lundi 30 novembre 2015

Even In Your 20s, Fitness Cuts Risk for Later Heart Disease, Major Study Finds

Even In Your 20s, Fitness Cuts Risk for Later Heart Disease, Major Study Finds

(AP Photo/Elaine Thompson)

(AP Photo/Elaine Thompson)

Feeling a bit bloated and sluggish after Thanksgiving weekend? A major study just out in the journal JAMA Internal Medicine offers an added nudge to get back on the exercise wagon. How fit you are even in your 20s, the study finds, can dramatically affect your risk of heart disease and death well into middle age.

So dramatically, in fact, that every minute matters.

Imagine you’re doing a stress test on a treadmill. Every two minutes, the machine makes you go faster and at a steeper incline. The first few minutes are no sweat — you’re walking, then trotting, then jogging — but soon you start to suck air, and finally hit the point that you can bear no more. (Or you may reach the 18-minute maximum, if you’re superhuman.)

Say you did that test in your 20s. Now fast-forward 25 years. The study found that every extra minute you could last on the treadmill meant you were at a 15 percent lower risk of death over that quarter-century, and at a 12 percent lower risk of harmful effects of heart disease, including stroke and heart attack.

“That’s a lot,” I found myself saying in a phone interview with the study’s two lead authors, Dr. Ravi V. Shah, of Harvard Medical School and Beth Israel Deaconess Medical Center, and Dr. Venk Murthy of the University of Michigan.

“We were surprised too,” Dr. Murthy said.

“Two, three, four, five minute differences are not uncommon,” Dr. Shah said. “That adds up. That’s 15 percent per minute — it’s pretty substantial.”

Though, of course, it must be noted that the overall risk of heart disease and death are relatively low in such a young population. Among the 4,872 people in the study, 273 died, but 200 of those deaths had no relation to heart disease. And just 4 percent of the study’s subjects had a “cardiovascular event” like a heart attack.

Still, the results cast new light on just how much fitness matters for heart health — even in our 20s, when many of us can still get away with a sleepless all-nighter or an all-weekend TV binge.

This new research is the first large study to examine people in their 20s onward over such a long period, the lead authors say, and underscores the importance of starting good fitness habits early — not just in later years, when the health price of inactivity is already well known.

The study also found that the heart benefits of fitness held true independent of weight and other heart risk factors. That suggests, Dr. Shah said, that “being fit is important for everyone, not just for people who are trying to lose or maintain weight.”

The study — an epic endeavor that began back in the mid-1980s and was led by four universities, including Harvard and Johns Hopkins — also suggests that early trajectory matters. That is, typical as it may be, it is not a good idea to let your fitness decline in your 20s.

Nearly 2,500 of the subjects underwent a second treadmill test just seven years after the first. For every minute less that they could last compared with their first test, their risk of death in the coming years went up by 21 percent, and their risk of heart disease by 20 percent.

And one other, particularly fascinating finding: Fitness as reflected by treadmill performance did not seem to matter for an accepted measure of heart health, the accumulation of calcium deposits in the arteries that supply the heart.

Drs. Shah and Murthy explain in an email:

“Calcium score” is something that we measure on a CAT scan that reflects how much calcium is deposited in the arteries that supply the heart (the coronary arteries). A higher calcium score is taken to indicate a higher burden of coronary artery disease, and many studies have found that calcium score is associated with poorer cardiovascular health and outcomes.

One would expect that greater fitness would therefore be related to a lower calcium score or absence of calcium in the arteries. We found that fitness in early adulthood was not related to the presence or extent of coronary artery calcium 25 years later.

This doesn’t mean that exercise and being fit doesn’t reduce your risk of heart disease — in fact, we found that markers of heart muscle health were certainly improved with greater fitness. It does, however, suggest that the biological relationship between exercise and heart health is complex, and needs further study.

“The surprise in this study was that there was not a relationship of outcomes to coronary calcium scores,” said Dr. Ira Ockene of UMass Medical School, who co-wrote a commentary on the study. “So what’s that all about? Well, the authors didn’t really know. But they raised a number of possibilities. One possibility is that in young people, disease has a different mechanism than you might see in older people,” and the effects in arteries may progress at a different rate.

There’s a great deal we don’t understand about the biology that underpins the health benefits of exercise. But clearly, Dr. Ockene said, “We’re designed to be very physically active, and when we just sit, it’s not good.”

Safety note: If you’re a quantified-self health hacker and now want to use the study’s calculations to assess your own heart-disease risk, Drs. Shah and Murthy caution against trying a treadmill test protocol at home or at the gym.

“We absolutely do not think that’s a good idea,” Dr. Murthy said. “These protocols are designed to wear people out very, very quickly; they’re done under medical supervision. And what we really wouldn’t say is a good idea is for people to go home and do this without that level of experience, because not only can they have heart complications, but they can have falls and injure joints. These are done with a whole medical team observing and supervising.”

“That being said,” he added, “People who feel like they’re not currently exercising and don’t feel like they’re fit, absolutely it’s a good idea to start an exercise program. But if you’re not actively engaged in exercise and you’re not in shape, it’s also probably a good idea to see your doctor first.”

Readers? Reactions, thoughts, personal experiences?

vendredi 27 novembre 2015

As If PMS Weren’t Bad Enough, Study Links It To Later High Blood Pressure

As If PMS Weren’t Bad Enough, Study Links It To Later High Blood Pressure

(Newton Free Library/Flickr Creative Commons)

(Newton Free Library/Flickr Creative Commons)

By Dr. David Scales

As if the symptoms of PMS itself weren’t bad enough – the hot flashes, dizziness, cramping, trouble sleeping — now researchers have found a possible link to high blood pressure.
Currently, doctors are naturally aware of Premenstrual Syndrome, but are not thinking about it as a warning sign that a patient is at risk for developing health problems down the line. A new study by Dr. Elizabeth Bertone-Johnson, an epidemiologist at UMass, and her colleagues may soon change that.

They studied over 1,200 women – all part of a well-known and long-followed group called the Nurses’ Health Study – who developed at least moderate PMS. The researchers matched them to twice the number of women without PMS symptoms and looked for links to the diagnosis of high blood pressure.
Their analysis, published this week in the Journal of Epidemiology, found women with moderate-to-severe PMS had a 40% higher risk of developing high blood pressure over the next 20 years than the control group that experienced few PMS symptoms.
The researchers took into account factors we already know lead to hypertension, such as obesity, smoking, or a lack of exercise.
Still, the study had a number of limitations, so it will need to be repeated to make sure the link between PMS and high blood pressure holds up to scrutiny.
Dr. Bertone-Johnson and her colleagues are also looking into ways to prevent the symptoms of PMS. So far, they have found that high dietary intake of certain vitamins like thiamine, riboflavin or vitamin D as well as calcium can lower the risk of developing PMS. Another study by Bertone-Johnson’s group suggested increased iron and zinc intake may be protective.
These studies are preliminary, though, so I wouldn’t go out and load up on vitamins, iron and zinc –- but they do suggest that PMS may be treatable, and that treatment might help prevent some of its potentially harmful downstream consequences.

Sorry, Intriguing Studies Are No Excuse To Skip The Flu Shot This Year

Sorry, Intriguing Studies Are No Excuse To Skip The Flu Shot This Year

 (Rick Wilson/AP Images for NCOA)

(Rick Wilson/AP for NCOA)

By Alison Bruzek

Warning: You may be tempted to use some of the following information to rationalize skipping your annual flu shot. But in fact, you’re out of luck. The message from public health authorities is absolutely clear: roll up your sleeve (or prepare your nasal passages) and get your flu vaccine.

“Just do it now, would be my advice,” said Dr. Larry Madoff, director of epidemiology and immunization at the Massachusetts Department of Public Health. “There’s always a benefit to getting the flu vaccine.”

Granted, you wouldn’t be entirely crazy for thinking otherwise, thanks to recent headlines like these:

From USA Today last winter: “Flu shots only 23% effective this season.

From CBS News: “Flu vaccine might be less effective in statin users.”

And on the front page of The Boston Globe earlier this month: “Repeated flu shots may lose potency.” (The story came from STAT, the Globe’s new online sibling publication covering medicine and bioscience, which used the headline, “Getting a flu shot every year? More may not be better.”)

The STAT story reports in its third paragraph that public health officials “still believe an annual vaccination is better than skipping the vaccines altogether.” But its primary emphasis is on a “growing body of evidence” that with flu vaccines, “more may not always be better.”

As one mother wrote on Facebook, “[It’s] very upsetting for someone like me, who has had their kids vaccinated every year.”

The message is confusing, even for someone well aware of the recommendation from public health authorities that everyone over six months old should get a flu vaccine unless there’s a medical reason to avoid it. Flu is no joke: It kills thousands, and probably tens of thousands, of Americans a year, the CDC says.

So what to do if you’re still worried?

To begin with, listen to the author of the study, Dr. Edward Belongia, an epidemiologist at the Marshfield Clinic Research Foundation. The STAT story notes he still strongly encourages everyone to get their flu vaccine.

As Dr. Belongia told me about his study: “At this point there really aren’t any implications for the general public.” Rather, it’s a jumping-off point for future research. Furthermore, the study was presented as a poster in October at an infectious diseases conference; it hasn’t yet been through the rigorous peer review required for publication in a scientific journal.

The study itself is intriguing — it concluded that children who had gotten a flu shot in two previous years, for a specific strain of the flu, were more likely to contract that flu than kids who had just been vaccinated for the first time.

But Dr. Madoff at the Massachusetts Department of Public Health said the idea that vaccines may bring diminishing returns isn’t new. In fact, it’s been around since the 1990s. And the bottom line, he said, is that “the return may diminish but there’s always a benefit to getting vaccinated.”

Or as a spokesperson for the CDC said, “This is an interesting new finding and CDC will be looking into it further. For now, the CDC recommendation for vaccination remains unchanged.”

The CDC recommends a flu vaccine every year because the body’s immune response prompted by vaccination declines over time, and flu viruses change from year to year. So “if you have been vaccinated recently, there’s still clearly a benefit to getting a flu vaccine this year and every year,” Dr. Madoff said. It’s true, he said, that “the additional benefit you gain isn’t as great if you’ve been vaccinated previously, but there’s still clearly a benefit.”

One of Dr. Madoff’s potential explanations for why flu vaccines could have a diminishing effect is that antibodies to the flu you already have may bind to portions of the new flu vaccine and make them less active. Or it could be that if you’re already immune to one strain of the flu and get another vaccine, instead of creating new antibodies for the new strain of flu, the vaccine instead boosts the antibodies for the older strain.

But “these are theories,” he said, “and I don’t think we really fully understand what’s accounting for this phenomenon.”

There’s reason to hope the question will someday be moot, though. Research is under way on a “universal” flu vaccine that would work for all strains and so there would no longer be a need for annual shots.

For now, if your head is still spinning from the back and forth, the best answer is to follow the CDC’s guidelines for the flu vaccine and let the scientists debate until they come to a consensus. Until they do, the guidelines won’t change.

Still not persuaded? Dr. Madoff has some good flu news for this year: The flu vaccine cocktail is better than ever. Last year, the flu vaccine strains that were chosen ended up being a poor match for the strains that were circulating. This year, he says, the match is much closer.

Wade Roush, a longtime technology journalist and outreach officer for the Program in Science, Technology, and Society at MIT, said he cringed a little when he saw the STAT headline, out of concern that it could reinforce the views of people who are already suspicious of vaccines.

“We know that thanks to the media ruckus over the measles vaccine, and the fraudulent idea that it might cause autism, there are still clusters of parents who don’t get their kids vaccinated,” he said. So when reporting on vaccines, a frame that doesn’t feed into the myths about vaccines is especially crucial.

“The risk of contracting influenza and getting sick or dying if you don’t get vaccinated is the same as it ever was, and you can still lower that risk drastically by getting vaccinated,” Roush said. That’s the context a story on any vaccine especially needs.

And if you’re finally convinced, there’s still time. The flu vaccine takes a few weeks to have an effect, Dr. Madoff said, but the peak of the season isn’t until January/February. And consider: In Massachusetts, the Department of Public Health now ensures that all flu vaccines for children under the age of 18 are free.

James Van Der Beek receives FluMist. (PRNewsFoto/AstraZeneca)

James Van Der Beek receives FluMist. (PRNewsFoto/AstraZeneca)

jeudi 26 novembre 2015

Elder Hunger: New Efforts To Combat Surprisingly Common Malnutrition Among Seniors

Elder Hunger: New Efforts To Combat Surprisingly Common Malnutrition Among Seniors

Jeff Kubina/Flickr

Jeff Kubina/Flickr

By Nell Lake

After her stroke, a 95-year-old woman in New York State found that she could no longer taste her food. She was also unable to feel hunger, so she didn’t know when she was supposed to eat. As a result, the woman began losing weight, grew weak and wasn’t getting the nutrients she needed.

Enter Meals on Wheels, a national home-delivered meals program established by the 1965 Older Americans Act. The woman (who asked that her name not be used) began receiving meals at her home five days a week. This, she says, helped her remember to eat regularly. Her weight improved, and so did her general health.

Malnutrition like hers is surprisingly common. Six percent of the elderly who live at home in the United States and in other developed countries are malnourished, according to a 2010 study in the Journal of the American Geriatric Society. The rate of elder malnutrition doubles among those in nursing homes — 14% according to the same study.

And rates skyrocket among elderly populations in rehabilitation facilities and hospitals: Various measures show an astonishing one third to one half of seniors are malnourished upon being admitted to the hospital.

“Malnutrition is a serious and under-recognized problem among older adults,” says Nancy Wellman, a nutritionist and instructor at Tuft University’s Friedman School of Nutrition Science and Policy.

It’s not a new problem. But growth in the elderly population, and concerns about healthcare costs, have helped renew efforts by nutritionists and other advocates to establish screenings for malnutrition in medical settings, and to improve interventions that can prevent or reverse the issue.

Nutrition Complexities

Most basically, malnutrition means not getting enough nutrients for optimal health. In older adults, the causes are complex, experts say. Illness, disability, social isolation, poverty — often a combination of these — can all contribute to malnutrition. An older person may become malnourished because she has trouble chewing or swallowing. The medications she takes may suppress appetite. She may be unable to get to a grocery store. She may live alone, be depressed, or simply be uninterested in eating.

It’s important to know, says Connie Bales, a dietician and faculty member at Duke University Medical Center, that obese and overweight seniors can be malnourished, too. Eating too many calories doesn’t necessarily mean you’re getting the right nutrients for maintaining muscle and bone. “One can be quite malnourished, yet not be skinny,” Bales says.

High Costs 

Whatever the cause, malnutrition leads to further trouble. It increases older adults’ risk of illness, frailty and infection. Malnourished people visit the doctor and are admitted to the hospital more often, have longer hospital stays and recover from surgery more slowly.

The association between malnutrition and hospitalization goes both ways, say Wellman and other experts: The sick are more likely to become malnourished, and the malnourished are more likely to get sick.

Thus, says elder advocate Robert Blancato, speaking at a recent panel on the topic, improving nutrition among older people is important not just to their well-being and quality of life, but to containing health care costs. The malnourished generate bills $2,000 to $10,000 higher per hospital stay than others do, according to a study in the Journal of the American Dietetic Association.

Another study published in the journal Clinical Nutrition found a threefold increase in medical costs among the malnourished. (Hospital stays can also cause or worsen elder malnourishment: Older patients often don’t eat well in the hospital, and doctors may prohibit them from eating or drinking in preparation for medical procedures.)

Food Insecurity 

Not surprisingly, financial hardship is a central cause of elder malnutrition. According to a 2014 report from the AARP Foundation, nearly 9 million older people in the U.S. can’t afford nutritious food. About one quarter of low-income adults 65 and older say they’ve reduced the size of their meals or have skipped meals because they didn’t have enough money.

Jeffrey Bubar might have been among them — his fixed income places him barely above the federal poverty line. Yet he’s well fed.

Earlier this week, Bubar, 76, dug happily into a plateful of sloppy Joe, baked potato and vegetables. He chatted with four other elderly men, also regulars at a Congregate meals program in Northampton, Massachusetts — one of hundreds of such programs across the country. (Another provision of the Older Americans Act.)

Bubar — who has no family, lives alone and has no car — walks to the program every weekday. The meals provide him with both companionship and nourishment — sources of health and well-being that would otherwise likely elude him. “I like being with people,” he says.

His fixed income places him barely above the federal poverty line. Without the meals, food would make a much bigger “dent” in his budget, he says; and the program’s nourishment “helps keep my health up.” It’s a nutritional and social anchor in his otherwise isolated life.

But many eligible seniors don’t receive such benefits. The AARP report, for example, found that of those elders eligible for the Supplemental Nutrition Assistance Program (SNAP), only 13 percent receive the benefit. It’s an important gap to address, says Lura Barber, director of Hunger Initiatives for the National Council on Aging, and there are many reasons for it. One is that “there’s a huge stigma attached to [food benefits],” she says. Older people worry, for example, that by receiving help they’ll take benefits away from children who need it. But “seniors are also less likely than other age groups to know about the program, about how to apply, and [to know] that they might be eligible.”

Following hospital stays, these programs could also help patients recover from illness or surgery. And yet very few hospital patients receive information about nutrition benefits. A recent survey by the Gerontological Society of America found that only 6 percent of hospitalized elderly received information about SNAP. Only 3 percent of hospitalized older people received information about group meals programs such as the one Bubar benefits from. And only 3 percent learned about the availability of delivered meals to home-bound seniors.

Good Nutrition, Better Outcomes 

Such lack of information is another problem worth addressing, Barber says. “There’s a huge gap in how we’re providing vulnerable older adults with help as they move from a healthcare setting” back to their homes. Even those simply “going to a doctor for a regular visit are not learning about [nutrition] programs.”

Rose Ann DiMaria-Ghalili, a nurse and researcher with Drexel University’s College of Nursing, says better nutrition can improve hospital outcomes and reduce hospital readmissions. “We know,” she says, “that weight loss increases the risk of 30-day readmission,” she says. “And that failure to thrive and weight loss are frequent reasons for readmission in surgical patients.”

Nancy Wellman says, “If you can’t eat well, you’re going to end up in a nursing home, or you’re going to end up back in the hospital.”

Given mounting evidence that better nutrition in both older patients and seniors living at home is a cost-effective way to improve health outcomes—not to mention quality of life—Wellman and others call for several manageable fixes:

Rethinking Hunger

“We should be thinking about nutrition as one of the key aspects of healthy aging, of maintaining our independence, maintaining our quality of life, staying out of nursing homes, and staying out of hospitals,” Wellman says. She and other advocates urge individuals, community programs, medical professionals, and policymakers to learn about and prioritize nutrition as an important and relatively inexpensive way of improving health.

Nutrition Screenings And Interventions

Including nutritional status and nutrition interventions in patients’ plan of care would promote better outcomes, says DiMaria-Ghalili. And Wellman says, “We need to establish systematic screenings and intervention models” for patients entering and leaving the hospital. Connie Bales of Duke Medical Center argues that doctors and nurses could usefully view patients’ nutritional status as a vital sign, as they do blood pressure or temperature: “We know what [a patient’s] pulse rate is, what their respiration rate is,” Bales says. “What about their nutritional status?”

Access To Benefits 

Barber would like to see nurses routinely asking elderly patients whether they’re receiving nutrition benefits, and referring them to meals programs and SNAP where appropriate. Nurses or other staff, she says, could also help older patients fill out applications for benefits before patients leave the hospital.

Eat Well

Finally, Wellman offers basic advice to older adults: “Bring home more fruits, more vegetables, some low-fat dairy…or full-fat milk if you’re underweight. Bring home prepared or prepackaged food, because it’s more likely that you’ll eat it.” If foods aren’t appealing, try adding more spices to enhance taste. If you’re overweight but ill, she says, it’s often better to prioritize eating well over losing weight. And if possible, seek out company: “People eat better when they’re with other people,” Wellman says.

On Monday, Bubar was looking forward to joining his friends at the Congregate program for the Thanksgiving meal. He’d already checked out the menu: “It’ll be turkey and whipped potatoes and butternut squash,” he said. He expected that the program’s cook would make the pies right there in the kitchen, so Bubar was eagerly anticipating house-made pumpkin pie with whipped cream.

Nell Lake is the author of “The Caregivers: A Support Group’s Stories of Slow Loss, Courage, and Love.” This article was written with support from the Journalists in Aging Fellowships, a program of New America Media and the Gerontological Society of America, sponsored by the Silver Century Foundation.

mercredi 25 novembre 2015

Why To Exercise (During Pregnancy) Today: Ob-Gyns Say It's The Best Time To Boost Health

Why To Exercise (During Pregnancy) Today: Ob-Gyns Say It's The Best Time To Boost Health

il-young ko/Flickr

il-young ko/Flickr

Yes, they’ve told us this before: If you’re pregnant, you needn’t refrain from exercise. But now, the influential (and fairly conservative) professional group of U.S. obstetricians and gynecologists is saying it even more forcefully: If you’re pregnant and facing no complications, you really should exercise — it’s the ideal time to improve your health, including your weight.

In an updated committee opinion, the group, the American College of Obstetricians and Gynecologists (ACOG)says: “Women with uncomplicated pregnancies should be encouraged to engage in physical activities before, during, and after pregnancy.”

The list of recommended activities includes: walking, swimming, stationary cycling, low-impact aerobics, yoga (modified and not hot), pilates (also modified), running, jogging, racket sports and strength training, and all with the usual caveats to check with your doctor first.

Importantly, the opinion says: “Some patients, obstetrician–gynecologists, and other obstetric care providers are concerned that regular physical activity during pregnancy may cause miscarriage, poor fetal growth, musculoskeletal injury, or premature delivery. For uncomplicated pregnancies, these concerns have not been substantiated…”

Here are the full set of ACOG’s updated recommendations:

• Physical activity in pregnancy has minimal risks and has been shown to benefit most women, although some modification to exercise routines may be necessary because of normal anatomic and physiologic changes and fetal requirements.
• A thorough clinical evaluation should be conducted before recommending an exercise program to ensure that a patient does not have a medical reason to avoid exercise.
• Women with uncomplicated pregnancies should be encouraged to engage in aerobic and strength-conditioning exercises before, during, and after pregnancy.
• Obstetrician–gynecologists and other obstetric care providers should carefully evaluate women with medical or obstetric complications before making recommendations on physical activity participation during pregnancy. Although frequently prescribed, bed rest is only rarely indicated and, in most cases, allowing ambulation should be considered.
• Regular physical activity during pregnancy improves or maintains physical fitness, helps with weight management, reduces the risk of gestational diabetes in obese women, and enhances psychologic well-being.
• Additional research is needed to study the effects of exercise on pregnancy-specific outcomes, and to clarify the most effective behavioral counseling methods and the optimal intensity and frequency of exercise. Similar work is needed to create an improved evidence base concerning the effects of occupational physical activity on maternal–fetal health.

Raul Artal, M.D., the main author of the new committee opinion, said that unlike in previous eras, pregnancy today “should not be looked at as a state of confinement.” He said in an interview that only a mere “16 percent of pregnant women engage in physical activity” and noted that the obesity rate among women of reproductive age is alarming. (Based on 2011–2012 data, the prevalence of obesity in women ages 20-39 in the U.S. is 31.8 percent and it’s 58.5 percent when the overweight and obese categories are combined, according to the ACOG report.)

Obviously, problems with obesity in pregnancy aren’t new, and ACOG has already issued recommendations on the issue, so why the update now?

“I strongly believe that pregnancy is an ideal time to initiate an exercise program,” said Artal, professor and chair emeritus of the department of obstetrics, gynecology and women’s health at St. Louis University. “Women have easy access to medical care in pregnancy more than any other time during their lives. They have more medical supervision than any other time in their lives. When else does a women have eight, 10 medical visits a year?”

He said this update is essentially more emphatic than earlier recommendations.

“Now we are more definitive in our advice,” Artal said, noting that the benefits of exercise for pregnant women include maintaining physical fitness, improving longevity, helping with weight management and preventing diabetes in women who are overweight or obese. Also, he said: “It helps them with preventing hypertension and other sedentary lifestyle co-morbidities.”

ACOG also put out a new practice bulletin on obesity in pregnancy, which it calls “the most common health care problem in women of reproductive age.”

Obesity, ACOG notes, can lead to a range of problems, including:

…an increased risk of miscarriage, premature birth, stillbirth and having a baby with a birth defect. Obese pregnant women are at an increased risk of cardiac problems, sleep apnea, gestational diabetes, preeclampsia and venous thromboembolism, or blood clotting in the veins. The cesarean delivery rate is also higher for obese women, and cesareans pose greater dangers for obese women than for normal-weight women because of increased risks associated with anesthesia, excessive blood loss, blood clots and infection at the incision site. Moreover, the negative impacts on the fetus are long-term: obesity in pregnancy may cause the newborn to have a medically complicated life, because the fetus is directly impacted by maternal obesity.

American College of Obstetricians and Gynecologists Practice Bulletin, 2015

American College of Obstetricians and Gynecologists: Practice Bulletin, 2015

However, the ACOG bulletin says: “Obese women who have even small weight reductions before pregnancy may have improved pregnancy outcomes.”

Based on guidelines issues by the Institute of Medicine, ACOG recommends the ideal weight gain for overweight pregnant women ranges from 15-25 pounds, and the range for obese pregnant women is from 11-20 pounds.

Of note, the group al so says that motivational interviewing (which we’ve reported on here) has been successful “to promote weight loss, dietary modification, and exercise.”

Opinion: Why The WHO Botched Ebola, And How Proposed Fixes Miss The Mark

Opinion: Why The WHO Botched Ebola, And How Proposed Fixes Miss The Mark

A World Health Organization worker trains nurses on how to use Ebola protective gear in Freetown, Sierra Leone last year. (AP)

A World Health Organization worker trains nurses on how to use Ebola protective gear in Freetown, Sierra Leone last year. (AP)

In the latest Lancet, a report from an independent panel of experts lambastes the World Health Organization for its handling of the Ebola outbreak. The panel makes 10 recommendations to help get the WHO in better shape for the next global epidemic alert.

I wish I could tell you not to worry, that the WHO will heed these recommendations and handle its next epidemic much better, so that the outbreak will never get as widespread and disturbing as Ebola was last year.

But I did my PhD dissertation on how the WHO plans for and responds to health problems like infectious diseases that don’t respect borders, and my sad conclusion is: Not gonna happen.

I agree wholeheartedly with many of the new recommendations — like that the WHO should focus on supporting countries with technical advice, and create a dedicated center for outbreak response. But if the WHO carries out even one of the 10, it will be a miracle.

Why should you care? Well, it’s widely thought that the WHO botched the Ebola outbreak: It was late in releasing information, and was even called out by Doctors Without Borders for its lackadaisical response.

And why did it botch the response? Because it is not built to rapidly balance politics with medicine, which is exactly what’s required in an epidemic. It can’t be helpful doctor and tough enforcer at the same time.

The independent panel, launched by the Harvard Global Health Institute and the London School of Hygiene & Tropical Medicine, includes world health experts and former high-level WHO officials, but it seems to forget how the WHO works. The experts have made pie-in-the-sky recommendations that the WHO is unlikely and probably even unable to implement, making it more likely that it will repeat its mistakes.

I spent close to four years working on my dissertation, which had the riveting title “Exit, Voice and (Trojan) Loyalty: The World Health Organization and the Dynamics of International Disease Control.” Luckily for you, you don’t need to read it (not even my mom has, to be honest). There are just two quotes you need to understand pretty much everything about my dissertation and how the WHO responds to infectious disease risks.

Quote No. 1: “Our clients are our member states.”

A WHO official told me this during my first week researching in the archives. You might think the WHO works for the health of the people. Unfortunately, that’s a common misunderstanding. The WHO’s first priority is to the governments of its member states. Understanding that allows you to make sense of the WHO’s actions (or lack thereof) during an epidemic.

It also makes many of the recommendations from the panel impractical. The panel is basically asking the WHO to go rogue and bite the hands that feed it, criticize sensitive and capricious governments that, if threatened, will simply throw the WHO and all of its officials out of the country.

The panel’s experts wants the WHO to get tough with countries that aren’t cooperating. They want countries to submit to inspections to make sure their abilities to detect epidemics are up to snuff. They want the WHO to reprimand countries that don’t report epidemics quickly enough, and “confront governments that implement trade and travel restrictions without scientific justification.”

I’ll believe it when I see it. The WHO’s first priority is to the governments with which it works.

That priority brings the benefit of being able to do vaccination campaigns and tuberculosis control in horrible places like North Korea or Syria.

But the downside is that the WHO will almost never “get tough” with governments that aren’t cooperating. It’s only ever done that once — by issuing travel advisories during SARS when information on disease spread was slow — and it was reprimanded for it by member states’ governments.

That’s why the WHO is even less likely to cross governments in the future. And that’s what happened with Ebola: Internal emails revealed that the WHO resisted declaring an outbreak out of concern it would anger African governments.

The WHO’s clients are its member states.

I don’t like it any more than you, but that’s the reality of how the WHO works. Somebody has to work with the North Koreas of the world.

Quote No. 2: “When we enter that room, we are not scientists anymore. We are about business.”

An African government official told me this during a global WHO conference that was trying to set safety standards. She was a scientific expert in her field, lamenting how science went out the window the minute they started negotiations. I thought it captured pretty accurately the false separation between politics and science that the WHO and other UN technical organizations have tried to create.

In theory, the WHO does “risk analysis” on one side, which is supposed to be scientific and objective, and “risk management,” the political process of balancing the scientific information with values, culture and politics, on the other. In reality the two are never separate.

Much of my dissertation focused on what happens at the WHO when trying to make concrete policy with uncertain science: politics inevitably intervenes (Sheila Jasanoff at Harvard has done wonderful work on this front.)

So when the International Health Regulations from 2005 required that the WHO convene an expert committee before declaring an epidemic, it hoped to make this more of a scientific process but instead turned it into a political one.

The expert panel’s recommendations don’t address this but entrench it. They suggest there should be a standing expert committee that would somehow be both transparent and “politically protected.” How? The expert panel gives no hints.

So what is to be done? What has worked: Soft power

The WHO is excellent at working with governments on cooperative endeavors. Its people are masters of the art of the possible.

The WHO has been highly successful, for example, in getting countries to prepare for pandemic influenza. They’ve done workshops, trainings, drafted pandemic preparedness plans and helped experts inside countries to get governments of poor countries to think about a problem that otherwise would not be as high on the agenda as HIV, malaria or tuberculosis.

By WHO’s count, well over half the countries in the world have developed pandemic influenza plans. There is no international law telling countries to make a plan. The WHO isn’t punishing those countries that have not created plans, nor is it shaming them.

WHO’s model has been to work in partnership with countries to try to build capacity in this area. And this strategy of soft power and cooperation has largely worked so far.

The problem is that during an epidemic, you might need someone to be the bad guy and call out countries that are being secretive. Asking the WHO to serve both functions is not only undermining the WHO’s strengths but actively trying to get the WHO to annoy its funders and its main clients.

We’d be better served to recognize this sooner rather than later. The UN should create a different organization that can serve as the tough guy during epidemics. The expert panel hints at this by recommending the UN Security Council create a global health committee (recommendation eight.)

A new committee would allow the WHO to stay neutral, cooperate with the global pariah states when necessary, and provide technical expertise — all things it is great at — while giving this other organization the teeth that the WHO lacks.

No matter how expert panels ask the WHO to take on the additional role of global policeman, it just isn’t going to happen.

mardi 24 novembre 2015

More On ‘Sundowning,’ And The Agitation That Can Grip Seniors After Dark

More On ‘Sundowning,’ And The Agitation That Can Grip Seniors After Dark

(edward musiak/Flickr)

(edward musiak/Flickr)

Our post last week on “sundowning” — a syndrome in which seniors’ behavior changes dramatically after dark — generated an outpouring of stories from patients, caregivers and people working in hospitals, in hundreds of comments on Facebook.

Many brought up the fact that delirium and sundowning are related. While sundowning is thought to happen in elderly patients with advanced dementia, many people described seeing sundowning in others — like a relative after surgery. While experts aren’t sure how much sundown syndrome and delirium overlap, they agree that not everyone who gets confused at night is sundowning.

Delirium is very common and also gets worse at night. So the first time someone experiences delirium they should be checked for underlying and reversible causes like infections or mind-altering medications.

People also pointed out that sundowning can happen at home as well as in the hospital. For people with severe dementia like Alzheimer’s, this is especially true.

Some commenters referenced “The Visit,” a recently released horror movie where two children are visiting their elderly grandparents who exhibit erratic and violent behavior each night. I haven’t seen it myself, but it seems to be taking the concept to the extreme in the most frightening way possible.

Many of the stories on Facebook were particularly moving. We thought we’d share a few:

The nurses told me this might happen and requested someone stay all night with her, which I did. She was seeing red roses everywhere and wanted to get out of bed and pick them! Her hands were moving just as if she had scissors and a basket to hold them. Another time she saw waterfalls. At least she saw something beautiful.

I watched my mom suffer through this. She would sleep all day unless the staff of the nursing facility kept her engaged in activities but she became increasingly agitated as evening fell. She actually got out one evening and a staff nurse who happened to be driving to work found her driving her wheelchair down the street at 2 a.m. “Going home” is what she told the nurse.

The article suggests keeping hearing aids within easy reach. My late father had dementia and had a habit of flushing inappropriate things down the toilet. His hearing aids disappeared while he was in a rehab hospital following hip surgery. We believed he may have flushed them down the toilet.

There also were a number of heartwarming stories of family and caregivers dealing with this condition in creative and heroic ways:

My grandmother had senile dementia and lived in her own apartment in our home. As her confusion increased, I began sleeping on the floor in her room because she was up all night and endangering herself. One night she screamed that she had to push the baby out. Not knowing what else to do, I said OK PUSH! And she did and I said Here’s the Baby! She calmed down and went back to sleep. The next morning she asked me where the baby was. Luckily my uncle (who had schizophrenia and lived her her apartment but with us also) was sitting across from her. I said, here’s your baby right here. Since it was true, she believed me and let it go…

We deal with this every night. We have kept my husband’s 91 year old grandmother in her own home with her husband through a lot of effort and determination but when that sun sets, it’s easy to consider putting her in a facility because she completely loses it and starts looking for kids and dogs that aren’t there, talking to herself, and being obsessed with electronics having lights…. if they have lights, she HAS to turn them off somehow and she will not go to bed until they turn off…. Sometimes she says the most bizarre things… It’s sad to watch, but we continue to work hard to keep her and her 99 year old husband in their home, and not in a facility.

Some years ago (I’ve been a nurse just over 20 years), I had a patient offer me a small stack of tri-fold paper towels, saying “These are all my war bonds. Can you help me escape?” It took an army itself to hold back my tears…this man trusted ME…. I said to him… I have have a safe place for you to sleep; I will watch over you while you rest…. I lead him back to his bed whilst he laid his head down, unable to take his “money” as he may need it for later. I think to myself… This man fought for ME; I will not let him down. We all have our inner fight… What are you struggling for??

While a few people lamented that some hospitals were clueless about sundowning and delirium, others talked about hospitals that were success stories:

The hospital I currently work in has an strong non-pharma approach to sundowning including “a sense of security,” “knowing baselines” (when possible), “providing hobbies” or simple activities,” and often we provide a “sitter” (someone who has received a brief training on how to interact w/ confused patients by implementing the previously listed interventions). As an RN, I would often direct support staff to initiate activity (walking when possible), but the fact that these patients are confused, usually a bit anxious or downright afraid, and the fact that we have other patients trying to sleep at night often made walking the halls prohibitive. These “sundowning” patients often have a goal of getting off the floor and out of the hospital, and walking by doors and elevators can often escalate their focus on wanting to “escape.” The interventions listed in this story are a jumping off point, but, in my experience (18 years as an RN and 2 years as a CNA), these interventions are ineffective. We need more research to help keep our sundowning patients safe.

And many people were thankful for the compassionate individuals who work in hospitals who went the extra mile to provide care for a loved one who may have been sundowning.

I will never forget one particular nurse who decided it was perfectly alright to let my mom sit in her wheelchair at the nurses station and answer a phone that they disconnected from the switchboard. It gave my mom a feeling of purpose in an otherwise scary and overwhelming time. I received one or those middle of the night “we can’t get her to calm down or cooperate” phone calls but by the time I got there the head nurse had decided to approach the situation differently than medicating and sending her back to her room. My mom was sleeping peacefully in a wheelchair at the nurses station having answered so many pretend calls.

Thank you so much for your compassion. When my grandpa had cancer, he had to be admitted to hospital for tests we already knew it was the worst. Sundowning was the hardest to see. The RNs and the CNAs were so amazing. The first couple of weeks we would rotate staying over night at the hospital. So we saw the Sundowners first hand, one night the RN pull us aside and said, “Go home and get some rest. I will personally see that he’s okay.”

David Scales, M.D., Ph.D. is a third year resident in internal medicine at Cambridge Health Alliance.


vendredi 20 novembre 2015

Mass. Moves To Adjust Controversial Medical Marijuana Testing Standards

Mass. Moves To Adjust Controversial Medical Marijuana Testing Standards

There are currently four medical marijuana dispensaries open in Massachusetts — in Salem, Brockton, Northampton and Ayer. But patients aren’t able to buy the full 10 ounces every 60 days that is allowed by state law because most of the marijuana grown by these facilities is not passing state testing standards, which dispensaries say are too strict and not realistic. Now the state is proposing a fix.

Revised draft testing standards released Friday by the Department of Public Health (DPH) propose changing the amount of marijuana — and in turn possible contaminants — regulators expect heavy users to consume.

The current assumption is up to 1 ounce a day. That’s a lot of marijuana — in the range of 40 joints, depending on the size. If you smoke 40 joints a day you’re much more likely to inhale a dangerous amount of lead, mercury or arsenic than if you smoke 12 to 15 joints a day, which is what the state would assume (using a very rough ounce to joint translation) under the new proposed standards.

To be more precise, the state’s revised standards are based on the assumption that patients would inhale or ingest 0.35 ounces a day, or 10 grams.

“The department is shifting away from a worst case risk assessment style approach and more to a pharmaceutical industry based approach,” said Marc Nascarella, director of the environmental toxicology program at DPH.

The revisions include allowing generally higher amounts of arsenic, cadmium, lead and mercury, but with more specific guidelines for recommended use. More lead is allowed, for example, in marijuana products a patient eats or drinks than in pot used for smoking, vaping and creams.

New labels would have to say how much of the product is safe for daily use and in what form — by inhalation, ingestion or topical.

“With this new pharmaceutical approach, we’re able to specify the amount of exposure and the intended use,” Nascarella said, “similar to what you’d see on a bottle of Tylenol.”

Here’s a DPH summary of the proposed before and after:

In this slide, DPH compares current testing regulations and the department's proposed changes. In first bullet point, AHP is short for American Herbal Pharmacopoeia, a non-profit that sets quality standards for herbal products and medicines. USP, the United States Pharmacopeia sets stands for medicines foods and dietary supplements.

In this slide, DPH compares current testing regulations and the department’s proposed changes. AHP is short for American Herbal Pharmacopoeia, a nonprofit that sets quality standards for herbal products and medicines. USP, the United States Pharmacopeia, sets standards for medicines, foods and dietary supplements. (DPH)

Nascarella says the state is comfortable making these adjustments because it now has some information now about how much patients are consuming and in what form.

The medical marijuana industry says it is encouraged by the revisions and is pleased the Baker administration will take comments before making the changes final.

“While the new standards appear to be a step in the right direction, there is still work to be done and we look forward to engaging with DPH during this comment period and beyond to provide additional research that may help to address any remaining areas of concern,” Commonwealth Dispensary Association executive director Kevin Gilnack said.

But a group that represents patients using marijuana says the revisions don’t go far enough.

If allowed levels for arsenic and hydrocarbons used to extract marijuana aren’t increased before these changes take effect, “marijuana flower and marijuana concentrates will no longer be accessible through dispensaries,” said Nichole Snow, executive director of the Massachusetts Patient Advocacy Alliance. Snow argues that slightly higher levels of arsenic and hydrocarbons in regulated marijuana would be safer than what’s sold on the street.

Snow and Gilnack plan to file comments on the state’s proposed changes, which are scheduled to become final on March 31, 2016.

Dispensary owners and patients who use marijuana for medical care are anxious to resolve the question of what’s safe for use and adjust testing rules. The medical marijuana industry is growing rapidly in Massachusetts. The state cleared a fourth dispensary to open in Ayer on Nov. 6. A fifth store, in Brookline, is expected to begin sales before the end of the year and there may be a sixth dispensary in January. The number of patients registering for the program and total sales are both rising rapidly.

This monthly update from DPH shows a continued dramatic increase in sales and registered patients. One additional dispensary, in Ayer, was approved to open on 11/6/15, bringing the total to four.

This monthly update from DPH shows a continued dramatic increase in sales and registered medical marijuana patients. One additional dispensary, in Ayer, was approved to open on Nov. 6, bringing the total of open dispensaries in the state to four. (DPH)

Paleo And Vegan Can Be Friends: 11 Points Of Consensus On What We Should Eat

Paleo And Vegan Can Be Friends: 11 Points Of Consensus On What We Should Eat

(J. Scott Applewhite/AP)

(J. Scott Applewhite/AP)

By Rebecca Sananes

For healthy eating fans, it was the All-Star Game. Pick your preferred diet — vegan, paleo, Mediterranean, you name it — and the scientist, clinician or academic behind it was at the table in Boston this week. Think Dean Ornish, S. Boyd Eaton and T. Colin Campbell.

They all gathered at the Finding Common Ground Conference, convened by the nonprofit Oldways, to hammer out a consensus on healthy eating — an antidote to what can seem like endless flip-flops on dietary research. And amazingly enough, they did.

What they found was that despite all the food fights, the prevailing theories of nutrition and healthy eating actually have more in common than you’d think. (Though it’s a bit more complex than Michael Pollan’s classic, “Eat food. Not too much. Mostly plants.”)

After two days of presentations on the latest research, debates over ethics and attempts to differentiate between nit-picky nuance and important distinctions, Harvard’s Walter Willett sums up the consensus like this in a press release: “The foods that define a healthy diet include abundant fruits, vegetables, nuts, whole grains, legumes and minimal amounts of refined starch, sugar and red meat, especially keeping processed red meat intake low.”

So there you have it. But for a more granular look, here’s my take on the 11 principles these top scientists and nutritionists agreed should be the guiding principles when thinking about what and how we eat:

1. Yes to the federal guidelines

From the consensus statement:

The Scientists of Oldways Common Ground lend strong, collective support to the food-based recommendations of the 2015 Dietary Guidelines Advisory Committee, and to the DGAC’s endorsement of healthy food patterns such as the Mediterranean Diet, Vegetarian Diet and Healthy American Diet.

The overall body of evidence examined by the 2015 DGAC identifies that a healthy dietary pattern is higher in vegetables, fruits, whole grains, low- or non-fat dairy, seafood, legumes, and nuts; moderate in alcohol (among adults); lower in red and processed meats; and low in sugar-sweetened foods and drinks and refined grains.

Additional strong evidence shows that it is not necessary to eliminate food groups or conform to a single dietary pattern to achieve healthy dietary patterns. Rather, individuals can combine foods in a variety of flexible ways to achieve healthy dietary patterns, and these strategies should be tailored to meet the individual’s health needs, dietary preferences and cultural traditions. Current research also strongly demonstrates that regular physical activity promotes health and reduces chronic disease risk.

The Dietary Guidelines Advisory Committee is a group of scientists handpicked by the government to create a report detailing nutritional and dietary guidelines. Every five years, their report is reviewed by the USDA and the Department of Human Health Services before being voted on by Congress and implemented as the American Dietary guideline — the public policy informing public school lunches, military food and food industry regulations. The official vetted guidelines are due out by the end of the year.

Along with endorsing that committee’s report, the Oldways Common Ground Committee also backed Mediterranean and vegetarian diets.

2. We have to think about the planet when we eat

Form the consensus:

We emphatically support the inclusion of sustainability in the 2015 DGAC report, and affirm the appropriateness and importance of this imperative in the Dietary Guidelines for Americans because food insecurity cannot be solved without sustainable food systems. Inattention to sustainability is willful disregard for the quality and quantity of food available to the next generation, i.e., our own children.

Background: The DGAC recommended to Congress, for the first time, that nutritional policy should take into account environmental impact.

Harvard professor Frank Hu, who sits on the DGAC and attended the conference, says: “I believe this issue will not go away, so even though those recommendations were not included in the 2015 Dietary Guidelines, hopefully, our work will plant seeds for future recommendations.”

“We can’t completely separate human health from the health of our planet,” he said.

3. Keep politics out of our food policy

The Scientists of Oldways Common Ground lend strong, collective support to the overall process, as well as the overall product, of the 2015 DGAC. We express confidence in their approach to the weight of evidence. We support a transparent process where the evidence-based report of the scientists is translated directly into policy without political manipulation.

One thing the scientists could agree on is that politics should not trump good food policy. When the DGAC’s nutrition report is vetted and voted on by Congress, science sometimes takes a backseat to lobbyists from particular food sectors.

4. The yum factor

Food can and should be:
• Good for human health
• Good for the planet (sustainability; ecosystem conservation; biodiversity)
• And simply…good – unapologetically delicious.

This is good news for food lovers and health nuts alike. Dean Ornish, a clinical professor of medicine at the University of California of San Francisco who researches vegan and vegetarian diets, wants to change the trope that plant-based food is rabbit food.

“What Steve Jobs did to make Apple aspirational — he wasn’t showing how much RAM was in his computer,” Ornish said. “He’d have John Lennon or Gandhi saying ‘Think Different.’ I’d love to see an ‘Eat Different’ type campaign.”

5. Let’s be clear

We express strong concern for the high level of apparent confusion prevailing, and propagated among the public about what constitutes a healthy eating pattern. Despite uncertainty about some details, much of this confusion is unnecessary, and at odds with the understanding of experts and the weight of evidence. We affirm that experts with diverse perspectives and priorities can find common ground.

Translation: We might bicker about whether to drink wine, cut out eggs, or whether bacon is the devil – but we agree on some basic tenets: more fruits and vegetables and less processed food.

6. The fundamental things apply

Fundamentals and current understanding do NOT change every time a new study makes headlines. The Oldways Common Ground Scientists emphasize the importance of basing understanding of diet and health on the weight of evidence, including ALL relevant research methods. Biology (adaptation, evolution, plausibility) is a relevant source of evidence. Heritage (cultural traditions) are an additional, relevant source of real-world information on long-term feasibility and health effects of diet.

The newest fad diet… is the oldest one. For the first time, paleos and vegans agreed at the conference that nutrition should come from the paradigm of human diets that have existed for millennia. Anecdotal evidence — albeit long term — is an acceptable measure of what works, as well as lab experiments, attendees said. This was the basis of the Mediterranean diet, which originally looked at good mortality rates in Greece during the 1960s and prompted experiments to test this diet. Trust your elders, was the message; what they ate is probably what nutritionists think you should keep eating. (Or as Michael Pollan puts it: “Don’t eat anything your great-great-great grandmother wouldn’t recognize as food.”)

7. If it bleeds (or involves butter or bacon), it leads

Representations of new diet studies to the public should be made in the context of the prevailing consensus. New evidence should be added to what was known before, not substitute for it sequentially. Accurate reporting is the responsibility of both scientists and the media.

In other words, just because a new study comes out every week, doesn’t mean it’s turning the whole world on its head. Studies come out all the time, that doesn’t mean the basic pillars of eating well change with it. Scientists are asking everyone to remain calm when a new study tells you butter is killing you and remember that it’s more about the big picture.

8. Bring in the subs

To make recommendations for dietary changes meaningful, we strongly endorse the general principal of specifying practical dietary substitutions – a “compared to what” approach. e.g, Instead of simply saying, “Drink less soda,” for instance, say “Drink water instead of soda.” What we consume and what we don’t consume instead, both contribute to health outcomes.

My reaction: “Finally!” Who is sick of being told what you can’t do? (Me!) These scientists are saying they will work to put more emphasis on what works than what doesn’t. More emphasis should be put on the importance of the nutrients you are putting in your body versus what you should cut out.

9. Food stamps, too

Oldways Common Ground Scientists recommend that education programming, policy, and legislation in support of these goals be implemented widely and in a timely manner, with regular monitoring and evaluation. For example, in the U.S., we urge compliance with 7 USC Sec. 5341, which calls for the Dietary Guidelines for Americans to “be promoted by each Federal agency in carrying out any Federal food, nutrition, or health program” – including food assistance programs.

10. Knowledge is power

We support the cultivation of widespread “food literacy” and believe that individuals benefit from becoming knowledgeable about the origins of their food, the conditions under which it is produced, and its impact on their health and the health of the planet. A knowledge of and respect for food traditions and the cultural context of food – health through heritage – is also beneficial, and can be a powerful motivator for better eating, as well as a means of imparting crucial life skills (e.g., cooking).

11. Locavores and composters

Oldways Common Ground Scientists agree that food systems (production, manufacture, food waste, etc.) should align with priorities for human and planetary health while supporting social responsibility/justice and animal welfare. Diverse, localized/regionalized solutions, that reflect site-specific priorities and capabilities are more resilient and democratic. Each of us has a role to play in ensuring a healthy and sustainable global food supply.

Scientists are agreeing that they are friends to the regional farms and ecosystems in the places people live. If you can find food that’s been grown in your area and represents what grows naturally – you’ve done something right, they say.

Overall – the scientists did seem to agree on more than you’d think. My own takeaways: One size does not fit all for healthy diets, and people should not experience whiplash every time a new study comes out. A few basic tenets cover the bases: eat whole foods, preferably grown locally and — my favorite — enjoy it.

Sundowning: Why Hospital Staffs Dread Nightfall, And How To Help Seniors Avoid It

Sundowning: Why Hospital Staffs Dread Nightfall, And How To Help Seniors Avoid It

By Dr. David Scales
CommonHealth Intern

The elderly woman had been normal all day, my colleague told me, tolerating it well when a tube was placed in her bladder to measure her urine. But that evening, she was found wandering the hospital halls yelling in Italian, carrying her urine bag under her arm thinking it was her purse, traumatized that hospital staff were trying to take it away.

Another night in the hospital, a female Sri Lankan colleague saw an elderly man who was convinced she was a Nazi soldier. Reassurances and even a plea from the doctor: “how could I be a Nazi? I have brown skin!” could not persuade him otherwise. The next day the patient was back to normal, incredulous when told about what transpired the night before.

An 80-year-old man — I’ll call him Bill — came to our emergency room after a fall. He seemed fine and his tests were negative, but his family wanted him admitted over night for observation. That evening, he began shouting out, repeatedly wanting to get up and walk to the bathroom (forgetting he had just gone). Our calming efforts only riled him up more.

This erratic nighttime behavior is called “sundowning.” Staff in hospitals and nursing homes always worry what will happen as twilight approaches. As the sun sets, many elderly patients can change drastically: They can become extremely confused, agitated, not know where they are, and even hallucinate. In other words, they exhibit signs of delirium, a confused state that can lead them to do things they otherwise wouldn’t.

nursing homeThankfully, not every elderly patient sundowns, but when one does, it can be emotionally traumatizing for everyone. To be confused or hallucinate, or to see a relative acting out in irrational ways is frightening and destabilizing. Yet, sundowning seems to be extremely common. So, what is it? Why do people sundown? And what can you do to minimize the risk of sundowning in yourself or a close friend or relative?

Experts agree that confusion and agitation are more common in the evening and at night. But there is surprisingly little scientific consensus on what sundowning actually is.

The debate is in how much sundowning and delirium are related. Some experts think they’re the same thing, others separate but related entities.

It’s hard to study sundowning without a clear definition and diagnostic criteria. Experts can’t even be sure how often it happens. A recent review found a rate of anywhere from 2.4 percent to 66 percent.

Dr. Eyal Kimchi, a neurologist at Massachusetts General Hospital who studies delirium (and a friend of mine from medical school), says we are still in the early stages of understanding sundowning. “There are probably many types of delirium — delirium after operations, delirium in the intensive care unit, delirium tremens associated with alcohol withdrawal — and some we haven’t separated out yet. Sundowning may be another one of them.”

We do know a few things, though. Elderly people with memory problems are the most likely to sundown, especially those with bad Alzheimer’s dementia. We know prevention works much better than treatment. Patients in hospitals and nursing homes are particularly prone to becoming agitated in the evening.

But being prone to sundowning isn’t enough — something has to tip the balance, like not being able to see or hear well. Other environmental factors can do it too, like being thrust into unfamiliar hospitals with bright fluorescent lights, having sticky heart monitors on your chest and alarm bells going off at all hours of the night.

Dr. Sharon K. Inouye, Harvard professor and Director of the Aging Brain Center at Hebrew SeniorLife, also pointed to a dizzying array of barely-pronounceable biological factors thought to contribute including “disruptions in circadian rhythms, nadirs in cortisol, stress hormones, sympathomimetic neurotransmitters, melatonin, or fluctuating cytokines.”

If syllable count is any measure, this is as complicated as it gets.

Which is why experts like Inouye and her colleagues developed a series of interventions to address the various factors that contribute to delirium, called Hospital Elder Life Program (HELP). (CommonHealth covered aspects of the program earlier this year)

Many hospitals have similar friendly-sounding protocols. Beth Israel here in Boston uses GRACE (Global Risk Assessment and Care plan for Elders). And there’s NICHE (Nurses Improving Care for Healthsystem Elders), a nursing protocol found in hospitals around the country. While they haven’t been studied specifically for sundowing, they are often used in hospitals to help prevent it.

All of these protocols are similar, and consist of keeping patients’ hearing aids and glasses within reach, getting patients out of bed, making sure they stay hydrated and well fed, avoiding medications that cause confusion, and reducing noise to allow patients to sleep.

It sounds simple and obvious, but these factors are so interrelated that changing one has only a tiny effect. Its power is in the package. HELP now being used by more than 200 hospitals nationwide and abroad.

Still, it’s an uphill battle convincing hospitals to invest in more staff to implement these protocols. “It’s the best thing for the patient and for maintaining quality,” Dr. Hollis Day, currently at University of Pittsburgh Medical Center but incoming Chief of Geriatrics at Boston Medical Center, told me. “Its hard to pay for something that doesn’t happen.”

But this is changing. Accountable care organizations are more common, so hospitals will get penalized if patients stay in the hospital too long. “The financial implications of increased length of stay is one thing motivating hospitals to try to prevent delirium more systematically,”  Kimchi said.

Implementing delirium precautions isn’t easy. It requires a change in mindset away from medications to behavioral interventions. “Doctors can’t always order therapeutic sleep protocols at night or reorientation activities three times a day,” Inouye said. “Giving a sleeping pill is so much quicker than a back rub, herbal tea and soothing music, but much more hazardous.”

While hospitals are changing, friends and families can get engaged in the effort as well. So what can you do to help prevent sundowning?

Ask what protocols the hospital has in place to detect and minimize sundowning or delirium. There’s no data on which is the best, but the important thing is checking that a hospital or nursing home is working to prevent and detect sundowning and delirium.

A “Sense” Of Security

Bring hearing aids, eyeglasses, or dentures to the hospital. This helps keeps patients involved in what’s going on, not to mention able to eat. But keep track of them – these items can get lost in the hustle and bustle, and can be expensive to replace.

Establish Baselines

Make sure the doctors and nurses know what normal behavior is for you or your relative. Is your relative usually sharp as a tack? Or is it normal for them not to know what day it is? This helps the medical team recognize sudden changes.

Be Present

Help patients stay informed on world events or maintain hobbies like crosswords or knitting. Pictures of loved ones or other familiar objects can make the hospital seem less foreign. These steps help keep people oriented and calmer.

Stay Active

Work with doctors, nurses and physical therapists to understand how your family member can stay active. Encourage them to take care of themselves by showering or brushing their teeth, or walk with them around the room – if that is ok with the hospital staff.

Dr. Deborah Rosenbloom, assistant professor at UMass College of Nursing researches family involvement in caring for patients with delirium. She acknowledges that many people cannot stay with their relatives all day — they might live hours away or need to work. In those cases, Dr. Rosenbloom suggests phoning the medical team at admission and then checking in daily.

In Bill’s case, we tried bed alarms, which made things worse. We tried dimming lights and minimizing noise so he could sleep. His bed was near the nurses’ station but we still worried he might jump out of bed and fall before someone could catch him.

At 11pm one recent night, we called his family and discussed two options – sedate him with medications to keep him from hurting himself — a last resort which might worsen the problem — or send him home. All the crucial tests were negative so we agreed that the safest thing, despite the late hour, was for him to go back home to familiar people and a familiar environment. I never heard from him again, but I hoped the familiarity helped him feel settled.

David Scales, M.D., Ph.D. is a third year resident in internal medicine at Cambridge Health Alliance.

jeudi 19 novembre 2015

Study: Risk Of Hidden Cancer In Gynecologic Surgery Higher Than Previously Thought

Study: Risk Of Hidden Cancer In Gynecologic Surgery Higher Than Previously Thought

Undetected cancer among women undergoing a type of minimally invasive hysterectomy or fibroid removal surgery is more common than previously thought, a new study finds. Researchers at Boston Medical Center report that the risk of such hidden cancer is about 1 in 352 women.

The upshot: these women may have had the undetected cancer spread within their bodies through a technique that has fallen out of favor called “power morcellation,” which was typically used in these types of surgeries. The technique involves cutting the woman’s uterus or fibroids into small pieces to make them easier to remove during the less invasive laparoscopic procedure.

The new findings (which looked at the cases of more than 19,000 women) support a 2014 estimate by the U.S. Food and Drug Administration that approximately 1 in 350 women undergoing this type of surgery face the risk of hidden cancer. But earlier conventional wisdom was that the risk of undetected cancer for women undergoing this kind of surgery was closer to 1 in nearly 5,000 or more.

(wikimedia commons)

(wikimedia commons)

“The take-home message of the study is that the true risk of an undetected cancer at the time of gynecologic surgery for what was assumed to be benign disease is about 1 in 352 women,” says Dr. Rebecca Perkins, a practicing gynecologist at BMC and lead author of the new study.

This kind of minimally invasive surgery had “increased greatly” over the past decade, researchers report, because the procedures involved less pain and shorter recoveries, among other benefits.

But power morcellation came under public and regulatory scrutiny a few years ago (in large part due to excellent reporting by Jennifer Levitz at The Wall Street Journal). In 2014, the FDA issued a series of warnings against the use of laparoscopic power morcellators in the majority of women undergoing these types of gynecologic surgeries because of the risk of spreading unsuspected cancer.

At that time, regulators estimated the risk of hidden cancer this way:

Based on an FDA analysis of currently available data, we estimate that approximately 1 in 350 women undergoing hysterectomy or myomectomy for the treatment of fibroids is found to have an unsuspected uterine sarcoma, a type of uterine cancer that includes leiomyosarcoma. At this time, there is no reliable method for predicting or testing whether a woman with fibroids may have a uterine sarcoma.

If laparoscopic power morcellation is performed in women with unsuspected uterine sarcoma, there is a risk that the procedure will spread the cancerous tissue within the abdomen and pelvis, significantly worsening the patient’s long-term survival. While the specific estimate of this risk may not be known with certainty, the FDA believes that the risk is higher than previously understood.

Since then, the use of laparoscopic power morcellation has fallen, according to Perkins and others in the field. “[Drug maker] Johnson & Johnson recalled the most popular power morcellator,” Perkins said, “and many hospitals banned the procedure and many insurers stopped paying for the use of morcellation with any gynecologic surgery.”

The new study, published online in the journal Women’s Health Issues, confirms the FDA number and also found that the risk of having an undetected cancer rose dramatically with age, with the highest risk among women over 55.

“This is important because it really supports the practice changes that were made around power morcellation and it should be taken as an opportunity to continue to look for safer alternatives for minimally invasive gynecological surgeries for women,” Perkins said.

She added that there are still other morcellators available and “many hospitals and clinics are developing ways to perform safer minimally invasive procedures, such as putting the tissue into a bag prior to removing it in small pieces to avoid the spill of tissue into the abdomen. But the research is still limited and we don’t have a proven, safe alternative that can be presented as the best option for women at this time.”

In clarifying the parameters of these findings, Perkins said: “Our study is not saying morcellation did or didn’t happen” in the cases analyzed, though she said typically it would have been used in the vast majority of such procedures. What it is saying is “if these women got morcellation, how many would have had a cancer morcellated? The answer is 1 in 350.”

So what’s the takeaway for patients?

“I would say women right now may be more likely to have an open abdominal surgery with a larger incision than they would have a few years ago,” Perkins said. “[That] will cause more difficult recoveries for a lot of women but may be lifesaving for a small percentage of women who might have an undetected cancer that could be morcellated, which could worsen their prognosis.”

Here’s more detail from the BMC news release:

Using a national insurance database of 55 million women, Boston Medical Center (BMC) researchers looked at cases from 19,500 women who underwent laparoscopic hysterectomies or myomectomies – procedures which typically incorporate power morcellation – to determine how frequently women are diagnosed with cancer after undergoing a gynecologic surgery for a problem that is believed to be benign. The study revealed that 1 in 352 women had an unsuspected cancer at the time of gynecologic surgery for disease that was thought to be benign. The study is published online in advance of print in the journal Women’s Health Issues.

“Our findings show that the risk for morcellating cancer is much higher than previously understood,” said Michael Paasche-Orlow, MD, MPH, general internal medicine physician at BMC and associate professor of medicine at Boston University School of Medicine (BUSM) who is the study’s senior author. “It makes sense to avoid morcellation for women with cancerous or pre-cancerous lesions. As it is difficult to ascertain in advance, safer alternatives are needed.”

The study also determined that more than half of the patients who were diagnosed with uterine cancer or endometrial hyperplasia, a pre-cancerous condition of the lining of the uterus, did not undergo endometrial testing prior to surgery. Thus, researchers suggest improving how physicians evaluate patients undergoing hysterectomies or myomectomies before they reach the operating room.

mercredi 18 novembre 2015

Walsh Proposes 21 As Legal Age For Tobacco Sales In Boston

Walsh Proposes 21 As Legal Age For Tobacco Sales In Boston

In this March 2013 file photo, cigarette packs are displayed at a convenience store in New York. Later in 2013, lawmakers in New York City voted to raise the cigarette-buying age from 18 to 21. Mayor Marty Walsh wants to do the same in Boston. (Mark Lennihan/AP, File)

In this March 2013 file photo, cigarette packs are displayed at a convenience store in New York. Later in 2013, lawmakers in New York City voted to raise the cigarette-buying age from 18 to 21. Mayor Marty Walsh wants to do the same in Boston. (Mark Lennihan/AP, File)

The age requirement for tobacco sales would rise from 18 to 21 in the city of Boston, under a proposal out Wednesday from Mayor Marty Walsh.

If the plan is approved by the city board of health, Boston would become the second major city in the United States, after New York City, to increase the legal age for tobacco sales.

Currently, 83 smaller communities across Massachusetts make 21 the threshold for purchasing tobacco products. (Click the map below to enlarge it.)

(Source: Courtesy of Patrick Mckenna and Lester Hartman/ Westwood Mansfield Pediatrics)

(Source: Courtesy of Patrick Mckenna and Lester Hartman/ Westwood Mansfield Pediatrics)

Walsh’s proposal includes e-cigarettes.

Walsh’s plan follows a strong recommendation from the American Academy of Pediatrics (AAP) last month, calling for a nationwide ban on tobacco sales to men and women under the age of 21.

“Tobacco use continues to be a major health threat to children, adolescents and adults,” Karen Wilson, chair of the AAP Provisional Section on Tobacco Control, said in a statement. “The developing brains of children and teens are particularly vulnerable to nicotine, which is why the growing popularity of e-cigarettes among adolescents is so alarming and dangerous to their longterm health.”

In 2005, nearby Needham became the first town in the country to pass a so-called Tobacco 21 law. Town Manager Kate Fitzpatrick says there were concerns about the impact on businesses initially, but “nobody has gone out of business because of it.” Fitzpatrick says many town residents are pleased with the results of the law.

study out earlier this year shows the youth smoking rate in Needham dropped almost 50 percent in the first five years after ban.

Some convenience stores owners in Massachusetts have argued against increasing the legal age for tobacco sales, but no one from the New England Convenience Store Association has responded to a request for comment for this story. Cumberland Farms declined to comment.


A Tale Of 2 Hospital Visits: How The Cost Of Care Can Vary Dramatically Depending On Where You’re Treated

A Tale Of 2 Hospital Visits: How The Cost Of Care Can Vary Dramatically Depending On Where You’re Treated

After receiving almost the exact same care at two different hospitals, a patient we're calling Nancy was stunned when she received both bills on the same day. (AP file photo)

After receiving almost the exact same care at two different hospitals, a patient we’re calling Nancy was stunned when she received both bills on the same day. (AP file photo)

The stomach cramp and nausea began one hot Friday evening in August, midway through a vacation on Martha’s Vineyard. The next morning, nearly doubled over in pain, a patient who we’ll call “Nancy” walked gingerly into the emergency room at Martha’s Vineyard Hospital.

Nancy is a 55-year-old former nurse who would prefer not to use her real name because she works with the hospitals in this story.

Even Nancy, who spends hours every day focused on health care costs, would gasp when she saw the bill for this visit.

In the ER, a doctor poked at Nancy’s tender belly and took blood for tests and a urine sample. The doctor ordered a CT scan of Nancy’s abdomen and pelvis, using contrast. It showed bulges, inflammation and thickening in Nancy’s colon. The diagnosis: uncomplicated diverticulitis. Nancy filled a prescription for an antibiotic, took some Advil, and felt better after a few days on a clear liquid diet.

Five weeks later, the diverticulitis monster invaded Nancy’s intestines again. This time she went to an urgent care center closer to home, run by Beth Israel Deaconess Medical Center (BIDMC). A doctor there ordered the same single CT scan of the abdomen and pelvis, again with contrast.

Nancy says the care she received at both places was great. But a month later, when she received the bills and her insurance company’s explanation of benefits for both visits on the same day, she was stunned.

The explanation of benefits show Blue Cross had paid Martha’s Vineyard Hospital almost seven times what it paid BIDMC’s urgent care center for the same CT scan — $3,888.76 vs. $574.97.

(Have a look at the explanation of benefits here. We compare the payment for the test, listed as “Technical Component,” and the payment to the radiologist, listed as “Professional Component.”)

Why a nearly seven-fold difference in payment for one test and the payment to read it?

I posed that question to Martha’s Vineyard Hospital (MVH). A spokeswoman said via email that MVH’s procedures and costs are very different from an urgent care center. The spokeswoman noted MVH is open 24/7 and must comply with lots of state and federal regulations that don’t apply to an urgent care center. MVH also said that Nancy had two scans at its facility, vs. one at BIDMC — that’s even though the Blue Cross summary only shows payment for one CT scan.

MVH also said it’s planning to open a walk-in clinic next year that would have a different, lower cost structure than the MVH emergency department.

The Blue Cross corporate office agreed with MVH that care in a hospital is more expensive than in an urgent care clinic. And a spokeswoman for Blue Cross said that MVH would be even more expensive because it’s an island hospital.

(A side note: If you’re sick on Martha’s Vineyard but you feel well enough to get on a ferry, a CT scan of the abdomen and pelvis, with contrast, goes for $1,398.35 at Falmouth Hospital. That’s the cash rate, which I got from the hospital. My Blue Cross representative said she did not know the Blue Cross negotiated rate.)

Martha’s Vineyard Hospital is part of the Partners HealthCare network, which includes some of the most expensive hospitals in the state. Neither the hospital nor Blue Cross mentioned this as a reason for the nearly seven-fold payment difference.

BIDMC declined a request to comment for this story.

Just for fun, I called the member line at Blue Cross to ask how much this CT scan would cost at BIDMC — the hospital, not their urgent care clinic. The member rep told me Blue Cross would pay BIDMC $1,276 for a CT scan of the abdomen and pelvis with contrast at any facility owned by that network. She said the hospital and urgent care center would receive the same payment for the test. She’s wrong, according to the summary Nancy received from Blue Cross, but this illustrates how tricky it can be to unravel the mysteries of this  — or any — health care bill.

If you have more tales from the rabbit hole of health care bills and price, do share. Maybe we can find our way out together.

mardi 17 novembre 2015

Clinicians Petition Boston Children’s Hospital To Preserve Prouty Garden

Clinicians Petition Boston Children’s Hospital To Preserve Prouty Garden

The Prouty Garden has won national acclaim. It has fountains, pine trees and birches, and a 65-foot dawn redwood tree, pictured here. (Jesse Costa/WBUR)

The Prouty Garden has won national acclaim. It has fountains, pine trees and birches, and a 65-foot dawn redwood tree, pictured here. (Jesse Costa/WBUR)

Seventy clinicians from Boston Children’s Hospital have sent hospital administrators a petition imploring them to “reverse course” on plans to demolish Prouty Garden, a healing garden that was gifted to the hospital 60 years ago.

The petition calls Prouty Garden a “precious asset,” an “enduring therapeutic resource” and a testament to the hospital’s commitment to compassionate care.

The doctors, nurses and nurse practitioners who signed the petition say they’ve been left out of the hospital’s decision to construct an 11-story clinical building on the site of the garden and build other smaller, green spaces throughout the property.

Dermatology program director Dr. Stephen Gellis helped organize the petition.

“You cannot replace [Prouty Garden] with indoor gardens or with the [outdoor] garden they’re planning,” Gellis told WBUR. “It’s just depressing. I think so many people have gotten joy from the garden and solace.”

Boston Children’s Hospital spokesman Rob Graham issued a statement saying the planned clinical building is “essential to meeting the needs” of the hospital’s patients and families, it has the support of the Prouty Garden donor’s family members and foundation, and it’s been subject to public approvals since 2012.

The planned building will feature a new state-of-the-art neonatal intensive care unit and will allow the hospital to offer all private patient rooms, thereby eliminating double-bedded rooms, according to administrators.

“Boston Children’s has great appreciation for what the Prouty Garden offers patients, families and our staff,” the hospital statement reads. “That is why our clinical expansion will focus on open and green spaces to support healing for everyone throughout our campus, year round.”

Hospital officials say the facility will ultimately have 25 percent more “green space” than it has now.

Dr. John Mulliken is a pediatric plastic surgeon, director of the Craniofacial Center and co-director of the Vascular Anomalies Center at Boston Children’s Hospital. He also signed the petition.

“Until I see a hole in the ground we still have a chance to save the Prouty Garden. It’s the soul of the hospital. It’s the sanctuary that we all need — particularly the kids, but the parents and the staff, as well, ” Mulliken says. “I’ve always been proud to work at Children’s Hospital for the last 40 years. But now I really question what they’re doing.”

Hospital administrators say construction on the new building will start next year.