratio increased the risk of hypertension by 75% in older women and by 35% in younger women, compared with those who had ratios at the lower end of the normal range, John P. Forman, M.D., of Harvard, and colleagues reported online in the Journal of the American Society of Nephrology.
"The findings of this study, in conjunction with the findings of numerous others . . . suggest that it may be time to reevaluate our current concept of 'normal' albumin excretion," the authors concluded.
Microalbuminuria has long been recognized as a risk factor for progressive kidney disease, diabetic complications, and adverse cardiovascular outcomes. The association with pathology has led to speculation that microalbuminuria is a generalized marker of vascular damage and a reflection of endothelial dysfunction and abnormal vascular permeability, the authors said.
More recently, data from the Framingham Heart Study and other investigations have suggested that higher albumin-creatinine ratios, even within the normal range, increase the risk of hypertension, the researchers continued. In many instances, however, the higher ratios have been accompanied by microalbuminuria.
In attempt to clarify the risk imparted by high-normal albumin excretion, Dr. Forman and colleagues analyzed data from the first and second Nurses' Health Study. The analysis included 1,065 postmenopausal women (median age 65) from NHS I and 1,114 younger women (median age 44) from NHS II. All women were normotensive, nondiabetic, and had normal albumin excretion rates.
Participants from NHS I had a median albumin-creatinine ratio of 2.7 mg/g, and the NHS II cohort had a median ratio of 2.4 mg/g.
During follow-up, 271 NHS I participants developed hypertension over four years, as did 296 participants from NHS II over eight years. In multivariate analysis, comparison of the highest and lowest quartiles of albumin excretion revealed a hypertension hazard ratio of 1.76 (P=0.004 for the trend) among women in NHS I and 1.35 (P=0.06 for the trend) among NHS II participants.
The results remained unchanged in further analyses that adjusted for alcohol and sodium intake, for use of aspirin, acetaminophen, and nonsteroidal anti-inflammatory drugs, and for exclusion of women with undiagnosed diabetes at baseline or who developed diabetes during follow-up.
The authors suggested several potential mechanistic explanations for the findings, all involving glomerular endothelial cell dysfunction or abnormalities leading to increased filtration of albumin.
"What seems to be clear is that the glomerular endothelial cell does play some role, however large, in the filtration barrier, and dysfunction of these endothelial cells may therefore lead to increased albumin excretion," they said.
The findings mesh with those from other laboratory and clinical studies and suggest that "higher levels of urine albumin excretion may reflect systemic endothelial dysfunction, which in turn may be a precursor to hypertension."
The authors noted several limitations to the study. Each participant submitted only a single morning specimen, BP measurements were reported and not directly measnured. The cohorts studied were predominantly white and entirely female so the results may not be generalizable.
The authors reported no disclosures.
Primary source: Journal of the American Society of NephrologySource reference:Forman JP, et al "Higher levels of albuminuria within the normal range predict incident hypertension" J Am Soc Nephrol 2008; DOI: 10.1681/ASN.2008010038.

HIV/AIDS Diagnoses Rising from Male-Male Sex


By Michael Smith
ATLANTA, 27 JUNE 2008-- The number of HIV/AIDS diagnoses among men who have sex with men grew 8.6% from 2001 through 2006, the CDC said today. Over the same period, there were significant declines (P<0.05) in new diagnoses in all other risk categories, the agency said in the June 27 issue of Morbidity and Mortality Weekly Report. The finding -- released on National HIV Testing Day -- came from an analysis of trends in the 33 states that have had confidential, name-based HIV case reporting since at least 2001, the agency said.
At the same time, New York announced a three-year plan to test all adults in the Bronx, which has the highest rate of AIDS deaths of the city's five boroughs.
The CDC said that in the 33 states, the estimated average annual percentage increase in new diagnoses among men who have sex with men was 1.5%.
In contrast, new diagnoses among injection drug users fell by an estimated 9.5% annually, while those among people with high-risk heterosexual contact fell by an estimated 4.4% a year.
Among men who have sex with men who were also injection drug users -- treated by the agency as a separate category from MSM -- the annual percentage decrease was 5.2%.
Among men who have sex with men, the increase in diagnoses was more marked in men ages 13 to 24 of all racial/ethnic groups and in black men, the agency said:
The number of HIV/AIDS diagnoses among all black men who have sex with men was 12.4% over the six-year period, for an estimated annual percentage change of 1.9%.
But for black men who have sex with men ages 13 through 24, the increase was 93.1%, with an estimated annual percentage change of 14.9%.
There were 7,658 diagnoses in black men who have sex with men ages 13 through 24, compared with 3,221 in their white counterparts.
The agency pointed out that the 33-state case surveillance data are not representative of all HIV-positive people in the U.S., and added that an estimated 25% of all HIV-positive people have not yet been diagnosed.
National HIV Testing Day "focuses on the importance" of people knowing their HIV infection status, the agency said, adding that getting a diagnosis is the first step to getting treatment.
In New York, city officials said their plan to test all adults in the 1.3-million-population Bronx will require making HIV tests a part of routine medical care.
"Routine would mean if you came into the emergency room for asthma or a broken leg, we test everyone for HIV, if they're willing," city health commissioner Thomas Frieden, M.D., told the New York Times.
The city estimated that 40% of the 830,000 Bronx residents ages 18 to 64 have been tested in the past year and another 250,000 people who have never been tested would be targeted for early testing.
The city plans to offer tests at about 40 clinics, community centers, churches and emergency rooms and will cover the $12 cost of each test, city officials said.
In New York, the rate of AIDS cases is 82 per 100,000 people in Manhattan, compared with 75 in the Bronx, 46 in Brooklyn, 26 in Queens, and 16 on Staten Island.
But 37 people die annually from AIDS for every 100,000 people in the Bronx, compared with 21 for Manhattan, 19 for Brooklyn, eight for Staten Island, and six for Queens.
The higher death rate in the Bronx was attributed to the relative poverty of the population, which may tend to delay testing until later in the process.
One obstacle to wider testing has been New York State's strict consent laws, which doctors have viewed as too onerous for settings such as emergency rooms.
For this push, doctors will be using a script that follows state law but squeezes the consent process into five minutes, according to Donna Futterman, M.D., of Montefiore Medical Center, who developed the script.
An experienced physician can deliver the script in three minutes, Dr. Futterman told the Times, and her own record is one minute.
Additional source: Morbidity and Mortality Weekly ReportSource reference: Centers for Disease Control and Prevention "Trends in HIV/AIDS diagnoses among men who have sex with men -- 33 States, 2001-2006." MMWR 2008; 57: 681-686.

Breast Cancer Vaccines Look Promising

By Kathleen Doheny
27 JUNE 2008-- Women with metastatic breast cancer who developed an immune response to an investigational vaccine lived twice as long as those who didn't have an immune response, new research shows.
"If you were an immune responder, you had double the survival of a non-responder," said study author Dr. Susan Domchek, an associate professor of medicine at the University of Pennsylvania.
Her report is one of several focusing on breast cancer vaccines expected to be discussed this week at the Department of Defense Era of Hope breast cancer research meeting, in Baltimore.
"Metastatic breast cancer is treatable but not curable," Domchek said. While the ultimate hope is to cure the cancer, breast cancer vaccines are one possible way to try to control the disease's spread.
Although most people think of vaccines as shots given to healthy people to prevent infectious diseases such as measles and the flu, various cancer vaccines that have been studied for decades use cancer cells, parts of cells or substances called antigens to trigger an immune response against cancer cells already in the body.
In her study, Domchek used pieces of a protein called human telomerase reverse transcriptase (hTERT) peptide to vaccinate 19 women with breast cancer that had spread. The peptide is nearly universally overexpressed in human cancers and is recognized by certain T-cells in the body's immune system.
At the start of the study, the women had no measurable T-cell response to hTERT. After up to eight vaccinations with the hTERT peptide, however, 13 of the 19 women made T-cells that reacted to the peptide.
"We biopsied the patients' breast cancer and saw that we could see these T-cells in the tumors themselves," she said. "And, in some cases, we could see evidence of tumor cells' death."
"Those who responded lived significantly longer," she said. "People who responded lived 32 months versus a median of 17 [for those who did not respond]. Three of the women who were responders have lived more than three years."
Among the questions that remain, however, said Domchek, is this: "Were those women going to do well no matter what we did? Is immune response just a marker for a healthier patient?"
Other research on breast cancer vaccines expected to be presented at the meeting include:A study that focused on breast cancer patients with HER-2-positive tumors (for whom relapse is common after treatment) treated with a combination of vaccine plus an anti-cancer drug. Dr. Lupe Salazar, an assistant professor of medicine at the University of Washington, in Seattle, and her team sequenced the HER-2 protein and put pieces of it into a vaccine. They gave it to patients, along with the anti-cancer drug Herceptin. The combination helped to generate significant levels of T-cell immunity specific to the HER-2 cells, she said. As of now, "all eight [women] have done this," she said. The study will eventually include 52 women. A study that uses immunostimulatory peptides as a vaccine looked at the best way to deliver them. Dr. Davorka Messmer, an assistant project scientist at the Moores Cancer Center at the University of California San Diego, and her team tested a vaccine using nanoparticles loaded with the HER2 peptide that carry an immune system-stimulating peptide, called Hp91, on the outside or the inside. "We found it more potent if the immunostimulatory peptide was put on the surface of the nanoparticle," she said. The study was conducted in animals.
While breast cancer vaccines have been studied for at least 30 years, they have yet to make a real difference in the lives of patients, said Dr. Len Lichtenfeld, deputy chief medical officer of the American Cancer Society. That's not to say they won't someday, he added.
"When you look at the theory, it makes sense," he said. "The bottom line is, we are getting there, but [we're] not there yet."
Many questions remain, he said, such as "why some patients have immune responses, and others don't." It is likely, he said, that some of the vaccines will be specific to one cancer, and others may work on more than one type of cancer.

W.H.O. Issues a Checklist to Make Operations Safer

By LAWRENCE K. ALTMAN
26 june2008--The World Health Organization issued its first guidelines on Tuesday aimed at reducing complications and deaths from the rising numbers of operations now being performed.
The guidelines are a list of simple safety checks that the health organization said could halve the rate of surgical complications. The list is intended to improve anesthetic safety practices, avoid infections and improve communication among members of surgical teams.
For example, one guideline calls for all members of the masked surgical team to identify themselves and their roles and ask simple questions like, “Does everyone agree that this is Patient X, undergoing a hernia repair?”
Other recommendations call for marking the correct site for surgery to avoid operating on the wrong patient or performing the wrong procedure; giving an antibiotic within 60 minutes of making an incision, to reduce infections; checking for allergies to drugs; inserting two intravenous lines for operations involving substantial blood loss; and counting sponges and needles to ensure that none are left in a patient.
Dr. E. Patchen Dellinger, vice chairman of surgery at the University of Washington, which took part in the W.H.O. research, said that when the checklist was discussed with nonmedical people, “the most common reaction is the question: ‘You mean you haven’t been doing this all along?’ ”
The surgical guidelines grew out of a similar checklist aimed at reducing infections in hospitals. The infection guidelines were developed by Dr. Peter J. Pronovost of Johns Hopkins University, who borrowed the idea from the aviation industry, said Dr. Atul Gawande, of the Harvard School of Public Health.
Dr. Gawande and his team at Harvard had been asked by the W.H.O. to develop a method to reduce surgical deaths, and he said they used the infection guidelines as a model.
Three countries — Britain, Ireland and Jordan — have said they will put the surgery guidelines in force in all hospitals, Dr. Gawande said. Professional groups endorsing checklists include the American College of Surgeons, the American Society of Anesthesiology and the Association of Perioperative Registered Nurses.
To develop the guidelines, the Harvard team did two studies with W.H.O.
Using surgical data from more than one-fourth of the organization’s 192 member states, Dr. Gawande’s team estimated that 234 million major surgical procedures were undertaken each year worldwide. Of the total, 172 million, or 74 percent, were in the wealthier countries, and 40 million of those were in the United States.
The number of surgical procedures performed in a year is nearly double the number of births “and is probably an order of magnitude more dangerous,” Dr. Gawande’s team reported in an article in the journal Lancet, which was released on Tuesday.
The team also conducted a pilot study involving 3,600 patients in eight hospitals in poor and rich countries to determine whether using a checklist could help reduce surgical complication rates.
Data from the first 1,000 patients, which is expected to be reported at a meeting in Washington on Wednesday, showed that the use of a checklist increased adherence to standards of care to 68 percent from 36 percent, and approached 100 percent in some hospitals. Final results are expected later this year.
Some sites in richer countries did worse than ones in poorer countries, Dr. Gawande said. The researchers and hospitals agreed not to disclose specific data from individual institutions.
The hospitals included the University of Washington in Seattle; the University of Toronto; St. Mary’s Hospital in London; the University of Auckland in New Zealand; Philippine General Hospital in Manila; Prince Hamza Hospital in Amman, Jordan; St. Stephen’s Hospital in New Delhi; and the District Hospital in Ifakara, Tanzania.
Creating an accurate, functional checklist for surgery took many revisions, Dr. Gawande said, adding: “You can make bad checklists and you can make good checklists. It is very easy to make a bad checklist that people want to throw away and never use.”

Many may "trust" their partner is a low STD risk

26 june 2008--Too many people may consider themselves at low risk of sexually transmitted diseases simply because they trust their partner, a new study suggests.
The study of patients at an STD clinic found that many people relied on subjective measures in judging their partner's "safety" -- such as how long they had known the partner or how intelligent or well-educated he or she was.
The findings suggest that when people feel they "just know" their partner, they may consider their STD risk to be low even in the absence of any STD/HIV testing, the researchers report in the journal Sexually Transmitted Diseases.
For the study, Cindy Masaro and colleagues at the University of British Columbia gave questionnaires to 317 men and women attending an STD clinic. All were visiting the clinic for the first time for an assessment and not yet been diagnosed with any STD.
The questionnaire asked patients whether they would be "pretty sure" that a sex partner was "safe" in various situations -- such as when they knew the person well, knew his or her friends, or simply felt they could trust the person.
The researchers found that people often took such subjective qualities as a sign that their partner would put them at low STD risk. For example, more than 70 percent of patients said they would probably consider a partner "safe" if he or she were generally trustworthy.
However, people's perceptions of their partners do not necessarily match reality.
Past studies, Masaro and her colleagues point out, have found that while many people are "confident in their assessments of their partner's character," their knowledge of the partner's STD risk factors is often off the mark.
"Developing interventions that target assumptions of safety and dispel incorrect beliefs about the selection of safe partners is needed to promote safer sexual behavior," the researchers conclude.
SOURCE: Sexually Transmitted Diseases, June 2008.

Obese men may have lower hernia risk

By Amy Norton
26 june 2008--Overweight and obese men may be less likely than their thinner counterparts to develop a hernia in the groin, a long-term study suggests.
Researchers found that among nearly 7,500 Swedish men followed for 34 years, the risk of developing a groin hernia declined as the men's weight increased.
Overall, men who were obese in middle-age were 43 percent less likely than normal-weight men to be diagnosed with the condition over the next three decades.
The findings are published in the Annals of Surgery.
Hernias occur when a part of an internal organ bulges through a weak area of muscle, usually in the abdomen. Groin hernias are also known as inguinal hernias; they arise when intestinal tissue protrudes through a weak spot in the inguinal canal, an opening between the layers of abdominal muscle in the groin area.
Excessive pressure on the abdominal wall, such as the strain of heavy lifting, can cause a hernia. In theory, obesity could contribute to groin hernias by creating extra pressure within the abdominal cavity but data thus far have been inconclusive.
The new findings, based on a large group of men followed for a long period, suggest that excess pounds may actually offer some protection against hernias, lead researcher Dr. Anders Rosemar told Reuters Health.
It's not clear why obesity would protect against hernia, according to Rosemar and his colleagues at Sahlgrenska University Hospital/Ostra in Sweden.
One possibility, they speculate, is that the extra fat and thickness of the abdominal wall keep hernias from forming.
It's also possible that hernias, which often cause a visible lump in the groin, are simply easier to detect in thinner men, the researchers note. However, they add, hernias also frequently cause pain, which would affect men whatever their weight.
Regardless of the effect of obesity on hernia risk, though, the fact remains that heavy men should try to shed pounds. Obese men may have a lower hernia risk, Rosemar said, but they still have an elevated risk of numerous other medical conditions.
SOURCE: Annals of Surgery, June 2008.

Merck's Gardasil not cleared for older women

By Lewis Krauskopf
26 june 2008--U.S. regulators have told Merck & Co they cannot yet approve Merck's application to expand marketing of its cervical cancer vaccine Gardasil to an older group of women, the drugmaker said on Wednesday.
Merck had applied for the use of Gardasil in women ages 27 through 45. The U.S. Food and Drug Administration said in a letter regarding the application that it has completed its review and there are "issues" that preclude approval within the expected review time frame, Merck said.
"It's hard to get a feel for if this is a dead issue or if this is delayed," said Linda Bannister, an analyst for Edward Jones. "At the minimum, it's going to be delayed."
Merck said it also failed to win FDA approval to expand Gardasil to protect against more strains of the Human Papillomavirus that causes cervical cancer. The company for now is dropping plans to pursue that expansion, a spokeswoman said.
Shares of the New Jersey-based drug maker, which also reiterated its long-term revenue and earnings targets, fell 0.8 percent.
Gardasil, approved in June 2006 for preventing cervical cancer and genital warts in females ages 9-26, has been one of Merck's most successful newer products and has helped the company recover after the 2004 withdrawal of its Vioxx arthritis treatment.
The Gardasil setbacks could raise concerns about the degree of growth that Merck can hope to achieve with the product, which is the world's first vaccine to prevent cervical cancer.
A Merck spokeswoman said the agency has specific questions regarding Gardasil's effectiveness in this older age group.
The company said it had already discussed the questions with the FDA and expects to respond to the agency in July.
"Once we go back to the FDA, we'll have a better sense of what the review timing looks like," spokeswoman Amy Rose said.
The agency's response on the application for the older group does not affect Gardasil's current approval for females ages 9 to 26, Merck said.
Global sales of Gardasil rose 7 percent in the first quarter to $390 million. Cowen and Co has predicted annual sales of the vaccine would reach $1.9 billion in 2008 and jump to $3 billion by 2012.
Edward Jones' Bannister said she had expected Gardasil sales to reach $2.6 billion by 2012, with about one-third to come from that older age group.
Deutsche Bank analyst Barbara Ryan said failure to win approval for the older age group could reduce her $3.8 billion estimate for 2012 sales by about $300 million.
Ryan said the most important new opportunity for the vaccine will be for its use in males. The vaccine could help prevent males from contracting Human Papillomavirus and spreading it to females through sexual contact. Merck is on track to seek approval for use in males by the end of the year, Rose said.
Gardasil has benefited from lengthy delays in approval of GlaxoSmithKline's rival Cervarix vaccine. The FDA in December issued a complete response letter for Cervarix, meaning it had completed its review of the product but had further questions about it.
Bannister said the Gardasil delay reflects broader challenges facing drug makers within the U.S. regulatory environment.
"It's not specific to Merck," Bannister said. "This is an industry-wide issue."
Merck shares fell 29 cents to $36.74 in afternoon trading on the New York Stock Exchange. The shares have fallen some 37 percent this year, hurt by setbacks to its cholesterol franchise.

Controversial obesity drug gets UK okay

26 june 2008--Sanofi-Aventis won a final green light for its obesity drug Acomplia from Britain's cost-effectiveness watchdog NICE on Wednesday, clearing the way for doctors to prescribe it on the state health service.
The move was expected following a positive appraisal from the National Institute for Health and Clinical Excellence (NICE) in March.
It marks a small positive for the French drugmaker's once much-hyped medicine, which has failed to live up to early expectations.
NICE's final guidance recommends using Acomplia, or rimonabant, as an addition to diet and exercise for obese or overweight adults who don't respond to or are intolerant of two other weight-loss drugs, orlistat and sibutramine.
But NICE cautioned that treatment should not continue beyond six months unless patients lost at least 5 percent of their initial body weight and there should, in any event, be a formal clinical assessment after two years.
The UK decision contrasts with Germany where Acomplia is not reimbursed by health insurers because it is deemed simply to improve lifestyle.
Acomplia was once touted as a multibillion-dollar seller, but hopes for the product dimmed last year when a U.S. expert panel recommended against its approval in the world's biggest market, after it was linked to rare cases of suicidal thoughts.
Sanofi said in October it expected only limited sales of the drug in the next few years, until new clinical trial results testing it in diabetes are ready for submission to regulators in 2009.
Worldwide sales of the drug were a meager 79 million euros ($122.9 million) last year.
Roche makes the older weight-loss drug orlistat under the brand name Xenical, while sibutramine is marketed by Abbott Laboratories under the brand names Meridia or Reductil.

Heart Disease Without the Symptoms

By Peter Libby, M.D.
25 june 2008--Tim Russert’s fatal heart attack revealed what many cardiologists already knew: Heart disease cannot always be detected. (Reuters)
The death of television commentator Tim Russert at age 58 has raised many questions about how cardiologists assess a patient’s condition, as Denise Grady reports in Science Times. Among other confusions, many are wondering how Mr. Russert could have passed a recent stress test, as well as other evaluations, and still have succumbed to sudden cardiac death.
Unfortunately, this is an all too common scenario. About half of men, and an even greater percentage of women, who die suddenly from coronary artery disease never have a warning symptom.
We used to think that heart attacks occurred due to the gradual and progressive formation of blockages that impede blood flow in the arteries coursing around the surface of the heart. According to this traditional view, the flow of oxygen and nutrients eventually becomes so scanty that the patient will experience chest pains, especially when the heart is stressed by exertion. Physicians also may be alerted to heart trouble by changes in electrocardiogram readings observed as a patient exercises, or by nuclear imaging scans used to visualize areas of poor blood flow.
More recently, however, we have come to understand that the disease plays tricks on us. As fatty plaques form in the wall of an artery, they usually first grow outward, toward the exterior of the vessel, and do not protrude inward where they might block blood flow. These plaques can develop for decades without causing symptoms or showing up on electrocardiograms or nuclear scans, even under maximal exercise effort during a stress test. The non-obstructive plaques may not even show up on conventional angiograms, during which a cardiologist injects a fluid opaque to x-rays directly into the heart’s arteries.
Two types of arterial plaques. The lesion shown at top, a stenotic plaque, usually will cause symptoms in the patient. The type below, a non-stenotic plaque, is more frequent and harder to detect. (Circulation. 2005;111:3481-3488. (c) 2005 American Heart Association, Inc. Used with permission.)
We now know that these outward-bowing plaques cause the lion’s share of fatal heart attacks, outnumbering the inward-growing plaques that produce the familiar warning signs. We probably will never know which sort of rupture caused Mr. Russert’s death, but heart specialists have learned that hidden plaques can prove particularly lethal.
Often an inward-growing plaque will stimulate the growth of extra arterial branches (collateral vessels) that allow the deprived muscle to receive blood redirected from less blocked arteries. But outward-growing plaques do not stimulate formation of these vessels, and so a sudden rupture, leading the formation of an occlusive blood clot, can prove particularly disastrous, as there is no back-up blood supply.
How can we assess the risk of a sudden unheralded heart attack, and how can we prevent them? Here’s an animation that describes the process in fuller detail. I’ll be posting more on this subject in the next couple of weeks. Meanwhile, please submit your questions below and I’ll do my best to offer a few answers on Tuesday.

Fit, Not Frail: Exercise as a Tonic for Aging

By JANE E. BRODY
25 june 2008
Fact: Every hour of every day, 330 Americans turn 60.
Fact: By 2030, one in five Americans will be older than 65.
Fact: The number of people over 100 doubles every decade.
Fact: As they age, people lose muscle mass and strength, flexibility and bone.
Fact: The resulting frailty leads to a loss of mobility and independence.
The last two facts may sound discouraging. But they can be countered by another. Regular participation in aerobics, strength training and balance and flexibility exercises can delay and may even prevent a life-limiting loss of physical abilities into one’s 90s and beyond.
This last fact has given rise to a new group of professionals who specialize in what they call “active aging” and an updated series of physical activity recommendations for older adults from the American Heart Association and the American College of Sports Medicine. These recommendations are expected to match new federal activity guidelines due in October from the United States Health and Human Services Department.
But you need not — indeed should not — wait for the government. Even if you have a chronic health problem or physical limitation, there are safe ways to improve fitness and well-being. Any delay can increase the risk of injury and make it harder to recoup your losses.
Miriam E. Nelson, director of the John Hancock Center for Physical Activity and Nutrition at Tufts University in Boston and lead author of the new recommendations, observed last fall in The Journal on Active Aging that “with every increasing decade of age, people become less and less active.”
“But,” Dr. Nelson said, “the evidence shows that with every increasing decade, exercise becomes more important in terms of quality of life, independence and having a full life. So as of now, Americans are not on the right path.”
Jim Concotelli of the Horizon Bay Senior Communities in Tampa, who oversees fitness and wellness program development for communities for the elderly in several states, noted this year in The Journal on Active Aging that many older Americans were unfamiliar with exercise activities and feared that they would cause injury and pain, especially if they have arthritis or other chronic problems. Yet by strengthening muscles, he said, they can improve joints and bones and function with less pain and less risk of injury.
The key is start slowly and build gradually as ability and strength improve. Most important is simply to start — now— perhaps under the guidance of a fitness professional or by creating a program based on the guidelines outlined here.
Although medical clearance may not be necessary for everyone for the moderate level of activity suggested, those with a known or possible problem would be wise to consult a doctor. And a few sessions with a trainer can help assure that the exercises are being done correctly and not likely to cause injury.
Until recently, physical activity recommendations for all ages have emphasized aerobics, or cardiovascular conditioning, through moderate to vigorous activities like brisk walking, cycling, lap swimming or jogging for half an hour a day five or more days a week. For those unable to do 30 minutes at a time, the activities can be broken up into three 10-minute intervals a day. If you have long been sedentary, start with even shorter intervals.
For people who prefer indoor workouts, a treadmill, cross-trainer, step machine or exercise bike can provide excellent aerobic training for the heart, lungs and circulation. Those unable to do weight-bearing exercise might try swimming or water aerobics. Keep in mind that 30 minutes a day of aerobic activity five days a week is the minimum recommendation. More is better and can reduce the risk of chronic disease related to inactivity.
Contrary to what many active adults seem to believe, physical fitness does not end with aerobics. Strength training has long been advocated by the National Institute on Aging, and the heart association has finally recognized the added value of muscle strength to reduce stress on joints, bones and soft tissues; enhance stability and reduce the risk of falls; and increase the ability to meet the demands of daily life, like rising from a chair, climbing stairs and opening jars.
Strength training can be done in a gym on a series of machines, each working a different set of major muscle groups: hips, legs, chest, back, shoulders, arms and abdomen. Or it can be done at home with resistance bands or tubes, hand-held barbells or dumbbells or even body weight. One program, the Key 3 program diagrammed here, was devised by Michael J. Hewitt, research director for exercise science at the Canyon Ranch Health Resort in Tucson. It can be completed in 10 minutes with practice.
As Dr. Hewitt explained in the International Longevity Center-USA newsletter, skeletal muscles can only contract and thus are always arranged in pairs. “One muscle of the pair pulls to bend the joint (flexion), and its antagonist pulls to straighten the joint (extension).” Thus, a strengthening program must be balanced, he said, “pairing every pulling lift with an opposite pushing action.”
Dr. Hewitt emphasized that to reduce the risk of injury and premature muscle fatigue, the large muscles should be exercised first, followed by the smaller muscles, with the postural muscles exercised last. For example, one would start with chest and upper back muscles, then the arms and shoulders and finally the lower back and abdomen.
Muscles have to be overworked to grow stronger. The goal for each exercise is three sets of 8 to 12 repetitions to muscle fatigue. Muscles also need time to recover. So strength training should be done two or three times a week on nonconsecutive days.
The new recommendations add flexibility and balance to the mix. Improving balance and reducing the risk of falls is critical as you age — if you fall, break your hip and die of pneumonia, aerobic capacity will not save you. Ten minutes a day stretching legs, arms, shoulders, hips and trunk can help assure continued mobility, and daily exercises like standing on one foot and then the other, walking heel to toe or practicing tai chi can improve balance.
The recommendations, issued last August, are geared to healthy adults 18 to 64, with a companion set for those 65 and older or those 50 to 64 who have chronic health problems or physical limitations. Details can be found at www.acsm.org. Under “Influence,” click on Physical Activity Guidelines From ACSM and AHA.
The experts who made these recommendations urge all adults to adopt them now. As C. Jessie Jones, co-director of the Center for Successful Aging at California State University, Fullerton, said, “People can’t wait until they’re in residential or long-term care to get started.”

Doctors Say Medication Is Overused in Dementia

By LAURIE TARKAN
25 june 2008--Ramona Lamascola thought she was losing her 88-year-old mother to dementia. Instead, she was losing her to overmedication.
Last fall her mother, Theresa Lamascola, of the Bronx, suffering from anxiety and confusion, was put on the antipsychotic drug Risperdal. When she had trouble walking, her daughter took her to another doctor — the younger Ms. Lamascola’s own physician — who found that she had unrecognized hypothyroidism, a disorder that can contribute to dementia.
Theresa Lamascola was moved to a nursing home to get these problems under control. But things only got worse. “My mother was screaming and out of it, drooling on herself and twitching,” said Ms. Lamascola, a pediatric nurse. The psychiatrist in the nursing home stopped the Risperdal, which can cause twitching and vocal tics, and prescribed a sedative and two other antipsychotics.
“I knew the drugs were doing this to her,” her daughter said. “I told him to stop the medications and stay away from Mom.”
Not until yet another doctor took Mrs. Lamascola off the drugs did she begin to improve.
The use of antipsychotic drugs to tamp down the agitation, combative behavior and outbursts of dementia patients has soared, especially in the elderly. Sales of newer antipsychotics like Risperdal, Seroquel and Zyprexa totaled $13.1 billion in 2007, up from $4 billion in 2000, according to IMS Health, a health care information company.
Part of this increase can be traced to prescriptions in nursing homes. Researchers estimate that about a third of all nursing home patients have been given antipsychotic drugs.
The increases continue despite a drumbeat of bad publicity. A 2006 study of Alzheimer’s patients found that for most patients, antipsychotics provided no significant improvement over placebos in treating aggression and delusions.
In 2005, the Food and Drug Administration ordered that the newer drugs carry a “black box” label warning of an increased risk of death. Last week, the F.D.A. required a similar warning on the labels of older antipsychotics.
The agency has not approved marketing of these drugs for older people with dementia, but they are commonly prescribed to these patients “off label.” Several states are suing the top sellers of antipsychotics on charges of false and misleading marketing.
Ambre Morley, a spokeswoman for Janssen, the division of Johnson & Johnson that manufactures Risperdal, would not comment on the suits, but said: “As with any medication, the prescribing of a medication is up to a physician. We only promote our products for F.D.A.-approved indications.”
Nevertheless, many doctors say misuse of the drugs is widespread. “These antipsychotics can be overused and abused,” said Dr. Johnny Matson, a professor of psychology at Louisiana State University. “And there’s a lot of abuse going on in a lot of these places.”
Dr. William D. Smucker, a member of the American Medical Directors Association, a group of health professionals who work in nursing homes, agreed. Though the group encourages doctors to conduct a thorough assessment and prescribe antipsychotics only as a last resort, he said, “Many physicians are absent without leave in the nursing home and don’t take an active role in the assessment of the patient.”
Some nursing homes are trying a different approach, so-called environmental intervention. The strategies include reducing boredom, providing intellectual and physical stimulation, exercise, calming music, bringing in pets for therapy and improving how the staff approaches and talks to dementia patients.
At the Margaret Teitz Nursing and Rehabilitation Center in Queens, social workers do life reviews of patients to understand their interests, lifestyle and former occupations.
“I had a patient who used to be in fashion,” said Nancy Goldwasser, the director of social services. “So we got her fabric samples. And she’d sit and look through the books, touch the fabric, and it would calm her.”
But such approaches are time consuming, they do not help all patients, they can be prohibitively expensive and they will be more difficult to provide as Alzheimer’s continues to increase.
“Our health care system isn’t set up to address the mental, emotional and behavioral problems of the elderly,” said Dr. Gary S. Moak, president of the American Association for Geriatric Psychiatry.
Nursing homes are short staffed, and insurers do not generally pay for the attentive medical care and hands-on psychosocial therapy that advocates recommend. It is much easier to use sedatives and antipsychotics, despite their side effects.
The first generation of antipsychotics, like Haldol, carry a significant risk of repetitive movement disorders and sedation. Second-generation antipsychotics, also called atypicals, are more commonly prescribed because the risk of movement disorders is lower. But they, too, can cause sedation, and they contribute to weight gain and diabetes.
Used correctly, the drugs do have a role in treating some seriously demented patients, who may be incapacitated by paranoia or are self-destructive or violent. Taking the edge off the behavior can keep them safe and living at home, rather than in a nursing home.
If patients are prescribed an antipsychotic, it should be a very low dose for the shortest period necessary, said Dr. Dillip V. Jeste, a professor of psychiatry and neuroscience at the University of California, San Diego.
It may take a few weeks or months to control behavior. In many cases, the patient can then be weaned off of the drugs or kept at a very low dose.
Some experts say another group of medications — antidementia drugs like Aricept, Exelon and Namenda — are underused. Research shows that 10 to 20 percent of Alzheimer’s patients had noticeable positive responses to the drugs, and 40 percent more showed some cognitive improvement, even if it was not noticeable to an observer.
“Sometimes, it’s enough to take the edge off the behavioral problems, so the family and patient can live with it and you don’t expose people to much risk,” said Dr. Gary J. Kennedy, director of geriatric psychiatry at the Montefiore Medical Center in the Bronx.
Other experts cite a lack of research backing these drugs for behavioral problems.
If patients begin showing behavioral symptoms of dementia, doctors said, they should have complete medical and psychiatric workups first, especially if symptoms develop suddenly.
“Just because someone is 95 does not mean one should not do a workup, especially if she’s been healthy,” Dr. Kennedy said.
Common causes of the symptoms include ministrokes, reparable brain hemorrhage from a mild bump on the head, hypothyroidism, dehydration, malnourishment, depression and sleep disorders.
Some doctors point out that simply paying attention to a nursing home patient can ease dementia symptoms. They note that in randomized trials of antipsychotic drugs for dementia, 30 to 60 percent of patients in the placebo groups improved.
“That’s mind boggling,” Dr. Jeste said. “These severely demented patients are not responding to the power of suggestion. They’re responding to the attention they get when they participate in a clinical trial.
“They receive both T.L.C. and good general medical and humane care, which they did not receive until now. That’s a sad commentary on the way we treat dementia patients.”
To family members looking at a nursing home for an aging parent, experts recommend seeking out homes with low staff turnover, a high ratio of staff members to patients, and programs with psychosocial components.
The Medicare Web site has basic information on individual homes at www.medicare.gov/NHcompare. The National Citizens’ Coalition for Nursing Home Reform, at www.nccnhr.org, offers a consumer guide to choosing a nursing home.
If medications are necessary, a family member should communicate with the prescribing doctor, learn the goal of each medication and be involved in making the decision.
Dr. Moak, of the psychiatry association, emphasized seeking out the doctor. Family members, he said, “often speak through the nursing staff, and that’s a huge mistake.”
Family members who are not convinced that a relative is receiving the best care should get a second opinion, as Ramona Lamascola did.
The physician she consulted, Dr. Kennedy of Montefiore, stopped her mother’s antipsychotics and sedatives and prescribed Aricept.
“It’s not clear whether it was getting her hypothyroid and other medical issues finally under control or getting rid of the offending medications,” he said. “But she had a miraculous turnaround.”
Theresa Lamascola still has dementia, but she went from confinement in a wheelchair — unable to sit still and screaming out in fear — to being able to walk with help, sit peacefully, have some memory and ability to communicate, understand subtleties of conversations and even make jokes.
Or, as her daughter put it, “I got my mother back.”

Genome Transforms as Years Fly By

By Michael Smith
BALTIMORE, 25 june 2008-- -- The individual genome -- far from being stable -- evolves during a lifetime, with changes that could influence disease susceptibility, according to researchers here.
Moreover, the so-called epigenetic changes are similar within families, suggesting that the pattern of alterations might be under genetic control, according to Andrew Feinberg, M.D., of Johns Hopkins, and colleagues.
Such changes might directly affect susceptibility to disease, Dr. Feinberg and colleagues reported in the June 25 issue of the Journal of the American Medical Association.
"We're beginning to see that epigenetics stands at the center of modern medicine because epigenetic changes, unlike DNA sequence which is the same in every cell, can occur as a result of dietary and other environmental exposure," Dr. Feinberg said.
"Epigenetics might very well play a role in diseases like diabetes, autism, and cancer," he added.
Many so-called "epigenetic marks" -- chemical changes to DNA that persist as the cell divides -- are known, but for this study the researchers concentrated on DNA methylation -- the addition of a methyl group to a section of the genome.
DNA methylation usually takes place at so-called "CpG islands" in the genome and changes in methylation can have the effect of turning genes on and off.
The researchers studied DNA from 111 people in an Icelandic cohort, who were sampled on average 11 years apart, as well as from 126 people in a Utah cohort of families who were sampled on average 16 years apart.
In the Icelandic cohort on the whole, Dr. Feinberg and colleagues found, the average individual change in DNA methylation over the 11 years was zero -- consistent with earlier studies.
On the other hand, when the volunteers were looked at individually, the researchers saw a wide range of changes, including gains and losses of methylation of up to 26% and 30% respectively.
The analysis found that:
70 volunteers (63%) had a gain or loss of 5%.
33 individuals (30%) had a change of 10% or more.
Nine (8.1%) had a change of at least 20%.
The results from the Utah cohort -- which consisted of members of 21 families originally part of a larger study of human genetic polymorphisms -- were similar, Dr. Feinberg and colleagues found.
Again there was a wide range of gains and losses, with 50 individuals (40%) showing a change of at least 5%, 23 (18%) with a change of at least 10%, and 13 (10%) with a change of at least 20%.
Because the Utah cohort consisted of family groups, the researchers asked whether the direction of the changes tended to be similar among family members.
In fact, analysis showed that members of the same family were all likely to have either gains or losses in methylation, a finding that was significant at P<0.001.
When one family -- all of whose members had between 40% and 50% losses in methylation -- was excluded, the familial clustering remained significant at P<0.003, the researchers found.
"What we saw was a detectable change over time, which showed us proof of the principle that an individual's epigenetics does change with age," said co-author M. Daniele Fallin, Ph.D., of the Johns Hopkins Bloomberg School of Public Health.
"What we still didn't know was why or how, but we thought 'maybe this, too, is something that's heritable' and could explain why certain families are more susceptible to certain diseases," she said.
They pointed out another potential application of these findings. "These data support the idea of age-related loss of normal epigenetic patterns as a mechanism for late onset of common human diseases (common disease genetic and epigenetic model) which could arise through the loss of functionally important epigenetic modifications as well as through the release of epigenetic buffering of intrinsic genetic variation."
The study was supported by the NIH, the Swedish Cancer Foundation, the Icelandic Parliament, the Huntsman General Clinical Research Center, the W. M. Keck Foundation, the George S. and Delores Doré Eccles Foundation, the Fulbright Foundation, and the Icelandic Student Innovation Fund. The researchers reported no conflicts.
Primary source: Journal of the American Medical AssociationSource reference:Bjornsson HT, et al "Intra-individual change over time in DNA methylation with familial clustering" JAMA 2008; 299(24): 2877-2883.

CDC: About 8 percent of Americans have diabetes

25 june 2008--The number of Americans with diabetes has grown to about 24 million people, or roughly 8 percent of the U.S. population, the government said Tuesday.
A report by the Centers for Disease Control and Prevention, based on data from 2007, said the number represents an increase of about 3 million over two years. The CDC estimates another 57 million people have blood sugar abnormalities called pre-diabetes, which puts people at increased risk for the disease.
The percentage of people unaware that they have diabetes fell from 30 percent to 25 percent, according to the study.
Dr. Ann Albright, director of the CDC Division of Diabetes Translation, said the report has "both good news and bad news."
"It is concerning to know that we have more people developing diabetes, and these data are a reminder of the importance of increasing awareness of this condition, especially among people who are at high risk," Albright said in a statement.
"On the other hand, it is good to see that more people are aware that they have diabetes."
A message left Tuesday night seeking further comment from the CDC wasn't immediately returned.
The disease results from defects in insulin production that cause sugar to build up in the body. It is the seventh leading cause of death in the country and can cause serious health problems including heart disease, blindness, kidney failure and amputations.
Among adults, diabetes increased in both men and women and in all age groups, but still disproportionately affects the elderly. Almost 25 percent of the population 60 years and older had diabetes in 2007.
After adjusting for population age differences between various groups, the rate of diagnosed diabetes was highest among American Indians and Alaska Natives (16.5 percent). This was followed by blacks (11.8 percent) and Hispanics (10.4 percent), which includes rates for Puerto Ricans (12.6 percent), Mexican Americans (11.9 percent), and Cubans (8.2 percent).
By comparison, the rate for Asian Americans was 7.5 percent, with whites at 6.6 percent.

Diabetes and Depression Track Each Other

By NICHOLAS BAKALAR
24 june 2008--Depressed people may have an increased risk of Type 2 diabetes, and those with diabetes may be at increased risk for depression. A study published on June 18 in The Journal of the American Medical Association suggests a new level of complexity in the relationship between the disorders.
Researchers studied 5,201 people without Type 2 diabetes and determined the risk for developing it among those with and without depressive symptoms over three years. The incidence of diabetes increased 1.1 times for each five-point increase in scores on a depression questionnaire.
Then they looked at 4,847 people without depressive symptoms and calculated the risk for developing depression among those with and without diabetes. Surprisingly, people with untreated diabetes or prediabetes were less likely to be depressed, but those being treated for Type 2 diabetes had more than a 50 percent increased relative risk for depression compared with those who did not have diabetes.
“The complications and burdens of managing significant diabetes can increase the risk for depression,” said Dr. Sherita Hill Golden, the lead author and an associate professor of medicine at Johns Hopkins. “And in our study, the people who had depression ate more, smoked more and were more obese, all of which can increase the risk for diabetes.”

Medical Pot Ineffective as Acute Pain Treatment


24 june 2008-- Oral cannabis (a form of medical marijuana) was ineffective in treating certain types of acute pain and actually increased sensitivity to some other kinds of discomfort, say researchers at the Medical University of Vienna, Austria.
Their study included 18 healthy women who were given oral cannabis or a placebo. The women were then evaluated for heat and electrical pain thresholds in skin areas that had induced sunburn. This is an accepted method of assessing response to acute pain.
"The surprising result of our study was the absence of any kind of analgesic activity of THC-standardized cannabis extract on experimentally induced pain using well-established human model procedures," study author Dr. Birgit Kraft said in a prepared statement. "Our results also seem to support the impression that high doses of cannabinoids may even cause increased sensitivity in certain pain conditions."
The study is published in the July issue of the journal Anesthesiology.
Previous research has suggested that cannabis and tetrahydrocannabinol (THC -- the main psychoactive component of marijuana) may help ease chronic pain in cancer patients, spinal cord injury patients, and people with multiple sclerosis. There have been inconsistent findings about the effects on acute pain.
This new study's findings about oral cannabis and acute pain are seemingly conclusive, according to the researchers.
"From comparisons with previous clinical data, the lack of pain relief from the cannabis dosage and oral administration in our study cannot be considered the result of inadequate dosage or insufficient intestinal absorption," Kraft said. "The high levels of THC detected in the blood of our subjects as well as the occurrence of typical THC side effects argue for sufficient availability, and thus we draw the conclusion that THC was not effective in treating acute pain."
However, cannabis may remain a viable treatment option for certain types of chronic pain.
"Pain is a very complex and subjective phenomena," Kraft said. "Chronic pain has not only been shown to lead to changes in peripheral and central neural processing, but also to be associated with psychosocial problems, physical disorders, and functional disabilities. Recent studies have indicated that cannabis can be effective in treating certain types of chronic pain and helping patients to cope by improving quality of life."

Brain injuries cause half of seniors' fall deaths

By MIKE STOBBE
24 june 2008--The elderly fear breaking a hip when they fall, but a government study indicates that hitting their head can also have deadly consequences: Brain injuries account for half of all deaths from falls.
The study by the Centers for Disease Control and Prevention is the first comprehensive national look at the role brain injuries play in fatal elderly falls. It examined 16,000 deaths in 2005 that listed unintentional falls as an underlying cause of death.
CDC researchers found that slightly more than half of the deaths were attributed to brain injuries. The other deaths were due to a variety of causes including heart failure, strokes, infections and existing chronic conditions worsened by a broken hip or other injuries sustained in a fall.
"A lot of people don't think a fall is serious unless they broke a bone, they don't think it's serious unless they break a hip. They don't worry about their head," said Pat Flemming, a senior physical therapist and researcher at Vanderbilt University
Each year, one in three Americans age 65 and older fall. About 30 percent of such falls require medical treatment.
Previous CDC research showed that the U.S. death rate from falling has risen dramatically — about 55 percent — for the elderly since the 1990s. The new study highlights the role that brain injuries play in such deaths.
As people age, veins and arteries can be more easily torn during a sudden blow or jolt to the head, said Marlena Wald, a CDC epidemiologist who co-authored the study.
That can cause a fatal brain bleed. Other factors can contribute, such as the use of blood-thinners, said Judy Stevens, another CDC researcher and co-author.
The severity of brain injuries isn't always immediately apparent, and some people may not lose consciousness. Wald noted a scenario seen in hospitals in which an elderly fall victim comes in alert and talking, but dies an hour or two later.
The study also found that deaths and hospitalization rates for fall-related brain injuries increased with age. Brain injuries accounted for about 8 percent of hospital stays for non-fatal falls.
There are several steps older Americans can take to try to prevent falls. Exercise can increase leg strength and balance. Glasses or other vision correction measures can help people avoid obstacles. And being careful with the use of drugs that can affect thinking and coordination — such as tranquilizers and sleeping pills — can also make a difference.
"Falls are not an inevitable consequence of aging. These head injuries are not inevitable, either," Wald said.
The research is being published in the June issue of a scientific publication, the Journal of Safety Research.

Cancer Prognoses Favor the Rich and Well-Educated

By Crystal Phend
DENVER, 24 june 2008 -- Cancer is crueler to minorities and others in lower socioeconomic brackets, according to a large population-based study.
Such cancer patients, commonly those with less education, had more advanced disease at diagnosis, got less aggressive treatment, and were more likely to die in the five years after diagnosis, reported Tim E. Byers, M.D., M.P.H., of the University of Colorado here, and colleagues in the Aug. 1 issue of Cancer.
A more aggressive tumor biology among patients from minority racial and ethnic groups may explain some of the associations with low income and education, the researchers said.
"Social factors, however, seem to be more important than biologic factors in explaining racial and ethnic cancer disparities," they said.
The researchers analyzed data from the Breast, Colon, and Prostate Cancer Data Quality and Patterns of Care Study that included a sample of patients from state cancer registries in California, Colorado, Illinois, Louisiana, New York, Rhode Island, and South Carolina.
The study included 4,844 breast cancer patents, 4,422 colorectal cancer patients, and 4,332 prostate cancer patients diagnosed in 1997. About 80% of these patients were non-Hispanic white, and more than half were older than 65.
Neighborhood-level census track data from 2000 was used to classify patients as living in a low socioeconomic status area according to whether less than 25% of adults in the area had a high school education, whether 20% or more of households had incomes below the Federal Poverty Level, or both.
Cancer patients who lived in a low socioeconomic status area were more likely to be diagnosed at an advanced stage than those in well-to-do areas. These findings included:
For breast cancer, regional disease was present in 23% versus 20% while distant metastasis was present in 4-6% versus 3% depending on the criteria for low socioeconomic status.
For prostate cancer, regional disease was present in 10% versus 9% while distant spread was present in 6% versus 4%.
For colorectal cancer, the associations of socioeconomic status with stage and all-cause mortality were not significant. It was a risk factor, though, for mortality among colorectal cancer patients younger than 65 (hazard ratio 1.37, 95% confidence interval 1.11 to 1.68).
"That this disparity disappeared after age 65 years may reflect an effect of Medicare coverage," the researchers suggested.
All-cause mortality was linked to socioeconomic status as well among breast cancer patients in models adjusted for age (HR 1.59, 95% CI 1.35 to 1.87) and when controlling for race or ethnicity (HR 1.33, 95% CI 1.11 to 1.58), although the association was no longer significant in the fully adjusted model (HR 1.16, 95% CI 0.97 to 1.38).
For prostate cancer, low socioeconomic status increased mortality when controlling for age (HR 1.33, 95% CI 1.13 to 1.57) though statistical significance was lost after adjustment for race and ethnicity (HR 1.17, 95% CI 0.98 to 1.40).
The association between mortality and socioeconomic status was stronger among minorities than among non-Hispanic whites for both breast cancer (HR 1.52 versus 1.11) and colorectal cancer (HR 1.28 versus 1.10).
For all three cancer groups, socioeconomic status appeared to impact treatment. Findings for patients in poorer areas with less education, compared with other areas, included:
Women with localized breast cancer and low socioeconomic status were more likely to have a mastectomy (46%-49% versus 38%).
Women who underwent lumpectomy were less likely to get adjuvant radiotherapy (77% versus 60%, P≤0.001).
Women with regional-stage breast cancer were slightly less likely to get adjuvant chemotherapy (68% versus 63%, P=0.16).
Women with hormone receptor-positive breast cancer were slightly less likely to get antiestrogen therapy (58% versus 52%, P=0.08).
Patients with regional-stage colon cancer were less likely to get adjuvant chemotherapy (56% versus 50%, P=0.02).
Men with prostate cancer were less likely to get prostatectomy or radiation (78% versus 67%, P≤0.0001).
The researchers noted that their study might have been limited by looking at all-cause rather than cancer-specific mortality and by use of neighborhood-level rather than individual socioeconomic status.
Race and ethnicity are often used as proxies for modifiable socioeconomic factors, such as health insurance, but this should change given the increasing evidence from this and other studies that a substantial proportion of disparities in cancer can be attributed to socioeconomic status, Dr. Byers and colleagues said.
"Better information on how cancer outcomes are related to socioeconomic status is needed if we are to properly identify and address the root causes of racial and ethnic cancer disparities in the United States," they wrote.
The study was supported by cooperative agreements between the CDC and the states of California, Colorado, Illinois, Louisiana, New York, Rhode Island, and South Carolina. The researchers reported no conflicts of interest.
Primary source: CancerSource reference:Byers TE, et al "The impact of socioeconomic status on survival after cancer in the United States: findings from the national program of cancer registries patterns of care study" Cancer 2008; 113.

Subtle Neurological Abnormalities Predict Early Mortality in Older Adults

By Michael Jahn
FLORENCE, Italy, 24 june 2008-- Otherwise healthy septuagenarians who have three or more subtle neurological abnormalities, such as difficulty maintaining balance, are at an increased risk for cognitive decline and early death, researchers here reported.
In a study of 506 men and women, average age 73, at least three of these abnormalities were associated with a 77% increase in risk of death over eight years compared with same-age adults who had fewer than three, reported Marco Inzitari, M.D., of the University of Florence, and colleagues in the June 23 issue of Archives of Internal Medicine.
The mortality rates were 22.6% per 1,000 person years for those with no abnormalities versus 58.6% for those with three and 91.9% per 1,000 person years for people with four or more subtle deficits.
In an accompanying editorial, Malaz Boustani M.D., M.P.H., and Michael Justiss, Ph.D., of the Regenstrief Institute Inc., in Indianapolis, said that meant that a 65-year-old American who visited a senior care center clinic and who had no overt neurological disease but had three or more abnormalities would have a life expectancy of about seven years. A same-age person with no evidence of neurological abnormalities could expect to live another 14 years.
The participants all lived in Dicomano, a small rural town near Florence, and 58% were women.
A neurological examination to assess cognitive status and disability was conducted at baseline and repeated four years later. Deaths and cerebrovascular events were documented over eight years. Expert geriatricians conducted the baseline examination, which required no more than 15 minutes and included a traditional neurological examination plus two additional simple tests.
The parameters measured included muscle strength on physical examination (reduced shoulder elevation, reduced or absent foot extension, pronator drift or shift, and shift of one leg) and as determined by dynamometry (handgrip and hip flexion). Sensitivity on physical examination was determined by reduced foot-plant sensitivity. Deep tendon reflexes were assessed by absent or reduced patellar and achilles reflexes.
At baseline 59% of participants had at least one abnormality (average per patient, 1.1).
When adjusted for age, sex, comorbidity, cognitive, and physical functions, and functional status, the increased number of abnormalities predicted mortality with a statistical significance of P=0.006 for the likelihood ratio test. But the risk of stroke did not track the number of neurological abnormalities.
According to Dr. Inzitari and colleagues, theirs is the first study showing the association between subtle neurological changes and functional and cognitive decline, death, and stroke prospectively in a relatively large sample of unselected older persons.
They concluded, "a simple neurological examination seems to be an additional prognosticator of hard outcomes, particularly death, above and beyond other measures used in clinical practice."
Moreover, they said the data "support the hypothesis that subtle neurological abnormalities in elderly individuals are a manifestation of early brain damage, a finding that may have important implications in research studies on the prevention of age-related cognitive and functional decline."
Drs. Boustani and Justiss wrote that the data suggested that clinicians could use a simple neurological assessment "to identify at-risk older adults and enroll them in research studies of interventions to prevent disability and eventually increase the active life expectancy of the aging population."
The study was support by the Italian Ministry of Scientific and Technological Research, by the government of Tuscany, and by the Azienda Osperdaliero-Universitaria Careggi-Firenze, Italy. Dr. Inzitari reported no financial disclosures, nor did Drs. Boustani and Justiss.
Primary source: Archives of Internal MedicineSource reference:Inzitari M, et al. "Subtle Neurological Abnormalities as Risk Factors for Cognitive and Functional Decline, Cerebrovascular Events, and Mortality in Older Community-Dwelling Adults" Arch Intern Med 2008; 168(12): 1270-1276.

New clue to Alzheimer's found in form of protein

By RANDOLPH E. SCHMID

23 june 2008--Researchers have uncovered a new clue to the cause of Alzheimer's disease. The brains of people with the memory-robbing form of dementia are cluttered with a plaque made up of beta-amyloid, a sticky protein. But there long has been a question whether this is a cause of the disease or a side effect. Also involved are tangles of a protein called tau; some scientists suspect this is the cause.
Now, researchers have caused Alzheimer's symptoms in rats by injecting them with one particular form of beta-amyloid. Injections with other forms of beta-amyloid did not cause illness, which may explain why some people have beta-amyloid plaque in their brains but do not show disease symptoms.
The findings by a team led by Dr. Ganesh M. Shankar and Dr. Dennis J. Selkoe of Harvard Medical School were reported in Sunday's online edition of the journal Nature Medicine.
The researchers used extracts from the brains of people who donated their bodies to medicine.
Forms of soluble beta-amyloid containing different numbers of molecules, as well as insoluble cores of the brain plaque, were injected into the brains of mice. There was no detectable effect from the insoluble plaque or the soluble one-molecule or three-molecule forms, the researchers found.
But the two-molecule form of soluble beta-amyloid produced characteristics of Alzheimer's in the rats, they reported.
Those rats had impaired memory function, especially for newly learned behaviors. When the mouse brains were inspected, the density brain cells was reduced by 47 percent with the beta-amyloid seeming to affect synapses, the connections between cells that are essential for communication between them.
The research, for the first time, showed the effect of a particular type of beta-amyloid in the brain, said Dr. Marcelle Morrison-Bogorad, director of the division of neuroscience at the National Institute on Aging, which helped fund the research.
It was surprising that only one of the three types had an effect, she said in a telephone interview.
Morrison-Bogorad said the findings may help explain the discovery of plaque in the brains of people who do not develop dementia. For some time, doctors have wondered why they find some brains in autopsy that are heavily coated with beta-amyloid, but the person did not have Alzheimer's.
The answer may lie in the two types of beta-amyloid that did not cause symptoms.
Now, the question is why one has the damaging effect and not others.
"A lot of work needs to be done," Morrison-Bogorad said. "Nature keeps sending us down paths that look straight at the beginning, but there are a lot of curves before we get to the end."
Dr. Richard J. Hodes, director of the National Institute on Aging, said that "while more research is needed to replicate and extend these findings, this study has put yet one more piece into place in the puzzle that is Alzheimer's."
In addition to the Institute on Aging, the research was funded by Science Foundation Ireland, Wellcome Trust, the McKnight and Ellison foundations and the Lefler Small Grant Fund.