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Minggu, 29 Januari 2012

FDA clears safety test to screen Tysabri patients

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WASHINGTON (AP) — The Food and Drug Administration on Friday approved a new diagnostic test to help identify patients who have an increased risk of developing a rare brain infection while taking Biogen Idec's multiple sclerosis drug Tysabri.

Tysabri is one of a handful of drugs used to control multiple sclerosis, a debilitating disease in which the body attacks its own nervous system. Prescribing of the drug has been tightly controlled by the FDA because of a rare infection that causes inflammation of the brain, known as multifocal leukoencephalopathy, or PML. Currently there is no treatment or cure for PML, which usually causes death or severe disability.

The newly approved Stratify JCV test is designed to detect a common virus that increases the likelihood of developing the brain infection. The John Cunningham virus is harmless in most people, but can become dangerous in patients taking immune system-suppressing drugs like Tysabri.

Doctors can use the results of the blood-based test, combined with facts about the patient's medical history, to determine whether they are at risk of developing the brain infection. Other factors that influence a patient's risk include how long they've been taking Tysabri and whether they've previously taken other medications that weaken the immune system.

The test was developed by Quest Diagnostics.

The FDA also updated Tysabri's label to specify that patients who test positive for the virus have a higher risk of developing PML.

"This label change marks an important advance in assisting people with MS and their physicians to make better-informed decisions concerning the challenges of balancing effectiveness with safety," said Dr. Nicholas LaRocca, vice president of the National MS Society.

Tysabri was temporarily pulled from the market shortly after its launch in 2005 after three patients taking the drug developed PML. FDA allowed the drug back on the market the following year but under a restricted distribution program. Only doctors and pharmacies registered with the company's distribution program are permitted to prescribe and dispense the drug.

Biogen, based in Weston, Mass., sells Tysabri through a partnership with Elan Corp., an Irish drugmaker.

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Sex poses surprisingly low risk to heart patients

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This Jan. 13, 2012 photo shows heart patient Tammy Collins who credits her recovery and confidence with her cardio rehabiltaion workouts at The Ohio State University CarePoint East facility in Columbus, Ohio. After suffering a heart attack and then healing she was apprehensive about how to safely return to her sex life. The American Heart Association says having sex only slightly increase the chance for having a heart attack. And that's true for patients with and without heart disease. (AP Photo/Mike Munden)

In this Jan. 13, 2012 photo, heart patient Tammy Collins, right, goes through her cardio rehabiltaion workout while being monitored by nurse Julie Walsh at The Ohio State University CarePoint East facility in Columbus, Ohio. After suffering a heart attack and then healing she was apprehensive about how to safely return to her sex life. The American Heart Association says having sex only slightly increase the chance for having a heart attack. And that's true for patients with and without heart disease. (AP Photo/Mike Munden)

CHICAGO (AP) — Good news: Sex is safe for most heart patients. If you're healthy enough to walk up two flights of stairs without chest pain or gasping for breath, you can have a love life.

That advice from a leading doctors' group on Thursday addresses one of the most pressing, least discussed issues facing survivors of heart attacks and other heart patients.

In its first science-based recommendations on the subject, the American Heart Association says having sex only slightly raises the chance for a heart attack. And that's true for people with and without heart disease.

Surprisingly, despite the higher risk for a heart patient to have a second attack, there's no evidence that they have more sex-related heart attacks than people without cardiac disease.

Many heart patients don't think twice about climbing stairs, yet many worry that sexual activity will cause another heart attack, or even sudden death, said Dr. Glenn Levine, lead author of a report detailing the recommendations and a professor of medicine at Baylor College of Medicine in Houston.

The report says sex is something doctors should bring up with all heart patients. Yet few do because they're uncomfortable talking about it or they lack information, Levine said. The new guidance is designed to fill that gap.

Heart patients should get a doctor's OK before engaging in sexual activity. Many may be advised first to do cardiac rehab — exercise while being monitored for heart symptoms, to improve heart strength and increase physical fitness. But the heart association says most eventually will be cleared to resume sexual activity.

The doctors' group offers advice for heart patients based on scientific research involving sometimes provocative sex-related topics:

—Who's most at risk for sudden death related to sex? Married men having affairs, often with younger women in unfamiliar settings. Those circumstances can add to stress that may increase the risks, evidence from a handful of studies suggests.

—Sex may be OK as soon as one week after a relatively mild heart attack, if patients can walk up a few flights of stairs without discomfort.

—Viagra and other drugs for erectile dysfunction are generally safe for men with stable heart disease.

"The risk of having a heart attack during sexual activity is two to three times higher than when not having sexual activity. However, this increased risk of heart attack during sexual activity represents only a very small part of a person's overall risk of having a heart attack, and sexual activity is the cause of less than 1 percent of all heart attacks," Levine said.

Among heart attack survivors, average risks for another heart attack or sudden death are about 10 in 1 million per hour; having sex increases that to about 20 to 30 in 1 million per hour of sexual activity, the new report says. People without heart disease face lower overall risks for a heart attack, but similar risks for a sex-related attack.

The updated advice was released online Thursday in the heart association journal, Circulation.

Dr. Keith Churchwell, chief medical officer of Vanderbilt University's Heart and Vascular Institute, said the guidance is important for patients, and that questions about sex are the most common ones he hears from heart patients.

Ohio State University heart specialist Martha Gulati praised the recommendations for emphasizing that sexual counseling is important not just for patients but also their partners, who she says are often just as nervous about resuming sexual activity.

Day-care operator Tammy Collins of Reynoldsburg, Ohio, one of Gulati's patients, says the advice is reassuring.

She had a heart attack last year on Sept. 11, during a trip to Cincinnati to celebrate her wedding anniversary.

Collins' mother died of a heart attack at the same age, on her 51st birthday. With high blood pressure and high cholesterol, Collins knew she was at risk. She developed symptoms a few hours after having sex. She dismissed it at first, until she felt a sharp pain in her upper back and had trouble breathing. She was rushed to the hospital and doctors used stents to open blocked arteries.

Collins said she wasn't embarrassed to ask Gulati about sex, who told her it was unlikely that her night of romance had caused the heart attack. After several weeks of cardiac rehab, she was cleared to resume sexual activity — advice that surprised her friends. But Collins said the exercise sessions have made her feel fitter than ever.

"A heart attack does not have to be the end of living," Collins said.

Chicago cardiologist Dan Fintel, a professor of medicine at Northwestern University, said he routinely gives heart patients a sex talk on their last day in the hospital, knowing that it's likely on their minds.

"Resuming sexual activity is safe and emotionally part of the healing process, with a few caveats," he tells patients.

Those caveats elicit nervous chuckles when he explains that includes no philandering, given evidence about that causing extra stress.

___

Online:

Circulation: http://bit.ly/1mt2UY

___

AP Medical Writer Lindsey Tanner can be reached at http://www.twitter.com/LindseyTanner

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Hospital patients 'still at risk'

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27 October 2011 Last updated at 18:45 GMT Patients at Romford's Queen's Hospital "remain at risk"

Patients are still at risk at an east London hospital, according to a health watchdog report after the deaths of two pregnant women.

The Care Quality Commission (CQC) review began in June after the deaths of Tebussum Ali and Violet Stephens at Queen's Hospital in Romford.

Mrs Stephens died in April and Ms Ali and her baby died in January.

The Barking, Havering and Redbridge University Hospitals NHS Trust said it would improve.

The CQC report identified "serious problems" and placed requirements on the trust to deliver "fundamental and wide-ranging improvements".

Midwives suspended

The report said: "Despite some signs of improvement in recent months, patients remain at risk of poor care in this trust.

"While the most immediate concerns were around maternity services, failings were also identified in emergency care and in radiology.

Continue reading the main story Verbally abusive and unprofessional behaviour by some staff to patientsLack of leadership from senior managementVacancies repeatedly filled by agency staff, reducing quality of care"Widespread improvement is needed in patient flows, the management of complaints, staff recruitment and governance in order to improve patient experience."

An independent report found in the case of Mrs Stephens, who was admitted with potentially life-threatening pre-eclampsia, there was a failure to give a blood transfusion and a delay in making the decision to deliver her baby.

In the case of Ms Ali, who was also known as Sareena, the report found staff had failed to spot signs of her ruptured womb and tried to resuscitate her with a disconnected oxygen mask.

Tebussum Ali and her baby died in January

Health Secretary Andrew Lansley said the standard of care provided by the trust must improve substantially.

"We should be prepared to shine a spotlight on problems where they exist, because poor performance is not just a statistic or a line on a graph.

"It means patients being let down, or hurt, or worse."

The CQC inquiry found the most significant problems were at Queen's Hospital, although elements of poor care were present across both of the trust's main sites.

However the CQC said leadership of the trust was improving due to the efforts of a new chief executive and medical director.

Speaking after the publication of the report, the trust's chief executive Averil Dongworth said: "We are taking the findings of this report extremely seriously and have already started work to implement its recommendations.

"We recognise that there have been failures in the past, but we are determined to continue to improve until we are among the best trusts in the country."

She said seven members of staff had already or were in the process of being disciplined and there were more to follow.

The trust also said it had recruited an extra 72 midwives this year and had improved staff support and training.

Lawyer Sarah Harman, who is taking legal proceedings on behalf of 20 maternity patients of Queen's Hospital, said: "For patients to receive a reasonable standard of care there needs to be a significant change in the staff culture.

"Patients' concerns should be listened to and their complaints acted on.

"Had this happened in the past, the tragedies in the maternity unit this year would have been avoided."

Director of nursing Deborah Wheeler said the trust was unable to comment on the legal action.

The government has said plans to move maternity and emergency services to Queen's Hospital from King George Hospital in Ilford can go ahead, as long as ministers are satisfied that services are safe.

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A GPS-Enabled Shoe to Track Wandering Alzheimer's Patients

12.17 egaoart No comments

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Now this sounds like a good idea: use GPS-enabled shoes to track the whereabouts of elderly people with Alzheimer's who may be prone to wandering.

Some 60% of patients with Alzheimer's will get confused and wander off, sometimes without warning, and become lost. They're not always easy to find — because paranoia is a common symptom of the disease, wandering patients may purposefully hide. Up to half of those who are lost and not found within 24 hours may die from dehydration, exposure or injury, AFP reports.

The new GPS-enabled walking shoe is a collaboration between Los Angeles-based GTX Corporation, which specializes in mini-GPS technology, and the footwear company Aetrex, with guidance from Andrew Carle, director of the senior housing program at George Mason University. They came up with walking shoes that look just like the typical shoe you'd see on many seniors' feet, with the GPS device hidden in a heel.

"It's especially important for people in the earliest stages of Alzheimer's who are at the highest risk," Carle told AFP. "They might be living in their home but they're confused. They go for a walk and they can get lost for days."

If you've ever used a GPS-enabled smartphone or other device, you're well-acquainted with the the new shoe's technology. Reported the New York Times earlier this month:

A family member sets a perimeter, a "geo-fence," so that the wearer can freely move around the house, around the yard, perhaps around a familiar immediate neighborhood. "But if he breaks the fence, Google maps pops up on my computer or my phone to show me where he is," explained Mr. Carle, now a consultant to GTX.
Even if your parent is in Tennessee and you're not, "I can call the Memphis police and say, 'My dad has Alzheimer's and he's wandering and he's at the corner of Fifth and Elm. Could you go get him?'" Mr. Carle thinks that possibility could be enormously reassuring "for family caregivers who are afraid to go to the bathroom because when they get back, their loved one may be out the door."

The advantage of putting GPS in shoes over, say, using a tracking bracelet or pendant is that patients with Alzheimer's are apt to take these items off, especially if they're unfamiliar, and discard them. Or they might lose them. People are less likely to take off their shoes.

The GPS shoes, which should be available online soon, will cost $299 per pair, plus a monthly fee of $34.99 for the monitoring service, NPR reports.

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Sanofi says Lemtrada helps MS patients in study

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PARIS | Sat Oct 22, 2011 3:15am EDT

PARIS (Reuters) - French drugmaker Sanofi said on Saturday that its experimental multiple sclerosis drug Lemtrada worked better than an older drug sold by competitor Merck KGaA at keeping patients free from relapses.

New data from a late-stage trial showed that 78 percent of patients treated with Lemtrada remained relapse-free for two years, compared with 59 percent using Rebif, an older multiple sclerosis drug sold by Germany's Merck.

Lemtrada is a key experimental product at Sanofi's Genzyme unit. The fortunes of the drug are closely watched by holders of Genzyme Contingent Value Rights certificates issued to shareholders as part of the U.S. company's takeover deal.

CVRs represent an extra fee holders will receive if Lemtrada hits certain targets or when Genzyme meets other milestones.

The commercial potential of the drug, already sold under the brand name Campath as a leukemia treatment, was a key bone of contention between Sanofi and Genzyme during takeover talks.

Multiple sclerosis, which affects 2.5 million people worldwide, is a chronic and progressive disease that attacks the central nervous system.

Previously published data from the same late-stage study were mixed. Although Lemtrada was found more effective than Rebif at preventing relapses, it did not prevent the disease from becoming disabling, as it had in earlier trials.

The results of the latest late-stage trial showed that side-effects, including respiratory and urinary tract infections, were mild to moderate, Sanofi said.

Serious adverse events were similar between Lemtrada and Rebif, Sanofi said, with 18.4 percent of patients on Lemtrada suffering from side effects that included autoimmune disorders compared to 14.4 percent in patients taking Rebif.

The drug's prospects should become clearer once the results of another late-stage trial are published by year-end. The study is comparing Lemtrada with Rebif in multiple sclerosis patients who have relapsed while on therapy.

Sanofi plans to submit Lemtrada for U.S. and European Union marketing approval in the first quarter of 2012. The drug, if approved, will face competition from Novartis's Gilenya.

(Reporting By Elena Berton; Editing by Helen Massy-Beresford)

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EU rules 'put patients at risk'

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19 October 2011 Last updated at 00:12 GMT By Nick Triggle Health correspondent, BBC News Stethoscope

The European Commission is already reviewing the regulations Patients are being put at "unacceptable risk" because of EU rules governing the movement of health workers, peers say.

A House of Lords committee said the current balance between free movement of labour and safety had been skewed.

It said regulatory bodies should be able to test the language skills of all doctors, nurses, midwives, dentists and pharmacists wanting to work in the UK.

They also called for better sharing of data about the disciplinary history of staff seeking to work abroad.

The ability of health professionals - and in particular doctors - to work across the European Economic Area (EEA) has been a controversial issue in the UK in recent years.

It hit the headlines after the case of Daniel Ubani, a German locum doctor, who gave 70-year-old David Gray a fatal painkiller overdose on his first and only shift in Britain in February 2008.

Investigations found Dr Ubani had been rejected for work in Leeds because of his poor English skills, but had been allowed on an approved list by another trust.

A UK coroner recorded a verdict of unlawful killing and accused Dr Ubani of gross negligence.

Frustration

The GP was given a suspended sentence in Germany for death by negligence but has still been able to work there.

Since the case, ministers and the General Medical Council, which regulates doctors in the UK, have expressed frustration at the current situation.

The European Commission has already announced a review of the rules with firm proposals expected by the end of the year.

It is likely they will recommend a tightening of the rules, although it could take another year for the changes to be made.

Continue reading the main story

The committee is right - the safety of patients should always come first. Like us, they believe that current EU rules are putting patients at risk and urgent changes are needed”

End Quote Niall Dickson General Medical Council In the meantime ministers in England have placed a duty on local trusts to vet the language skills of doctors - they have had the power to do this but it was inconsistently carried out - as well as giving the GMC powers to investigate language competency where concerns are raised.

But the conclusions reached by the House of Lords social policies and consumer protection committee call for a much more radical overhaul.

The peers have suggested that an alert system be set up to ensure that information about disciplinary procedures are shared between regulators from different countries.

They also want regulators to be given the power to vet language skills - as they have for doctors from outside the EEA - while the qualifications and skills recognised as being appropriate need to be updated to ensure staff are trained to the appropriate standards.

Committee chairwoman Baroness Young said: "It is absolutely unacceptable that current EU rules put patients at risk. The EU is failing our patients.

"We recognise that mobility can bring significant benefits, but we have to make sure that this is not at the expense of patients' health, care and confidence."

The report has been warmly welcomed by regulators, ministers and campaigners in the UK.

Niall Dickson, chief executive of the General Medical Council, said: 'The committee is right - the safety of patients should always come first. Like us, they believe that current EU rules are putting patients at risk and urgent changes are needed."

Health Secretary Andrew Lansley: 'We are able to apply language tests to European doctors for employment purposes on the NHS'

And Peter Walsh, chief executive of Action Against Medical Accidents, described the current arrangements as "crazy".

"Patient safety must be put before political correctness."

Health Secretary Andrew Lansley added: "It's completely unacceptable for doctors to work in the NHS if they can't speak English properly."

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Patients' lists exceed population

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9 October 2011 Last updated at 14:37 GMT One GP said his practice faced problems after it removed 1,500 patients from its list

The number of people registered with GPs in London is at least a million higher than the population, research by BBC One's The Politics Show suggests.

The total is approximately 9m, compared with the 7.75m population, a series of Freedom of Information requests found.

The system has become "a real mess" because of the difficulty in keeping track of people moving around the city, Labour MP Emily Thornberry has said.

The London Local Medical Council (LLMC) added that names can vanish by mistake.

Lists are "cleansed" by surgeries which cannot contact patients and at least 460,000 names have been removed in the past five years, the figures show.

People would be dropped if they had not spoken to a practice in six months and there was no response to at least two written requests, the Department of Health said.

"This ensures that GPs are not paid for patients who have moved out of the area and who are no longer receiving services from that practice," said a spokesperson.

"If patients are contacted and confirm they remain in the area, then they will remain on the practice list and continue to receive services."

'Nature of London'

But Dr Michelle Drage, from the LLMC, said people could become "really scared" when they tried to book appointments and were told they were no longer registered, thinking they had "done something wrong" when this was not the case.

Surgeries regularly "cleanse" their lists if they lose touch with patients, but this can lead to mistakes

Patients who are wrongly deleted from lists must re-register to keep their doctor.

In the east London borough of Tower Hamlets, this was the case for 61% of those removed in a recent overhaul, the documents showed.

Another 10,000 people had to do the same in nearby Newham in recent months.

Mrs Thornberry, the shadow health and social care secretary and MP for Islington South and Finsbury, said people would not necessarily respond to letters from surgeries, particularly if their English was poor.

"In Islington, between the 2005 election and the 2010 election, there were 65% of the population who had moved.

"It's very difficult to keep up with people," she added. "It's the nature of living in inner London."

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VIDEO: Emergency patients 'put at risk'

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29 September 2011 Last updated at 06:44 GMT Help

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Emergency patients 'put at risk'

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29 September 2011 Last updated at 07:59 GMT By Dominic Hughes Health correspondent, BBC News Surgical team at work

Non-cardiac emergency surgery patients are 'forgotten', says the Royal College of Surgeons The lives of thousands of non-cardiac NHS emergency surgery patients are being risked by poor care and delays in treatment, leading surgeons say.

The Royal College of Surgeons says poor access to facilities like operating theatres and scans means some abdominal emergencies are not spotted in time.

The RCS also says not enough patients receive critical care after surgery.

NHS managers said they, surgeons and ambulance services needed to work together to achieve "real change".

The RCS adds that junior staff are often left to deal with complications.

A report by the college highlights figures that show that about 170,000 patients undergo non-cardiac emergency operations each year.

Of those, 100,000 will develop complications and 25,000 of these patients will die.

Among the elderly, deaths can climb to 40%.

The report says the non-cardiac category includes most major gastro-intestinal and vascular procedures.

Emergency major gastrointestinal (abdominal) surgery has one of the highest mortalities, which can reach 50% in the over 80s, the report says.

The report also says that while survival rates vary from hospital to hospital, there can even be significant differences from day-to-day within the same institution.

Continue reading the main story Recognition of the need for improved services, including access to operating theatresRoutine risk assessment and tailored management of every patientBetter use of critical careImproved post-operative care, including treatment of severe infectionRoutine audit of emergency patientsThe report says that poor access to facilities such as scanners and operating theatres means diagnosis is sometimes slow, not enough patients receive critical care after surgery and when they do it is for too short a time.

It also says less experienced junior staff are often left to deal with complex and dangerous cases.

There is also the suggestion that elective or planned surgery has been prioritised over emergency surgery and some may link this to the pressure on hospitals to bring down waiting lists.

The study says hospitals need to provide fast access to operating theatres.

Iain Anderson, the author of the report and a consultant general surgeon at Salford Royal NHS Foundation Trust, said trusts needed to acknowledge that problems exist and review the way their services work.

Iain Anderson: "There are 8 or 10 simple steps that could lead to substantial improvement"

"Every single emergency patient who comes through the door of an NHS hospital should have an individual risk assessment, diagnosis, treatment plan and post-operative care plan prioritised according to need," he said.

"Instead we have some of the NHS's sickest patients languishing on inappropriate wards, treated by juniors and with no plan in place to deal promptly with unexpected complications.

"These tend to be the patients who end up in intensive care units for lengthy periods of time or, sadly, too sick to be helped."

Mr Anderson told Radio 4's Today programme the high-risk nature of emergency abdominal surgery was not being recognised.

"These are the largest abdominal operations and emergency operations and I think there's been a general failure to understand just how high risk this surgery is, both by the patients - sometimes by the doctors - but certainly by health service managers."

'Forgotten patients'

The report suggests improvements but the surgeons say NHS managers in particular need to recognise the problems facing those described as the "forgotten patients" of the health service.

David Stout, deputy chief executive of the NHS Confederation which represents NHS managers, says: "If we want to make a real change to emergency services we need to get everyone - managers, surgeons and ambulances services - working together to ensure patients receive properly planned, quality surgical care."

Bruce Taylor, president of the Intensive Care Society, said: "It is vital that the guidance is initiated as it in the best interest for potentially vulnerable patients who require surgical procedures."

A spokesman at the Department of Health said the NHS was being modernised to improve results for patients and safety was at the heart of the service.

"It is essential that hospitals provide the safest possible care for patients," he said.

"Hospitals should follow this guidance and monitor the quality of care they are giving to their patients and ensure that they are providing appropriate levels of services and staffing."

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Dementia patients suffer dubious hospitalizations

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One-fifth of Medicare nursing home patients with advanced Alzheimer's or other dementias were sent to hospitals or other nursing homes for questionable reasons in their final months, often enduring tube feeding and intensive care that prolonged their demise, a new study found.

Nursing homes may feel hospital care is warranted when a frail, elderly patient develops swallowing problems, pneumonia or a serious infection, but researchers suspect a different motive for many transfers: money. Medicare pays about three times the normal daily rate for nursing homes to take patients back after a brief hospitalization.

"I think that's unfortunately a factor in what's happening here," said Dr. Joan Teno, a palliative care physician and health policy professor at Brown University. "A lot of this care just feels like in and out, in and out. You really have to question, is the health care system doing a good job or not."

She is a co-author of the study, published in Thursday's New England Journal of Medicine and done with researchers from Harvard University and Dartmouth Medical School.

Among the nearly 475,000 patients studied, 19 percent were moved for questionable reasons. The study provided no evidence that money motivated such transfers or that there was wrongdoing involved. However, the large variation that researchers saw from state to state suggests money may be playing a role.

Rates of such transfers varied from 2 percent in Alaska to more than 37 percent in Louisiana. In McAllen, Texas, 26 percent of study participants had multiple hospitalizations for urinary infections, pneumonia or dehydration — conditions that usually can be treated in a nursing home. That compares to just 1 percent of patients in Grand Junction, Colo.

The researchers used Medicare records from 2000 through 2007 to identify "burdensome" transitions of care: moving patients in the last three days of life, moving them multiple times in the last three months of life, or moving them so they landed in a new nursing home afterward.

Medicaid pays on average $175 per day, depending on the state, for long-term care, but Medicare will pay three times that for skilled nursing care after a patient returns from three days or more in a hospital.

"If you have a nursing home that is operating on a margin, it adds up. It can be a tremendous incentive to hospitalize these people," Teno said.

Researchers found that patients who had a dubious transfer were more likely to have a feeding tube inserted, to spend time in intensive care in the last month of life, to have a severe bedsore or to be enrolled in hospice late (three days or less before they died).

Dubious transfers were more common with black patients, Hispanics and those without advance directives, legal documents spelling out care wishes.

The National Institute on Aging sponsored the study. One author consults for a nursing home system and owns stock in a long-term care information services company.

The study is important because more than 1.6 million Americans live in nursing homes, and nearly one-quarter of people admitted to one after hospitalization wind up back in the hospital within a month, Dr. Joseph Ouslander of Florida Atlantic University in Boca Raton and Dr. Robert Berenson of the Urban Institute in Washington, D.C., wrote in an editorial in the journal. Nursing homes may fear legal liability if they don't hospitalize a very sick patient, they wrote.

However, people with advanced dementia have a terminal condition.

"These are people who are unable to recognize their relatives, they're bed-bound and they're now usually having problems with swallowing. This is a population where the burdens of hospitalization often outweigh the possible benefits," Teno said. "These patients actually do better when they stay in a nursing home," where caregivers and surroundings are familiar, she said.

For families and nursing homes, "it may be difficult to recognize that in fact, this person is in the dying process," said Dr. Michael Malone, medical director of senior services for Aurora Health Care, a network of 15 hospitals in eastern Wisconsin. His 87-year-old father, Wendell Malone, died in January of advanced dementia in a nursing home that managed his care without frequent hospitalizations.

"It provided dignity, it provided comfort for the family," and let him stay in a place and with caregivers he knew, Malone said.

Beth Kallmyer, who runs programs for caregivers for the Alzheimer's Association, said the most important thing is to have a plan in place, with legal documents like "do not hospitalize" directives, before a nursing home has to make a decision about whether to hospitalize someone or instead focus on comfort care and not try to prolong life.

"When the time comes, the family will be able to say 'This is what dad wanted,'" Kallmyer said.

She and other experts offered these tips:

—Involve patients in planning their care while they're still able to do so, and make sure wishes like "do not resuscitate" or "do not call 911" are spelled out in legal documents.

—Develop good relationships with nursing home staff and attending physicians so they understand the family's goals of care.

—Consider hospice care when seniors with advanced dementia are admitted.

—Revisit and review the plan whenever there is a change in a loved one's status. Someone may not be end-stage when they enter a nursing home but that can change.

—Seek advice. The Alzheimer's Association has a 24-hour toll-free number, 1-800-272-3900, with counselors to help families.

___

Online:

Medical journal: www.nejm.org

State reports: www.LTCFocUS.org

___

Marilynn Marchione can be followed at http://twitter.com/MMarchioneAP

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'Robo legs' for stroke patients

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23 September 2011 Last updated at 04:29 GMT By Neil Bowdler Health reporter, BBC News

The LOPES therapeutic robot can do all or some of the walking for you Scientists in the Netherlands are using robotic legs to try to improve the movement of stroke patients.

The prototype device is called the Lower-extremity Powered ExoSkeleton, or LOPES, and works by training the body and mind of a patient to recover a more natural step.

The machine is also being tested on spinal injury patients who have recovered some restricted movement in their legs.

It is hoped a commercial version could be made available to rehabilitation centres around the world as early as next year.

Feedback mechanism

LOPES has been developed by engineers at the University of Twente in Enschede in the Netherlands over several years. Designed for the rehabilitation clinic, it is not a mobile device but supports the patient as they walk on a treadmill.

It can do all the walking for the patient, or it can offer targeted support in either one leg or with one element of the walking process. The machine can also detect what the patient is doing wrong.

"For instance, some people cannot lift their foot up appropriately," explains Dr Edwin van Asseldonk, who is working on the project. "What this device does is it senses that the foot is not lifting properly.

"It then compares it with a reference pattern and then exerts a force or torque to assist that subject in doing it."

Dr Edwin van Asseldonk explains what LOPES can do

Petra Hes is one of those testing the device. She suffered a stroke aged just 17. Years of physiotherapy have helped, but she still has what is known as a "drop foot", which means she cannot lift and flex her left foot in the way she once did, or even remember how to do so.

The machine provides the forces to enable her to physically move her left leg and foot the way it should move, but it also operates as a memory aid, the researchers believe.

"I got a eureka moment because I felt an old feeling of how to walk normally," she recalls of the first time she used the machine.

"That push-up I felt and my knee lifting it is what I've forgotten. I couldn't reproduce it myself so I had to feel it again."

Dr van Assledonk believes that by physically showing patients how to walk properly, the machine can help them develop the brain signals required to drive improved movement.

"With stroke survivors, it's very important that they get signals to the brain but also that they send signals downwards from the brain," he says.

"It's only when you get information from your legs to your brain and vice-versa that can you hope for some plasticity in your brain."

Dr Sharlin Ahmed from The Stroke Association in the UK hopes the innovation will help.

"Mobility issues have negative effects upon stroke survivors' quality of life, so we welcome any research or technology that will help improve mobility for stroke survivors and enable them to have a better quality of life," she told the BBC.

Military exoskeletons Soldier lifting weights with the HULC exoskeleton

The HULC exoskeleton is designed to take the load off US infantry

Work on a commercial version of the LOPES machine is already under way, with two private companies co-operating on the project. Two rehabilitation centres in the Netherlands will then test the device before it is rolled out to other clinics at home and abroad.

The LOPES project is by no means the only example of scientists turning to "exoskeletons" to aid human performance.

Berkeley Bionics of California has designed an exoskeleton called the Human Universal Load Carrier (HULC). The device enables infantry soldiers to lift and carry weights of up to 90kg in the field, and consists of a hydraulic-powered frame which straps around the soldier's body.

The same company has also developed an exoskeleton called "eLegs". Billed as an alternative to the wheelchair for those with restricted mobility, the frame can help users to walk upright with the aid of sticks.

A rival machine called ReWalk by Israeli company Argo Medical Technologies is also intended to help those with lower-limb disabilities to walk upright using sticks.

Dr van Asseldonk believes the possibilities are manifold.

"I foresee that older people in the future might just wear an exoskeleton when they're going around so they can keep pace with the grandchildren.

"You can imagine devices like this could keep people mobile for longer."

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Peliculas Online

Novartis drug may help older breast cancer patients

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By Kate Kelland

STOCKHOLM | Sun Sep 25, 2011 11:20am EDT

STOCKHOLM (Reuters) - Novartis's bone drug Zometa extended survival in older breast cancer patients but failed to improve disease-free survival among younger women patients in a large-scale clinical trial, researchers said on Sunday.

Detailed data presented at the European Multidisciplinary Cancer Congress (EMCC) in Stockholm showed that Zometa, a bisphosphonate drug known generically as zoledronic acid, only improved overall survival rates in patients who had undergone the menopause at least five years earlier.

Researchers said the effect was likely to be linked to levels of reproductive hormones, which are lower in women who have been through the menopause.

"This is not a treatment for ever woman with breast cancer," said Robert Coleman of Britain's Sheffield University, who led the study. But for women with low levels of female hormones, either due to aging or specific treatments to induce menopause, Zometa "appears very promising."

An analysis of the subset of older patients showed that at a the five-year follow-up, there was a 26 percent reduction in recurrence of tumors, Coleman said, as well as a 26 percent reduction in the risk of an early death.

These strong results could lead to "a major new treatment approach" for post-menopausal patients, he said.

Zometa, which generated sales of $2.1 billion for Novartis in 2010, is an intravenous drug from a widely used class of osteoporosis medicines called bisphosphonates.

It is increasingly being prescribed to help reduce or delay fractures and other skeletal complications in a variety of cancers that have spread to the bones. From 65 to 75 percent of breast cancer recurrences occur in the bones.

This trial, called AZURE and also published in the New England Journal of Medicine on Sunday, involved 3,360 women with early-stage breast cancer from 174 centers in Britain, Australia, Spain, Ireland, Portugal, Taiwan and Thailand.

Patients randomly allocated receive standard chemotherapy and/or hormone therapy, either with or without the addition of Zometa, a drug that works by inhibiting the cells that break down bone, called osteoclasts.

The results showed that looking across all trial participants, there was no significant difference in disease-free survival or overall survival between patients who received Zometa and those who didn't. But in a subset of older patients, the addition of the Novartis drug did bring clear benefits.

These women, who had at least five years since their last period, had an overall survival rate at five years of 85 percent on Zometa compared with 79 percent for those not on the drug. For all other patients, overall five-year survival was similar, at 86 percent in the Zometa group and 85 percent in the control group.

Investigators said that most surprising among the findings was the drug's effect on the rate at which the cancer recurred outside the bone. The relative risk for developing metastases, or secondary tumors, outside bone during treatment with Zometa was approximately halved in the postmenopausal women compared with the younger patients.

Coleman said the results shed new light on the role bones may play in the progress of the disease.

"The effects on metastasis and recurrence outside bone suggests that the bone marrow is an important sanctuary for tumor cells which can be activated after, sometimes, many years of dormancy," he said. "With help from bone marrow stem cells, they may then spread via the blood stream to set up metastases at other sites."

(Editing by Will Waterman)

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Peliculas Online

'Robo legs' for stroke patients

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