OUPblog » Health & Medicine

American psychiatry is morally challenged

Alice — Fri, 17 May 2013 12:30:16 +0000

By Michael A. Taylor

The fundamental problem with American psychiatry is American psychiatrists. It seems every few months there’s fresh news about some well-known academic psychiatrist paid boatloads to endorse a new treatment that doesn’t work—or worse—causes harm. Among the 394 US physicians in 2010 who received over $100,000 from the pharmaceutical industry, 116 were psychiatrists, well out of proportion of the percentage of psychiatrists in medical practice. The American Psychiatric Association is also heavily supported by the drug industry. Its annual meetings, once efforts to educate members, are now basically week-long infomercials for Big Pharma. This influence has seeped into clinical trials as well, where study design is carefully manipulated by industry representatives to favor their new product. In turn, companies analyze their data out of view of academics, sequestering data unfavorable to their product, and ghostwriting journal articles for academics.

In similar fashion, fancy devices have been introduced with claims of wondrous benefits, none of which have materialized. Light-emitting boxes, for example, were supposed to be the next great psychiatric advent to prevent winter depressions, but the evidence for this claim is still weak. Similarly, vagal nerve stimulation (an implanted electronic pacer in the chest with electrodes attached to a nerve in the neck) was supposed to relieve treatment-resistant depressions. Yet it offers no demonstrated benefit and costs the poor soul subjected to it about $20,000 out of pocket. Transcranial magnetic stimulation, a ring-shaped magnet that delivers a magnetic pulse to the head, was going to replace electroconvulsive therapy. At best it has a placebo effect. And yet, these treatments continue because of their support by psychiatrists, many of whom have a vested interest in the success of the products. Integrity, it seems, is the only thing in short supply for psychiatry these days.

Just like the new antidepressant and antipsychotic drugs that have been introduced in the past three decades, the idea behind these new treatments was simply to make money. In 2006, US sales alone for these new gadgets topped 289 billion, and continue to rise. Between 1998 and 2006, the industry spent 855 million dollars on lobbying—a total which exceeds that of all other lobbies—to keep that momentum rolling.

You can’t fault the desire to make money; it’s the American way. But when treatments are equated to widgets, profits will always trump concerns of efficacy and safety. Can you think of an industry in which that has not been the case? Sadly, this was not always the situation with psychiatry. The early psychiatric drugs were developed by industry and psychopharmacologists working in concert, striving toward the production of effective and reasonably safe agents. And they succeeded. The older and less expensive antidepressants and antipsychotics are still just as good as or better than the new agents. In fact, the cost to patients drops from 18% to 6% of their medical dollar when they switch from patented to generic medications.

The new psychiatric drugs and novel treatments are frauds. The evidence that they work is weak and is often distorted to the point of fabrication. Studies show that the new antidepressants (e.g., Prozac, Paxil, and Citalopram) achieve remissions at only slightly better rates than a placebo. The widely prescribed anticonvulsant valproic acid (Depakote) outpaces lithium in prescriptions as a mood stabilizer, and yet it’s not as effective. That’s because the guidelines for psychiatric drug treatments are written by academics paid out of the pocket of Big Pharma. These guidelines are required reading in residency training and dictate the diagnostic and treatment decision-making of most psychiatrists, but really they’re just cookbooks, following the bottom line not the data. The most recent version of the DSM, for example, was drafted by academics, many of whom continue to receive substantial financial support from the industry. This clear conflict of interest in part accounts for why the thresholds for illnesses in the manual continue to get lower and lower: if more people are “ill,” it justifies the prescription of more psychotropic medication. Thus perpetuating the whole corrupt cycle.

Over the past half-dozen years, academic psychiatry has started to wean itself from the pharmaceutical milk-cow. Drug “reps” are restricted at most medical centers now, and direct payments to departmental activities are increasingly limited. These are good first steps, but financial support to departments still occurs. Multisite clinical trials are still industry affairs. The well-known psychiatrists and experts crafting treatment guidelines and new versions of the DSM are still industry supported. Despite the financial pain that might ensue, the only solution is to end the relationship. No academic responsible for the training and mentoring of medical students and young physicians should accept any industry money. They already receive adequate financial support from their institutions. If the industry wants its products tested, unrestricted grants can be given to the institution, which can then monitor the use of the funds for a small overhead fee as is done in the case of other funding sources. No more industry-designed and analyzed research. No more hidden unfavorable data. No more industry-supported lectures. No more direct industry support of any kind. This way, even if we make mistakes, our medicine will at least have integrity.

Michael A. Taylor, MD, is the author of Hippocrates Cried: The Decline of American Psychiatry. He works as an adjunct clinical professor of psychiatry at the University of Michigan Medical School. He was founding editor of the peer-reviewed journal, Cognitive and Behavioral Neurology, and also worked as professor, chairman, and director at the Department of Psychiatry and Behavioral Sciences at the Chicago Medical School. He established and directed the psychiatry residency-training program at the State University of New York at Stony Brook.

Oxford University Press is running a series of articles on psychiatry and the DSM-5 in anticipation of the launch of the DSM-5 at the American Psychiatry Association meeting on 18 May 2013.

The OUPblog is running a series of articles on the DSM-5 in anticipation of its launch on 18 May 2013. Stay tuned for a view from Joel Paris. Read previous posts: “DSM-5 will be the last” by Edward Shorter, “The classification of mental illness” by Daniel Freeman and Jason Freeman, and “Personality disorders in DSM-5″ by Donald W. Black.

Subscribe to the OUPblog via email or RSS.
Subscribe to only health and medicine articles on the OUPblog via email or RSS.
Image credit: Human brain function grunge with gears. Image by Francesco Santalucia, iStockphoto.

The post American psychiatry is morally challenged appeared first on OUPblog.

Personality disorders in DSM-5

LaurenH — Thu, 16 May 2013 12:30:58 +0000

By Donald W. Black, MD

Those of us in the mental health professions anxiously await the release of the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Others may wonder what the fuss is about, and may even wonder what the DSM-5 is. In short, it is psychiatry’s diagnostic Bible. While some imbue it with the reverence given a religious tract, it is not inerrant and only reflects the collective wisdom of those entrusted with the charge of revising it. The current manual, DSM-IV, came out in 1994 with a text revision in 2000, so in some ways the march to DSM-5 has been a 19 year journey.

As a psychiatrist, I am interested in classification, but I am particularly interested in how antisocial personality disorder, or ASP, has been classified over time. Over the past 200 years, ASP has been consistently recognized as one of the most identifiable and important of the psychiatric disorders, whether called manie sans délire, moral insanity, or even psychopathic personality. These terms all describe, at their most fundamental, bad behavior unconnected to medical illness or psychosis. During the DSM-5 deliberations, I and others became concerned that the committee dedicated to discussing personality disorders (the Personality and Personality Disorders Work Group) might decide to ditch the current diagnostic criteria and replace them with a combination of new diagnostic criteria and a “dimensional,” rather than categorical, evaluation of various personality traits.

The DSM-5 deliberations, for the most part, took place quietly and behind closed doors by clinicians and researchers who devoted many hours to their deliberations. They were tasked with considering the literature, research advances, and the users and patients’ needs when recommending changes to a diagnosis. Having watched the process as an interested observer, I can say that it was — for the most part — open, transparent, and free of conflicts of interest, despite loud and strident complaints from some quarters. Yet the Personality and Personality Disorders Work Group still produced a plan deemed by many as unworkable and overly complicated. This new plan was rejected by the leadership of the American Psychiatric Association in December 2012. The Personality and Personality Disorders Work Group was the only committee involved with the DSM-5 revision process in which two members openly and publicly resigned. No other work group had its many years of work rebuked.

So what went wrong? My own belief is that the work group overreached. In response to researchers on the committee whose life’s work was to understand and test dimensional schemes for describing personality traits, the committee wed itself to developing a scheme to replace the existing criteria for personality disorders. They came up against considerable pushback. I believe they never fully grasped that psychiatrists and many other clinicians tend to think categorically (is trait ‘x’ present or not?), rather than dimensionally (how much of trait ‘x’ is present?), and are very concerned with insurance reimbursement (would an insurer pay for the care of someone with some, but not all, of these traits?). The scheme itself appeared overly time consuming to busy practitioners; instead of simply deciding on a diagnosis, they might have to rate up to 5 personality ‘domains’ and 25 trait ‘facets’. Many clinicians, too, were concerned that some of the personality disorders that are well-researched and whose criteria were known to be valid (antisocial and borderline personality disorders, for example) would be changed for no good reason. In my view, the committee members have only themselves to blame for what proved to be an embarrassing turn of events. To preserve comity, the American Psychiatric Association leadership agreed to place the new scheme in the appendix of DSM-5 so as to be available to researchers and clinicians.

So, to those who wonder what has happened with antisocial personality disorder in DSM-5: the answer is nothing. After all those hours of deliberation and discussion, the criteria set for ASP, and all the other personality disorders, in the DSM-5 is exactly the same as it was in DSM-IV.

Donald W. Black, MD, is the author of Bad Boys, Bad Men: Confronting Antisocial Personality Disorder (Sociopathy), Revised and Updated Edition. He is a Professor of Psychiatry at the University of Iowa Roy J. and Lucille A. Carver College of Medicine in Iowa City. A graduate of Stanford University and the University of Utah School of Medicine, he has received numerous awards for teaching, research, and patient care, and is listed in “Best Doctors in America.” He serves as a consultant to the Iowa Department of Corrections. He writes extensively for professional audiences and his work has been featured in television and print media worldwide. Read his previous blog posts.

The OUPblog is running a series of articles on the DSM-5 in anticipation of its launch on 18 May 2013. Stay tuned for views from Michael A. Taylor and Joel Paris. Read previous posts: “DSM-5 will be the last” by Edward Shorter and “The classification of mental illness” by Daniel Freeman and Jason Freeman.

Subscribe to the OUPblog via email or RSS.
Subscribe to only psychology articles on the OUPblog via email or RSS.

The post Personality disorders in DSM-5 appeared first on OUPblog.

The classification of mental illness

Alice — Wed, 15 May 2013 10:30:41 +0000

By Daniel Freeman and Jason Freeman

According to the UK Centre for Economic Performance, mental illness accounts for nearly half of all ill health in the under 65s. But this begs the question: what is mental illness? How can we judge whether our thoughts and feelings are healthy or harmful? What criteria should we use?

This month sees the publication of the latest version of the psychiatrist’s bible: the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM is arguably the definitive reference work on mental illness, used by health services worldwide (though the World Health Organisation’s International Classification of Diseases and Health Related Problems is widely used in the UK). Sales of the previous edition, DSM-IV, are estimated at about a million copies — not bad for a book that runs to almost 1000 densely packed pages and retails for around £80.

What’s changed in DSM-5 — apart from the move from Roman to Arabic numerals in the title? Well, terms have been revised (“mental retardation” has become “intellectual disability”, for example). New disorders have been introduced. For instance, “premenstrual dysphoric disorder” has been added to the list of depressive disorders. And, perhaps most controversially, some professionals have worried that the threshold for diagnosis of certain disorders appears to have been lowered — meaning that more people may be classified as mentally ill. Indeed there is organised opposition to the new edition, exemplified by the International DSM-5 Response Committee.

The DSM’s basic approach, on the other hand, has remained consistent for more than 30 years: a painstaking enumeration of symptoms, designed to make the clinician’s task of diagnosis easier and more consistent. This is an objective that it has undoubtedly achieved. But are those diagnoses scientifically valid?

Take clinical depression, for example. Nine possible symptoms are listed in DSM-IV, and you’d need to report at least five of them to warrant a diagnosis. These symptoms must be sufficiently intense to really interfere with a person’s life and they must have lasted for a while.

One effect of this approach is to emphasize the severe end of a spectrum that also includes relatively mild psychological problems. So the DSM criteria won’t capture everyday fluctuations in mental health. And they won’t pick up people with, say, four symptoms rather than five.

Implicit here is a debate about the nature of mental illness. The DSM uses a medical model of psychiatric illness. It thinks in terms of separate, discrete disorders, just like physical medicine. The approach is binary: either you meet the criteria for a particular condition, or you don’t.

Many would argue that this kind of all-or-nothing attitude, with hundreds of separate conditions, doesn’t fit well with people’s real-life experience of psychological problems. Better instead to think of psychological experience as being dimensional — that is, encompassing a wide variety of experiences, from the unproblematic to the severely distressing. The further along that dimension, the more symptoms a person is likely to have and the more upsetting and disruptive those symptoms will be.

This is the psychological model of mental illness. It argues that there’s no binary opposition between disorder and ‘normality’. Psychological disorders are simply the extreme manifestation of traits that we all possess to varying degrees. For example, almost everyone experiences occasional feelings of anxiety. People who develop what the DSM classes as an anxiety disorder aren’t experiencing something qualitatively different. They’re simply undergoing a more intense version of the same thing.

There is a third approach to understanding mental illness: the sociological model. Proponents argue that psychological disorders aren’t illnesses at all. They’re a label used to stigmatize and control behaviour society deems objectionable — such as homosexuality, which featured in the DSM until 1980.

Our view is that psychological problems aren’t illusory. They are real expressions of distress, for which most people — understandably — want help. However there is variability in the validity of individual diagnoses. Therefore it is often wisest not to focus on particular diagnoses. Better instead to adopt a dimensional approach, and to concentrate on the key problems and day-to-day symptoms that lead people to seek assistance. To help us understand these problems, we can look at epidemiological information to see which experiences occur together, and therefore may share common causes. Psychologists call this a data-driven approach.

We can also be guided by our knowledge of how the brain works. For example, basic emotions such as fear or unhappiness are powered by relatively distinct circuits in the brain. So we can understand certain psychological problems as what follow when these emotional circuits don’t function properly. We can match up the emotion and the problem: sadness and depression, fear and anxiety disorders, for example. This is what we might call a theory-driven approach, though given the complexity of brain activity it may – at least at present — be a little optimistic.

Importantly, even such a psychological, evidence-based approach doesn’t get around the need to classify problems. Mental health professionals must still make decisions about how to label the problems people describe to them. Without some kind of classificatory system, we can’t communicate, research, and evaluate treatments.

But the problems inherent in the current systems arguably constitute the greatest obstacle to that work. Given the extent of the burden on society and individuals alike, improving the scientific understanding of psychological disorders remains a priority. And that means DSM-5 certainly won’t be the last word on the classification of mental illness.

Daniel Freeman is a Professor of Clinical Psychology in the Psychiatry Department at the University of Oxford. Jason Freeman is a writer and editor. Their latest book is The Stressed Sex: Uncovering the Truth about Men, Women, and Mental Health (Oxford University Press).

The OUPblog is running a series of articles on the DSM-5 in anticipation of its launch on 18 May 2013. Stay tuned for views from Donald W. Black, Michael A. Taylor, and Joel Paris. Read yesterday’s post “DSM-5 will be the last” by Edward Shorter.

Subscribe to the OUPblog via email or RSS.
Subscribe to only psychology articles on the OUPblog via email or RSS.
Image credit: Thinker, created by Auguste Rodin at the end of the 18 century. San Francisco Legion of Honor. © Rafael Ramirez Lee via iStockphoto.

The post The classification of mental illness appeared first on OUPblog.

DSM-5 will be the last

AshleyP — Tue, 14 May 2013 12:30:00 +0000

By Edward Shorter

In assessing DSM-5, the fog of battle has covered the field. To go by media coverage, everything is wrong with the new DSM, from the way it classifies children with autism to its unremitting expansion of psychiatry into the reach of “normal.” What aspects should we really be concerned about?

Think of a bowl of spaghetti. There are the central swirls of spaghetti in the middle of the bowl and the strands of spaghetti hanging over the side. Most of the controversy has been about the strands dangling down, how we classify marginal disorders of various kinds. It’s not that people with these disorders, such as the hyperactive and the autistic, aren’t important, but they aren’t the meat and drink of psychiatry.

The problem that the DSM-5 doesn’t address lies at the center of the bowl. It concerns psychiatry’s main diagnoses, not its marginal outliers, and those main diagnoses are major depression, bipolar disorder, and schizophrenia. The new edition hasn’t really touched any of them; the way they were defined and classified, and the way they continue to be recognized, ignores major differences within each diagnosis.

Keep in mind how easy it has been to get funny-sounding new diagnoses into psychiatry. Some, such as bipolar disorder, come in as a result of fad. A German psychiatrist named Karl Leonhard created bipolar disorder in 1957 when he said that there are two kinds of depression, unipolar depression (no mania) and the depression that alternates with mania (later called, in DSM-3 in 1980, bipolar disorder). Leonhard’s European and American disciples — a small but influential band — saw to it that separating depressions by “polarity” was widely accepted. Yet there was no new science here; it was the whim of one man.

Some of the diagnoses at the heart of the bowl came in by fiat. Robert Spitzer, the architect of DSM-3, simply decided in 1980 to collapse psychiatry’s various depressions — which had been as diverse as chalk and cheese — into a single disorder: major depression. There were howls of protest, but, hey, the thing was already in print. Set in stone. Even though it makes no scientific sense to classify depressions on the basis of polarity, that’s what we have ended up doing.

Serious depression — or melancholia — remains serious depression whether an episode of mania complicates it or not. Sooner or later, many patients with serious depression will experience some manic features, without that changing their basic diagnosis.

Related to schizophrenia, psychosis (loss of contact with reality via hallucinations or delusions) certainly exists. And there are many forms of it: some come out of the blue, others begin insidiously and seem to grow out of the patient’s personality; some involve loss of brain tissue, others don’t; some end very badly, others stabilize at the ability to lead a more or less normal life: you may not become a neurosurgeon, but you get married, have kids, keep a job, the whole ball of wax. These are different diseases.

St. Elizabeth’s Hospital. Wall of room in Ward Retreat 1. Reproductions made by a patient with dementia praecox…Pictures symbolize events in patient’s past life and represent a mild state of mental regression. Undated, but likely early 20th century. Washington, DC. Selected by Kathleen.

Yet we now give all these forms of psychosis a single diagnosis: schizophrenia. That’s without a plural “s.” If you’ve got chronic psychosis you’ll be called schizophrenic, even though you may not have any symptoms in common with others who have that diagnosis. You may have quite different family (genetic) backgrounds; you may not have a common response to treatment; and you may not have a common course and outcome. Those are all the ways we delineate separate diseases and “schizophrenia” demonstrates none of those hallmarks. It’s an artifact that Emil Kraepelin, the great German disease classifier, inserted into the literature in the 1890s, calling it dementia praecox. So powerful was his concept — that all the different “subtypes” of schizophrenia went remorselessly downhill — that the term has survived the relentless scientific plucking that all other diagnoses in medicine continually experience.

But conceptual power is not the same thing as verification. There is no marker telling us that everybody with “schizophrenia” has the same disease. (There are, by the way, such markers for some other major diseases; I don’t have space to go into it here, but google “dexamethasone suppression test”.)

So, are there problems with DSM-5? Yes, but they aren’t the problems most critics pick at. Criticisms of DSM-5 seem to be rising in a crescendo, as though a gaggle of high-school teachers were called to assess the work of a very naughty schoolboy. The drafters of the current edition were mightily concerned with maintaining stability; they didn’t want to hack great changes into previous editions. So there is not a chance in the world they would have looked critically at these central problems.

But out there in the real world, there are growing numbers of nosological rebels, or skeptics about the DSM version of disease classification. They have mainly stayed off the airwaves up to now. But you can feel the dubiety rising. There probably will not be a DSM-6.

Edward Shorter is Jason A. Hannah Professor in the History of Medicine and Professor of Psychiatry in the Faculty of Medicine, University of Toronto. He is an internationally-recognized historian of psychiatry and the author of numerous books, including How Everyone Became Depressed: The Rise and Fall of the Nervous Breakdown, A Historical Dictionary of Psychiatry and Before Prozac: The Troubled History of Mood Disorders in Psychiatry. Read his previous blog posts.

The OUPblog is running a series of articles on the DSM-5 in anticipation of its launch on 18 May 2013. Stay tuned for views from Daniel and Jason Freeman, Donald W. Black, Michael A. Taylor, and Joel Paris.

Subscribe to the OUPblog via email or RSS.
Subscribe to only psychology articles on the OUPblog via email or RSS.

Image credit: By Otis Historical Archives National Museum of Health and Medicine (originally posted to Flickr as Reeve37258). Creative commons license via Wikimedia Commons.

The post DSM-5 will be the last appeared first on OUPblog.

Insomnia in older adults

AlanaP — Mon, 13 May 2013 12:30:00 +0000

What keeps you up at night? Do the effects of sleep deprivation change with age? What are risks associated with insomnia in older adults? Mr. Christopher Kaufmann and Dr. Adam Spira join us to discuss their most recent research in The Journals of Gerontology Series A: Biological Sciences and Medical Sciences.

How common is insomnia in older adults, and what are the repercussions of chronic sleep problems?

Insomnia is very common among older adults, and is associated with adverse health outcomes, including cognitive and functional decline. It has been estimated that approximately 40-70% of older adults age 65 and older experience sleep problems, with about 20% experiencing severe sleep problems. Insomnia has multiple causes, but chronic health conditions such as diabetes, hypertension, cancer, and osteoarthritis are among the most common health problems associated with poor sleep. Another common cause of insomnia is depression. Furthermore, insomnia in older adults may exacerbate the severity of pre-existing health conditions, perhaps leading to costly health service use.

Who were your participants in this study?

The sample of our study consisted of middle-aged and older adults aged 50 years or older who participated in the longitudinal Health and Retirement Study. Individuals in our sample were assessed for insomnia symptoms in 2006, and their health service utilization was assessed two years later. At baseline, 55% of participants were women, 88% were non-Hispanic white, 59% had a diagnosis of hypertension, 38% had osteoarthritis, and 21 percent had diabetes. Twenty-four percent reported one insomnia symptom, and 18% reported two or more insomnia symptoms at baseline.

According to your research, what is the link between insomnia and the use of health care services in older adults?

We found that individuals reporting one insomnia symptom, as well as two or more insomnia symptoms at baseline, were more likely to use a number of health services two years later compared to those reporting no insomnia symptoms. This health service utilization included hospitalization, use of home healthcare services, and use of a nursing home. Surprisingly, we found this association was still statistically significant for hospitalization and use of any of the three health services after accounting for a number of common health conditions, and depression.

Image courtesy of the authors.

What do your results suggest?

Our results suggest that insomnia is associated with greater use of costly health services, and that perhaps preventing, or at least clinically addressing insomnia symptoms, might minimize healthcare costs for middle-aged and older adults. Our results also suggest that the assessment and recognition of insomnia by clinicians might help identify individuals at greater risk of hospitalization and other costly services. Medical professionals might be able to target and provide more intensive preventive care to individuals reporting insomnia symptoms. Our study found that if the association between the experience of insomnia symptoms and health service use were in fact causal, we would expect to see a six to fourteen percent decrease in health service use. It should be noted that our findings are based on self-reported insomnia symptoms and health service utilization, which is subject to reporting and recall bias. Furthermore, we only examined any use of health services, and we did not assess the duration and frequency of use. Our findings need to be confirmed in other population-based studies of older adults, and more research is needed to examine this association using objective measures of sleep quality and measures that capture the intensity of health service use.

What are some ways to prevent and treat insomnia?

Very often, simple sleep hygiene measures such as reducing environmental stimuli at night, establishing bedtime routines, or avoiding day-time naps would be sufficient to address insomnia. Adequately addressing and managing chronic health conditions can also prevent the development of insomnia. If these measures do not improve sleep, behavioral therapy can be effective. In some cases, sleep medications may be used on a short-term basis. However, the use of sleep medications in older adults, if taken for a longer period of time, has been shown to lead to numerous adverse health outcomes, such as falls, hip fractures, and cognitive and functional impairment.

Mr. Christopher Kaufmann is a doctoral student in the Department of Mental Health at the Johns Hopkins Bloomberg School of Public Health. His research interests are in the utilization of health services related to psychiatric disorders, as well as the use of prescription medications among older adults. Dr. Adam Spira is an Assistant Professor in the Department of Mental Health at the Johns Hopkins Bloomberg School of Public Health. He studies the link between sleep disturbance and both cognitive and functional decline in older people. Together they are the authors of “Insomnia and Health Services Utilization in Middle-Aged and Older Adults: Results From the Health and Retirement Study” in The Journals of Gerontology Series A, which is available to read for free for a limited time.

The Journals of Gerontology were the first journals on aging published in the United States. The tradition of excellence in these peer-reviewed scientific journals, established in 1946, continues today. The Journals of Gerontology, Series A publishes within its covers the Journal of Gerontology: Biological Sciences and the Journal of Gerontology: Medical Sciences.

Subscribe to the OUPblog via email or RSS.
Subscribe to only health and medicine articles on the OUPblog via email or RSS.

The post Insomnia in older adults appeared first on OUPblog.

Ten things you need to learn about heart failure

Alice — Fri, 10 May 2013 10:30:48 +0000

By Kenneth Dickstein

A diagnosis of heart failure can be overwhelming. Here are ten things you can learn to cope with this condition.

(1) Learn how the heart and heart failure works. This series of informative animations can take you on a journey through heart failure and its management.

(2) Learn to navigate an enormous amount of information. You’ll receive advice from cardiologists, nurses, and GPs — not to mention family, friends, and everyone who wants to help.

(3) Learn about the causes, symptoms, and developmentof heart failure.

(4) Learn the warning signs of heart failure, their level of severity, and who to consult and when.

(5) Learn to adjust your lifestyle to get the most out of life when you have heart failure. This condition will have an impact on every aspect of your life including travel, work, and relationships.

(6) Learn to work with your doctors, nurses, and other medical professionals. They help patients understand what is wrong: take patients through their medicines, introduce them to the people they need to work with, and describe heart failure clinics. Ask for tools, such as medicine charts or a symptoms and events diary, to help you stay oragnized.

(7) Learn your treatment options and what to ask your doctor. You’ll feel more reassured.

(8) Learn how this will affect your caretakers, who face many problems including depression. They need as much support as you.

(9) Learn how other patients overcome their difficulties. You can gain knowledge from their experiences.

(10) Learn to network with other people who have heart failure. Meeting fellow sufferers can help you feel less alone and more able to cope.

Professor Kenneth Dickstein is the creator and full-time enthusiast of the patient centred website Heart Failure Matters! Designed to meet a global educational need by helping patients understand their complex medical condition, it is available in in English, French, German, Spanish, Dutch and Russian (with the translation to Arabic happening this year).

The European Journal of Heart Failure, edited by Professor Dirk van Veldhuisen, is the International Journal of the European Society of Cardiology dedicated to the advancement of knowledge in the field of heart failure.

Oxford University Press is supporting Heart Failure Awareness Day with resources from across the press. Read our previous blog posts: “The five big lifestyle changes for heart health” ; “Why do we have a Heart Failure Awareness Day?” ; “Seven things you never knew about heart failure” ; and “More malignant than cancer?”

Subscribe to the OUPblog via email or RSS.
Subscribe to only health and medicine articles on the OUPblog via email or RSS.
Image credit: Male anatomy of human organs in x-ray view. Image by janulla, iStockphoto.

The post Ten things you need to learn about heart failure appeared first on OUPblog.

What’s the secret of bacteria’s success?

ChloeF — Fri, 10 May 2013 07:30:48 +0000

By Sebastian Amyes

Bacteria have achieved many firsts; they were the first cellular life-forms on the planet, they are the primary biomass on the planet; they are the most prevalent cell type in and on the human body outnumbering our own cells; they are responsible for more human deaths than any other infectious agents; and, in some parts of the world, they are the premier cause of all deaths. How did these small, single-cell organisms, that are invisible to the naked eye become so successful? Essentially this has been through rapid evolution leading to adaptability. All living organisms evolve. The speed at which they can do this is dependent on the generation time; for humans this is about 25 years whereas for bacteria it is often measured in minutes, sometimes as little as 20 minutes. It is believed that 99% of the species that have lived on the planet are now extinct; this is often because their generation time was too long for the necessary evolutionary adjustments needed to survive changes in their environment. Every year yet more species of animals and plants become extinct because they have been too specialised to adapt.

The rapid division of bacteria means that they can adapt overnight to changes in their surroundings. A prime example has been the development of antibiotic resistance in clinical bacteria. It has often been reported that the US Surgeon General indicated in the 1960s that the discovery, first of penicillin, and then of the rest of antibiotics heralded the end of clinical bacterial infections. It is now common knowledge that such a view was fatally flawed. Simple mutations in key genes during cell division provided the bacteria with a means of escaping the action of the antibiotic (resistance). Once learned and part of the bacterial DNA, these genes could then be passed on to other bacteria by the process known as conjugation (bacterial sex) so that these new bacteria benefited from the resistance “learnt” in earlier bacteria. Seventy years ago, almost all clinical bacteria were sensitive to all antibiotics; now many bacteria are resistant to some, some bacteria are resistant to most, and a few bacteria are resistant to all antibiotics. Within one human lifetime, clinical bacteria have evolved the means of overcoming all the antibiotics we can produce.

electron micrograph of Vibrio cholerae

Witnessing this remarkable adaptive ability, it is hardly surprising that bacteria have been able to inhabit all parts of the planet, from hot springs to the Antarctic, from mountain tops to the bottom of the ocean. The demise of any species is often dependent on the loss of its food supply. Bacteria evolve so quickly that they can adapt to use different nutritional sources. They have evolved so that they can live off virtually any organic matter, they can even adapt to use crude oil. Like some insect populations, bacteria form colonies. Many bacterial colonies comprise one billion individual cells or more. Total eradication of that number of bacteria is difficult and often impossible. Unlike bees, ants, and wasps, for example, the survival of that colony is more egalitarian and is not dependent on a single individual, the queen. If there is a catastrophe, any one of the individual bacterial cells in a bacterial colony can go on to form a new colony if it can survive the eradication of the previous colony. When it has formed a new colony and the next threat comes, the same survival tactic is engaged.

Bacteria preceded mammals by nearly four billion years. It is almost certain that they will be predominant long after humans and other mammals are extinct. There have been suggestions that bacteria arrived on Earth on meteorites; this may be true but it is more likely that they evolved here. However, we have already sent our bacteria into space on satellites and these may, at some time, colonise other planets. Here on Earth, our own bacteria will continue to thrive. As we have unearthed the fossil record, we have classified different eras in geological time, which are often colloquially rephrased as epochs such as the “Age of the Dinosaurs” or the “Age of the Fish”. As they have always been the largest biomass, the truth is that from the Precambrian era, four billion years ago, the Earth has always been in the “Age of the Bacteria” and probably will be forever.

Sebastian Amyes is Professor of Microbial Chemotherapy at the University of Edinburgh. He has specialised on the development of antibiotic resistance in bacteria. He has published more than 500 papers on bacteria and written a number of books on the subject, including Bacteria: A Very Short Introduction.

The Very Short Introductions (VSI) series combines a small format with authoritative analysis and big ideas for hundreds of topic areas. Written by our expert authors, these books can change the way you think about the things that interest you and are the perfect introduction to subjects you previously knew nothing about. Grow your knowledge with OUPblog and the VSI series every Friday and like Very Short Introductions on Facebook.

Subscribe to the OUPblog via email or RSS.
Subscribe to only VSI articles on the OUPblog via email or RSS.
Image credit: electron micrograph of Vibrio cholerae [Public Domain] via Dartmouth College

The post What’s the secret of bacteria’s success? appeared first on OUPblog.

The five big lifestyle changes for heart health

KatherineS — Wed, 08 May 2013 10:30:22 +0000

By Lionel Opie

Today’s problem for the health-conscious person is information overload; new health studies pour out daily from newspapers, radio stations, and television networks. Just how true are the studies? How compelling are the facts they claim? After reading countless scientific articles, listening to hundreds of international experts, and keeping an ear open when patients tell me about their experiences, I’ve identified the only five lifestyle changes with compelling evidence behind them. Taken together, these steps provide about 80% protection from heart attacks, as well as stroke and cancer, and this message comes from three major studies organized by the Harvard Medical School and published in highly rated journals.

(1) Unfortunately, the image of smoking as ‘sexy’, which was promoted for years in the USA and elsewhere, still lingers; young women remain the group least likely to give up smoking. But giving up smoking (or not starting in the first place) it essential. It confers just over one-third of the lifestyle benefits associated with healthy living.

(2) “Exercise is the elixir of life,” says Richard Verrier, from the Harvard School of Public Health. You need at least thirty minutes of moderate to vigorous exercise daily — ideally every day, but five days per week will do. How much effort should you put into it? A simple criterion: you should be sweating by the end of it.

(3) We know that the Western diet (with its high intake of fat, sugars, and calories) damages the arterial endothelium and promotes obesity, diabetes, and heart attacks. There are several validated, health promoting diets which counteract this, including the Prudent diet (which emphasises a high intake of vegetables, fruit, legumes, whole grains, fish and poultry), the DASH BP-reducing diet (similar, but with the addition of salt restriction; ideal for the many people with hypertension) and the Healthy Eating diet (again similar, but using a numerical index to score components). The Mediterranean diet may be the best of all of these, being immortalised by the declaration that it now belongs to the Intangible Cultural Heritage of Europe. Furthermore, in April 2013 in probably the largest and longest diet study ever undertaken, five years of the Mediterranean diet with high olive oil and nuts reduced heart attacks, strokes and (of note) total mortality in 7447 persons , all versus a standard low fat diet.

(4) Consistent studies show that fat around the middle — abdominal fat — is closely linked to increased heart disease and diabetes. Therefore a health body weight, indicated by a body mass index (BMI) of 25 or below, is vital for keeping the heart healthy. Fat tissue is not only cosmetically undesirable, but produces a variety of hormones, each of which is capable of adverse effects. For example, release of these hormones from fat tissue into the blood can trigger a series of chemical changes that eventually produce more fat. In brief, fat produces fat.

(5) Moderate alcohol, the fifth protective factor (and part of the Mediterranean diet) is a two-faced friend. A little helps, but more than that harms substantially. The ‘red wine’ hypothesis, which states that the beverage has benefits extending beyond its alcohol content, may also have some truth in it; deep red grape juice has the same effect of inhibiting blood clots, but only in higher doses. A fine Pinot Noir — the author’s favourite — may therefore be safely considered as one of the ‘big five’, but only in small doses.

Lionel Opie qualified as a medical doctor at the University of Cape Town, before winning a Rhodes Scholarship to Oxford University where he trained in heart research and later worked with leaders of thought at Harvard University. After the world’s first heart transplant in Cape Town, he was invited back to South Africa to develop heart research at Groote Schuur Hospital, where he still works. His book Living Better, Living Longer guides the reader through this morass of information with the message that just five key steps taken now will promote long-term health benefits for heart and mind and give protection from future heart disease and brain deterioration.

Oxford University Press is supporting Heart Failure Awareness Day with resources from across the press.

Subscribe to the OUPblog via email or RSS.
Subscribe to only health and medicine articles on the OUPblog via email or RSS.
Image credit: Rustic Italian Dinner with red wine olives and salad. Photo by edoneil, iStockphoto.

The post The five big lifestyle changes for heart health appeared first on OUPblog.

This is your brain on food commercials…

Kirsty — Wed, 08 May 2013 07:30:44 +0000

By Ashley N. Gearhardt

Gooey chocolate and scoops of mouth-watering chocolate ice cream. Steaming hot golden French fries. Children see thousands of commercials each year designed to increase their desire for foods high in sugar, fat, and salt like those mentioned above. Yet, we know almost nothing about how this advertising onslaught might be affecting the brain.

A recent study in Social Cognitive and Affective Neuroscience conducted by researchers from the University of Michigan, Oregon Research Institute, and Yale University starts to uncover how the brain responds to food commercials in teens. Thirty adolescents visited a lab to watch a typical television show that included commercial breaks composed of frequently advertised food (e.g., McDonald’s, Wendy’s) and non-food commercials (e.g., AT&T, Ford). But unlike a typical TV viewing experience, these participants had their brain response measured in a functional magnetic resonance imaging (fMRI) scanner.

While watching the food commercials, regions of the brain linked with reward, attention, and cognition were more active for all participants. After completing the fMRI scan, teens also remembered the food commercials better than the non-food commercials. Why does this matter? It appears that food advertisements (by far the most frequently marketed product to this age group) are better at getting into the mind and memory of kids. This makes sense because our brains are hard-wired to get excited in response to delicious foods. When these calorie-laden products are combined with $1 billion dollars’ worth of marketing by the food and beverage industry, it creates a potent combination.

Surprisingly, healthy-weight teens had greater brain activity in regions associated with reward and attention than obese adolescents. Why might this be? The study suggests that obese adolescents may have been trying to control their response to the food commercials, which might have altered the way their brain responded.

Yet, what happens after obese teens come into contact with more and more food cues later that day? Their self-control might decline in the face of an environment that pushes consumption of high-calorie foods. If a teen is stressed, hungry, or depressed, his or her willpower might be even more likely to falter. The healthy-weight adolescents might also be impacted by how their brain responds to food commercials, but the consequences might not be apparent immediately. A number of brain regions that were more responsive in the lean adolescents during the food commercials have been linked with future weight gain. It will be important to explore how brain responses to food marketing might be related to increased risk of obesity in the future.

This research highlights the possible ways that food advertising may affect younger generations. How do we prevent food advertisers from being the major driver of what our kids eat? We can rely solely on parents to police what teenagers buy or attempt to educate children about how advertising might impact them. We also may need to set guidelines that prevent marketers from aggressively targeting kids with commercials for unhealthy foods. The road ahead is not without challenges, but action must be taken to turn back the tide of childhood obesity.

Dr. Ashley N. Gearhardt is an assistant professor of psychology at the University of Michigan. Her work focuses on the overlap between addictive and eating behaviors, as well as the role of the environment in obesity. Gearhardt is a co-author of the study ‘Relation of Obesity to Neural Activation in Response to Food Commercials‘, which is published by the journal Social Cognitive and Affective Neuroscience.

Social Cognitive and Affective Neuroscience (SCAN) provides a home for the best human and animal research that uses neuroscience techniques to understand the social and emotional aspects of the human mind and human behavior.

Subscribe to the OUPblog via email or RSS.
Subscribe to only health and medicine articles on the OUPblog via email or RSS.
Image credit: French fries. By dja65, via iStockphoto

The post This is your brain on food commercials… appeared first on OUPblog.

Advice from the CDC on travel and H7N9

KimberlyH — Tue, 07 May 2013 17:30:22 +0000

By Megan Crawley O’Sullivan, MPH

Avian influenza. H7N9. Bird flu. If you are planning a trip to China, these phrases might have you concerned. There are still many uncertainties regarding the new influenza A (H7N9) virus: it isn’t clear where the virus started or how people are getting sick, and a vaccine is not yet available. Amid these unanswered questions, it’s not surprising that many travelers are doubting their plans. You may find yourself wondering if travel to China is still safe, or if you should cancel your trip.

Travelers should be aware that the Centers for Disease Control and Prevention (CDC) is not recommending against travel to China at this time. Currently no sustained person-to-person spread of the H7N9 virus has been found. So, while public health officials will continue closely monitoring the situation and working to determine how the virus is spreading, travelers don’t need to cancel their trips at this time.

However, travelers and their physicians should take this opportunity to remember that healthy behaviors are always important, especially while traveling. CDC is repeating its standard advice to travelers and Americans living in China to follow good hand hygiene and food safety practices and to avoid contact with animals. Simple actions like staying away from animals, eating food that is fully cooked, and washing your hands often can go a long way toward preventing illness (including H7N9). Travelers should also see a doctor right away if they become sick with fever, coughing, or shortness of breath during or after travel to China.

It’s important for travelers to remember that, although new illnesses like H7N9 make it into the news, any international travel can pose a health risk if you aren’t prepared. If you are planning an international trip, you should visit your doctor at least 4-6 weeks before your trip. You may need vaccines or medicine to stay healthy while traveling and your doctor can advise you on actions you can take while you are overseas to make sure your trip is safe and healthy.

For the most up-to-date information for travelers from the CDC regarding H7N9, see the CDC Travel Notice. CDC will also provide updated information on the H7N9 situation as it becomes available. For more information on healthy travel, please visit the CDC travel website and follow them on Twitter @CDCtravel.

Megan Crawley O’Sullivan, MPH is a Health Communications Specialist in the Travelers’ Health Branch, Division of Global Migration and Quarantine, National Center for Emerging and Zoonotic Infectious Diseases at the Centers for Disease Control and Prevention.

The new 2014 edition of CDC Health Information for International Travel (commonly known as The Yellow Book) will be released later this year by Oxford University Press.

Subscribe to the OUPblog via email or RSS.
Subscribe to only health and medicine articles on the OUPblog via email or RSS.

The post Advice from the CDC on travel and H7N9 appeared first on OUPblog.

Getting from “is” to “ought” near the end of life

AshleyP — Tue, 07 May 2013 14:30:06 +0000

By Nancy Berlinger

There is a saying in ethics: you can’t get an “ought” from an “is.” Descriptions of the world as it is do not reveal truths about the world as it ought to be. Even when descriptions of real-world conditions suggest that something is seriously wrong — that our actions are causing unintended and avoidable harms to ourselves, to others, to our common environment — reaching agreement on how we ought to change our thinking and our behavior, and then putting these changes into practice, is hard. Efforts at reform may fail again and again, but we need “is” to understand how to get to “ought.” In health care work, describing and reflecting on current conditions can shed light on persistent ethical challenges. Palliative care workers who focus on the relief of suffering and other goals central to the care of the sick observe and experience many such challenges daily.

In the United States each year, 2.5 million people die. Because cause of death is often a condition typically associated with age, Medicare billing-code data offers a reliable way to understand where older people were, day by day, as they approached the end of their lives. A recent article by Joan M. Teno, health services researcher at Brown University, and her team, published in JAMA in February 2013 and subsequently picked up by the media, compared samples of Medicare patients who died in 2000, 2005, and 2009. Each sample included nearly 300,000 patients, all of whom had a medical diagnosis of cancer, chronic obstructive pulmonary disease, or dementia for the final six months prior to death. This data suggests that these patients were hospice-eligible and their deaths were not unexpected.

Digging into the data, the researchers found that over the course of this nine-year period the percentage of patients who died in hospice increased. However, these hospice referrals tended to come only after dying patients had spent time in the intensive care unit. That is, the intensity of treatment near the very end of life first spiked sharply upward. As Teno and her co-authors explain, “Site of death, as noted on a death certificate, only provides information on where a person was at the moment of death,” while understanding the end of life as an “experience” involves looking at all places of care, the transitions between these places, and when and why these transitions occurred. They conclude that, even with more frequent referrals to hospice and the expansion of palliative care programs in hospitals over the period they studied, “the notion that there is a trend toward less aggressive care” may be unfounded.

Reading Joan Teno’s careful research and analysis in this article and others, I am reminded of the technique of Jan van Eyck, the 15th century northern European painter who was the first master of the new medium of oil painting. Analysis of van Eyck’s works reveal that he applied layer upon layer of translucent paint to create the impression of light that shapes space and reveals surface and texture. (The Getty Museum has created this public website of images from its recent documentation of van Eyck’s “Ghent Altarpiece.”) It was not a quick or simple way to work, but it built up the light. So, too, does the science that describes, day by day, layer by layer, the complexity of the end of life in our society, and that suggests the complexity of the work needed to change this experience. If the picture that emerges from this study — of the ICU as the route to hospice — troubles us, are we willing to think and act differently? And how much earlier in the journey?

Nancy Berlinger is a research scholar at The Hastings Center. With Bruce Jennings and Susan M. Wolf, she is the author of The Hastings Center Guidelines for Decisions on Life-Sustaining Treatment and Care Near the End of Life: Revised and Expanded Second Edition (Oxford University Press, 2013). Learn more at HastingsCenterGuidelines.org.

Subscribe to the OUPblog via email or RSS.
Subscribe to only health and medicine articles on the OUPblog via email or RSS.

Image credit: Nursing home corridor by Thomas Bjørkan (Own work). Creative commons licensce via Wikimedia Commons.

The post Getting from “is” to “ought” near the end of life appeared first on OUPblog.

Give weight-loss diets a rest

JonathanK — Mon, 06 May 2013 17:30:35 +0000

By Abigail C. Saguy and Tamara B. Horwich

A respected cardiologist of our acquaintance recently confessed that he often tells his patients to lose weight. This may sound like good advice, but he knows better. Scores of clinical studies show that heavier patients with heart disease are, on average, less likely to die than thinner ones. Furthermore, weight loss efforts are typically counterproductive. Our cardiologist friend knows the studies but can’t quite bring himself to let go of the association between weight and health. He is not alone. In fact, the pervasive clinical and cultural bias against fat and fat people distorts medical practice, despite mounting evidence that human metabolic function is far more complex than previously understood.

Weight Loss Advertisement from Woman Beautiful Magazine, November 1908 via Library of Congress

It is true that heavier individuals are more likely to develop heart disease on average than are thinner patients, although it is not clear that being heavier causes heart disease. It may be that some related factor or factors — such as diet, exercise, stress, socio-economic status or a combination of these — causes both increased weight and makes one susceptible to heart disease.

That said, a growing body of evidence has shown that, among people who already have heart disease, heavier patients are less likely to die. This is so counter-intuitive that medical researchers refer to this burgeoning body of research as “reverse epidemiology” or the “obesity paradox.”

A recent study has shown that this “obesity paradox” holds for Type II Diabetes as well. Granted, people in the general population are more likely to develop Type II Diabetes in the first place if they are heavier, although the causal pathways remain unknown. However, among those who develop Type II Diabetes, many are in the “normal weight” category. Furthermore, among Type II Diabetes patients, the heavier ones are less likely to die than their thinner counterparts.

In the general population, heavier body mass is indeed associated with cardiometabolic abnormalities (i.e., high blood pressure, triglycerides, cholesterol, glucose, insulin resistance and inflammation). However, even here, the association is far from perfect. Specifically, almost one quarter of “normal weight” people — or 16 million Americans — have metabolic abnormalities, whereas more than half of “overweight” and almost one third of “obese” people — or 56 million Americans — have normal profiles, according to a 2008 study. We are beginning to understand that it is not the quantity but rather the quality of fat in our bodies that predicts cardiovascular risk; the unseen fat deeply embedded in our internal organs, known as visceral adipose tissue, is the type of fat most likely to lead to cardiometabolic abnormalities while visible fat beneath our skin may be more metabolically benign.

These studies belie the idea that heavier or bigger bodies are automatically diseased bodies and that weight loss is a panacea. When we further consider that 90-95% of dieters end up regaining what they lose, and that use of diet drugs or supplements may be particularly dangerous in patients with heart disease, the insistence on weight loss is more puzzling.

Rubber Reducing Garment advertising, Woman Beautiful Magazine, November 1908. via Library of Congress

“It took a lot of self-discipline, but I finally gave up dieting,” quips a popular Facebook posting. This post is funny because it inverts the common assumption that dieting requires discipline and is a virtuous endeavor. Indeed, being fat is still widely regarded as evidence of the sins of sloth and gluttony, despite — or perhaps because — of growing talk of “obesity” as a medical problem and public health crisis. It is this conviction that being fat is morally wrong that makes it hard for doctors, as well as ordinary people, to give up dieting and dieting advice. This is all the more true in times and places, like the contemporary United States, where the socially and economically privileged tend to be thin and the disadvantaged are more likely to be heavy.

Especially distressing are studies showing that many medical professionals regard their heavy patients as lazy and non-compliant. A recent study showed that doctors treat their heavy patients with less empathy and compassion than their thinner peers. In extreme cases, convinced that excess weight is responsible for ill health and that weight loss is the solution, doctors may not conduct necessary diagnostic exams that would have pointed to the underlying cause of illness.

It is time that medical professionals give up the focus on fat. This won’t be easy; the belief that if overweight and obese patients lost weight they would be healthier is deeply embedded in both our popular and our medical culture. Yet, there is a better way. Rather than focusing on outward appearance, it would be infinitely more productive and accurate to talk about cardiometabolic risk and to recognize that there are both metabolically-healthy and metabolically-unhealthy individuals in all categories of weight. Instead of promoting weight loss, doctors should emphasize that patients of all sizes incorporate physical activity and a balanced diet into their lives. Several studies have shown that physically fit “obese” individuals have lower incidence of heart disease and mortality from all causes than do sedentary people of “normal” weight. Similarly, a recent clinical trial published in the New England Journal of Medicine showed that adopting a Mediterranean diet reduced cardiovascular risk without inducing weight loss. The sixth of May is International No-Diet Day and a good time for doctors and patients alike to give up their unhealthy focus on weight loss.

Abigail C. Saguy, PhD is Associate Professor and Vice Chair of Sociology at UCLA and author of What’s Wrong with Fat? (Oxford, 2013).Tamara B. Horwich, MD, MS is a UCLA cardiologist who has published research on the link between body mass and mortality among heart disease patients.

Subscribe to the OUPblog via email or RSS.
Subscribe to only sociology articles on the OUPblog via email or RSS.

The post Give weight-loss diets a rest appeared first on OUPblog.

Why do we have a Heart Failure Awareness Day?

Alice — Mon, 06 May 2013 10:30:46 +0000

By Anya Creaser

How would you feel if you were told you had heart failure? Once you had recovered from the shock, what are the questions you’d ask? European Heart Failure Awareness Days aim to combat all those blank looks in doctors’ offices.

So you have heart failure and now you have to live with it. But you’re not alone; millions of people out there have heart failure. That’s millions of people who struggle to make their daily lives just a bit better every day. And it’s possible. That’s another aim of the Awareness Days — making people’s lives better every day.

Anybody can get heart failure in many different circumstances, though it is most common in older people. Heart failure is a serious medical condition but it doesn’t mean that your heart is going to stop; it means that your heart is finding it difficult to pump your blood round your body to meet the needs of your daily activities. This means that you can have heart failure for a long time and live with it to the best of your ability.

It is with this in mind that the Heart Failure Association of the European Society of Cardiology initiated the first Heart Failure Awareness Day in 2010. The lack of knowledge among doctors as well as the general public concerned heart failure specialists who were looking for a way to access potential sufferers, help those already with the condition as well as their families, and inform local doctors and nurses. As a result, they turned to local heart failure organisations which are usually linked to national cardiac societies. Read the report from the very first Awareness Day.

Since then, the event has grown dramatically. Where at first a hospital in one country held an open house and a newspaper in another country published an article, now the Awareness Days have a huge variety of events from experienced organisers who plan countrywide to newcomers who start small but with big ambitions.

This year, countries all over Europe will hold their events on one or more days over the weekend of 10-12 May. The Heart Failure Association offers a basic structure for events and has created a poster and comprehensive leaflets that can be translated and tailored for each country. Organisers can also download a web banner for their local websites. In order to reach the maximum of people, the Association has created an exhaustive patient information website, translated into six languages.

Some countries organise walks, others hold public events where blood pressure readings are done. Informational leaflets are given out and medical staff give talks on heart failure. Most organisations contact local newspapers and television and radio stations to reach a wider audience.

Alongside newcomers Cyprus, the former Yugoslav republic of Macedonia, and Belarus — all enthusiastically preparing their events and media campaigns — the Russian Federation organisers have extended the dates of their Awareness Days so that they can cover their vast territory. In one month, they will go to 30 cities and try to reach over 20,000 patients. Germany has spread its awareness day programme over 16 hospitals, introduced a public cooking programme on The Mediterranean Kitchen, arranged an art competition in regional schools on the subject “My heart – A technical miracle,” and created a walk-through artery for their visitor health screenings. In the UK, the Awareness Day events are very much nurse-run. Read what is happening around Europe on 10-12 May 2013.

Those who are aware of the problem and closest to their patients are working hard to see that the message gets out to those with the condition and those who live with sufferers: find out all you can about heart failure; you’ll feel better, prolong your life, and enjoy it more. This is the essence of the Awareness Day campaigns. Europe has woken up and is taking up the challenge by spreading the word.

Anya Creaser works for the Heart Failure Association, a registered branch of the European Society of Cardiology. With Prof Petar Seferovic, Coordinator of the HFA Committee for National Heart Failure Societies, she has coordinated the Awareness Days since the inception in 2010.

Oxford University Press is supporting Heart Failure Awareness Day with resources from across the press and blog posts on the subject.

The European Journal of Heart Failure, edited by Professor Dirk van Veldhuisen, is the International Journal of the European Society of Cardiology dedicated to the advancement of knowledge in the field of heart failure.

The post Why do we have a Heart Failure Awareness Day? appeared first on OUPblog.

John Snow and cholera: how myth helped secure his place in history

Kirsty — Mon, 06 May 2013 07:30:02 +0000

By Sandra Hempel

The high-profile marking of John Snow’s bicentenary on the fifteenth of March would have surprised the great man. The London School of Hygiene and Tropical Medicine, the WellcomeTrust, and The Lancet were among the august UK organisations to honour him with events including an exhibition, three days of seminars, and a gala dinner. The physician was also celebrated in the United States where he has a large fan base.

By the time of his death, on 16 June 1858 at the age of 45, Snow was convinced beyond doubt that his theory on the mode of transmission of epidemic cholera was correct but had little expectation that any credit would accrue to him. His friend, the Soho curate Henry Whitehead, said Snow predicted that he might not live to see the day when great cholera outbreaks were in the past — which was true — and also that his name would be forgotten when that day came, which was not. On the contrary, he is now widely regarded as the father of the science of epidemiology, with his life and work the subject of countless books, articles and web pages, while 200 years after his birth his legacy remains the focus of lively academic debate.

But it’s an unfair world. Achievement alone isn’t always enough to ensure that an individual, however deserving, secures a place in history and in Snow’s case, myth had a role to play. Not that Snow appeared at all interested in fame, posthumous or contemporary. Another friend, Josuah Parsons from his student days, remarked: “The naked truth for its own sake was what he sought and loved. No consideration of honour or profit seemed to have the power to buy his opinions on any subject.” That was just as well, for both honour and profit were in short supply, at least where his groundbreaking work on epidemic disease was concerned.

By the mid-1850s when Snow published his seminal work on cholera he was enjoying some success in the fast-developing specialism of anaesthesia, even attending Queen Victoria at the birth of two of her children. His thinking on disease was largely ignored, however, mainly because he rejected the then widely accepted belief that foul air, or miasma, was to blame. He reasoned, correctly, that cholera was spread when some of the matter thrown off by a victim — the vomit or the massive cloudy discharges from the bowels — found its way into a healthy person’s mouth. He also explained the disease’s frightening habit of striking hundreds of people simultaneously without warning: the cause was infected sewage leaking into the water supply, a common occurrence in the first half of the 19th century. He was not believed.

In the summer of 1854 in order to test his theory Snow carried out what become known as the Grand Experiment, tramping the streets of South London while the country was in the grip of its third cholera epidemic, knocking on doors and asking which of two water companies the householder used. He discovered that customers of the company that took its supplies untreated from the Thames, right next to where the sewers of London were discharged, were between eight and nine times more likely to die of cholera than those whose supplier had recently moved its source upriver, out of reach of the filth.

It was as Snow was putting the finishing touches to this work that he became involved in the Broad Street episode. His serious academic reputation is largely based on the South London research, but it is Broad Street that has contributed most to his enduring reputation, linking as it does a compelling story with two icons — a “death map” and the image of a street pump — with the addition of a little fiction along the way.

Overnight on Thursday, 31 August 1854, 200 people in a tiny part of Soho around Broad Street and Golden Square were struck down by a massive explosion of cholera, the fastest and most deadly ever seen in Britain. Whole families were carried off together. The epidemic continued for 10 days, still confined to a few streets, before petering out. The eventual death toll was over 600.

When Snow heard what was happening, he first looked at the addresses where the fatal cases had occurred and then went on to pioneer what is now a vital tool in epidemiology, disease-mapping, marking the deaths, house by house, on a street plan. The map showed just how local the outbreak was; all the deaths clustered in and around Broad Street. What interested Snow, however, was that those deaths either plummeted or stopped altogether at every point where it was easier to go to another pump than the one in Broad Street.

On the night of 7 September then, a week into the epidemic, Snow gate-crashed a parish meeting at St. James’s church, Piccadilly, where the Board of Guardians responsibly locally for public health were discussing the outbreak. Polluted water from the Broad Street well was to blame, he told the Guardians. They must put the pump out of action.

So far, all true. At this point in some accounts though a little creative licence creeps in. After a bitter row with the recalcitrant authorities, we are told, Dr Snow then storms off, either to chain up the pump handle himself or wrench it off with his own hands. In fact while the authorities were far from convinced, they did take Snow’s advice and the pump was disabled.

The next piece of fiction is that the deaths then stopped in their tracks and, hey presto, overnight John Snow was vindicated. Truth was, the epidemic had already peaked of its own accord; putting the pump out of action proved nothing. The longer, more complex story of how John Snow was proved right is actually more interesting but it’s easy to see why such a satisfying ending to the tale has evolved. And if myth has proved helpful in ensuring that a brilliant man who was dismissed and reviled during his lifetime is now so rightly celebrated, it’s no bad thing.

Sandra Hempel is a writer and editor who specialises in health and social issues. Her book The Medical Detective – John Snow, Cholera and the Mystery of the Broad Street Pump won the British Medical Association book award for the public understanding of science and the Medical Journalists’ Association book award. Her next book The Inheritor’s Powder, which looks at arsenic poisoning and forensic toxicology, is published by Weidenfeld and Nicolson on 13 June 2013. She recently gave a talk at the London School of Hygiene and Tropical Medicine about John Snow.

Throughout the year, the International Journal of Epidemiology will be publishing special reprints marking John Snow’s bicentenary, including The Siege of Krishnapur by J. G. Farrell and Cholera, with reference to the geological theory: A proximate cause – a law by which it is governed – a prophylactic by John Lea. The IJE is an essential requirement for anyone who needs to keep up to date with epidemiological advances and new developments throughout the world. It encourages communication among those engaged in the research, teaching, and application of epidemiology of both communicable and non-communicable disease, including research into health services and medical care. OUP publishes the journal on behalf of the International Epidemiological Association.

Subscribe to the OUPblog via email or RSS.
Subscribe to only health and medicine articles on the OUPblog via email or RSS.
Image credits: (i) John Snow, seated, resting right arm on table, anon. (ii) ‘A cholera patient’, caricature of a cholera patient experimenting with remedies (Robert Cruikshank’s random shots No. 2) (iii) Street Map of Soho, around Golden Square, illustrating incidences of cholera deaths during the period of the Cholera Epidemic, 1853. All three images are used with permission from the Wellcome Trust. Do not reproduce without express permission.

The post John Snow and cholera: how myth helped secure his place in history appeared first on OUPblog.

Seven things you never knew about heart failure

Alice — Sat, 04 May 2013 07:30:38 +0000

Heart failure affects 750,000 people in the UK alone and is fast becoming a greater threat to public health than cancer. But how much do you know about this condition? The European Heart Failure Awareness Day is designed to raise awareness of heart failure, including possible symptoms, the importance of an early and accurate diagnosis, and the need for optimal treatment. In that spirit, we’ve prepared this brief quiz on heart failure for you to test your knowledge.

Get Started!

Your Score:

Your Ranking:

Find out more about how to prevent heart failure and keep your heart healthy.

Oxford University Press in conjunction with the European Society of Cardiology and the Heart Failure Association is offering 20% off all our books in cardiology for the month of May, including the authoritative Oxford Textbook of Heart Failure, the practical and concise Oxford Specialist Handbooks on the topic of Heart Failure, and three titles in cardiology published in conjunction with the European Society of Cardiology. In addition we will be offering one month’s free access to the Oxford Textbook of Heart Failure on Oxford Medicine Online, as well as free articles from the European Journal of Heart Failure. We are also publishing a series of special, related articles on the OUPblog.

Subscribe to the OUPblog via email or RSS.
Subscribe to only health and medicine articles on the OUPblog via email or RSS.

The post Seven things you never knew about heart failure appeared first on OUPblog.

DSM-5 and psychiatric progress

ChloeF — Fri, 03 May 2013 07:30:28 +0000

By Tom Burns

National Mental Health week in May this year will see the launch of the eagerly anticipated DSM-5. This is the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual which defines all psychiatric diagnoses and is often referred to as ‘the psychiatrists’ bible’. How can something so dry and dull sounding as a classificatory manual generate such fevered excitement? Indeed how did the DSM compete for space in a short book such as the VSI to Psychiatry? Why does it take its place alongside acknowledged classics like Sigmund Freud’s Interpretation of Dreams, or RD Laing’s The Divided Self? The answer is that psychiatry is a practice that is highly sensitive to cultural and social pressures and the origins of the DSM-III, published in 1980, reflected a crisis in psychiatry’s self confidence and is a classic case of unintended consequences.

American psychiatry (which had been dominated by psychoanalysts from about 1940 to 1970) had its prestige seriously dented in the early 1970s. Two major international studies had indicated that they tended to dramatically over-diagnose schizophrenia compared to other developed nations. To make matters worse Rosenham’s famous study ‘being sane in insane places’ was published in 1973. Rosenham got eight volunteers to go to different emergency rooms and say that they were hearing voices that said ‘empty’, ‘hollow’, or ‘thud’ but otherwise to behave absolutely normally. All were admitted to hospital and kept there for several weeks, all were diagnosed with schizophrenia and none had their diagnosis questioned. Clearly this was dire, something had to be done.

DSM-III was the response, a totally new approach to diagnosis. Instead of making a diagnosis by recognising an overall pattern of the illness DSM-III introduced ‘criterion based diagnosis’. So to be diagnosed with a disorder, say depression, the psychiatrist had to identify a core symptom (criterion) of lowered mood for at least two weeks and then four more symptoms (e.g. disturbed sleep, reduced appetite, poor concentration or feelings of worthlessness) out of a list of eight. If you ‘score’ on enough symptoms you have the disorder, if not you don’t. This approach emphasises reliability; the symptoms are simply defined and explained so most doctors will agree on them. It leaves little scope for an overall judgment or deciding on the ‘feel’ of the patient’s presentation. Improving reliability and reducing the variation between different psychiatrists with sharper definitions was meant to reduce the loose over-diagnosis that had plagued US psychiatry up till then. It also should improve the reliability of the drug trials that were coming into prominence.

One should be careful what one hopes for. While the DSM criterion based system has undoubtedly made diagnosis more consistent, it has certainly not made it tighter. As we approach DSM-5 the expansion in this classification is simply staggering. DSM-I in 1952 had 130 pages and 106 diagnoses and has ballooned to DSM-IV in 1994 with 886 pages and 297 diagnoses. The number of individuals who are diagnosed with psychiatric disorders is at an all time high. There is a growing recognition that the DSM system has lead to a medicalisation of everyday life; far too many people with transitory sadness find themselves classified as depressed and prescribed antidepressants. Anxiety disorders such as PTSD and Social Phobia are all too easy to define and hence diagnose, but can they really be as widespread as current practice suggests? Most patients now end up with more than one diagnosis. Even the psychopharmacologists who agitated for DSM-III are now concerned that diagnoses are cast so widely that they undermine, rather than guarantee their trials.

The fact that one can define something and agree on the definition does not make it either real or important. For example, there was good agreement four centuries ago on how to recognise a witch, but that does not mean that these poor women were witches. Similarly having a definition for ‘Oppositional Defiant Disorder’ in adolescents who ‘often argue with adults’ does not make it a psychiatric disorder (any more than nicotine or caffeine dependency which are, believe it or not, listed in there).

Of course we should not be too dismissive about the progress that has been made in reliability and consistency. Psychiatric practice is vastly safer, more predictable and evidence based than ever before. We can hope that DSM-5 will transcend its committee structure and weed out earlier mistakes and sharpen up and refine the range of diagnoses, perhaps deleting those that are hardly ever used. It will certainly not be dull. Since its origins two hundred years ago psychiatry has never been without its controversies and disputes and all the signs are that this is likely to continue.

Tom Burns is Professor of Social Psychiatry at Oxford University and author of Psychiatry: A Very Short Introduction. He has worked as a psychiatrist in Scotland, Sweden, and London before moving to Oxford. He trained as a group analyst and worked as a full time NHS consultant for 10 years before becoming an academic. His research is focused on interpersonal relationships in psychiatry – increasingly relationships with health care staff and the best forms of care for patients with severe illnesses such as psychoses. He has authored over 200 scientific papers and chapters and is the author or co-author of five books. He was awarded a CBE for his services to mental health in 2006.

The Very Short Introductions (VSI) series combines a small format with authoritative analysis and big ideas for hundreds of topic areas. Written by our expert authors, these books can change the way you think about the things that interest you and are the perfect introduction to subjects you previously knew nothing about. Grow your knowledge with OUPblog and the VSI series every Friday and like Very Short Introductions on Facebook.

Subscribe to the OUPblog via email or RSS.
Subscribe to only VSI articles on the OUPblog via email or RSS.
Subscribe to only psychology articles on the OUPblog via email or RSS.

The post DSM-5 and psychiatric progress appeared first on OUPblog.

Sir Robert G Edwards (1925 – 2013)

KatherineS — Thu, 02 May 2013 16:30:55 +0000

By David H. Barlow

With the announcement of the death of Bob Edwards at the age of 87, on 10 April 2013, a field of medicine and science has lost its grandfather. What is more, for more than five million children worldwide the man whose life’s work made their conception possible is no more. In every generation there are scientists whose discoveries and innovations make a difference but only a small number become household names. As one half of ‘Steptoe and Edwards’ Bob Edwards achieved that elevation in the popular imagination. As a result large numbers of people know his name and that he was one of the team who made IVF possible, but it is likely that few have any idea of the scale of his contribution. His whole postgraduate career, from the early 1950s, was spent in the progressive study of the biology of fertilization leading step by step to the in vitro fertilization of a human egg in 1968 and to the possibility that human pregnancy might eventually be achievable. Although through the 1970s Patrick Steptoe’s skill in laparoscopy provided the vital practical contribution that made the eventual establishment of the first IVF pregnancy possible, it was Bob Edwards’ long-term vision that had been the driving force.

The scale of opposition to their work is difficult now to imagine. In the years leading up to the landmark event in 1978 both the Vatican and many opinion leaders raised huge concerns. Even the Medical Research Council failed to provide support. In the years after 1978 the diverse opposition continued and ultimately in the UK the sensitivity perceived to surround human in vitro fertilization lead to the Warnock Commission, then the Human Fertilization and Embryology Act 1990. With the establishment of the HFEA in 1991 this area of medical practice has been regulated more heavily than any other. The scale of the opposition over decades would have crushed lesser men and their work.

Having demonstrated that human IVF could indeed lead to the birth of healthy babies might have been sufficient for some, but Steptoe and Edwards together took clinical IVF forward by establishing the first ever IVF clinic at Bourne Hall. Through the 1980s this and a growing number of IVF clinics around the world developed the processes involved so that by the end of that decade IVF had become an effective infertility treatment option. It is important that Bob Edward’s role in the progression of IVF through the 1980s and 90s is recognized. His status as the father of IVF was unquestioned and this gave him access as a significant presence at all the major international scientific conferences on human reproduction. In this role he was continually challenging the growing clinical and scientific community to address fundamental questions of reproduction as well seeking to improve clinical progress in clinical IVF. His presence at scientific meetings was often inspirational for the following generation of IVF scientists.

An important contribution was his leading role in founding ESHRE, the European Society of Human Reproduction and Embryology in 1984. Two years later he founded the scientific journal Human Reproduction, becoming its first Editor-in-Chief and serving from 1986 up to 2000. ESHRE has become one of the world’s most influential bodies in the development of all aspects of the field and Human Reproduction and its sister journals, again created by Bob (Human Reproduction Update and Molecular Human Reproduction), became world leaders. In 2000 although now in his mid-seventies Bob Edwards founded the online scientific journal Biomedicine Online, which also carries forward his vision. Both ESHRE and the journals he created continue to carry forward his vision.

I succeeded Bob as Editor-in-Chief of Human Reproduction in 2000 and my own strongest memories of him are of conversations about how journals might meet the challenges of encouraging young scientists and of advancing knowledge in the field. Well into retirement he always demonstrated an acute grasp of key unanswered questions and communicated his deep fascination with how reproduction works.

Bob Edwards received awards from bodies around the world and this high esteem was well deserved. He received the ultimate recognition as a British scientist in being elected to the Fellowship of the Royal Society in 1984 but it is bitter-sweet that the world’s most prestigious award, the Nobel Prize for Physiology or Medicine, which many of us felt was long-overdue, came late in his life in 2010 when his health was poor. In the circumstances his Nobel Prize was received by his wife, Ruth, and his Nobel Symposium lecture was given by his eminent student, Professor Martin Johnson, and this provides a superbly detailed and affectionate portrait of a great scientist. This and Bob’s own memoir in Nature Medicine serve as excellent guides to the long and successful path to his landmark achievements.

He was awarded a knighthood in 2011.

David H Barlow is Emeritus Professor, previously Executive Dean of Medicine at the University of Glasgow. He was 20 years at the University of Oxford where he was Nuffield Professor of Obstetrics and Gynaecology and a Fellow of Oriel College. He has contributed, through various national roles, to the strategic development of IVF in the UK and is Emeritus Editor-in-Chief of Human Reproduction having succeeded Bob Edwards in 2000. He is currently Director of Women’s Health Services at the Hamad Medical Corporation, Qatar.

Human Reproduction features full-length, peer-reviewed papers reporting original research, clinical case histories, as well as opinions and debates on topical issues. Papers published cover the clinical science and medical aspects of reproductive physiology and pathology, endocrinology, andrology, gonad function, gametogenesis, fertilization, embryo development, implantation, pregnancy, genetics, genetic diagnosis, oncology, infectious disease, surgery, contraception, infertility treatment, psychology, ethics and social issues.

Image credit: Artificial insemination. Image by alex-mit, iStcokphoto.

The post Sir Robert G Edwards (1925 – 2013) appeared first on OUPblog.

More malignant than cancer?

Alice — Thu, 02 May 2013 12:30:56 +0000

In anticipation of Heart Failure Awareness Day on 10 May, Oxford University Press has pulled together information across the press to provide resources on heart failure. We’re also running a series of blog posts on this dangerous disease. To kick us off today, we chatted with Professors Theresa MacDonagh, past Chair of the British Society for Heart Failure, and Andrew Clark, Chair-elect, about the diagnosis of heart failure and the importance and benefit of adequate treatment.

So what is heart failure?

Andrew Clark: It sounds terrible, doesn’t it? It must be an awful thing for a patient to hear during a consultation as it sounds on the face of it as if the heart is about to stop. That’s absolutely not what it means, of course. Heart failure is just the term used to describe the situation in which the heart does not pump as strongly as it should to drive blood round the body. The consequences can be dramatic: if heart failure develops suddenly, then a patient can develop fluid in their lungs, called pulmonary oedema, very rapidly; but more commonly, patients gradually retain fluid and present with breathlessness and swollen ankles. It’s a very common reason for people to be referred to medical clinics at hospital.

Theresa MacDonagh: I think that makes the point that it’s important for patients to have someone with them when they first encounter heart failure. It’s a complex disease, and whilst medical treatment is hugely beneficial, there’s a lot of information to take in. Education of the patient and their supporters is a key part of good management.

What are the causes of heart failure? How common is it?

Andrew Clark: Well, the most common cause of heart failure is one or more previous heart attacks. This is the cause in perhaps a half of patients. During a heart attack, some of the heart muscle itself dies and is replaced by scar tissue. Enough heart muscle can be damaged that heart failure develops. A cause in about a third of patients is dilated cardiomyopathy in which all the heart muscle is damaged by a disease process. It’s not completely clear how this happens: in some people there is a genetic cause, in others an infective one. In many cases, we simply don’t know as yet. There are many other less common causes of heart failure, such as heart valve disease.

Heart failure is very common. As your work showed, around 1% of the population have heart failure due to impairment of the pump function of the heart, and another 1% have damage to the heart but have no symptoms.

Theresa MacDonagh: The diagnosis of heart failure carries such a bleak prognosis. We know from data collected for the National Heart Failure Audit that around a third of patients being discharged from hospital after an admission for heart failure will die during the subsequent year.

What treatment is there, or is it just a diagnosis with no hope?

Andrew Clark: The fluid retention of heart failure can usually be managed quite straightforwardly with diuretics, medications that make the kidneys produce more urine. The more profound treatment, though, arises from the realisation that heart failure causes many of the body’s natural hormonal systems to be greatly activated. Patients with heart failure have high levels of adrenaline and a closely related chemical, noradrenaline, in the circulation, together with other hormones, particularly angiotensin II and aldosterone. High levels of hormones are implicated in the progression of heart failure and eventual death.

The mainstays of modern medical therapy are blockers of these hormones, particularly betablockers (such as carvedilol), angiotensin converting enzyme inhibitors (such as ramipril) and mineralocorticoid receptor antagonists (such as spironolactone). Used together, these drugs have a profound effect on the outlook of patients with heart failure and can approximately double life expectancy.

Theresa MacDonagh: We should also mention the role of implantable devices, such as defibrillators, which can stop life-threatening fast heart rhythms by administering an internal electric shock, and cardiac resynchronisation pacemakers, or CRT, which can improve the overall function of the heart in selected patients. Both can improve outlook, and CRT can result in a dramatic improvement in exercise capacity.

Andrew Clark: One of the main challenges for heart failure cardiologists is devising care pathways and systems to get this therapy to as many patients as possible. Indeed, and that’s one of the major aims of the Heart Failure Audit and the British Society for Heart Failure.

What information is there available for patients and their carers?

Theresa MacDonagh: There can be a bewildering amount of information on the web which can be very unhelpful and give conflicting advice. One excellent resource is the site run by the European Society of Cardiology, Heart Failure Matters, which is well-written and emphasises individual patient experience as well as being a comprehensive factual resource.

Andrew Clark is Professor of Clinical Cardiology in the University of Hull. He trained in Manchester, London and Glasgow, and has research interests in exercise physiology and clinical aspects of heart failure. He is Chair-elect of the British Society for Heart Failure. Theresa A. McDonagh is a consultant cardiologist at King’s College Hospital in London, UK. They are the editors of the Oxford Textbook of Heart Failure with Roy S. Gardner and Henry Dargie.

Oxford University Press is supporting Heart Failure Awareness Day with resources from across the press.

Subscribe to the OUPblog via email or RSS.
Subscribe to only health and medicine article on the OUPblog via email or RSS.
Image credit: Male anatomy of human organs in x-ray view. Image by janulla, iStockphoto.

The post More malignant than cancer? appeared first on OUPblog.

“If a child can be born in a stable, I guess I can die in a hospital.”

Kirsty — Thu, 02 May 2013 07:30:38 +0000

By Sinéad Donnelly

A palliative medicine physician colleague of mine asked an audience of physicians where they would like to die: at home, hospice, or hospital? Sitting in the audience I can only remember the number in favour of the third option. One person — and that was me.

If a child can be born in a stable, I guess I can die in a hospital. With 22 years experience of palliative medicine, hospital does not seem to me like the worst place to die. More than anything, I want someone to care for me and about me, and the first line in my advanced care directive will make this preference clear. Then I may add that I don’t want to be on a Care Pathway to Anywhere. I don’t want nurses and doctors to say I had one “variant” last night according to the protocol but instead talk about me as a human being with pain or nausea or anxiety or comfortable, at peace, tearful, whatever. Don’t distance yourselves from me and the reality of my dying, a reality that you too will share one day. By the way, I don’t actually want to die. That’s another story.

If you really want my opinion about acronyms (and this is an opinion blog), one more abbreviation might well be the death of me. I don’t want an ANP asking about my ACP before putting me on the LCP.

A patient dying in hospital should be an honoured guest in an honoured place. What a novel concept! This idea is adapted from an inspiring essay by Ken Warpole. Commissioned by the Irish Hospice Foundation in 2005, Warpole reviewed the architecture and design of the hospital spaces in which the dying find themselves. The idea of hospital being an honoured place with dying patients as honoured guests opens a new window into our daily reality of working in hospitals.

The Royal College of Physicians in 2012 cautioned against the introduction of tools for the care of dying without an extensive programme of education and support to hospital staff. They discouraged the counterproductive tick-box approach to care of the dying patient. More recent literature points to a need to look at our behaviour towards dying patients, their families, and our colleagues. In addition to resources such as pathways or protocols, we need to pose new questions about hospital care of the dying patient:

How do we behave towards other people within the hospital environment?
How do staff members show that they care for the dying patient and grieving family?
How can we make time for the dying patient and family?
How can senior doctors and nurses show leadership and model compassionate and competent behaviour?
How do we support our less experienced staff and colleagues in the face of dying and death in hospital?

Let’s imagine that I am the dying person in hospital. Imagine that you as hospital staff believe and know that you work in an honoured place. Let’s imagine that I feel like an honoured guest, that you make me feel like an honoured guest. Can we imagine how that might be?

Dr Sinéad Donnelly is a Consultant in Palliative Medicine at Wellington Regional Hospital, New Zealand. Her article, ‘Patient dying in hospital: an honoured guest in an honoured place?‘ appears in QJM: An International Journal of Medicine.

QJM is a long-established, leading general medical journal. It focuses on internal medicine and publishes peer-reviewed articles which promote medical science and practice. Published monthly, QJM includes original papers, editorials, reviews, commentary papers to air controversial issues, and a correspondence column.

Subscribe to the OUPblog via email or RSS.
Subscribe to only health and medicine articles on the OUPblog via email or RSS.
Image credit: Old and young hands photo by SilviaJansen via iStockPhoto.

The post “If a child can be born in a stable, I guess I can die in a hospital.” appeared first on OUPblog.

Mediterranean diets and health risks for the elderly at high cardiovascular risk

AlanaP — Tue, 30 Apr 2013 12:30:02 +0000

What is the relationship between a Mediterranean diet and the risk of hyperuricemia in the elderly? Dr. Salas-Salvado joins us to discuss his most recent research in the The Journals of Gerontology Series A: Biological Sciences and Medical Sciences.

What is hyperuricemia, how common is it, and what can be its consequences?

Hyperuricemia is defined as elevated concentrations of serum uric acid in plasma (higher than 7 mg/dL in men and higher than 6 mg/dL in women). It occurs when there is an overproduction or underexcretion of uric acid or often the combination of both.

The prevalence of both gout and hyperuricemia has increased over the past two decades, which is related to increasing frequencies of adiposity and hypertension. It has been estimated that the prevalence of gout among US adults was 3.9%, 5.9% for men and 2% for women, this mean that 8.3 million individuals suffer from gout in the United States. It has also been estimated that 21.4% of adults had elevated serum uric acid levels, namely 43.3 million of individuals in the United States. It has also been shown that its prevalence increases with age.

Hyperuricemia has also been regarded as the precursor of gout; an inflammatory arthritis triggered by the crystallization of uric acid within the joints, decreasing life quality. Moreover, it has been strongly associated with metabolic syndrome, hypertension, type-2 diabetes mellitus, and chronic kidney disease and also with cardiovascular morbidity and mortality.

Why is your study significant? What are its significant findings?

We have evaluated the associations between adherence to the Mediterranean Diet (MeDiet) and the prevalence, incidence and reversion of hyperuricemia in elderly subjects at high cardiovascular risk participating in a primary prevention randomized trial. Also, we have assessed which of the specific typical components of the MeDiet were associated with hyperuricemia. We have shown that after a median follow-up of five years, 24.9% of subjects who did not have hyperuricemia at baseline developed hyperuricemia, whereas 43.2% of hyperuricemic individuals at baseline reverted this condition. In the cross-sectional analyses, we have observed that an increase in the adherence to the MeDiet was associated to a decreased prevalence of hyperuricemia. The baseline consumption of red meat, fish and seafood, and wine were associated with a higher prevalence of hyperuricemia. We have also found that those individuals who have a higher adherence to the MeDiet had more probabilities to reverse this condition than those individuals with a lower adherence. Furthermore, these associations were independent of other risk factors for hyperuricemia, such as age, body-mass-index, smoking, physical activity, hypertension, and diabetes.

Even though previous studies have assessed the relationship between some dietary factors and hyperuricemia, the association between dietary patterns and hyperuricemia remains unknown. Our study is unique in prospectively evaluating the adherence to the MeDiet and hyperuricemia. Our findings provide evidence of the benefits of healthy dietary patterns on the reversion of hyperuricemia. What is more, reversion was achieved by the MeDiet alone, without weight loss or physical activity counselling.

What constitutes a MeDiet?

The traditional Mediterranean diet is characterized by a high consumption of fruits, vegetables, legumes, olive oil, nuts, and whole grain; a moderate consumption of wine, dairy products, and poultry; and a low consumption of red meat, sweet beverages, creams, and pastries. The sofrito sauce is also another component of the Mediterranean diet; it is made with tomato, onion, spices, garlic and simmered with olive oil. Its high content in antioxidants makes it anti-inflammatory.

Is a MeDiet beneficial in other ways, such as in decreasing or reversing the risk of gout?

It has been consistently demonstrated that Mediterranean Diet has many healthy benefits mainly due to its antioxidant and anti-inflammatory properties. It has been inversely related with dyslipidemia, diabetes, metabolic syndrome, hypertension, and other chronic diseases. Recently, the findings of the PREDIMED Study — a large, multicenter randomized clinical trial — showed that among persons at high cardiovascular risk, a Mediterranean diet supplemented with extra-virgin olive oil or nuts reduced the incidence of major cardiovascular events. So, Mediterranean diet has also been strongly and inversely related with cardiovascular morbidity and mortality.

Jordi Salas-Salvadó is in the author of “Mediterranean Diet and Risk of Hyperuricemia in Elderly Participants at High Cardiovascular Risk” (available to read for free for a limited time) in the latest issue of The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. He has occupied teaching and research posts at the Faculty of Medicine in Reus (UB) since 1984. At present, he is professor of Nutrition (Department of Biochemistry and Biotechnology) and director of the Human Nutrition Unit of the Faculty of Medicine and Health Sciences of the Rovira i Virgili University (URV). He has directed 12 research projects financed by public bodies and 21 projects in conjunction with the pharmaceutical or food industries. He is one of the leaders of the PREDIMED clinical trial and has published more than 220 original articles in national and international journals, as well as numerous reviews and editorials. Editor of 7 books, he has also co-authored more than 50 books.

The Journals of Gerontology were the first journals on aging published in the United States. The tradition of excellence in these peer-reviewed scientific journals, established in 1946, continues today. The Journals of Gerontology, Series A publishes within its covers the Journal of Gerontology: Biological Sciences and the Journal of Gerontology: Medical Sciences.

The post Mediterranean diets and health risks for the elderly at high cardiovascular risk appeared first on OUPblog.

The latest developments in cardiology

KimberlyH — Sun, 28 Apr 2013 12:30:45 +0000

What is the relationship between atherosclerosis and acute myocardial infarction? How do aldosterone blockers reduce mortality? What steps are doctors taking toward personalized cardiac medicine? What are the new drugs and devices to treat hypertension? What is salt’s role in the human diet? The international cardiology community examined these questions and more at the Cardiology Update 2013 in Davos, Switzerland earlier this year.

A two-member video team from the European Society of Cardiology (ESC) was also there to conduct interviews with the thought leaders in the field as part of the MyCardio interview series. The ESC and European Heart Journal are now present at all the major cardiology congresses worldwide to record these MyCardio interviews and almost 200 interviews available on the European Heart Journal website, covering a wide spectrum of topics in cardiology.

A selection of the interviews for Cardiology 2013 is presented below.

Salim Yusuf on salt’s implications for cardiovascular health

Click here to view the embedded video.

Franz Messerli on hypertension

Click here to view the embedded video.

Joseph Loscalzo on personalized cardiovascular medicine

Click here to view the embedded video.

Peter Libby on atherosclerosis, inflammation, and acute myocardial infarction

Click here to view the embedded video.

Bertram Pitt on the history of Cardiology Update in Davos

Click here to view the embedded video.

The European Heart Journal is an international, English language, peer-reviewed journal dealing with Cardiovascular Medicine. It is an official Journal of the European Society of Cardiology and is published weekly. The journal aims to publish the highest quality material, both clinical and scientific, on all aspects of Cardiovascular Medicine. It includes articles related to research findings, technical evaluations, and reviews. In addition it provides a forum for the exchange of information on all aspects of Cardiovascular Medicine, including education issues.

Subscribe to the OUPblog via email or RSS.
Subscribe to only health and medicine articles on the OUPblog via email or RSS.

The post The latest developments in cardiology appeared first on OUPblog.

‘No choice for you’ according to the ACMG

AshleyP — Sun, 28 Apr 2013 10:30:26 +0000

By Dr. Anna Middleton

The American College of Medical Genetics (ACMG) has recently published recommendations for reporting incidental findings (IFs) in clinical exome and genome sequencing. These recommendations advocate actively searching for a set of specific IFs unrelated to the condition under study. For example, a two-year-old child may have his (and his parents’) exome sequenced to explore a diagnosis for intellectual disability and at the same time will be tested for a series of cancer and cardiac genetic variants. The ACMG feel it is unethical not to look for a series of incidental conditions while the genome is being interrogated, conditions that the patient or their family may be able to take steps to prevent. This flies in the face of multiple international guidelines that advise against testing children for adult onset conditions. The ACMG justify this as “a fiduciary duty to prevent harm by warning patients and their families.” They conclude that “this principle supersedes concerns about autonomy,” i.e. the duty of the clinician to perform opportunistic screening outweighs the patients right not to know about other genetic conditions and their right to be able to make autonomous decisions about testing.

Family have exome sequencing to determine son’s diagnosis

There is strength in the above argument if opportunistic genetic screening did indeed reveal an established predisposition to a treatable and preventable condition where steps could be taken to protect the individual or their family. But this isn’t the case with some of the conditions the ACMG insist on testing for. There are many apparently ‘disease causing’ variants that appear in healthy people with no evidence of disease, and in the absence of a strong family history it will be difficult to interpret some results. It is not too far fetched to imagine that, in the hands of a health professional who doesn’t understand the limitations of the testing, that a supposed BRCA1 gene fault will be identified in a women who is then advised to have preventative surgery to remove her ovaries and breasts. And yet in the absence of a family history, it is impossible to tell whether the BRCA1 gene fault is fully penetrant and whether there are any modifying genes at play.

The ACMG acknowledge “there are insufficient data on clinical utility to fully support these recommendations… and… insufficient evidence about benefits, risks and costs of disclosing incidental findings to make evidence-based recommendations”. Yet, they clearly felt the need to draw a line in the sand and create a starting point. This is a bold and fearless move. The result is that a set of conditions, genes and variants are listed, many of which will reveal uncertain pathogenicity in the absence of a family history. Moreover, in many cases, there is no screening program available (what should be offered to a child with a P53 mutation? There is no universal agreement on whether screening for rhabdomyosarcoma is appropriate). The intent was to identify “disorders where preventative measures and/or treatments were available” but the reality falls short somewhat.

Finally, the ACMG “Working Group encourages prospective research on incidental or secondary findings and the development of a voluntary national patient registry to longitudinally follow individuals and their families who receive incidental or secondary findings as part of clinical sequencing and document the benefits, harms and costs that may result.” In effect, what they are saying is that we don’t really know what the impact of this technology will be, and only time will tell whether our risk predictions are correct. Given such uncertainty and also the fact that many of the families and individuals who will be accessing this technology are incredibly vulnerable (by virtue of their desperate need for a diagnosis for example, for a developmental disorder), it strikes us that this all should actually be part of a research project and not offered as a clinical service. Under the guise of ‘research’ this makes much more sense. What do you think? If you want to contribute to other discussions about ethics and genomics, see our survey.

Consider the ACMG guidelines with the following fictitious case study in mind….

Case study

Bobby is a severely disabled six-year-old. He has a learning disability and hyperactivity, and is incontinent. Numerous paediatricians have seen the family over many years, but existing tests haven’t led to a diagnosis. Bobby’s parents are anxious to have a name for his condition. Without an actual diagnosis it is more challenging to access the educational and respite care he needs.

At their latest paediatric review, Bobby’s parents are given the first glimmers of hope: there is a new test, an exome sequence, that will explore the subtle changes in Bobby’s genes to (hopefully) reveal previously undetected genetic causes for his condition. However, there is a catch — the testing comes in a package where other conditions are also explored at the same time. The parents aren’t interested in anything else and they are confused when the paediatrician tells them Bobby will be tested for a whole set of adult-onset cancers as well as cardiac conditions. The paediatrician explains that these latter conditions are likely to be totally unrelated (‘incidental’) to Bobby’s condition, may not be relevant until Bobby grows up and also it may not be possible to tell with any certainty what the actual risks are of developing them. The parents are surprised — isn’t this a paediatric clinic? Why is a paediatrician talking to them about adult conditions completely outside her area of expertise?

The paediatrician explains that this is just the same as having a full blood count done or an X-ray; there is always the chance of picking up something unexpected. But, the lab will be specifically searching for a set of additional conditions, there doesn’t seem to be much that is ‘incidental’ about this. ‘Call it opportunistic screening’ says the paediatrician’; however, what shocks Bobby’s parents is the fact there is no choice. In order to access the exome sequencing technology they have to receive information on a set list of conditions, there is no opt-out only an opt-in. So, they have to proceed.

Some months later they receive a telephone call from their paediatrician, the exome did not reveal an obvious genetic diagnosis for Bobby’s disabilities however, after several weeks of additional exploratory work by the laboratory staff, they reported a change in a gene called ‘P53’ that is ‘likely’ to given him an increased risk of cancer. The lab had spent a long time looking through the medical literature. Although the gene change looked as if it should be significant in that cancer was possible, the fact that no-one in the family had already had cancer (and the family was large with many people living well into old age), it was difficult to know what this actually meant for Bobby and his parents, and whether cancer screening would be necessary or not. Bobby’s parents are stunned, they proceeded with testing that they had no choice about and now have to deal with uncertain results together with an uncertain plan of action. Should they be worrying about this result or not? Does it have implications for other members of the family? The paediatrician isn’t sure.

A version of this article originally appeared on the Genomethics blog.

Anna Middleton is the co-editor of Getting the Message Across: Communication with Diverse Populations in Clinical Genetics with Jennifer Wiggins. She has had two parallel careers, the first as a registered genetic counselor working in various regional clinical genetics services in the UK and the second as a social scientist exploring the ethical implications of genetic and genomic technologies. She has a PhD in Genetics and Psychology and is currently working as an Ethics Researcher at the Wellcome Trust Sanger Institute in Cambridge, UK. She has been the Vice-Chair of the Genetic Counselor Registration Board and on the editorial board for the Journal of Genetic Counseling (US).

Subscribe to the OUPblog via email or RSS.
Subscribe to only health and medicine articles on the OUPblog via email or RSS.
Image credit: Genomethics blog.

The post ‘No choice for you’ according to the ACMG appeared first on OUPblog.

World Malaria Day 2013

Alice — Thu, 25 Apr 2013 08:30:45 +0000

By Johanna Daily

The WHO’s Sixtieth World Health Assembly proclaimed the 25^th of April as World Malaria Day in recognition of the continued high mortality caused by this parasitic infection, particularly in young children. The goal of World Malaria Day is “to provide education and understanding of malaria as a global scourge that is preventable and a disease that is curable.”

Over the past few decades, increasing understanding of parasite and vector biology, as well as advancement in diagnostics and therapeutics, are providing inroads into controlling malaria infection and improving clinical outcomes. The development and implementation of diagnostic tests, for example, has been critical for providing reliable data to the treating clinician and for the evaluation of malaria control programs’ effectiveness.

An obstacle to the fight against malaria is the parasite’s capacity to develop drug resistance. Drug combinations are now used routinely, and efficacy studies around the world demonstrate excellent drug treatment outcomes with artemisinin combination therapies (ACT). Future generation antimalarials are being developed to provide additional treatment options in case artemisinin resistance emerges despite ACT.

In October 2007 a goal set by the Bill and Melinda Gates Foundation during the Malaria Gates Forum reignited the pursuit of malaria eradication. Efforts in the 1940 and 1950s resulted in eradication from Europe, North America, and other regions; however, minimal impact in Africa was achieved. It is for this reason that the proposal for malaria eradication was initially met with skepticism. Nevertheless, this agenda has now been embraced by public health organizations and the scientific community. Countries that have eradicated malaria or are in pre-eradication status are increasing, and there is renewed commitment to reduce the number of malaria cases globally by 75% from 2000 levels by the end of 2015.

An effective vaccine has been a long sought goal in preventing malaria. However, recent studies have shown only modest protection against infection in African children. The development of a malaria vaccine has posed a daunting challenge and may be related to the long evolutionary relationship between humans and malaria. The parasite has developed strategies to prevent the development of sterilizing immunity, as persistence in a human blood stream is crucial for continued transmission. Residents of endemic areas typically do not develop complete sterilizing immunity and thus vaccine developers need to devise ways to provide the human host with a more effective response to prevent or limit infection. Currently, there are a number of vaccines in development and the effectiveness of these additional vaccination strategies will be closely watched.

What is striking about malaria is that, while it is a “preventable and curable” infection, it continues to cause devastating global statistics and individual suffering. Targeting the vector was central for many successful eradication programs. Eliminating or limiting contact with the anopheles mosquito, the disease vector, prevents infection. Efforts to impact vector biology have been primarily through distribution of bed nets and pesticide spraying. Educating local communities to apply sustainable interventions such as habitat modifications to limit vectors (housing modifications with screens, for example) could be important adjunctive approaches and have the benefit of long term sustainability, not requiring long-term donor dependence.

Malaria is curable. Unlike HIV, which requires chronic therapy, and tuberculosis, which requires months of therapy, malaria treatment requires only a short course of medications. How can we assist malaria endemic regions to build an effective health care system to provide rapid diagnosis and timely therapy? Leaders in business such as Michael Porter and his colleagues in the Global Health Delivery Project have advocated for the rapid dissemination of management strategies for the design and management of health care delivery systems in resource poor settings. Funding both practical and known interventions along with funding of discovery of new treatments/vaccines may further improve malaria related outcomes.

World Malaria Day provides an opportunity to critically assess the state of the battle against malaria. Today should be a day to reflect on the approaches that are having a measurable impact, and those that are not. It is a day to reinforce the global and local commitments to control this preventable and curable infection.

Johanna Daily, MD is an Associate Professor of Microbiology & Immunology and of Medicine (Infectious Diseases) at Albert Einstein College of Medicine.

To raise awareness of World Malaria Day, the Editors of Clinical Infectious Diseases and The Journal of Infectious Diseases have selected recent, topical articles, which have been made freely available through the end of May. Both journals are publications of the Infectious Diseases Society of America.

Subscribe to the OUPblog via email or RSS.
Subscribe to only health and medicine articles on the OUPblog via email or RSS.
Image credit: An African girl holding a sign with “Malaria Kills” written on it. Photo by MShep2, iStockphoto.

The post World Malaria Day 2013 appeared first on OUPblog.

What to do in winter?

Kirsty — Thu, 25 Apr 2013 07:30:24 +0000

By Marie-Louise Bird

If you live a long way from the equator, the amount of daylight that you have access to in summer compared to winter varies hugely. For example at 41 degrees (Launceston in Tasmania, Australia; Boston, MA, USA; and Portugal, Europe) the length of daylight varies from just over 9 hours in winter to over 15 in summer and even more dramatic at 53 degrees, with hours of daylight from 7.5 in winter to 17 in summer. It is not surprising that this will have impact on the total amount of physical activity that people perform in the different seasons with less activity in winter (14% at 41 degrees south). This is especially true for the amount of active time spent out-of-doors. The flow-on effect of limited outside activity has several health consequences to consider in winter; both reduced sun exposure for vitamin D production and changes in strength from potential deconditioning. This may also impact winter fall rates in older adults, particularly trip related falls.

Vitamin D levels within the body are important for muscle and bone health outcomes as well as adequate immune function. Recommendations for achieving adequate levels of vitamin D include maximizing safe sun exposure where possible, and opting for supplementation when not. At high latitudes in winter the availability of ultraviolet light for vitamin D production is minimal for 3 months (at 40 degrees south reducing from 36 Mega joules/m² in summer to 8 Mega joules/m²in winter). This closed window last even longer at higher latitudes (5 months at 53 degrees north). As well the climate at those latitudes is often not conducive to exposing skin for vitamin D gain!

We have recently identified small changes in ankle strength (reduced by 8% in winter) and dynamic balance (reduced 4% in winter) that may be related to the reduction of outside activity during the winter season. Ankle strength is one important link in the chain of physical fall risk factors for older adults. However, the control of motion around the ankle is equally or more important for maintaining postural balance and prevent falling and requires more than just strength. Postural control also relies on proprioceptive input and central balance mechanisms to maintain good ankle strategy. Walking outside in summer appears to offer challenges to balance and proprioceptive input to assist in balance reaction maintenance. Are there activities that we can recommend people do in winter to maintain ankle strength and balance, and help prevent falls?

It appears that typical falls in summer and falls in winter may be different. Information about inside and outside falls is available for some healthy populations. There are gender differences being found, with more men falling outside than women. The important context of frailty is being explored in Canada, with inside falls being reported to occur in populations that have more markers of physical frailty in terms of slower gait speed and step variation than outside fallers We have found a larger number of outside falls compared to inside falls in summer recently, although other researchers have found weather in winter makes outside falls in winter more common. So perhaps for those able to safely negotiate outside, the adage ‘make hay while the sun shines’ has an important corresponding saying for those who do not work the land ‘walk outside while the sun shines’. Of course there are caveats on this recommendation, with walking programs found to increase falling in people who attempt them who are too frail.

If exercising outside is too difficult because of the weather, we can deliver exercise interventions inside the home. An interesting new area of research is the use of video games to improve activity levels in older adults, and some of these are designed to challenge balance as well. Is this something that older adults may want to do in winter when the weather prevents them going outside? Current recommendations in Australia for exercise to assist in preventing falls indicates that balance activities should be done for 2 hours a week to help reduce falls. These activities should include challenges to balance that move the centre of gravity over the base of support and progressively reduce the base of support. Balance can also be challenged by altering sensory input in terms of surfaces for exercise (softer surfaces are more challenging) or changes to visual input (less visual input increases the challenge). Researchers at Monash University suggest that the level of difficulty should be such that you are challenged but not unsafe. If you use your hands to support you while exercising, it will not challenge your balance or train better balance reactions. So if you want to improve your balance — don’t use your hands.

Following these current guidelines that are based on Cochrane level evidence, it is possible to reduce the risk of falling by up to 38% through targeted exercise programs. Uptake of these appropriate exercises and adherence to fall exercise programs after starting remains disappointingly low, in light of the strong evidence. This is where technology may come into ‘play’ with exer-gaming providing new ways for participants to interact with games and each other, often from the comfort of their own home. The current commercially available sensors allow accurate and immediate feedback for ‘gamers’ and can been used for a variety of exercise goals, not only aerobic, but also to promote stepping and balance reactions. At present no interventional research currently exists to look at seasonal exercise programs to help with the winter reduction in activity (particularly outside activity) that may flow on to impact ankle strength and dynamic balance and winter fall rates. Perhaps activity based videogames may be a new recommended winter pastime for older adults to use with their friends and family.

Dr Marie-Louise Bird is a physiotherapist working at the University of Tasmania, whose area of research includes exercise interventions to improve fall risks in older adults and has recently become increasingly interested in the role of incidental activity to combat sedentary behaviours and motivation for physical activity. She is a committee member for the Australian Gerontology and Geriatrics Group (Tasmanian Branch). She is also a Pilates instructor and mentor for Polestar Pilates Australia. Marie-Louise enjoys mountain biking in Tasmania and Spain. She is the lead author of the paper, ‘Serum [25(OH)D] status, ankle strength and activity show seasonal variation in older adults: relevance for winter falls in higher latitudes’, which appears in Age and Ageing.

Age and Ageing is an international journal publishing refereed original articles and commissioned reviews on geriatric medicine and gerontology. Its range includes research on ageing and clinical, epidemiological, and psychological aspects of later life.

Subscribe to the OUPblog via email or RSS.
Subscribe to only health and medicine articles on the OUPblog via email or RSS.
Image credit: Feet bones anatomy with toes lateral view. By janulla, via iStockPhoto.

The post What to do in winter? appeared first on OUPblog.

How can we respond to the widespread inadequate understanding of dementia?

KatherineS — Wed, 24 Apr 2013 07:30:28 +0000

By Dr Victor Pace

Dementia is always in the news nowadays. Every day brings a new story: of poor care, of concerns about future numbers, of some new approach to treatment. From something that was never spoken about, it has moved centre stage, stemming from the combined realisation that many of us or our loved ones will develop it as we all live longer, and that the care people with dementia receive is grossly inadequate. This is difficult to remedy as care will become even more expensive as the number of dementia patients grows. Dementia has replaced cancer as the dreaded disease of the twenty-first century.

With increasing awareness of the condition has come a slow realisation that people die of and with dementia – and that the last few years of dementia are accompanied by severe physical frailty, which brings with it malnutrition, an increased risk of injury and infection, immobility and incontinence.

How can we respond to the widespread inadequate understanding of dementia? Firstly, we need to admit that many people die of dementia; it contributes to one in seven deaths in England. We need to move away from the tendency to give an optimistic gloss to this condition; with such a common illness, optimism soon wears thin, as most of us have direct experience of what dementia really means. Many years ago, no one spoke of cancer so as not to frighten sufferers with details of inadequate care and gloomy prognoses, but with openness came a focus on care as well as cure. Here, dementia still lags behind: the search for cures is certainly of top importance, but with such a multi-faceted disease, whose roots we now realise start many years before it first manifests itself, it is not likely we will have a general cure soon. It took a hundred years to improve cancer cure rates by half.

Therefore, we also need to concentrate on optimising dementia care. While most people with early or moderate dementia live at home, two thirds die in institutions. And of those living in care homes, four out of five have some degree of dementia. So our care home model must be brought up to date. We need to put right the disastrous changes made in the 1980s, when homes were moved out of the health service and lost the input of geriatricians and other health service staff. Specialists need to go regularly into care homes to educate staff. Currently we only respond after problems occur, and these are often identified late. And we need to reward staff for responding to their instinct to care. This means rethinking the way in which care homes are remunerated. In health the cheapest option is often far more costly, as it stores huge problems for other health services. Nothing is more expensive than something that does not work. So the current pressure for people to die in their own homes and care homes is right, but it needs to be matched with a transfer of funds to develop home care to meet the needs of people with dementia in the twenty first century. We need to respond to the fact that, because we all live longer, nursing home residents nowadays have more complex medical conditions on top of their dementia than before; and because society is more atomised, they are often more isolated or have families which need skilled support. The medical, nursing, and social care infrastructure needs to develop hugely without the homes losing the feel of being someone’s home.

A second obstacle in effective dementia care is that nursing, and to a lesser extent medical training, is divided into separate physical health and mental health strands. With a condition that so deeply affects both in interdependent ways, this will never work. Those of us who have worked with people with end stage dementia have seen many psychiatric disturbances go unrecognised by general nurses, or disturbed behaviour from pain and other physical problems being put down to psychiatric causes by mental health staff. Our model of training and care provision is not fit for purpose, and until we make it far more holistic, people with dementia will fall between the cracks. Meanwhile, close collaboration between primary care, old age medicine, old age psychiatry, and palliative care is needed. At the moment single specialty silos deliver care slanted to only one aspect of the condition. At the same time, not spotting complexity and responding inadequately could be hugely expensive for the economy, and the human cost would be incalculable.

So what can we all do in the meantime? We can think what we would want our care to be if we could no longer choose, set it down formally as an Advance Directive, and talk to family about our wishes. It is important to discuss the qualities of the care we would most want, so that relatives could find the best fit for us if we should ever be faced with dementia. And if we have relatives with dementia living in care homes, we should try to build personal relationships with the staff, believing that this will also translate into them having more human relationships with our loved one and others in their care. Because only by the human in each of us recognising the human in the other is there any hope that dementia care will become what it ought to be, based on skill and respect for the enduring dignity of the individual.

Dr Victor Pace is a consultant at St Christopher’s Hospice in Sydenham, London. He led a four year project looking after people with end stage dementia and edited Dementia: from advanced disease to bereavement, a medical text in the Oxford Specialist Handbook series.

Subscribe to the OUPblog via email or RSS.
Subscribe to only health and medicine articles on the OUPblog via email or RSS.
Image credit: The word “Dementia”, by alexdans via iStockphoto

The post How can we respond to the widespread inadequate understanding of dementia? appeared first on OUPblog.