For-Profit Hospitals Most Likely to Overtreat Dementia Patients

Tube-feeding patients with advanced dementia -- a practice whose effectiveness has been questioned by two widely cited literature reviews -- is most common in larger hospitals and those run for profit, researchers said.

The odds of a feeding-tube insertion in a hospitalized patient with advanced dementia were about 50% greater when the hospital was larger than 310 beds than in facilities with 100 beds or less, and it was 33% more common in for-profit versus government-owned facilities, reported Joan M. Teno, MD, of Brown University in Providence, R.I., and colleagues.

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SEATTLE, May 1 -- A diet that's high in vegetables, nuts, and fish but low in fatty dairy products may help protect against Alzheimer's disease, researchers said here.

Patients in the highest tertiles of such a diet had a 42% reduced risk of developing Alzheimer's, Yian Gu, Ph.D., of Columbia University, and colleagues said at the American Academy of Neurology Meeting.

"There was a significant relationship for the seven nutrients that are most consistently associated with Alzheimer's disease," Dr. Gu said.

Dr. Gu and her colleagues used the Reduced-Rank Regression model to analyze dietary patterns that might explain the variation of nutrients that is believed to be related to disease risk.

They evaluated the diet via those seven Alzheimer's disease-related nutrients: saturated fats, monounsaturated fats, omega-3 fatty acids, omega-6 fatty acids, vitamin E, vitamin B12, and folate.

The researchers prospectively assessed 2,136 healthy elderly patients in New York who
provided dietary information. Participants were evaluated with the same standardized neurological and neuropsychological measures every one-and-a-half years.

A total of 251 patients developed Alzheimer's disease over the four-year follow-up period.
In a multivariate analysis, the researchers found that a diet high in omega-3, omega-6, folate, and vitamin E, and low in saturated fat and B12, was strongly associated with lower risk of Alzheimer's disease.

Compared with the lowest scores for dietary pattern, the middle and highest tertiles had significantly reduced risks of developing Alzheimer's (HR 0.77, 95% CI 0.56 to 1.05 and HR 0.58, 95% CI 0.40 to 0.84, respectively, P<0.01).

Dr. Gu said the B12 finding was "surprising" since deficiency of the nutrient is associated with dementia. However, a major dietary source of B12 is meat, which is also a large source of saturated fat, she said.

The protective diet was characterized by higher intakes of cruciferous vegetables, green-leafy vegetables, fish, nuts, and tomatoes, and by a lower intake of high-fat dairy products.

Dr. Gu said that further study of Alzheimer's disease-related nutrients can better identify dietary patterns that relate to disease risk. .......report in MedPage Today

DENVER, April 21 -- Reprogrammed immune cells could become targeted "killing machines" against prostate cancer, a researcher said here.

In the early stages of a phase I study, these reprogrammed T cells sharply reduced the levels of prostate specific antigen (PSA) in two patients with metastatic prostate cancer, according to Richard Junghans, M.D., Ph.D., of the Roger Williams Medical Center in Providence, R.I.

Within a few weeks of the infusion of the engineered cells, one patient's PSA level had fallen by half and the other's by 75%, Dr. Junghans reported at the annual meeting of the American Association for Cancer Research. T cells, Dr. Junghans told reporters, are the "perfect killing machines" when faced with a cell infected with a virus. "We have to fool the T cells into thinking that the cancer has a virus infection," he said.

To do that, he and colleagues isolate a patient's T cells from a blood sample and use genetic engineering techniques to make them sensitive to a molecule that only occurs in prostate cancer -- prostate specific membrane antigen, or PSMA.

Over a period of weeks, the modified cells are amplified in culture. Meanwhile the patient undergoes chemotherapy to knock down his remaining lymphocytes, creating "hematopoietic space" for the engineered T cells.

Finally, he said, the cells are infused into the patient and begin attacking cells that express PSMA. A marker for that activity, Dr. Junghans said, is the level of prostate specific antigen.
The falling levels of PSA in the two patients treated so far were obtained despite the low dose of cells they were given -- about a billion each.

The researchers plan to test that dose in one more patient and then escalate the dose -- first to 10 billion in six patients and then to 100 billion in another six.

In the two patients treated so far, the falling PSA levels appeared to have bottomed without reaching zero -- possibly because the methods used to activate them caused them to enter a resting state without completely eradicating the cancer cells, Dr. Junghans said.

With the higher doses, he said, he hopes to see PSA levels fall all the way to zero.
"We are very hopeful that when we get to higher doses," he said, "all those activated (cells) may get us to 100% suppression before they go to the resting state."

Dr. Junghans said the redirected T cells are a "brave new world" for cancer treatment. "I predict the FDA will have approved one of these designer T-cell constructs -- if not this one, then another one -- as standard therapy in the next five or so years," he said.

Dr. Junghans' approach is a new twist on ideas that have been around for "two decades or more," said Louis Weiner, M.D., of Washington's Lombardi Cancer Center, who was not part of the research.

"What Dr. Junghans and colleagues have done is to really combine two critical elements" -- redirecting the T cells and creating space for them by chemotherapy, Dr. Weiner said.

He said while the idea is intriguing and the early results promising, "at the end of the day, we will need properly conducted efficacy trials."

But "the early returns are sufficiently encouraging that I certainly hope they continue doing the work," he said.
MedPage Today

SEATTLE, Feb. 18 -- Middle-age and older adults who prefer a mental workout to passive activities, such as watching TV, may be less likely to develop memory loss as they age, researchers said.

Mentally stimulating social activity and reading in middle age reduced the likelihood of mild cognitive impairment in old age by more than 40%, found Yonas E. Geda, M.D., of the Mayo Clinic in Rochester, Minn., and colleagues.

After age 65, reading, making crafts, using the computer, playing games, and watching less TV were associated with 30% to 50% lower risk of mild cognitive impairment, Dr. Geda's group reported in a case-control study to be presented at the American Academy of Neurology meeting here.

Dr. Geda said these findings provide concrete evidence for the "use it or lose it" axiom. "This means perhaps aging does not have to be a simple passive process."

In the multivariate analysis adjusted for age, sex, and education, the researchers found the following activities done over the prior year late in life protective against mild cognitive impairment:

• Reading books (odds ratio 0.67, 95% confidence interval 0.49 to 0.94)
• Playing games (OR 0.65, 95% CI 0.47 to 0.90)
• Crafting activities, such as quilting or pottery (OR 0.66, 95% CI 0.47 to 0.93)
• Computer activities (OR 0.50, 95% CI 0.36 to 0.71)
• Watching television less (OR 0.48 for fewer than seven hours per day versus more, 95% CI 0.27 to 0.86)

Dr. Geda cautioned that the findings were based on patients' memories of activities and need to be confirmed in prospective studies.

full story and video in MedPage Today

IOWA CITY, Iowa, Feb. 11 -- The difficult judgment call on whether Alzheimer's patients are safe to drive can be helped by a battery of cognitive tests, researchers here said.

"By measuring driver performance through off-road tests of memory, visual, and motor abilities, we may be able to develop a standardized assessment of a person's fitness to drive," Dr. Dawson said.

To determine whether performance on tests of cognition, visual perception, and motor function could predict the level of safety in licensed drivers with early Alzheimer's, the researchers conducted a controlled trial of 40 patients with mild disease and 115 patients without dementia.

"Given that driving puts demands on diverse cognitive functions, it is unlikely that a test of any single cognitive ability will be an accurate predictor of driving safety," the researchers said.

The study may have been limited by a lack of investigation of other environmental factors, such as having family members in the vehicle and time of day, as well as a possible lack of generalizability because only seven of the 40 patients in the experimental group were women.

Still, the researchers concluded that for predicting safety errors within the Alzheimer's disease group, "off-road neuropsychological tests of cognition, vision, and motor abilities gave additional information above and beyond diagnosis alone. Hence, performance on these tests can be helpful when predicting whether a patient with Alzheimer's disease can safely drive a vehicle."
full story in Medpage Today

Kapil D. Sethi, MD, Professor of Neurology; Director, Movement Disorders Program, Medical College of Georgia, Augusta
Medscape Today

STANFORD, Calif. — You come into a doctor’s office with severe knee pain. The physician orders an MRI, which reveals substantial loss of cartilage — osteoarthritis, that is—in your knee joint. At this point, not much can be done beyond gulping down palliatives and trying to keep your weight off the joint. But the damage may have started building as much as 20 years earlier, possibly due to a traumatic injury to the affected joint.

Just ask Garry Gold, MD, an associate professor of radiology at the Stanford University School of Medicine. Now 45, Gold sustained a knee injury 20 years ago while playing in a pickup basketball game. These days, he’s starting to wish his house, currently being remodeled, didn’t have any stairs.

Gold, who has been diagnosed with osteoarthritis, is working with an imaging technology called sodium MRI to diagnose osteoarthritis as long as decades before the onset of physical symptoms. That may spawn new therapies that could possibly have blocked his disease before it put an end to his basketball days.

Using the new imaging technology, Gold and colleagues have been able to spot, soon after such an injury, telltale signs of cartilage deterioration consistent with the development of osteoarthritis.

Sodium MRI has been around for years, but until recently it couldn’t be used in clinical settings. For one thing, the magnets employed to excite sodium atoms were too puny, making crisp resolution possible only with tiny creatures such as mice. Gold and his colleague Brian Hargreaves, PhD, assistant professor of radiology, have designed improved magnets and software to scale up the technology for human application.

Gold and Hargreaves’ project is being conducted with funding from the National Institutes of Health and GlaxoSmithKline, an international pharmaceutical company. Neither researcher owns stock in, or receives consulting fees from, the company.

Catching osteoarthritis during its stealth phase may spur clinical trials that would be prohibitively time-consuming and costly if standard MRI were employed, because of the huge lag from the time of an ACL injury until the time cartilage deterioration can be detected by that old method.

With sodium MRI, cohorts of treated vs. untreated at-risk patients could be imaged over time to see if, within a few years of the injury, a drug or a lifestyle change is reducing or arresting the loss of glycosaminoglycan from the ligament. Once promising drugs or lifestyle changes are identified, they could then be administered to at-risk patients long before symptoms surface, Gold said.

As for Gold himself, he has yet to see what his own damaged knee looks like under sodium MRI. The 6-foot-6 once-avid amateur basketball center’s knee is too big for even his improved new experimental apparatus to fit. It’s probably too late for any kind of imaging to do Gold much good now, anyway. He already knows he’s got arthritis. “I don’t even want to look,” he said.

Full story & Video: Stanford School of Medicine

The original Dear Abby, now living with Alzheimer's disease, once positively impacted millions of lives. Her daughter, the current Dear Abby, shares what her life is like now.

http://www.empowher.com/community/herstory/video-herstory-dear-abby-shares-what-her-alzheimers-mothers-life-today

High neuroticism has been associated with a greater risk of dementia, and an active/socially integrated lifestyle with a lower risk of dementia. The aim of the current study was to explore the separate and combined effects of neuroticism and extraversion on the risk of dementia, and to examine whether lifestyle factors may modify this association.
NEUROLOGY 2009;72:253-259

STANFORD, Calif. — Scientists at the Stanford University School of Medicine and at UC-San Francisco have succeeded in isolating stem cells from human testes. The cells bear a striking resemblance to embryonic stem cells — they can differentiate into each of the three main types of tissues of the body — but the researchers caution against viewing them as one and the same....full story in Stanford School of Medicine Medical News

January 8, 2009 — Results of a randomized trial show that compared with best medical therapy, deep brain stimulation (DBS) increased "on" time without dyskinesias and improved motor function as well as quality of life at 6 months in patients with moderate to severe Parkinson's disease (PD), but at the cost of increased serious adverse events (SAEs)........full story
Medscape Today

LONDON, Jan. 8 -- For patients with Alzheimer's disease, antipsychotic medications substantially increase one-year mortality risk, researchers found. Patients who continued on their antipsychotic regimen were 42% more likely to die over a one-year... full story

MedPage Today

Don't let osteoporosis rob your bones of their strength. Here are some exercises to prevent or treat this common bone disease.
The Mayo Clinic

Osteoporosis treatment may involve medication along with lifestyle change. A Mayo Clinic specialist answers some of the most common questions about osteoporosis treatment.
The Mayo Clinic

Technologies like a flu-tracking app and phone wipes could help you get through flu season unscathed.
PC Magazine

NEW YORK (Reuters Health) Dec 29 - Tests show that certain MRI machines may demagnetize magnets used in cochlear implants to couple external and implanted components, according to a report in the December issue of Otolaryngology--Head and Neck Surgery.
Medscape Today

December 30, 2008 — Memory decline with age appears partly explained by increased blood glucose levels that cause decreased activity in the dentate gyrus, a new study published in the December issue of the Annals of Neurology suggests.

Since blood glucose levels tend to rise with age, this study suggests that improving blood glucose regulation may be a good way to ameliorate age-related memory decline, said Dr. Small.

"Whether through physical exercise, diet, or drugs, this research suggests that improving glucose metabolism could help some people avert the cognitive slide that occurs in many of us as we age," he said.

Their study suggests that moderating blood glucose levels, through physical exercise, diet, or medication, may aid in preventing cognitive decline, he added.

Nevertheless, "the results showed a clear difference in cognitive performance as a function of diet . . . [and] the data suggest that diet can affect more than just weight," Dr. Taylor said in a statement. "The brain needs glucose for energy, and diets low in carbohydrates can be detrimental to learning, memory and thinking."
Medscape Today

Judicious Drinking Associated with Reduced Risk of Dementia
MAYWOOD, Ill., Dec. 30 -- Having a drink only occasionally may reduce the risk of dementia, perhaps because long exposure to low alcohol levels help brain cells survive other stresses, researchers here said.
Medscape Today - Full story

NEW YORK, Dec. 30 -- Lowering blood glucose levels may help lessen the cognitive decline of normal aging, even in diabetes-free patients, researchers here said.
Medscape Today - Full story

The U.S. Food and Drug Administration today announced it will require the manufacturers of antiepileptic drugs to add to these products' prescribing information, or labeling, a warning that their use increases risk of suicidal thoughts and behaviors (suicidality). The action includes all antiepileptic drugs including those used to treat psychiatric disorders, migraine headaches and other conditions, as well as epilepsy.

The FDA is also requiring the manufacturers to submit for each of these products a Risk Evaluation and Mitigation Strategy, including a Medication Guide for patients. Medication Guides are manufacturer-developed handouts that are given to patients, their families and caregivers when a medicine is dispensed. The guides will contain FDA-approved information about the risks of suicidal thoughts and behaviors associated with the class of antiepileptic medications.

"Patients being treated with antiepileptic drugs for any indication should be monitored for the emergence or worsening of depression, suicidal thoughts or behavior, or any unusual changes in mood or behavior,” said Russell Katz, M.D., director of the Division of Neurology Products in the FDA's Center for Drug Evaluation and Research. “ Patients who are currently taking an antiepileptic medicine should not make any treatment changes without talking to their health care professional.”

The FDA today also disseminated information to the public about the risks associated with antiepileptic medications by issuing a public health advisory and an information alert to health care professionals. Health care professionals should notify patients, their families, and caregivers of the potential for an increase in the risk of suicidal thoughts or behaviors so that patients may be closely observed.

The FDA's actions are based on the agency's review of 199 clinical trials of 11 antiepileptic drugs which showed that patients receiving antiepileptic drugs had almost twice the risk of suicidal behavior or thoughts (0.43 percent) compared to patients receiving a placebo (0.24 percent). This difference was about one additional case of suicidal thoughts or behaviors for every 500 patients treated with antiepileptic drugs instead of placebo.

Four of the patients who were randomized to receive one of the antiepileptic drugs committed suicide, whereas none of the patients in the placebo group did. Results were insufficient for any conclusion to be drawn about the drugs' effects on completed suicides. The biological reasons for the increase in the risk for suicidal thoughts and behavior observed in patients being treated with antiepileptic drugs are unknown.

The FDA alerted health care professionals in January 2008 that clinical trials of drugs to treat epilepsy showed increased risk of suicidal thoughts and actions. In July 2008, the FDA held a public meeting to discuss the data with a committee of independent advisors. At that meeting the committee agreed with the FDA's findings that there is an increased risk of suicidality with the analyzed antiepileptic drugs, and that appropriate warnings should extend to the whole class of medications. The panel also considered whether the drugs should be labeled with a boxed warning, the FDA's strongest warning. The advisers recommended against a boxed warning and instead recommended that a warning of a different type be added to the labeling and that a Medication Guide be developed.

Acting under the authorities of the Food and Drug Administration Amendments Act of 2007 (FDAAA), the FDA is requiring manufacturers of antiepileptic drugs to submit to the agency new labeling within 30 days, or provide a reason why they do not believe such labeling changes are necessary. In cases of non-compliance, FDAAA provides strict timelines for resolving the issue and allows the agency to initiate an enforcement action if necessary.

The following antiepileptic drugs are required to add warnings about the risk of suicidality:
Carbamazepine (marketed as Carbatrol, Equetro, Tegretol, Tegretol XR)
Clonazepam (marketed as Klonopin)
Clorazepate (marketed as Tranxene)
Divalproex sodium (marketed as Depakote, Depakote ER)
Ethosuximide (marketed as Zarontin)
Ethotoin (marketed as Peganone)
Felbamate (marketed as Felbatol)
Gabapentin (marketed as Neurontin)
Lamotrigine (marketed as Lamictal)
Lacosamide (marketed as Vimpat)
Levetiracetam (marketed as Keppra)
Mephenytoin (marketed as Mesantoin)
Methosuximide (marketed as Celontin)
Oxcarbazepine (marketed as Trileptal)
Phenytoin (marketed as Dilantin)
Pregabalin (marketed as Lyrica)
Primidone (marketed as Mysoline)
Rufinamide (marketed as Banzel)
Tiagabine (marketed as Gabitril)
Topiramate (marketed as Topamax)
Trimethadione (marketed as Tridione)
Valproic Acid (marketed as Depakene, Stavzor Extended Release Tablets)
Zonisamide (marketed as Zonegran)

Some of these medications are also available as generics.

Health care professionals and consumers may report serious adverse events or product quality problems with the use of this product to the FDA's MedWatch Adverse Event Reporting program either online, by regular mail, fax or phone.

-- Online : http://www.fda.gov/MedWatch/report.htm

-- Regular Mail : use postage-paid FDA form 3500 available at: http://www.fda.gov/bbs/topics/NEWS/2008/www.fda.gov/MedWatch/getforms.htmand mail to MedWatch, 5600 Fishers Lane , Rockville , MD 20852-9787

-- Fax: (800) FDA-0178

-- Phone: (800) FDA-1088

For more information
Information for Health Care Professionals and Public Health Advisory: http://www.fda.gov/cder/drug/infopage/antiepileptics/default.htm

U.S. Food and Drug Administration - FDA News

UMEA, Sweden, Dec. 16 -- Long-term mortality in locally advanced prostate cancer was improved by 50% when external-beam radiation was added to hormone therapy, found researchers here.

At 10 years, prostate specific mortality was 23.9% for those given only hormone therapy versus 11.9% for the combination therapy arm, wrote Anders Widmark, M.D., of Umea University, and colleagues in the Scandinavian Prostate Cancer Group.

The findings derived from evaluable results from 875 men, 439 who received three months of total androgen blockage followed by continuous hormone therapy using flutamide, and 436 who had the same hormone regimen combined with external beam radiation.

Yet Drs. Tan and Parker concluded that the findings represented a pivotal trial that should "change current practice, making long-term hormonal therapy plus radical radiotherapy the standard of care for men with locally advanced prostate cancer."

MedPage Today

URBANA, Ill., Dec. 11 -- Older individuals may be able to stem the age-related decline in cognitive function by playing video games, researchers here found.

Nearly two dozen hours of playing a strategic video game over several weeks led to increased performance on four out of six tests of executive function, Arthur Kramer, Ph.D., of the University of Illinois at Urbana-Champaign, and colleagues reported in the December issue of Psychology and Aging.

"Whether similar transfer effects would be observed with video-game-based training to everyday cognition in older adults is a both theoretically as well as practically important question, especially given the rapid expansion of commercial products and computer programs touted to improve the cognitive abilities of older adults," the researchers said.

Previous studies have shown that training individuals in a particular cognitive task can enhance performance on that specific task, the researchers said.

But opinions are mixed on whether training can result in improvements in an array of cognitive skills, they said.

Commercially available computer products that claim to improve cognitive function, he said, tend to "take a more piecemeal approach."

The authors acknowledged that the study was limited by the fact that the control group did not play a video game.

Future studies should evaluate whether the improvements in laboratory-based measurements of cognitive function translate into everyday activities like driving a car or working in a busy office, they said.

MedPage Today

LA JOLLA, Calif., Dec. 4 -- Alzheimer's patients with coexisting obstructive sleep apnea may derive cognitive benefits from treatment with continuous positive airway pressure (CPAP), investigators here concluded.

CPAP led to significant improvement on a neuropsychological test battery compared to baseline, Sonia Ancoli-Israel, Ph.D., of the University of California San Diego, and colleagues reported in the November issue of the Journal of the American Geriatrics Society.

"Although it is unlikely that obstructive sleep apnea causes dementia, the lowered oxygen levels and sleep fragmentation associated with obstructive sleep apnea might worsen cognitive function," said Dr. Ancoli-Israel. "This study, which showed significant improvement in patients' neurological test scores after treatment with CPAP, suggests that clinicians who treat patients with Alzheimer's disease and sleep apnea should consider implementing CPAP treatment."

Alzheimer's patients have a high prevalence of obstructive sleep apnea. Estimates range from 70% to 80% of patients having at least five episodes of apnea or hypopnea per hour to 40% to 50% having 20 or more episodes per hour.

Some evidence has suggested that more severe dementia is associated with more severe obstructive sleep apnea, they continued.

Studies of CPAP treatment for sleep apnea in patients without dementia have demonstrated improvement in neuropsychological function. Whether CPAP would lead to similar improvement in patients with Alzheimer's disease had not been examined in a randomized, placebo-controlled trial.

After the first three weeks, the two groups did not differ in changes in neuropsychological scores. However, in a paired analysis at six weeks (at which time one group had received six weeks of therapeutic CPAP and the other three weeks), both groups had significant improvement that averaged 0.077 points (P=0.01).

The study was limited by the small sample size, which did not allow for analysis of specific cognitive tests, and by the short duration of the study.

"[Obstructive sleep apnea] may aggravate cognitive dysfunction in dementia and thus may be a reversible cause of cognitive loss in patients with Alzheimer's Disease," the authors concluded. "OSA treatment seems to improve cognitive functioning."

Co-author Jody Corey-Bloom, M.D., Ph.D., also of UC San Diego, commented that "any intervention that improves cognition in patients with Alzheimer's disease is likely to result in greater independence and less burden on their caretakers."

A previous report from the same study showed that CPAP significantly reduced daytime sleepiness, a common complaint of Alzheimer's patients, Dr. Corey-Bloom added.

MedPage Today

Starting on Jan. 1, New York City ambulances will take many cardiac arrest patients only to hospitals that use a delicate cooling therapy believed to reduce the chances of brain damage and increase the chances of survival, even if it means bypassing closer emergency rooms.

The move by the city’s Fire Department and Emergency Medical Service, after a year of preparation, indicates a shift away from the prevailing view among emergency workers and the public that how fast critically ill patients reach the hospital is more important than which hospital treats them.

It amounts to an endorsement by the Bloomberg administration of a labor-intensive, often expensive and still-developing therapy that smaller community hospitals say they lack the staffing and financial wherewithal to provide.

Some hospital officials fear that the policy could be unfair to these smaller hospitals, depriving them of income from emergency-room patients and hurting their reputations with the public.

Since the Fire Department sent letters to hospital chief executives this week informing them of the impending change, about 20 of the 59 hospitals with emergency rooms have said they will have cooling operations ready by the Jan. 1 deadline.

Dr. David J. Prezant, chief medical officer of the New York Fire Department, acknowledged the culture change and the possibility that some hospitals would feel slighted. But he argued that scientific data shows the survival rate of cardiac arrest patients treated with therapeutic hypothermia, as the cooling process is called, is so much better than with conventional treatment that it would be irresponsible not to provide it.

“Theoretically every closest 911-receiving hospital will be able to provide this service,” he noted. “Whether that will be a reality or not is not for me to say.”

New York joins a handful of other American cities, including Seattle, Boston and Miami, as well as Vienna and London, in requiring transport to hospitals with cooling systems. But given New York’s large population and concentration of hospitals, the policy may provide the largest test to date of therapeutic hypothermia.

Most patients who suffer total cardiac arrest outside hospitals die because their brains have been starved of oxygen. But studies show that if the pulse of patients can be restarted and the body temperature cooled to about 8 degrees Fahrenheit below normal, brain damage can be reduced or minimized.

Only those cardiac arrest patients revived enough to show a pulse and whose heart problems are not associated with some other trauma are eligible for the cooling treatment, Dr. Prezant said. In New York City, that represents 1,500 to 2,000 of the about 7,500 out-of-hospital cardiac arrest cases reported each year.

Dr. Prezant said that in deference to hospital finances, the city has set no requirements for the kind of cooling techniques hospitals must use — some may start with inexpensive saline solutions and plastic bags filled with ice, while others employ sophisticated equipment manufactured and aggressively promoted by companies like Alsius, Innercool Therapies and Medivance.

The American Heart Association endorsed cooling for some types of cardiac arrest patients after two studies on its effectiveness were published in The New England Journal of Medicine in 2002. One study found that 55 percent of the patients who received the cooling treatment ended up with moderate or no brain damage, compared with 39 percent who received standard treatment. About 41 percent of the cooled patients died within six months, compared with 55 percent of the others.

But hospitals have been slow to adopt the treatment because it requires a precision of temperature regulation that is difficult to achieve, constant vigilance and cooperation among nursing, emergency, cardiac and neurological units.

The research has shown that cooling is effective for cardiac arrest from ventricular fibrillation, in which the heart muscle wriggles ineffectively.

If a pulse can be restarted quickly enough — within a matter of minutes — with a defibrillator, such patients can walk away relatively unscathed. But if not, they become comatose and suffer a cascading series of cellular-level injuries to the brain, which frequently lead to permanent brain damage or death.

Inducing moderate cooling of the body within 6 hours, for 24 hours, followed by gradual warming, slows cerebral metabolism and seems to reduce such injuries, studies have shown. (The technique’s effectiveness on other medical problems, including traumatic brain injury, is more controversial.)

“It was a very slow process in terms of really getting it to take hold,” Dr. Mayer said of the cooling treatment. “One reason is that cardiac arrest patients have just been surrounded by this shroud of therapeutic nihilism. They come in after cardiac arrest, they’re intubated, in a coma, everybody’s reflex thought process in terms of caregivers is ‘Oh God, there’s nothing you can do for these people.’ ”

He said that his main motivation was not financial but experiential, and that he had been converted by seeing patients who were comatose and given up for dead recover full or near-full function after hypothermia.

The New York Times

Although aging puts people at greater risk for serious eye disease and other eye problems, loss of sight need not go hand in hand with growing older. Practical, preventive measures can help protect against devastating impairment. An estimated 40% to 50% of all blindness can be avoided or treated, mainly through regular visits to a vision specialist. Regular eye exams are the cornerstone of visual health as people age. Individuals who have a family history of eye disease or other risk factors should have more frequent exams. Don’t wait until your vision deteriorates to have an eye exam. One eye can often compensate for the other while an eye condition progresses. Frequently, only an exam can detect eye disease in its earliest stages. You can take other steps on your own. First, if you smoke, stop. Smoking increases the risk of several eye disorders, including age-related macular degeneration. Next, take a look at your diet. Maintaining a nutritious diet, with lots of fruits and vegetables and minimal saturated fats and hydrogenated oils, promotes sound health and may boost your resistance to eye disease. Wearing sunglasses and hats is important for people of any age. Taking the time to learn about the aging eye and recognizing risks and symptoms can alert you to the warning signs of vision problems. Although eyestrain, spending many hours in front of a television or computer screen, or working in poor light do not cause harmful medical conditions, they can tire the eyes and, ultimately, their owner (see below). The eyes are priceless and deserve to be treated with care and respect — and that is as true for the adult of 80 as it is for the teenager of 18. 5 common eye myths dispelled Myth: Doing eye exercises will delay the need for glasses. Fact: Eye exercises will not improve or preserve vision or reduce the need for glasses. Your vision depends on many factors, including the shape of your eye and the health of the eye tissues, none of which can be significantly altered with eye exercises. Myth: Reading in dim light will worsen your vision. Fact: Although dim lighting will not adversely affect your eyesight, it will tire your eyes out more quickly. The best way to position a reading light is to have it shine directly onto the page, not over your shoulder. A desk lamp with an opaque shade pointing directly at the reading material is the best possible arrangement. A light that shines over your shoulder will cause a glare, making it more difficult to see the reading material. Myth: Eating carrots is good for the eyes. Fact: There is some truth in this one. Carrots, which contain vitamin A, are one of several vegetables that are good for the eyes. But fresh fruits and dark green leafy vegetables, which contain more antioxidant vitamins such as C and E, are even better. Antioxidant vitamins may help protect the eyes against cataract and age-related macular degeneration. But eating any vegetables or supplements containing these vitamins or substances will not prevent or correct basic vision problems such as nearsightedness or farsightedness. Myth: It’s best not to wear glasses all the time. Taking a break from glasses or contact lenses allows your eyes to rest. Fact: If you need glasses for distance or reading, use them. Attempting to read without reading glasses will simply strain your eyes and tire them out. Using your glasses won’t worsen your vision or lead to any eye disease. Myth: Staring at a computer screen all day is bad for the eyes. Fact: Although using a computer will not harm your eyes, staring at a computer screen all day will contribute to eyestrain or tired eyes. Adjust lighting so that it does not create a glare or harsh reflection on the screen. Also, when you’re working on a computer or doing other close work such as reading or needlepoint, it’s a good idea to rest your eyes briefly every hour or so to lessen eye fatigue. Finally, people who stare at a computer screen for long periods tend not to blink as often as usual, which can cause the eyes to feel dry and uncomfortable. Make a conscious effort to blink regularly so that the eyes stay well lubricated and do not dry out.

FEATURED CONTENT: How the eye works The eye examination Cataract Glaucoma Age-related macular degeneration (AMD) Diabetic retinopathy Other common eye diseases of later life Presbyopia: Ready for reading glasses? Safeguarding your sight Reprinted from The Aging Eye: Preventing and treating eye disease – A Special Health Report from Harvard Medical School, © 2008 by Harvard University. All rights reserved. Harvard Health Publications Harvard Medical School

CHICAGO, Dec. 1 -- Older adults who exercise regularly may have increased cerebral blood flow and a greater number of small blood vessels in the brain, researchers here said.

This could be the mechanism by which exercise prevents cognitive decline in the elderly, Feraz Rahman, M.S., a medical student at Jefferson Medical College in Philadelphia, told attendees at the Radiological Society of North America meeting.

"Aerobic exercise improves cognitive function … and counteracts the effects of aging on the brain," Rahman said. "That may be due to blood flow and vasculature."

Previous research has shown that exercise reverses small vessel disease elsewhere in the body, and increases brain volume and cognitive function in the elderly.

Rahman concluded that the findings of this study show that "exercise is a vital part of healthy aging and might slow the loss of small vessels."

MedPage Today

When Peter Nicholson’s mother suffered a series of strokes last winter, he did something women have done for generations: he quit his job and moved into her West Hollywood home to care for her full time.

Mr. Nicholson, 53, is part of a growing number of men who are providing primary care for their aging parents, usually their mothers.

The Alzheimer’s Association and the National Alliance for Caregiving estimate that men make up nearly 40 percent of family care providers now, up from 19 percent in a 1996 study by the Alzheimer’s Association. About 17 million men are caring for an adult.

“It used to be that when men said, ‘I’ll always take care of my mother,’ it meant, ‘My wife will always take care of my mother,’ ” said Carol Levine, director of the families and health care project at the United Hospital Fund. “But now, more and more men are doing it.”

Often they are overshadowed by their female counterparts and faced with employers, friends, support organizations and sometimes even parents who view caregiving as an essentially female role. Male caregivers are more likely to say they feel unprepared for the role and become socially isolated, and less likely to ask for help.

Women still provide the bulk of family care, especially intimate tasks like bathing and dressing. At support groups, which are predominantly made up of women, many women complain that their brothers are treated like heroes just for showing up.

But with smaller families and more women working full-time, many men have no choice but to take on roles that would have been alien to their fathers. Just as fatherhood became more hands-on in the baby boom generation, so has the role for many sons as their generation’s parents age.

And then there is the inevitable question: What happens when I have to bathe her?

“That’s where the rubber meets the road,” said Donna Wagner, the director of gerontology at Towson University and one of the few researchers who has studied sons as caregivers.

Though he is not squeamish about it, he said: “The weirdness permeates our relationship. She doesn’t know if I’m her husband or her boyfriend or her neighbor. She knows she trusts me. But there are times when it’s very difficult. I need to keep her from embarrassing herself. She’ll say things like, ‘I adore you.’ I don’t know who she’s loving, because she doesn’t know who I am. Maybe I’m embarrassed about it — it’s my mom, for Christ sakes. But it’s weird how the oldest son becomes the spouse.”

On a recent evening, Mr. Kassin visited his mother, Doris Golden, in her Manhattan apartment. Ms. Golden, 82, is in the early stages of Alzheimer’s and still lives independently, but relies on Mr. Kassin to arrange her schedule, pay her bills and make sure she remembers her daily tasks (his sister also helps).

In past generations, men might have answered this question by pointing to their accomplishments as breadwinners or fathers. Now, some men say they worry about the conflict between caring for their parents and these other roles.

In a 2003 study at three Fortune 500 companies, Dr. Wagner found that men were less likely to use employee-assistance programs for caregivers because they feared it would be held against them.

“Even though the company has endorsed the program, your supervisors may have a different opinion,” Dr. Wagner said. “I had a man who worked for a large company with very generous benefits, and he was told that if he took more time to go with his dad to chemotherapy, he was at risk of losing his job. He ended up not going with his father.”

Mr. Kassin said that although his employer had been understanding, he was reluctant to talk about his caregiving because “I think it would be looked at like, when they hire a male, they expect him to be 100-percent focused.”

“Nursing homes have a very difficult time dealing with male caregivers,” Ms. Torres said. “It’s unusual for them. The male caregiver is made to feel their interest in their relative is inappropriate. Our male callers say they’re made to feel what they’re doing is unusual, that it’s wrong.”

She gave the example of a son who was the health care agent for his mother and wanted to be in the room when the staff changed her diaper because he was concerned about her skin condition. “The staff refused to allow it,” Ms. Torres said. “They said the mother’s dignity was at risk.”

After two weeks of pressing, she said, he finally got his way. With a daughter, this would not have been an issue, Ms. Torres said.

And even when they are acknowledged, for many male caregivers, as for women, there is the lingering sense that whatever they do is not enough.

“I don’t know if this is just the musings of someone who’s on the verge of tossing everything and putting her in a home,” he said. “But this is a very revealing journey about who I am to me and my family, and what’s important to me.”

The New York Times

A new Israeli device the ReWalk -- worn like an exoskeleton and maneuvered with crutches -- promises to give mobility to paraplegics. The company developing it, Argo Medical Technologies, has made news that has circled the globe.

Cancer researchers have known for years that it was possible in rare cases for some cancers to go away on their own. There were occasional instances of melanomas and kidney cancers that just vanished. And neuroblastoma, a very rare childhood tumor, can go away without treatment.
The New York Times

Danish researchers have found that statins, the drugs widely used to control cholesterol, may have another beneficial effect: lowering the risk of death from pneumonia.
The New York Times

Older adults whose parents lived 100 years or longer are healthier than others their age and have dramatically lower risks of heart attack, stroke, diabetes or dying from any other cause, researchers at the Boston University School of Medicine report in a new study.
The New York Times

Medicare patients started on a thiazolidinedione for diabetes had a higher mortality rate and were more likely to develop congestive heart failure if given rosiglitazone (Avandia) than pioglitazone (Actos), researchers here reported.
MedPage Today

Medical expert: Glenn Smith, Ph.D.
Total time: 0:07:52 minutes

TheMayoClinic.com - Podcast

Author Sara Davidson talks to two medical scientists about how the body ages and the research on trying to extend our healthy life span.
The New York Times - Magazine - Video interview

This morning’s WSJ tells the story of Brian Kammerer who developed Alzheimer’s in his 40s, and the toll the illness takes on him and his family.

Early on, the CFO for a hedge fund forgets what a stapler is and calls his wife from the bathroom for help identifying it. He winds up unemployed. He stops driving.

Even now, at 51, his math skills remain sharp, but he has trouble recognizing neighbors he has known for two decades. Sometimes, he takes a cab to a nearby golf course without telling anyone and hitches a ride back from a stranger, says his wife, Kathy.

Some half a million Americans are living with early-onset Alzheimer’s, the WSJ says. An explainer from the federal Agency for Health Research and Quality gives some signs that go beyond basic loss of short-term memory:

• Problems finding or saying the right word.
• Inability to recognize objects.
• Forgetting how to use simple, ordinary things, such as a pencil.
• Forgetting to turn off the stove, close windows, or lock doors.

Now, just because you have occasional lapses — forgetting a name, leaving a window open — it doesn’t mean you have Alzheimer’s.

And, AHRQ reminds us, many cases of dementia aren’t Alzheimer’s. Often, they’re caused by factors that can be modified, such as depression, alcohol, or medication.

WSJ reporter Shirley Wang talks with Kathy Kammerer about the warning signs for her husband’s Alzheimer’s in this podcast.

The Wall Street Journal

Early-Onset Sufferers Juggle Children, Job and Dementia

Brian Kammerer, the 45-year-old chief financial officer of a small hedge fund, called his wife one day from a cellphone in the men's room of his Manhattan office building. A colleague had just asked him for something, he whispered, but he had no idea what it was.

"It clicks and it holds papers together," he said.

"A stapler?" Kathy Kammerer asked.

"I think that's what it's called," he replied.

Soon after that exchange in early 2003, the father of three was diagnosed with Alzheimer's disease, capping nearly five years of uncertainty and fear about his increasing forgetfulness and difficulty with language.

While most people who get Alzheimer's are over 65, Mr. Kammerer is one of about 500,000 Americans living with Alzheimer's or other dementias at an atypically young age. Alzheimer's takes a long time to develop -- usually, it isn't diagnosed until 10 years after the first symptoms appear -- but more Americans are identifying it early, thanks in part to aggressive screening programs pushed in recent years by groups including the Alzheimer's Foundation of America, a national alliance of caregivers.

The disease can be especially torturous when it creeps up on those in their 30s and 40s. As these patients move through Alzheimer's early stages, they are forced to cope with the dread of not knowing what is happening to them, often in the years when they're raising young children and building financial security. As the disease progresses, there are slip-ups to cover, appearances to keep up. When these "early onset" Alzheimer's sufferers are finally diagnosed, they face hard questions -- whom to tell and when, and what these divulgences mean for their jobs and health insurance.

There are no Alzheimer's cures now on the market. Current medications mitigate some symptoms but don't slow or halt the disease's progression. Pharmaceutical companies are working on new therapies that reduce or remove amyloid, a sticky substance in the brain thought to play a role in the disease. There are more medicines in development for Alzheimer's than any other neurologic disease except pain, according to Pharmaceutical Research and Manufacturers of America, the industry trade group. It will likely be years before a new generation of drugs makes it to market.

Now 51 years old, Mr. Kammerer, like many Alzheimer's patients, had no history of the disease in his family. He grew up on the north shore of Long Island, where he stood out at school for his talent with numbers. After attending college at the State University of New York-Albany, he got a job on Wall Street.

The Wall Street Journal

In Brief:

Heart attack and heart failure patients have a higher risk of a second heart attack or death if they take painkillers, including the generic drug ibuprofen and Celebrex, made by Pfizer, a Danish study has found.

Patients who had suffered a heart attack and were taking Vioxx, a painkiller that has been withdrawn from the market, had 2.7 times the risk of having another heart attack or dying compared with patients not taking painkillers, according to research presented Tuesday at the American Heart Association meeting in New Orleans. Patients taking Celebrex had double the risk; patients taking the generic diclofenac had 1.9 times the risk, and those taking ibuprofen had 1.3 times the risk, the study found.

Based on the findings, doctors should avoid prescribing nonsteroidal anti-inflammatory drugs for these patients, or give them at low doses, a researcher said.

Also Tuesday, researchers said that the risk of heart attacks and strokes for heart-stent patients taking the anti-clotting drug Plavix increased if they also took anti-ulcer medicines like Nexium.

Doctors implant about two million stents a year and often prescribe blood thinners like Plavix, made by Bristol-Myers Squibb and Sanofi-Aventis, to avoid clots. But the drugs raise the risk of stomach bleeding, so they also prescribe Nexium, made by AstraZeneca, or a rival drug in a group known as proton pump inhibitors. About a third of these patients suffered complications within a year, the study said.

The New York Times

Japanese researchers said Thursday they had created functioning human brain tissues from stem cells, a world first that has raised new hopes for the treatment of disease. Stem cells taken from human embryos have been used to form tissues of the cerebral cortex, the supreme control tower of the brain, according to researchers at the government-backed research institute Riken.

The research was led by Yoshiki Sasai at Riken Center for Development Biology in Kobe.

The tissues self-organized into four distinct zones very similar to the structure seen in human fetuses, and conducted neuro-activity such as transmitting electrical signals, the institute said.

Research on stem cells is seen as having the potential to save lives by helping to find cures for diseases such as cancer and diabetes or to replace damaged cells, tissues and organs.

The team’s previous studies showed stem cells differentiated into distinct cells but until now they had never organized into functioning tissues.

“In regenerative therapy, only a limited number of diseases can be cured with simple cell transplants. Transplanting tissues could raise hopes for greater functional recovery,” the institute said in a statement.

“Cultivated tissues are still insufficient and too small to be used to treat stroke patients. But study of in-vitro cultivation of more mature cortex tissues, such as those with six zones like in the adult human brain, will be stepped up,” it said.

The tissues could also serve as “a mini organ” for use in studying the cause of the Alzheimer’s disease and developing vaccines, it said.

Embryonic stem cells are harvested by destroying a viable embryo, a process that some people find unacceptable.

Riken said cortex tissues were also obtained from “induced pluripotent stem cells,” which are similar to embryonic stem cells but artificially induced, typically from adult cells such as skin cells. The cultivated tissues look like miniature mushrooms two millimeters in diameter.

The team also succeeded in making cortex tissues from the embryonic stem cells of mice. Using mouse tissues, scientists confirmed they had formed a network of neurons that properly respond to stimulus.

The tissues can also be selectively induced to different cortex types controlling memories, visual sensation and other tasks.

The findings of the study were published in the Nov 6 online journal Cell Stem Cell in the United States.

Japan Today

PHILADELPHIA, Nov. 4 -- For patients with early age-related macular degeneration, impaired night vision is a risk factor for progression to advanced disease, researchers here found.

The worst scores on an assessment of night vision were significantly associated with a drop in visual acuity and development of choroidal neovascularization and geographic atrophy through follow-up of at least five years, Gui-shuang Ying, Ph.D., of the University of Pennsylvania here, and colleagues reported in the November issue of Ophthalmology.

The associations remained significant after adjusting for baseline participant and ocular characteristics and established risk factors.

"Because of the ease of ascertainment compared with testing dark adaptation or rod sensitivity," the researchers said, "assessing night vision symptoms may be useful in identifying patients with early or intermediate age-related macular degeneration who are at a relatively high risk of progression."

"These results are consistent with the biological and psychological findings that rod photoreceptor degeneration precedes cone degeneration in early age-related macular degeneration, and that rod dysfunction may contribute to the later degeneration of cones because of their interdependence," the researchers said.

The results also implied that different pathophysiological processes resulted in choroidal neovascularization and geographic atrophy because of differences in their associations with night vision symptoms, they said.

In addition to providing independent predictive information about the progression of disease, the researchers said, measuring night vision symptoms may help identify patients for use in clinical trials evaluating agents for the prevention of geographic atrophy.

"Including only patients with night vision symptoms, and therefore higher risk of progression and loss of vision," they said, "would be one way to decrease the risk-benefit ratio in these clinical trials and to decrease the total sample size or follow-up period required to attain a specific amount of statistical power."

MEDPAGE TODAY

NEW HAVEN, Conn., Nov. 4 -- Patients 65 and older may fare better when they are brought into the decision-making of complex treatment trade-offs, researchers here said.

When patients with multiple medical conditions weighed outcomes of treatment options against one another, they typically preferred those that would achieve the outcome they most desired, Terri Fried, M.D., of Yale, and colleagues reported in the October issue of the Journal of the American Geriatrics Society.

"Prioritizing across all outcomes can help clarify what is most important to seniors who are faced with complex healthcare decisions," Dr. Fried said.

About 65% of older Medicare beneficiaries have at least two chronic conditions, and 24% have four or more, the researchers said. These patients often face complex care decisions when the treatment for one condition could worsen another -- which the researchers call "competing outcomes."

For example, if a patient with high blood pressure, heart disease, and osteoarthritis finds that the hypertension medication causes leg cramps that preclude the pool exercises needed to keep the arthritis symptoms in check, the patient may elect to stop taking it.

"I have high cholesterol," one participant said. "I took something but … I had such pain in my calf, so I was taken off whatever that was. I think [my cholesterol] is 241, and I'm willing to live with that."

Many participants initially thought of outcomes in terms of disease-specific goals, such as prevention of a stroke or heart attack. But during the discussions, they changed their focus to more global outcomes, such as quality of life, the researchers said.

For example, some participants, when debating taking a medication that would increase their risk of heart attack in order to treat pain, defined thresholds of decreased function at which they would become willing to take on a greater risk of cardiovascular mortality.

"When participants thought about outcomes in these global terms, they were able to weigh these more general outcomes against one another, in order to reflect on what was most important to them," the researchers wrote.

The researchers said that asking patients to prioritize their desired outcomes would enable physicians to subsequently determine a course of care that would most likely meet their priorities.

They said their study can only be used to "understand how older persons with coexisting conditions think about their illnesses and interventions and not to draw conclusions about their knowledge or perceptions."

However, they said, their findings suggest that asking older patients "to prioritize a set of global outcomes that can be applied across a spectrum of specific diseases may be one easily understood approach to eliciting values in a manner that can inform a range of healthcare decisions."

MEDPAGE TODAY

A 3-year longitudinal study

Objective: To investigate longitudinal change in the medical decision-making capacity (MDC) of patients with amnestic mild cognitive impairment (MCI) under different consent standards.

NEUROLOGY 2008;71:1474-1480