A multi-institutional team of researchers, led by the Mandel School of Applied Social Sciences at Case Western Reserve University, will begin a five-year, $2.9 million National Institutes of Health-funded study. They will examine the lives of patients with both cataracts and Alzheimer’s disease (AD) to document how restored vision improves everyday life for people with dementia.

“This project addresses a major social justice issue in the disparity in vision care of persons diagnosed with Alzheimer’s disease,” said Grover “Cleve” Gilmore, dean of the Case Western Reserve Mandel School and principal investigator of the study.

Gilmore will lead faculty from the departments of Ophthalmology and Visual Sciences and Neurology at the Case Western Reserve University School of Medicine and physicians from the Eye Institute and Neurological Institute at University Hospitals and the Division of Ophthalmology at MetroHealth Medical Center.

In 20 years of research, Gilmore has found people with dementia lose their ability to see objects in medium- and low-contrast environments, but boosting the contrast of objects improves their ability to move around their homes; eat better; read; and do other simple, everyday tasks.

Cataracts cloud and blur the vision in the eye causing AD patients additional problems. If untreated, the cataracts lead to blindness, but sight can be restored with surgery to remove the cataract.

Co-investigator Jonathan Lass, M.D., the Charles I Thomas Professor and chair of the department of ophthalmology and visual sciences at the Case Western Reserve School of Medicine and director of the Eye Institute at University Hospitals, says, surprisingly, a preliminary study has shown 10 percent of patients over 65 who have an eye exam have some memory impairment along with cataracts. Most people start to show signs of cataracts in their early 60s.

“This research is important because we are a visual world,” said Thomas Steinemann, M.D., professor of ophthalmology at the School of Medicine and ophthalmologist in the ophthalmology division at Metrohealth Medical Center.

Steinemann said he has observed improvements in AD patients following cataract surgery. Some who were combative before surgery are more cooperative following it. And even though they still are cognitively impaired to some degree, Steinemann said improved vision may even help AD patients recognize family members.

“Ultimately, if you can’t perceive something, it is hard to remember it,” says Alan Lerner, associate professor of neurology at the Case Western Reserve School of Medicine and director of the Memory and Cognition Center in University Hospital’s Neurological Institute. “If the vision is blurry, then your memory may be more faulty than necessary. The cataract removal may offer benefits of improved quality of life which is a major aim in AD therapeutics overall.”

“This grant demonstrates that the NIH recognizes a major disparity in healthcare for individuals with Alzheimer’s disease and cataracts,” said Gilmore. “We hope to provide evidence that AD patients also benefit from cataract surgery.”

In the randomized controlled NIH-funded study, half of the 210 patients will receive cataract surgery and the other half will have surgery delayed for six months. The researchers will follow the progress of the two groups. During this time, the primary caregivers associated with these patients also will supply information about the patient’s quality of life and activity levels by answering surveys and other measures.

In addition to finding scientific evidence that cataract surgery helps AD patients, the researchers hope to identify a warning sign of AD. They will test changes in the thickness of the retina, a part of the eye that is an extension of the brain. Using a technology called optical coherence tomography (OCT), they will track changes in the retinal thickness of these patients over six months to determine if there is a connection with AD.

By using the technology, Gilmore says they hope to find an indicator of the onset of AD and prompt referrals to neurologist for early interventions and medicines to delay memory loss.

In addition to Gilmore, Lass, Lerner and Steinemann, Julie Belkin, M.D., assistant professor of ophthalmology at the Case Western Reserve School of Medicine and of the Eye Institute at University Hospitals, will work with the co-investigators.

Source:
Susan Griffith
Case Western Reserve University

On the one-year anniversary of Hurricane Katrina, the American Academy of Pediatrics (AAP) is encouraging families, pediatricians and communities to prepare for potential natural and other disasters to minimize the physical and emotional toll on children.

Children are especially vulnerable during and after disasters. The AAP recommends that parents discuss possible disaster plans with their children, so the children will know what to do in hazardous situations.

Parents can create a family disaster plan by taking these simple steps.

- Talk with your children about the dangers of disasters that are common to in your area and how to prepare for each type. Make sure they know where to go in your home and school to stay safe during an earthquake, tornado, hurricane or other disaster.

- Teach your child how to recognize danger signals. Ensure your child knows what smoke detectors, fire alarms and local community warning systems (horns and sirens) sound like and what to do when they hear them.

- Explain to children how and when to call for help. Keep emergency phone numbers where family members can find them.

- Pick an out-of-state family contact person who family members can “check-in” with if you are separated during an emergency. For older children, help them to memorize the person’s name and phone number, or give them a copy of the emergency list.

- Agree on a meeting place away from your home (a neighbor or relative’s house or even a street corner) where you would get together if you were separated in an emergency. Give each family member an emergency list with the name, address and phone number of the meeting place.

- Put together a disaster supplies kit for your family. aap/family/frk/frkit.htm

- Practice your family disaster plan every six months, so everyone will remember what to do in an emergency.

- Include your pet in your family disaster plan. In an emergency, shelters can’t take pets, so plan what to do in case you have to evacuate. Ask your humane society if there is an animal shelter near you. Prepare a list of kennels and veterinarians who could shelter your pet in an emergency.

“It is imperative to consider both the physical and emotional needs of children during and after a disaster,” says AAP President Eileen M. Ouellette, MD, JD, FAAP. “The thousands of children still displaced by Katrina, and still grieving the loss of their homes and loved ones, need continued care and support.”

Because of children’s developmental limitations, they are often unable to express their needs directly or clearly. They rely on adults to help them identify and express their concerns, to help them access supportive services, to model appropriate coping behaviors, and to provide a supportive environment so they can begin to understand and adjust to the crisis.

The AAP urges parents and caregivers to remember that if children receive appropriate support, they may emerge from a crisis more capable and resilient. Without such support, children are more likely to have difficulty adjusting, and may be at risk for long-term problems.

More information can be found on the AAP Web site, aap and on the following links:

Children, Terrorism, and Disasters Web site

aap/terrorism

Family Readiness Kit: Preparing to Handle Disasters aap/family/frk/frkit.htm

Feelings Need Check Ups Too CD ROM aap/profed/childrencheckup.htm

Responding to Children’s Emotional Needs During Times of Crisis
aap/terrorism/topics/parents.pdf

Pediatricians & Disaster Preparedness Policy Statement & Technical Report
aappolicy.aappublications/cgi/content/full/pediatrics;117/2/560
aappolicy.aappublications/cgi/content/full/pediatrics;117/2/e340

Tip Sheet on Four Steps to Prepare Your Family for Disaster
aap/terrorism/topics/TIPP_VIPP.pdf

The AAP will be holding an educational session and reception on “Disaster Preparedness, Response & Recovery for Children & Pediatricians” at the AAP National Conference & Exhibition in Atlanta. This session will be held Friday, October 6, 2006 from 1:00-6:30pm at the Georgia World Congress Center, Rm B308/309. To register for the NCE and to attend this session, visit aap/nce.

The American Academy of Pediatrics is an organization of 60,000 primary care pediatricians, pediatric medical subspecialists and pediatric surgical specialists dedicated to the health, safety and well being of infants, children, adolescents and young adults.

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The first PEGylated, Fc-free, anti-tumour necrosis factor (TNF) alpha agent Cimzia (certolizumab pegol), in development for rheumatoid arthritis (RA) as an add-on therapy to methotrexate (MTX), has demonstrated X-ray evidence of ability to protect joints from structural damage at an unprecedented early stage (16 weeks). Even more remarkable is that the protective effect was demonstrated in patients apparently not responding to the drug clinically. The finding may have implications for future clinical trial design and treatment evaluation. There is growing recognition that early effective treatment in RA, especially aggressive disease, is vital to achieve remission before irreversible joint damage and loss of physical function occurs. Ideally patients should start treatment within 10 to 12 months of experiencing their first symptoms, say experts.

Data presented at the 9th Annual European Rheumatology Congress (EULAR) meeting in Paris 11-14 June 2008 show that, compared to a placebo/MTX combination, Cimzia added to standard MTX significantly reduced mean modified Total Sharp Score (mTSS) – a measure of bone erosion and joint space narrowing evaluating whether joint destruction is progressing – as early as 16 weeks after commencing treatment. Findings emerged in patients withdrawing from treatment because of apparent lack of response on other measures.

Patients were participating in two randomised double-blind phase III trials, RAPID 1 and RAPID 2, evaluating safety and efficacy of two subcutaneously-administered doses (200 and 400mg) of Cimzia and 10-30mg MTX, against placebo and MTX, at 52 and 24 weeks respectively. RAPID 1 is a year-long trial of 982 patients randomly allocated to receive one of three treatment regimens together with MTX 10-30mg. In arm 1, 393 patients were randomised to the lyophilised formula of Cimzia 400mg at baseline and at weeks 2 and 4, followed by 200mg every other week. In arm 2, 390 patients received Cimzia 400mg every other week. In the remaining arm, 199 patients were randomised to placebo every two weeks. RAPID 2 is a six-month trial in which 619 patients were randomised to the liquid formula of Cimzia in three treatment arms as in RAPID 1 – 246 to each of arms 1 and 2 and 127 to placebo. Both formulas are effective.

Co-primary endpoints for RAPID 1 were the American College of Rheumatology 20 (ACR20) score, which looks for a 20 per cent improvement on a range of subjective and objective measures, at week 24, and the change from baseline in the mTSS reflecting progressive damage, at one year. The primary endpoint of RAPID 2 was the ACR20 responder rate at week 24.

Patients not meeting usual ACR20 criteria for clinical response were considered treatment failures and were withdrawn at week 16 so they could switch to an alternative treatment. Around 20 per cent of Cimzia/MTX-treated subjects withdrew from each trial compared to 61 per cent of placebo/MTX patients in RAPID 1 and 80 per cent in RAPID 2. Radiographic assessments were then compared against baseline X- rays.

Professor Desiree van der Heijde of Leiden University Medical Centre, Leiden, The Netherlands, said patients withdrawn from the trials showed little change in RA disease activity from baseline but X rays of those randomised to Cimzia/MTX (assessed by 3 blinded independent reviewers) showed significantly lower mTSS measures than those of placebo/MTX-treated patients. The mean mTSS score was even lower compared to placebo for patients who continued Cimzia/MTX for 24 and 52 weeks. For the 400mg dose, there was not only evidence of less progression but of damage reversal and repair. “This supports shorter-term imaging studies in RA,” she concluded. This was one of the earliest known time points when treatment effects on joint protection were demonstrable. Normally radiographic assessment of treatment efficacy in preventing structural damage is not performed until six months after starting treatment. However, this may now be possible as early as 12 weeks. “To be able to do this three months earlier than usual is a big advance” she commented. “Early radiographic evidence of benefit depends on how effective a drug is and its speed of onset”. Progressive structural damage is linked to impaired physical function and deterioration in ability to work so the finding has important implications.

Benefits appear as early as one week

Other data at EULAR show Cimzia appears to be the fastest anti-TNF in reducing clinical signs and symptoms of RA when added to MTX. “Treatment benefit was observed with Cimzia/MTX as early as within the first week of starting therapy, with around 50 per cent of patients either achieving an ACR20 response or at least an average of 20 per cent improvement in ACR core set measures at this time point”, reported Professor Ronald van Vollenhoven of Karolinska University Hospital, Stockholm, Sweden and colleagues. The earliest reported response for other anti-TNFs is 2 weeks.

As early as week one, patients treated with Cimzia/MTX also saw highly significant improvements in physical function and health-related quality of life compared to patients treated with placebo/MTX according to Health Assessment Questionnaire – Disability Index (HAQ-DI) scores which were sustained through to the end of the trials (p0.22 points) in the HAQ-DI at week one was between 40 and 46 per cent. By the end of the studies the proportions had risen to between 83 and 86 per cent in RAPID 1 and between 79 and 90 per cent in RAPID 2.

Health-related quality of life (HTQoL) assessments were made using SF-36 scores from week 12 to study end. These showed sustained and clinically meaningful improvements for Cimzia/MTX regimens compared to placebo/MTX (p

A doctor’s positive attitude to Alzheimer’s diagnosis and their trusting, personal relationships with local dementia support service providers are powerful enablers for early diagnosis of Alzheimer’s, according to new research reported at the Alzheimer’s Association 2009 International Conference on Alzheimer’s Disease (ICAD 2009) in Vienna.

Current data suggests that less than 35 percent of people with Alzheimer’s disease or other dementias have a diagnosis of the condition in their medical record (Boise et al., 2004; Boustani et al., 2005; Ganguli et al., 2004; Valcour et al. 2000). While there is currently no cure for Alzheimer’s, early detection and diagnosis is critical to ensuring that people living with Alzheimer’s have the power to plan their own healthcare and future, according to the Alzheimer’s Association.

“By getting diagnosed late in the progression of the disease, opportunities are missed to make key decisions about treatment, care and, future planning. Being diagnosed early is vital to receiving the best help and care possible, living one’s life to the fullest, and capitalizing on opportunities such as participating in clinical studies,” said William Thies, PhD, Chief Medical & Scientific Officer at the Alzheimer’s Association.

Dr. Nerida Paterson, Senior Lecturer in the Discipline of General Practice at the University of Newcastle, Australia, and colleagues are interviewing more than 100 general practitioners (GPs) from four Australian research sites, taping and transcribing the interviews, and analyzing the content for themes and insights that can improve the diagnostic process.

“Increasing evidence suggests that early diagnosis of Alzheimer’s and timely intervention is beneficial, both for people with the disease and their caregivers,” Paterson said. “Because doctors are the primary entry way to healthcare services for the elderly and the usual point of contact with the health system for individuals with dementia and their caregivers, there remains a need to overcome their attitudes of ‘therapeutic nihilism’ surrounding dementia.”

According to Paterson, “therapeutic nihilism” is a belief that there is no recognized cure or effective treatment for an illness, and therefore treatment or intervention in any form is not important.

At ICAD 2009, Paterson reported an interim analysis including interviews with 25 GPs.

The most cited enabler to early Alzheimer’s diagnosis is a doctor’s positive attitude to the diagnosis and treatment of dementia. In addition, GPs reported that having a trusting, personal relationship with individuals who provide dementia support services is a powerful enabler for dementia diagnosis and management. Most of the GPs reported that referral to support services for legal and financial planning, patient education, and caregiver support is an important part of disease management.

Additional factors that encourage early Alzheimer’s diagnosis include: support from relatives and caregivers, belief in the patient’s right to know, and the desire of GPs to be honest and open with their patients.

According to the researchers, the most frequently cited barriers to diagnosis of dementia in this study are that patients and GPs have differing health priorities, GPs are largely dependent on being alerted by either the patient or a relative about symptoms of memory loss, and GPs’ challenges with properly timing referral to support services. Also reported by GPs was fear of damaging the doctor-patient relationship, especially around the issue of declaring the patient’s inability to drive safely.

“Older patients frequently have complex and overlapping illnesses involving multiple body systems. Often these diseases are having a bigger impact on their day to day lives than mild cognitive impairment. As a result, when they see the doctor, their priority is to have their non-cognitive health needs addressed,” Paterson said.

According to the study, this is especially true if the person is also a caregiver. GPs reported that caregivers tend to downplay their own needs and behave as though they cannot afford to become ill and give up their caregiving role. They reported that caregivers spend most of their appointments discussing the person for whom they are a caring, and not their own health needs.

If a patient appeared to be functioning well, GPs in this study were less likely to suspect cognitive impairment. GPs reported that a cognitive deficit is more often brought to their attention by a relative or caregiver than by the patient; an informant is seen as vital for early diagnosis.

GPs also identified that they find it difficult to remember to re-offer referral to Alzheimer’s support services to patients and caregivers. GPs generally suggest these services soon after the diagnosis is made. However, patients and caregivers are still adjusting to the diagnosis at this time and may be suffering from denial, anger and guilt and often reject the referral. When they are ready to accept support, the GP is often unaware that their attitude has changed.

The researchers recommend that doctors should be educated to have a higher level of suspicion for symptoms of cognitive decline, especially in caregivers and people with complex, multi-system diseases, and that GPs should offer referrals to support services for people with dementia and caregivers on multiple occasions during the diagnostic and treatment process.

A literature review on early diagnosis of dementia and diagnostic disclosure in primary care conducted by the same researchers and also presented at ICAD 2009, reinforced these themes and suggested that the involvement of practice and community nurses in the diagnostic process may overcome some of the barriers and improve detection rates.

About ICAD 2009

The 2009 Alzheimer’s Association International Conference on Alzheimer’s Disease (ICAD 2009) brought together more than 3,000 researchers from 70 countries to share groundbreaking research and information on the cause, diagnosis, treatment and prevention of Alzheimer’s disease and related disorders. As a part of the Association’s research program, ICAD 2009 serves as a catalyst for generating new knowledge about dementia and fostering a vital, collegial research community. ICAD 2009 was held in Vienna, Austria at Messe Wien Exhibition and Congress Center from July 11.

About the Alzheimer’s Association

The Alzheimer’s Association is the leading voluntary health organization in Alzheimer care, support and research. Our mission is to eliminate Alzheimer’s disease through the advancement of research, to provide and enhance care and support for all affected, and to reduce the risk of dementia through the promotion of brain health. Our vision is a world without Alzheimer’s.

Nerida E. Paterson, et al – Early diagnosis of dementia in primary care in Australia: A qualitative study into the barriers and enablers (Funder: National Health and Medical Research Council, Australia.)

Nerida E. Paterson, et al – The barriers to the early diagnosis of dementia and diagnostic disclosure in primary care (Funder: Dementia Collaborative Research Centres, Australia.)

Control #: 09-A-1096-ALZ P1 – Sunday Posters, Presentation #P1-046
>
Early diagnosis of dementia in primary care in Australia: A qualitative study into the barriers and enablers
Nerida E. Paterson, Dimity Pond; University of Newcastle, Callaghan. NSW, Australia.


Disclosure Block: N.E. Paterson, None; D. Pond, None.

Background: GPs are the gatekeepers to service provision for the elderly and the usual point of contact with the health system for individuals with dementia and their carers. Increasing evidence suggests that early diagnosis and timely intervention is beneficial, both for patients and their carers. Despite this, there remains a need to overcome GPs’ therapeutic nihilism surrounding dementia. GPs report that the most difficult problem with the management of dementia is the communication and disclosure of the dementia diagnosis.

Research indicates the barriers to the early diagnosis of dementia and diagnostic disclosure of that diagnosis in primary care include:
Negative attitudes to dementia care/therapeutic nihilism

Stigma

Paucity of dementia services, especially in rural areas

GPs’ lack of confidence or training

Lack of a recognised and the time-efficient screening tool

Methods: Although there is much literature on barriers to diagnosis, little research has been done on enablers. To identify the barriers and enablers experienced by Australian GPs, a qualitative study, using individual, semi-structured interviews, is being conducted. Participants are GPs across four Australian research sites who have consented to participate in a larger trial on dementia. Interviews are audio taped and transcribed. Data is then coded and subjected to thematic analysis.

Results: A number of themes have emerged. Enablers to diagnosis include: 1) Support from relatives/carers. 2) Access to services 3) the belief in the patient’s right to know 4) the desire of GPs to be honest and open with their patients 5) Availability of a quick and effective screening tool. Barriers to diagnosis include the lack of the aforementioned enablers and also the fear of damaging the doctor-patient relationship, especially around the issue of driving cessation and license cancellation. Further data is being collected and preliminary findings will be presented.

Conclusions: Compelling evidence suggests that there are several structural and ideological obstacles that GPs encounter when attempting to diagnose dementia. However, there is also evidence of factors which encourage diagnosis and disclosure. Future educational supports for GPs need to concentrate on both of these areas.

Control #: 09-A-1092-ALZ P1 – Sunday Posters, Presentation #: P1-047


The barriers to the early diagnosis of dementia and diagnostic disclosure in primary care
Nerida E. Paterson, Dimity Pond; University of Newcastle, Callaghan. NSW, Australia.


Disclosure Block: N.E. Paterson, None; D. Pond, None.

Background: GPs are the gatekeepers to service provision for the elderly and the usual first point of contact with the health system for individuals with dementia and their carers. Increasing evidence suggests that early diagnosis and timely intervention is beneficial, both for patients and carers. Despite this, there remains a need to overcome GPs’ therapeutic nihilism surrounding dementia. GPs report that the most difficult problem with the management of dementia is the communication and disclosure of the dementia diagnosis.

Methods: An extensive literature review was performed to determine the barriers and enablers for diagnosis of dementia by GPs. The Medline and Google Scholar databases were searched for peer reviewed articles published in English from January 1996 to 2009. No limitations were placed on sample size or response rate. Qualitative and quantitative studies were included. A structured search methodology was used to locate the relevant body of publications and the search strategy allowed for the fact that a number of terms are used inter-changeably in the literature. Additional references were identified through hand searches of selected journals and bibliographies of relevant articles.

Results: Forty-nine papers met the inclusion criteria. Research indicates the barriers to the early diagnosis of dementia and diagnostic disclosure in primary care include:
Negative attitude to dementia care/therapeutic nihilism

Stigma

Difficulties in differentiating normal ageing from dementia

The paucity of specialist diagnostic services, especially in rural areas

GPs lack of confidence or training

Lack of a recognized, time-efficient screening tool

A perceived lack of need to determine a specific diagnosis

Limited time

Risk of misdiagnosis

The patient’s impaired ability to provide an accurate history and participate in self-care

Perception that the patient cannot comprehend/cope with the diagnosis

Risk of damaging the doctor-patient relationship

There is emerging evidence that the involvement of practice and community nurses in the diagnostic process may overcome some of the barriers and improve detection rates.

Conclusions: Compelling evidence suggests that there are several structural and ideological obstacles that GPs encounter when attempting to diagnose dementia. However, there is also evidence of factors which encourage diagnosis and disclosure. Future educational supports for GPs need to concentrate on both these areas.

Source:
Niles Frantz

Alzheimer’s Association

Much of the devastation of stroke and head trauma is due to damage caused the overproduction of a substance in the brain called glutamate. Preventing this damage has been impossible, until now, as many drugs don’t cross the so-called blood-brain barrier, and those that do often don’t work as intended. But a method originally devised at the Weizmann Institute of Science may, in the future, offer a way to avert such glutamate-induced harm.

Prof. Vivian I. Teichberg of the Institute’s Neurobiology Department first demonstrated a possible way around these problems in 2003. Glutamate – a short-lived neurotransmitter 0 is normally all but absent in brain fluids. After a stroke or injury, however, the glutamate levels in brain fluid become a flood that over-excites the cells in its path and kills them. Instead of attempting to get drugs into the brain, Teichberg had the idea that one might be able to transport glutamate from the brain to the blood using the tiny “pumps,” or transporters, on the capillaries that work on differences in glutamate concentration between the two sides. Decreasing glutamate levels in blood would create a stronger impetus to pump the substance out of the brain. He thought that a naturally-occurring enzyme called glutamate-oxaloacetate transaminase (GOT, for short) could “scavenge” blood glutamate, significantly lowering its levels. By 2007, Teichberg and his colleagues had provided clear evidence of the very strong brain neuroprotection that oxolacetate (a chemical similar to GOT) afforded rats exposed to a head trauma.

Two new studies – conducted by Fransisco Campos and others from the lab of Prof. Jose Castillo in the University of Santiago de Compostela, Spain – now provide a definitive demonstration of Teichberg’s results. In the first, the scientists conclusively showed that oxoloacetate injected into rats with stroke-like brain injuries reduces glutamate levels both in the blood and in the affected brain region, while significantly lessening both cell death and the swelling that can accompany stroke. In the second, a team of neurologists in two different hospitals checked the levels of glutamate and GOT in several hundred stroke victims who were admitted to their hospitals. They found that the most significant predictor of the prognosis – how well they would recover at three months and how much brain damage they would suffer – was the levels of these two substances. High glutamate levels correlated with a poor outcome, high GOT levels with a better one.

The overall implication of these two papers is that administering GOT might improve a patient’s chances of recovering, as well as speeding up the process. In addition to stroke and head trauma, a number of diseases are characterized by an accumulation of glutamate in the brain, including Alzheimer’s disease, Parkinson, multiple sclerosis, epilepsy, glaucoma, certain brain tumors and amyotrophic lateral sclerosis, and there is hope that, in the future, treatments to scavenge glutamate could relieve the symptoms and improve the outcomes for a number of neurological problems. Yeda, the technology transfer arm of the Weizmann Institute, holds a patent for this method.

Notes:

Prof. Vivian I. Teichberg’s research is supported by the Nella and Leon Benoziyo Center for Neurosciences; the Carl and Micaela Einhorn-Dominic Brain Research Institute; and the Legacy Heritage Fund Program of the Israel Science Foundation. Prof. Teichberg is the incumbent of the Louis and Florence Katz-Cohen Professorial Chair of Neuropharmacology.

Source:
Yivsam Azgad

Weizmann Institute of Science

Stress during pregnancy may raise the risk of asthma in offspring, according to researchers at Brigham and Women’s Hospital and Harvard Medical School in Boston. The researchers investigated differences in immune function markers in cord blood between infants born to mothers in high stress environments and those born to mothers with lower stress and found marked differences in patterns that may be associated with asthma risk later in life.

“This is the first study in humans to show that increased stress experienced during pregnancy in these urban, largely minority women, is associated with different patterns of cord blood cytokine production to various environmental stimuli, relative to babies born to lower-stressed mothers,” said Rosalind Wright, M.D., M.P.H., associate physician at Brigham and Women’s Hospital.

The findings have been published online ahead of print publication in the American Thoracic Society’s American Journal of Respiratory and Critical Care Medicine.

Asthma is known to be more prevalent among ethnic minorities and among disadvantaged urban communities, but the disparity is not completely explained by known physical factors. Urban women living in the inner-city also experience significant stress, particularly minority women.

The role of stress in asthma development is poorly understood, but animal studies have suggested that the mother’s stress during pregnancy can influence the offspring’s immune system, starting in the womb.

To determine whether a similar transference of stress-mediated immune differences may occur with humans, Dr. Wright and colleagues recruited pregnant women in several cites, including Boston, Baltimore, New York and St. Louis. Their families were largely ethnic minorities, 20 percent of whom were living below the poverty level. Each child’s mother or a father had a history of asthma or allergy.

In total, 557 families answered detailed questions about the various stressors in their lives, at home (including domestic violence), in their financial situations and in their neighborhoods (community violence). When the infants were born, their cord blood was collected and isolated immune cells were stimulated with a number of factors (allergens like dust and cockroach, viral and bacterial stimulants), then analyzed for the production of various cytokines as indicators of how the child’s immune system was primed to respond to the environment.

The researchers found that the patterns of cytokines related to certain stimulants differed based on the level of stress mothers reported.

“The ctyokine patterns seen in the higher stress groups, which are an indication of how the child’s immune system is functioning at birth, may be a marker of increased risk for developing asthma and allergy as they get older,” explained Dr. Wright.

“For example, while the debate continues as to whether primary sensitization to allergens begins before birth, these findings suggest the possibility that prenatal stress may enhance the neonates’ response to inhalant antigens, specifically those antigens that the fetus is likely to encounter more directly in utero, like dust mite.”

The research, a prospective cohort study funded by the National Institute of Allergy and Infectious Diseases, will continue as the infants grow up to determine whether maternal stress levels do indeed have an impact on asthma development.

“The current findings suggest that psychological stress is involved in programming of the infant immune response and that this influence begins during pregnancy,” said Dr. Wright. “As these infants mature, we will learn how these factors manifest later in terms of the development of asthma and allergy.”

Link to original article

Source
American Thoracic Society (ATS)

Researchers at the UC Davis M.I.N.D. Institute have found that infants later diagnosed with autism exhibited unusual exploration of objects long before being diagnosed. Studying a group of children at high risk for developing autism, the researchers found that those eventually diagnosed with the disorder were more likely to spin, repetitively rotate, stare at and look out of the corners of their eyes at simple objects, including a baby bottle and a rattle, as early as 12 months of age.

These findings could help pediatricians diagnose and treat autism earlier, reducing some of the social and educational challenges associated with the disorder.
“There is an urgent need to develop measures that can pick up early signs of autism, signs present before 24 months,” said M.I.N.D. researcher Sally Ozonoff, first author of the current study, which was published in the October issue of Autism, the journal of the National Autistic Society.

The American Academy of Pediatrics has recommended that all infants be screened for autism twice before their second birthdays. Currently, pediatricians look for the hallmark social and communication signs of autism, which include language delays and lack of interest in people.
“The finding that the unusual use of toys is also present early in life means that this behavior could easily be added to a parent check-list or quickly assessed during a visit to a pediatrician’s office,” Ozonoff said.

The study involved 66 one-year-old infants. Nine of the children were later diagnosed with autism. Seven of the nine children displayed significantly more spinning, rotating and unusual visual exploration of objects than typically developing children.

“We found that these behaviors were relatively rare in the contrast group, but very high in the group who later developed autism,” Ozonoff said.

Current screening tests focus on social-communicative behaviors like responding to name, making eye contact and word learning. These measures accurately distinguish children developing autism from children who are developing as expected.

The average age of autism diagnosis in the United States is three years of age or older. Interviews with parents, however, have shown that signs of autism often are present long before the diagnosis is made.

“About a third of parents notice signs before a child’s first birthday,” Ozonoff said. “We felt that our field could do a better job at early diagnosis, so we decided to look at multiple candidates for early screening and early detection,” she explained.

Ozonoff and her colleagues decided to look at repetitive behaviors that previous studies indicated developed later than two years of age. These retrospective studies, however, relied on the memory of parents whose children were ultimately diagnosed with autism.

“We wanted to directly test whether or not repetitive behaviors so characteristic of autism might actually be apparent earlier and therefore useful in early diagnosis,” Ozonoff said.

In contrast to previous research, the current prospective study began with a group of 12-month olds who had not received any diagnosis. The study group included infants from families who had either an older child diagnosed with autism or an older child developing typically.

To approximate the skewed gender ratio of autism in the real world, 62 percent of the infants enrolled were male. The children in the study were presented with four objects – a metal lid, a round plastic ring, a rattle and a plastic baby bottle – one at a time for 30 seconds each while being videotaped.

Researchers blind to the outcomes coded the behaviors in the tapes. The children were screened for autism at 36 months. Ozonoff and her colleagues found that children later diagnosed with autism were more likely to repeatedly spin and rotate objects. They were also more likely to explore objects in unusual ways, like glancing sideways at them or starting intently at them for prolonged periods.

“Our results suggest that these particular behaviors might be useful to include in screening tests,” Ozonoff said.

More research involving more infants will have to be done first. Ozonoff and her colleagues have already begun a larger five-year study that also includes a high-risk sibling group like the one used in the current study.

“We will also want to check that we find the same results in a random community sample,” she said.

These kinds of long-term studies, Ozonoff said, are the keys to improving early detection and diagnosis of autism.

“The earlier you treat a child for autism, the more of an impact you can have on that child’s future,” she said.

Other study authors included UC Davis M.I.N.D. Institute researchers Gregory Young, Stacy Goldring, Megan Thompson, Sally Rogers and Suzanne Macara, who is now at Yale University. The study was supported by a grant from the National Institute of Mental Health.

The UC Davis M.I.N.D. Institute, in Sacramento, Calif., was founded in 1998 as a unique interdisciplinary research center where parents, community leaders, researchers, clinicians and volunteers collaborate to study and treat autism and other neurodevelopmental disorders. More information about the institute is available on the Web at ucdmc.ucdavis/mindinstitute.

UC Davis M.I.N.D. Institute

Relief organizations and medical workers in Haiti are increasingly struggling to find enough doctors and supplies to attend to women in labor in the aftermath of the Jan. 12 earthquake, the Miami Herald reports. Hospitals have become overcrowded and have been forced to turn away pregnant women, according to the Herald. “People here are giving birth under the absolute worst conditions,” Jonathan Evans, a pediatric gastroenterologist volunteering at a University of Miami field hospital, said, adding that women “can’t find access to midwives. Little problems become big problems.”

There is growing concern about the 63,000 pregnant women currently living in the Haitian capital of Port-au-Prince, where more than 7,000 women are expected to give birth this month. “If we don’t act, we are foreseeing an increase in the already obscene maternal mortality rate,” the World Health Organization’s Cristian Morales said.

According to the most recent data from UNICEF and WHO, Haiti’s maternal mortality rate before the earthquake was 670 maternal deaths per 100,000 births each year, compared with 150 per 100,000 in the neighboring Dominican Republic and 11 per 100,000 in the U.S.

Prior to the earthquake, about one in five pregnant women delivered in a hospital, often only if complications arose, according to Jean-Edouard Viala, chief of staff in obstetrics at the Port-au-Prince General Hospital. The majority of women gave birth at home. In the four weeks since the earthquake, the hospital has delivered more than 100 infants in its maternity tents, and surgeons have performed more than 27 caesarean sections, Viala said.

In addition, some relief organizations have been forced to turn away pregnant women because they did not bring obstetricians or the proper equipment for deliveries. “We came here with earthquake specialists — orthopedics and surgeons,” Morales said, adding, “In an emergency, they can deliver babies. But we need to replace adequate facilities for obstetrics and gynecology.”

Marjorie Michel, the Haitian minister in charge of women’s affairs, said that her office is working to address some of the concerns and that the government will set up special tents where deliveries can be performed in sanitary conditions. Michel’s office also is working to provide pregnant women with nutritious food, and provide new mothers with diapers, sheets and blankets. WHO also is expected to send more obstetricians to Haiti, according to a spokesperson for the organization (McGrory, Miami Herald, 2/19).

Reprinted with kind permission from nationalpartnership. You can view the entire Daily Women’s Health Policy Report, search the archives, or sign up for email delivery here. The Daily Women’s Health Policy Report is a free service of the National Partnership for Women & Families, published by The Advisory Board Company.

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Research has shown that varenicline tartrate – a novel new drug specifically developed for smoking cessation – allows smokers to abstain from cigarettes significantly longer and more effectively than smokers using a placebo.

A paper in Respirology, published by Wiley-Blackwell, compared the efficacy of a standard 12-week regimen of varenicline for smoking cessation with a placebo on 333 subjects in 15 test sites across China, Singapore and Thailand.

“The smoking cessation rate achieved after the treatment period and the follow-up period was significantly higher with varenicline than with placebo. Likewise, the long-term quit rate for smokers treated with varenicline was also significantly higher”, said Dr. Chen Wang from the Beijing Institute of Respiratory Medicine.

More than half of the smokers from the varenicline group abstained from cigarettes within the treatment period while 38% continued to abstain for the next 12 weeks after the treatment. The abstinence rate for the placebo group was significantly lower with only 31% of the participants managing to abstain during the treatment period and 25 % for the non-treatment period.

Varenicline tartrate is a selective nicotinic acetylcholine receptor which is licensed in Europe, the USA and Japan. This study further evaluates and establishes the efficacy, tolerability and safety profiles of varenicline in Asian smokers.

AboutRespirology

Respirology is a journal of international standing, publishing peer-reviewed articles of scientific excellence in clinical and experimental respiratory biology and disease and its related fields of research including thoracic surgery, internal medicine, immunology, intensive and critical care, epidemiology, cell and molecular biology, pathology, pharmacology and physiology.

About Wiley

Founded in 1807, John Wiley & Sons, Inc. has been a valued source of information and understanding for 200 years, helping people around the world meet their needs and fulfill their aspirations. Since 1901, Wiley and its acquired companies have published the works of more than 350 Nobel laureates in all categories: Literature, Economics, Physiology/Medicine, Chemistry and Peace.

Our core businesses include scientific, technical, medical and scholarly journals, encyclopedias, books, and online products and services; professional/trade publishes books, subscription products, training materials, and online applications and websites; and educational materials for undergraduate and graduate students and lifelong learners. Wiley’s global headquarters are located in Hoboken, New Jersey, with operations in the U.S., Europe, Asia, Canada, and Australia. The Company’s Web site can be accessed at wiley. The Company is listed on the New York Stock Exchange under the symbols JWa and JWb.

About Wiley-Blackwell

Wiley-Blackwell is the international scientific, technical, medical and scholarly publishing business of John Wiley & Sons, with strengths in every major academic and professional field and partnerships with many of the world’s leading societies. Wiley-Blackwell publishes over 1,400 peer-reviewed journals as well as 1,500+ new books annually in print and online, as well as databases, major reference works and laboratory protocols. For more information, please visit wileyblackwell or interscience.wiley.

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Wiley-Blackwell

Leading mental health researchers are warning that some of the most important health consequences of climate change will be on mental health, yet this issue is unlikely to be given much attention at the UN climate change conference in Copenhagen next week.

Dr Lisa Page and Dr Louise Howard from the Institute of Psychiatry (IoP) at King’s College London reviewed a range of recent research by scientists into the potential mental health impacts of climate change.

In an article published in Psychological Medicine online, the two mental health experts conclude that climate change has the potential to have significant negative effects on global mental health. These effects will be felt most by those with pre-existing serious mental illness, but that there is also likely to be an increase in the overall burden of mental disorder worldwide.

The scientists urge for the lack of research into the mechanisms that cause the effects of climate change on mental disorder to be addressed, so that mental health policy makers can plan for the significant impacts of climate change on mental health that are to be expected.

Dr Page, lead author of the article and Clinical Lecturer in Liaison Psychiatry at the IoP, comments: ‘Climate change is assuming centre stage with the upcoming UN conference in Copenhagen. While delegates will discuss the effects of climate change and possible responses by the international governments, we fear that the effects of climate change on mental health will be largely ignored, posing a tremendous risk to the mental health of millions of people in the not-too-distant future.’

Dr Page and Dr Howard identified the following ways in which climate change is likely to impact mental health:
Natural disasters, such as floods, cyclones and droughts, are predicted to increase as a consequence of climate change. Adverse psychiatric outcomes are well documented in the aftermaths of natural disasters and include post-traumatic stress disorder, major depression and somatoform disorders.

The needs of people with chronic mental illness have often been overlooked following disaster in favour of trauma-focused psychological interventions and yet the mentally ill occupy multiply vulnerabilities for increased mortality and morbidity at such times.

As global temperatures increase, people with mental illness are particularly vulnerable to heat-related death. Contributing risk factors such as psychotropic medication, pre-existing respiratory and cardiovascular disease and substance misuse, are all highly prevalent in people with serious mental illness. In addition, maladaptive coping mechanisms and poor quality housing are likely to further increase vulnerability, and death by suicide may also increase above a certain temperature threshold.

Adverse impacts such as psychological distress, anxiety and traumatic stress resulting from emerging infectious disease outbreaks are also likely to increase if the predicted outbreaks of serious infectious diseases become reality.

Coastal change and increased flooding is expected to lead to forced mass migration and displacement, which will undoubtedly lead to more mental illness in affected population.

Urbanisation, a phenomenon which will be partially beneficial, for example by increasing opportunities for work and better access to health services, is associated with an increased incidence of schizophrenia in developed countries. In many low- and middle-income countries, mental health provision is already hugely inadequate and is unlikely to be prioritised should further economic collapse occur secondary to climate change.

The knowledge of man-made climate change could in itself have adverse effects on individual psychological well-being.

Notes
L. Page and L. Howard, ‘The impact of climate change on mental health (but will mental health be discussed at Copenhagen?’,) 30 November 2009. Psychological Medicine online.

Source: Melanie Haberstroh

King’s College London