Good days and bad days in dementia

Jul14 blog pic - Hiscox

The August International Psychogeriatrics Article of the Month is entitled ‘Good days and bad days in dementia: a qualitative chart review of variable symptom expression’ by Kenneth Rockwood, Sherri Fay, Laura Hamilton, Elyse Ross and Paige Moorhouse.

Anyone who works with people with dementia is bound to experience poignant moments. Especially striking is hearing that a person seemingly lost to permanent unknowing – even near muteness – suddenly spoke a full sentence, or sometimes more. Much more common, but still compelling, are reports of people with dementia having remarkably good or bad days.

In what does daily variability consist? For some years, that question has motivated our group. In a paper in this month’s issue, we report the findings of a clinical chart review spanning 30 months, to understand how patients and families experienced variability living with dementia from day to day. This line of inquiry was born from the realization that, for many patients and families, variability was a source of expectations – and often disappointments. Families asked questions that I couldn’t answer: “why can he be so helpful some days, and other days can’t even do for himself?” Often, they had answers as good as anything I could muster: “it’s best if he has a good night’s sleep”, or “I can tell if he’s missed his medications”.

The challenge is to understand the mechanisms of variability. To get there, we need to know just what is happening, and for that we need careful qualitative studies. The area is tricky, because variability threatens reliability, and that undermines measurement, which undermines understanding. Or so the argument goes. Progress however, obliges investigating the variability itself – as is being done in Lewy body dementia – and not just seeking ways to reduce it for testing purposes.

Our study offers some clues. For an important proportion of patients, variability occurs within the same symptom set: a good day is when the symptom is seen less, and a bad day when it occurs more. This makes fluctuation in specific neurochemical transmission seem likely. That some are implicated more than others is suggested by the patterns: most of these symptoms involve social conduct and engagement; other descriptions sound like attentional problems. For a second group of dementia symptoms, a bad day is marked by even a single occurrence of a bad problem: not being struck does not constitute a good day, even if being struck means a bad one.

Our group also gives thought to the mathematics of variable disease expression in dementia. On scales of months and years, a comprehensible, stochastic process can be modeled with high precision. Is what we see clinically another face of that, or does it signal instability that so often heralds more rapid decline, or is it a variation of the fluctuating attention seen in delirium and in Lewy Body dementia?

However it works, we should aim for treatment. Many families believe that some part is modifiable. Are they correct? Aiming for therapies might seem obvious, but against the thankfully fading fashion of rubbishing symptomatic treatments, it’s good to be reminded of how big is the gap between what we offer and what people need. And that is poignant.

Kenneth Rockwood, Dalhousie University, Halifax, Canada


The full paper “Good days and bad days in dementia: a qualitative chart review of variable symptom expression” is available free of charge for a limited time here.

The commentary on the paper, “Symptom variability in dementia” is also available free of charge for one month here.


Autism rates steady for two decades


A University of Queensland study has found no evidence of an increase in autism in the past 20 years, countering reports that the rates of autism spectrum disorders (ASDs) are on the rise.

The study was led by Dr Amanda Baxter from UQ’s Queensland Centre for Mental Health Research at the School of Population Health, and was a first-of-its-kind analysis of research data from 1990 to 2010. Dr Baxter and her colleagues found that rates had remained steady, despite reports that the prevalence of ASDs was increasing.

“We found that the prevalence of ASDs in 2010 was one in 132 people, which represents no change from 1990,” Dr Baxter said.

“We also found that better recognition of the disorders and improved diagnostic criteria explain much of the difference in study findings over time.”

Part of the Global Burden of Disease project, this is the largest study to systematically assess rates and disability caused by ASDs in the community, using data collected from global research findings in the past 20 years.

ASDs are chronic, disabling disorders that stem from problems with brain development. They affect people from a young age and are among the world’s 20 most disabling childhood conditions.

The study shows that about 52 million children and adults around the globe meet diagnostic criteria for an ASD.

Dr Baxter said researchers hoped the study would help guide health policy and improve support for those with ASD and their families.

“As ASDs cause substantial lifelong health issues, an accurate understanding of the burden of these disorders can inform public health policy as well as help allocate necessary resources for education, housing and employment.”

The study was a collaboration with the University of Leicester and the University of Washington’s Institute for Health Metrics and Evaluation, and is published in the journal Psychological Medicine.


The full paper “The epidemiology and global burden of autism spectrum disorders” can be viewed free of charge for a limited time here.


Sociology, Stigma and Innovation – Sam Rowlands on editing a book about abortion

Abortion Care Cover

After last month’s article about the journey of a medical book from an author’s perspective, this month we hear from Sam Rowlands, editor of Abortion Care, about editing a book which boasts more than 40 contributors – and which is about a particularly emotive topic…

There aren’t many medical books dedicated to abortion care. I felt there was a gap in the market for a smaller book that could be easily carried around. I wanted to produce a book that had all the conventional ingredients such as the methods of abortion, complications and so on but also looked at abortion from a wider perspective.

I drew up a list of around 30 chapters and identified potential authors for each. Cambridge were keen for the book to have international appeal so I endeavoured to select recognised specialists from around the world. I am fortunate to have met many of these personally through my career in sexual and reproductive health but still I was delighted (and surprised) that most of the colleagues I chose readily agreed despite their very busy schedules. I was then intrigued by how many chapter authors (15) asked to collaborate with their selected colleagues. This has resulted in an even richer authorship.

I had originally thought I might ask a couple of collaborators to co-edit with me but on reflection decided to edit the book on my own. The advantage of this was that I could be in control and do things my way, especially as I had by now a clear view of how the book would look. The downside was that when more than 20 chapter manuscripts arrived in a rather short space of time, I felt a bit overwhelmed! The lead chapter authors are all authorities in their fields. Some are academics and some are skilled practical clinicians, some both. Some are neither of these, just incredibly knowledgeable and wise. All authors developed their chapters in their own way; I encouraged them but tried not to steer them in any particular direction.

Although the book is mainly for readers with a medical bent, I have tried to include chapters to stretch their minds on topics that they might not necessarily otherwise tackle. Sociological topics are included but the authors of these were banned from using inaccessible terminology! There are two chapters with an epidemiological flavour which are not too daunting even to the numerically-challenged. There are two chapters written by lawyers which really flow, despite references to statute and case law.

Although the book is about a controversial subject and is bound to be serious in most of its content it is written in language that I hope is accessible and uses a lighter touch at times, for example a quote from Monty Python in the ethics chapter. The historical chapter provides a wonderful backdrop, painting a vivid picture of days gone by with some poignant examples of tragic cases. Stigma is a theme that runs through the book. Half a chapter is dedicated to this but reference is also made elsewhere, particularly in the chapter on staff. Although we all know that abortion is stigmatised, it’s only quite recently that it’s been written about and even measured.

I tried to include some innovations in the book and two chapters come up trumps in this respect. One covers abortion care provided by personnel other than doctors, showing that all the evidence points to this being not only safe but actually preferred by many women. The other looks to the future and shows how telemedicine can be applied to facilitate communication and treatment when the clinician and the woman are not in the same place, which has potential to improve access in more rural areas or in those parts of the world with restrictive regimes.

I’ve found it very rewarding to head up this project but don’t claim it is perfect. I invite anyone to make suggestions for a second edition.

Sam Rowlands MBBS, MD, LLM, FRCGP, FFSRH, Clinical Lead in Community Sexual and Reproductive Health, Dorset HealthCare and Visiting Professor, School of Health & Social Care, Bournemouth University

Sam Rowlands is the editor of Abortion Care (out now).

Effect of oat intake on glycaemic control and insulin sensitivity

Diabetes blog

The August Nutrition Society Paper of the Month is from the British Journal of Nutrition and is entitled ‘Effect of oat intake on glycaemic control and insulin sensitivity: a meta-analysis of randomised controlled trials’.

Diabetes mellitus (DM) is one of the most serious chronic diseases, the incidence rate is consistently increasing all over the world however it used to be most common (especially type 2) in developed countries. The greatest increase in prevalence is, however, expected to occur in Asia and Africa. Perhaps a “Western-style” diet is the most important factor of the DM incidence increase in developing countries. There is no obvious cure for DM and the main management is keeping blood glucose levels as close to normal as possible, without causing hypoglycemia. A number of efficacy trials provided strong evidence for lifestyle change programmes in preventing type 2 diabetes among individuals with impaired glucose tolerance. Exploring a healthy diet and lifestyle to get the blood glucose levels controlled is critical for the prevention of type 2 diabetes.

Oat was recognized as a healthy food in the mid 1980s helping prevent heart disease and then it became more popular for human nutrition. Recent studies in food and nutrition have revealed the importance of its various components, such as dietary fiber especially, β-glucan, minerals and other nutrients. Oats and oat-enriched products have been proven to control blood glucose and are helpful in the treatment of diabetes. However, the results from clinical trials in humans investigating the effect of oat intake on glycemic control and insulin sensitivity are inconsistent. Therefore, we conducted a meta-analysis of randomized controlled trials (RCTs) to quantitatively assess whether oat intake has beneficial effect on glycemic control and insulin sensitivity and aim to make some suggestions for diabetes diet based upon what we found.

What have we done?

We conducted a literature search in PubMed, ScienceDirect Online and the Cochrane Library (up to October 2013) for RCTs that assessed the effect of oat intake on glucose control and insulin sensitivity. A random-effects model was used when overall pooled studies showed significant heterogeneity. Otherwise, a fixed-effects model was adopted. Quality assessment was conducted according to the modified Jadad scale.The sensitivity analyses and dose-effect calculations were also done to strengthen this work.

What did we find?

A total of 569 articles were initially identified after duplicates removed and 15 eligible articles were selected for analysis. The total numbers of participants were 673 in all studies. There was a slight decrease in fasting glucose concentrations, glycated hemoglobin and HOMA-IR in subjects after oat intake, but the difference was not significant. Subgroup analysis suggest that additional long-term and high-quality RCTs conducted in human subjects with parallel design are needed to further investigate the effect of oat intake on fasting glucose, which may provide evidence for the therapeutic potential of oats in diabetic patients or preventing glucose dysregulation in those with risk factors for DM.

This paper is freely available for one month via the following link:

Expert Reviews in Molecular Medicine launches ‘Discovery’ section

ERM Cover final

Expert Reviews in Molecular Medicine launches ‘Discovery’ section and welcomes original research under a gold Open Access extension.

We have launched the ‘Discovery’ section within our journal Expert Reviews in Molecular Medicine (ERMM) and now welcome high-quality, innovative original research papers to complement its authoritative ‘Reviews’ section. Authors who wish to publish their papers in ‘ERMM: Discovery’ will be able to do so under a gold Open Access model and payment of an article processing charge (APC). Reviews will continue to be accessed via a subscription to ERMM, with Open Access as an option for Review authors to choose should they wish to pay the APC.

ERMM has been publishing high-quality peer-refereed review articles since late 1997, which have proved a valuable forum for authoritative reviews in the area of molecular medicine. The Journal has an impressive Impact Factor of 6.628 (2012), which places it in a strong position amongst its competitors and this expansion will provide readers and authors with an enhanced resource for molecular medicine research.

ERMM: Discovery will be overseen and edited by Dr Julian Sale who will be working alongside the Editor-in-Chief, Professor Timothy Cox.

“We are delighted that Cambridge University Press has decided to enrich its portfolio of contemporary biological science by taking this publication initiative; it will incorporate new pages of experimental research to synergise with Expert Reviews. We welcome this innovative step and greatly look forward to receiving fresh discovery science in molecular medicine for competitive publication.”

Molecular medicine as a broad definition refers to elucidating the pathogenesis of disease at the molecular or physiological level, which may lead to the design of specific tools for disease diagnosis, treatment or prevention – this highlights the timeliness and importance of the Journal in the field. ERMM: Discovery will publish original work from across the full breadth of molecular medicine and pathology. Its scope mirrors that of ERMM: Reviews focussing on the molecular mechanisms of disease, diagnostics and therapy. The Journal particularly invites original research papers which provide mechanistic insights, while papers of a purely descriptive or correlative nature and case reports are unlikely to be accepted unless they provide exceptional scientific insight.

The Editors are inviting high-quality contributions of original research for ERMM: Discovery andreview papers for ERMM: Reviews. For detailed instructions on how to prepare your submission, please see our Instructions for Contributors.

Content from Expert Reviews in Molecular Medicine can be viewed A subscription will be required to access Review articles but all Discovery articles will be freely available under an OA license and are not included in the subscription price. All Open Access articles in this journal have article level metrics available.

Football focus: A study into preparedness of the health sector in Brazil for the 2014 FIFA World Cup

brazil world cup

This post is taken from the abstract of the paper “Hospital Preparedness in Advance of the 2014 FIFA World Cup in Brazil” published in Prehospital and Disaster Medicine.

Regardless of the capacity of the health care system of the host nation, mass gatherings require special planning and preparedness efforts within the health system. Brazil will host the 2014 Fédération Internationale de Football Association (FIFA) World Cup and the 2016 Olympics. This paper represents the first results from Project ‘‘Prepara Brasil,’’ which is investigating the preparedness of the health sector and pharmaceutical services for these events.

This study was designed to identify the efforts taken to prepare the health sector in Brazil for the FIFA World Cup 2014 event, as well as the 2016 Summer Olympics.

Key informant interviews were conducted with representatives of both the municipality and hospital sectors in each of the 12 host cities where matches will be played. A semi-structured key informant interview guide was developed, with sections for each type of participant. One of each municipality’s reference hospitals was identified and seven additional general hospitals were randomly selected from all of the inpatient facilities in each municipality. The interviewers were instructed to contact a reference hospital, and two of the other hospitals, in the jurisdiction for participation in the study.

Questions were asked about plans for mass-gathering events, the interaction between hospitals and government officials in preparation for the World Cup, and their perceptions of their surge capacity to meet the potential demands generated by the presence of the World Cup events in their municipalities.

In all, 11 representatives of the sampled reference hospitals, and 24 representatives of other general private and public hospitals in the municipalities, were interviewed.

Most of the hospitals had some interaction with government officials in preparation for the World Cup 2014. Approximately one-third (34%) received training activities from the government. Fifty-four percent (54%) of hospitals had no specific plans for communicating with the government or other agencies during the World Cup. Approximately half (51%) had plans for surge capacity during the event, but only 27% had any surge capacity for isolation of potentially infectious patients.

Overall, although there has been mention of a great deal of planning on the part of the government officials for the World Cup 2014, hospital surge to meet the potential increase in demand still falls short.


The full paper “Hospital Preparedness in Advance of the 2014 FIFA World Cup in Brazil” can be viewed free of charge for a limited time here.


Does the Baby-Friendly Hospital Initiative increase breastfeeding?

The July Nutrition Society Paper of the Month is from Public Health Nutrition and is entitled ‘Evaluating the impact of the Baby-Friendly Hospital Initiative on breast-feeding rates: a multi-state analysis’.

PHN NS POM image

Not only does breastfeeding improve the health of mothers and infants, but it also reduces health care costs and has a smaller environmental footprint than formula-feeding. Although currently three-quarters of US women start breastfeeding, women with lower education are much less likely to try. One known barrier is the lack of breastfeeding support that women receive in the hospital.

The Baby-Friendly Hospital Initiative (BFHI) was developed by the World Health Organization and UNICEF in 1991 to promote, protect, and support breastfeeding within the birth facility and after. While more than 20,000 hospitals and birth centers in 156 countries have been designated as Baby-Friendly, there are only 182 BFHI facilities in the US in 43 states and DC. Despite the success of the BFHI on breastfeeding practices internationally, research in the US has been limited. We wanted to determine whether the BFHI increased breastfeeding overall and, particularly, whether it improved breastfeeding among women with lower education.

Using data from 5 states, we compared breastfeeding outcomes between 11,723 mothers who gave birth in 13 BFHI hospitals and 13,604 mothers from 19 non-BFHI birth facilities. Although overall women who gave birth in BFHI hospitals were no more likely to start or continue breastfeeding than women from non-BFHI facilities, we showed that it benefited women with lower education. Only 78% of women with a high school degree or less started breastfeeding, but we found that those women who delivered in BFHI hospitals were 3.8 percentage points more likely to start breastfeeding than women with the same educational attainment who delivered in non-BFHI facilities. In contrast, 90% of women with more than a high school degree started breastfeeding, but giving birth in a BFHI hospital did not further increase their likelihood of starting or continuing breastfeeding.

What are the implications of these findings?

Women with low education benefited the most from giving birth in Baby-Friendly hospitals, suggesting that the BFHI may be one way to help decrease socio-economic disparities in breastfeeding. Currently only 7% of births in the US are in BFHI facilities. Our results support the recommendation to increase the number of BFHI-accredited birth facilities to encourage women to start breastfeeding, but more may be needed to help women continue breastfeeding after discharge.

This paper is freely available for one month via the following link:


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