Global challenges and opportunities for tackling antimicrobial resistance

This post was written by Sophie Allcock andoriginally posted on the Global Health, Epidemiology and Genomics blog – view more at:

Antimicrobial resistance (AMR) is a global public health concern. In 2014, an estimated 700,000 deaths were attributed to AMR globally and it is predicted that by 2050 this number could reach 10 million.[1] Antibiotics have been the cornerstone of many medical interventions, for example surgical interventions, transplants and the treatment of common bacterial infections, for decades. Without effective antibiotics, many medical practices that we now consider to be routine will be jeopardised.

Although there is much global attention to AMR, there is a need to better understand the burden, distribution and determinants of AMR at the population level. Antimicrobial use, appropriate or inappropriate, is a driver of AMR yet there is a lack of specific advice as to which interventions are likely to have the greatest impact on reducing the emergence and spread of AMR in both hospital and community settings.

In our paper “Antimicrobial resistance in human populations: challenges and opportunities”, we argue for the integration of a range of epidemiological approaches, which could help to improve our understanding of the population level factors that may influence the development and spread of AMR. This is important for informing interventions to reducing excess use of antimicrobials, whilst also ensuring that those in need of these treatments have access to them.

One such approach is to use routine clinical data and electronic health records (EHRs) in combination with pathogen surveillance, using techniques such as whole-genome sequencing. This could help to improve our understanding of drug resistance, how it emerges and how it spreads. EHRs could also provide an insight into prescribing practices in general practices and hospitals, and how this could be related to the emergence of drug-resistant infections. Using prospective (or longitudinal) study designs, researchers could explore the real-time development of resistant strains in a given population as well as the factors that may drive resistance.

Other preventative strategies to reduce the burden of AMR include basic hygiene and sanitation practices, waste management and safe food preparation. However, in some low- and middle-income countries (LMICs), conducting these basic practices can be challenging due to human resource constrains and weaker civil and health infrastructures. Furthermore, it is often the case in these countries that more people suffer due to a lack of access to drugs than drug resistance itself.

The suggested research initiatives may help to better understand the burden, distribution and determinants of AMR. These approaches should be combined with improved preventative measures, including vaccinations and good hygiene and sanitation practices to reduce the need for therapy in the first instance, and strategies to reduce excess use of antimicrobials to slow the development of resistance. Furthermore, although AMR is a global problem, we need to consider that the issue differs by county and setting, therefore so must the approach taken to tackle AMR.

1. O’Niell J., Tackling Drug-Resistant Infections Globally: Final Report and Recommendations, in The review on antimicrobial resistance. 2016, HM Government and the Wellcome Trust: London.

The paper “Antimicrobial resistance in human populations: challenges and opportunities” by S. Allcock, E. H. Young, M. Holmes, D. Gurdasani, G. Dougan, M. S. Sandhu, L. Solomon and M. E. Török has been published Open Access in Global Health, Epidemiology and Genomics and is available here.


Knowledge gaps in the epidemiology of Toxocara: the enigma remains


The latest Parasitology Paper of the Month is “Knowledge gaps in the epidemiology of Toxocara: the enigma remains” by Celia Holland.

Some parasites seem to have a Cinderella status. Down in the basement of the ugly stepmother’s house, they are working away, busily infecting many hosts but there is no handsome prince, in the form of generous research funding, to bring them to the ball. Despite the most welcome initiatives concerning Neglected Tropical Diseases (NTDs), human toxocariasis, with its worldwide distribution, remains strangely ignored. Why is this so? There is no doubt that its multiple routes of transmission to hosts, both domestic and feral, its cryptic disease picture in humans, problems with diagnosis and treatment and its widespread environmental contamination, all contribute to the challenge of researching this enigmatic helminth and to devising appropriate preventative and control measures.

However, that is not the full story. The number of investigators who make Toxocara their main focus is diminishing. Tragically, Huw Smith, of the Scottish Parasite Diagnostic Laboratory, passed away and several other leading figures, such as J-F Magnaval and Mervyn Taylor, have retired. We now need young, able scientists to contribute to the challenge. However, Peter Hotez remains a passionate advocate, raising awareness of Toxocara. He recently included the parasite in a ‘Viewpoint’ for JAMA Psychiatry, focusing on five infections affecting the American brain. From the veterinary perspective, Dwight Bowman and Paul Overgaauw are equally passionate in educating veterinarians about the zoonotic potential of Toxocara.

This is the background to my paper “Knowledge gaps in the epidemiology of Toxocara: the enigma remains”, a contribution to the One Health special issue in Parasitology and the BSP symposium. The enigma refers to the title of the book, Toxocara the enigmatic parasite, edited by Huw Smith and I back in 2006. We have made some progress since then. But, as outlined in my paper, there remain at least nine gaps in our knowledge, gaps that seem shocking when we contrast them with our knowledge of other major human parasites. For example, it seems inconceivable that we do not know what species of Toxocara contributes most to human exposure, Toxocara canis or T. cati and still lack information on the precise relationship between exposure and disease.

As outlined in the paper, what we urgently require is a One Health approach to the study of Toxocara and toxocariasis. I suggest an ideal scenario initially involving a single country or defined region, in which sources of infection in humans, other animals and the environment are comprehensively assessed. The relationship between seropositivity in humans and the extent of significant disease is also explored, as is the detection of eggs in the environment and larvae in paratenic hosts. The collection of such crucial baseline epidemiological data would provide the basis for an intervention study encompassing anthelmintic treatment and anti-fouling, with subsequent follow up. There is no doubt that such an approach would be logistically challenging and costly. But, for the first time, it would place Toxocara in a One Health context, and provide a framework for future prevention and control. Now is the time for major pharmaceutical companies, for whom veterinary anthelmintics is a lucrative line of production and sale, to join with the research community, by funding a significant One Health programme of research focused upon Toxocara.

Read the full article “Knowledge gaps in the epidemiology of Toxocara: the enigma remains” in full for free until 28th February 2017.

The challenges of big data in low- and middle-income countries: from paper to petabytes


Generation of digital data has expanded exponentially over the last decade, inspiring visions of data-driven healthcare and precision medicine. But the promise of big data is tempered by today’s reality in low resource settings: weak health systems and limited governance structures complicate its application. Many of the countries in greatest need continue to struggle to collect vital statistics on births and deaths, with epidemiological data of variable reliability typically coming from only small, sentinel sites. However, with the falling cost of aggregating and coordinating resources and services electronically, big data stands to deliver disproportionately large benefits to low- and middle-income countries (LMICs). Effective targeting of interventions is increasingly important when the availability of resources is limited.

The collection of individual level information – a prerequisite for big data – is fraught with ethical, regulatory and procedural challenges. Of widespread concern is the risk of breach of privacy, and, as a result, the thought of digitised and centralised repositories of personal records instils fear in many. This concern is further amplified when information is about individuals in vulnerable populations and communities. Even very basic health data – ethnicity, reproductive health history, sexually transmitted infections, diseases with a genetic basis, or risk exposures for disease – has the potential for misuse, leading to discrimination, personal danger or death. The risk of accidental or intentional breaches of data security may be increased with limited literacy, high corruption, or rapid technology transition. In many LMIC settings, legislation supporting the privacy and security of information is frequently underdeveloped and rarely enforced. Robust data sharing guidelines between LMIC stakeholders are often lacking, hampering big data solutions and compromising those in play.

The persistent tension between disease-specific (‘vertical’) programs and health-system (‘horizontal’) focused approaches remains unresolved. Big data arguably fits best with a horizontal approach, potentially improving data for a breadth of diseases to support the new Sustainable Development Goals. However, global health remains a siloed undertaking, often driven by disease specific interests. Ensuring inclusive data collection, dissemination and application is critical for maximizing big data’s potential.

Informed, reflective and resourced stewardship is critical to enable positive outcomes from health big data in LMICs. Unfortunately, the global health community has a patchy record of cohesive and inclusive governance of technical developments. Optimising the application of big data is much more than establishing confidentiality safeguards and minimum standards. A broad effort to establish enforceable interoperability standards is imperative to creating meaningful insight.

Big data’s mechanism of action is magnification; sheer size makes risks and benefits larger. This magnification is greater in low resource settings where big data are most needed and most vulnerable to fragmentation and misuse. Conscious and committed leadership, analysis and technical guidance are needed to minimise these risks. Complexities should not be underestimated; the shift from paper to petabytes in LMICs is a seismic change. Shepherding that transition provides an opportunity for global health institutions to demonstrate governance.

Image caption: “Logo for the Big Data for Health in Africa meeting, hosted by the African Partnership for Chronic Disease Research in Entebbe, Uganda on 3rd-4th November 2016. An initiative building capacity and expertise in Big Data and data science to ensure that African countries are able to capitalise on the scientific  technical, social and economic benefits of this new global industry”

Which behaviours and symptoms are the most distressing for family carers of people with dementia?

Mature woman (60s) helping elderly mother (90s).

The November International Psychogeriatrics Article of the Month is entitled “A systematic review of the relationship between behavioral and psychological symptoms (BPSD) and caregiver well-being” by Alexandra Feast, Esme Moniz-Cook, Charlotte Stoner, Georgina Charlesworth, Martin Orrell.

During the course of dementia the vast majority of people will experience some form of behavioural or psychological symptoms (BPSD). BPSD include agitation, aggression, calling out repeatedly, sleep disturbance, and lack of interest and motivation. Numerous studies have reported that these BPSD can be a major source of distress for family caregivers of people with dementia. BPSD are also important predictors of family caregiver depression, burden and care home admission.

In the past people tended to group BPSD as one big category without trying to consider whether one symptom was more distressing for family caregivers than the others. We investigated this by reviewing research articles published in English between 1980 and December 2015 which reported which individual BPSD affected caregiver well-being.

So which behaviours and symptoms are the most distressing for family carers? We found 40 research articles which could help answer our question during our search, however, only 20 research articles were comparable and could be used in the analysis. When we looked at the 16 research articles which reported the frequency of BPSD it was found that depression in the person with dementia was the most distressing for caregivers, followed by agitation/aggression, and lack of interest and motivation. As expected, the person with dementia being excessively happy was the least distressing. However, surprisingly, when we looked at research articles that reported the relationship between BPSD and caregiver well-being (4 research articles) rather than frequency, we found that different BPSD were related to higher levels of distress. Irritable behaviour, inability to sit still, and delusions were the most strongly related to distress. Disinhibited behaviours demonstrating a lack of control, disregard for social conventions, impulsivity, and poor risk assessment were the least related to caregiver distress.

What is the take-home message? We are still unsure whether some BPSD impact caregiver well-being more than others. Studies which look at BPSD individually were limited, and had different ways of measuring BPSD and caregiver well-being. In future we need to measure BPSD and caregiver well-being consistently, and also look at BPSD individually rather than as one big category. Once this is addressed we can identify which BPSD affect well-being the most and prioritise these when we develop ways to support caregivers at home. Nevertheless, our inconsistent findings may not just be due to a lack of information and varied types of analysis, they may also be due to the individual differences between what caregivers find upsetting. To fully understand the relationship between caregiver well-being and BPSD, we also need to examine the influence of caregiver variables such as caregiver strategies, acceptance, gender, their relationship with the person with dementia and their confidence. We can then work out whether clinicians should be providing different kinds of support to different caregivers, depending on their circumstances.

The full paper “A systematic review of the relationship between behavioral and psychological symptoms (BPSD) and caregiver well-being” is available free of charge for a limited time here.

The commentary paper “Progress in BPSD research: analyzing individual BPSD might hold the key to better support caregivers” by Nicola T. Lautenschlager is also available free of charge for a limited time here.

Insomnia more common in teens whose mums had postnatal depression

More than a third (36%) of teenagers whose mothers suffered from postnatal depression experienced sleep problems at the age of 18, compared to only one in five (22%) teenagers whose mothers didn’t suffer from postnatal depression.

Insomnia affects between one in two and one in 10 people worldwide and can be debilitating. It can lead to memory problems and fatigue, and raises the risk of developing high blood pressure and heart disease.

Such health problems have a high economic cost, both direct (healthcare, drugs, tests and research) and indirect (absenteeism, lack of productivity).

Now, for the first time, researchers have looked to see if postnatal depression in women could contribute to their children having sleep problems in adolescence. It is already well established that postnatal depression can affect a child’s mental health and how well they do at school but the impact of it on sleep has not been examined before.

By looking at Children of the 90s (University of Bristol), a unique 25-year-long study of 14,500 mothers and their children (born in 1991 or 1992), researchers were able to ask teenagers when they were 16 and 18 about their sleep problems and compare their answers to the information more than 10,000 mothers had provided years before about postnatal depression. The study is based at the University of Bristol.

By assessing the problem so many years after the children were born, the researchers were able to rule out sleepless nights during infancy as the cause of the postnatal depression and ask the teenagers themselves about their sleep problems rather than rely on what their mothers said (which may have been affected by their depression).

What they found is that more than a third (36%) of teenagers whose mothers suffered from postnatal depression experienced sleep problems at the age of 18, compared to only one in five (22%) teenagers whose mothers didn’t suffer from postnatal depression.

This was the case even after a number of important factors were taken into account:

  • Whether the teenager suffered from depression when they were aged 16
  • Whether the teenager had experienced sleep problems as a young child (measured at the ages of 6, 18 and 26 months)
  • The mother’s education, her age when the child was born, and the number of other children in the family
  • Whether the mother smoked or experienced depression when pregnant

Although a mother’s depression increases the likelihood that her child will have sleep problems, the reasons for this are not clear.

Dr Rebecca Pearson from the University of Bristol, who supervised the research, suggests three possible reasons:

  • Shared genes between the mother and child can affect sleeping patterns
  • Antenatal depression which precedes postnatal depression can have a biological effect on the child while it is still in the womb
  • Postnatal depression can make it more difficult for mothers to help regulate their baby’s emotions and their ability to establish regular and calm sleeping patterns. Continued depressive symptoms in the mother during her child’s early years (up to age 12) were also found to play a role.

Speaking about the findings, she said:

“Postnatal depression can make it more difficult for mothers to interact with their babies and this could make it particularly hard to establish a regular sleeping routine and help babies to learn to regulate their emotions and settle themselves to sleep. A noisy, disruptive house can also make it difficult for children to sleep and such environments can be linked to maternal depression.

Depressed mothers are increasingly offered support to improve their mood and to promote positive interactions with their babies and we would advocate that such support also considers the child’s sleeping pattern. As we’ve shown here, maternal depression can potentially have serious long-term implications for the health and wellbeing of both the mother and her child.

There is substantial evidence that postnatal depression is linked with a broad range of child difficulties. Individual risks are often small but because depression in mothers can influence so many aspects of their child’s development, in total it is very costly.”

Anna Taylor, a medical undergraduate student at the University of Bristol who led the research, explained that:

“Poor sleep affects school performance as well as physical and mental health, all of which can have significant impact on the child’s life and what they are able to achieve, so preventing sleep problems is really important. The cost of supporting depressed mothers is far smaller than the longer-term costs of dealing with multiple problems later in life.”

Dr Pearson added:

“As far as we’re aware, no one has ever looked at the long-term effects of postnatal depression on a child’s sleeping habits as reported by the children themselves as teenagers. Luckily, Children of the 90s, with its 25-year dataset, allows us to go back in time and examine these issues in great detail.”

via University of Bristol – ALSPAC – Insomnia more common in teens whose mums had postnatal depression

The full paper, The association between maternal postnatal depressive symptoms and offspring sleep problems in adolescence has been published Open Access in Psychological Medicine, and can be viewed here.

Towards an exposure-dependent model of post-traumatic stress

Imagine sitting at your desk at work, on a Friday afternoon, just waiting for the weekend to begin. Then; a loud bang, the walls are shaking, your office windows shatter. With ears ringing, you crawl out into the corridor. The guy in the office next to yours is hurt. His shirt is covered in blood. You help him down the stairs. There’s smoke and dust everywhere. By the main entrance you pass someone who is beyond help.

Or; you are on summer holiday, relaxing at the family cottage. Suddenly, your husband calls out, telling you to come and watch the news. On the TV you see pictures from the bombed-out office building where you normally spend your workdays. You try to remember; who among your colleagues is on holiday this week? And who is at work, now possibly dead or injured? You immediately call a colleague; all she can tell you is that a bomb has gone off. No one knows what to do next.

On July 22nd 2011, these scenarios sadly became reality when a right-wing extremist triggered a car bomb in the executive government quarters in Oslo, Norway. Several office buildings were severely damaged in the blast. Luckily, as the terror attack happened on a Friday afternoon in July, a lot of people were on holiday or had gone home for the day. Still, 8 people were killed and more than 200 were injured. The Norwegian nation was in shock.

In a new study published in Psychological Medicine, researchers at the Norwegian Centre of Violence and Traumatic Stress have examined patterns of post-traumatic stress reactions (from approx. 10 months to 3 years after the attack) in the government employees who were or were not present at work at the time of this terrible attack. What they found might hold an important key to our understanding of post-traumatic stress disorder.

For government employees who were at work that fateful day, anxiety provoking intrusive memories from the incident seem to be the main driver behind prolonged stress. Together these primary symptoms seem to work as the “psychological engine” behind the development of other common post-traumatic stress reactions, in some cases (24%), creating the complex, heterogeneous post-traumatic stress symptomatology we see in sufferers of post-traumatic stress disorder.

However, for the indirectly exposed employees (those who were on holiday or had gone home) dysphoric arousal (sleeping difficulties, irritability and problems concentrating) emerged as the best predictors of prolonged symptom severity. Although present in their symptomatology, intrusions of that fateful day do not include the same horrific details (e.g. smoke, blood, fire), and therefore do not seem to provoke the same anxious arousal. Instead a sequel of dysphoric arousal and emotional numbing, possibly related to depressive symptoms or negative affect, seem to emerge.

Why is this difference important?

This difference is important because it adds important empirical clues to contemporary theories that help us understand the development and chronicity of post-traumatic stress disorder. And in turn, it sheds light on how to treat sufferers of this debilitating disorder.

The full paper, “Towards an exposure-dependent model of post-traumatic stress: longitudinal course of post-traumatic stress symptomatology and functional impairment after the 2011 Oslo bombing” by Ø. Solberg, M. S. Birkeland, I. Blix, M. B. Hansen and T. Heir can be viewed here free of charge for a limited time

Danish Suicide Prevention Clinics prevent more than deaths by suicide


This post was written by Johannes Birkbak and Annette Erlangsen.

A new Danish study finds that psychosocial therapy for suicide prevention does more than preventing deaths by suicide. The treatment also reduces risk of death by other causes.

Mental and physical well-being are interrelated. People at risk of suicide have a considerably increased risk of dying, not only by suicide, but also by other causes of death.

A group of Danish researchers examined causes of death among nearly 6,000 persons who, following an episode of deliberate self-harm, received psychosocial therapy at one of the Danish Suicide Prevention Clinics. The group who received the intervention was compared to people receiving standard care following an episode of deliberate self-harm. Psychosocial therapy was associated with a 37% decrease in alcohol-related deaths as well as in deaths due to injuries and accidents. The risk of dying by a heterogeneous group of medical causes was reduced by 39%, while the risk of dying by suicide was reduced by 28%.

“This is the first European study to show improvements in mortality among persons who have received psychosocial therapy after deliberate self-harm. While we knew that the treatment in the Suicide Prevention Clinics does more than prevent suicidal behavior, we found it important to uncover what additional causes of death were prevented by the intervention,” says Johannes Birkbak, M.D., from the Danish Research Institute of Suicide Prevention, Mental Health Centre Copenhagen.

In conjunction with other research in this area, the results indicate that psychosocial therapy might enable patients to revise their coping strategies and, as a possible result, improve their general lifestyle, which might explain the mortality reductions.

About the study:

The study compares 5,678 people who received psychosocial therapy at a Suicide Prevention Clinic after an episode of deliberate self-harm with people who received standard care following an episode of deliberate self-harm. The multi-center study enrolled users from seven of the regional Suicide Prevention Clinics in Denmark during 1992-2011.

Using data from the national Danish registers, the researchers followed the treatment group and the control group for up to 20 years, and all deaths and causes of death were registered.

Given that the study evaluated an already established intervention after self-harm, it was not possible to randomise the patients. To account for this, a comparison group was selected to match the treatment group on 31 different factors using propensity score matching. The treatment group and the control group are comparable on factors such as age, sex, social background and clinical factors.

The study found that psychosocial therapy was associated with reduced risk of death by suicide, injuries and accidents, mental disorders, alcohol-related causes as well as a group of heterogeneous medical causes. Deaths caused by cancer and diseases of the circulatory system were not significantly reduced.

The study was designed and carried out by the Danish Research Institute for Suicide Prevention.

The full paper “Psychosocial therapy and causes of death after deliberate self-harm: a register-based, nationwide multicentre study using propensity score matching” by Johannes Birkbak, Elizabeth A Stuart, Bertel Dam Lind, Ping Qin, Elsebeth Stenager, Kim Juul Larsen, August G Wang, Ann Colleen Nielsen, Christian Møller Pedersen, Jan-Henrik Winsløv, Charlotte Langhoff, Charlotte Mühlmann, Merete Nordentoft, Annette Erlangsen can be read free of charge for a limited time here.

Get your sleep and treat depression to guard against Alzheimer’s disease


The September International Psychogeriatrics Article of the Month is entitled “Associations between depression, sleep disturbance, and apolipoprotein E in the development of Alzheimer’s disease: dementia” by Shanna L. Burke, Peter Maramaldi, Tamara Cadet and Walter Kukull. This blog piece was released by Florida International University and can be viewed here.

New research suggests that lack of sleep and untreated depression may increase the risk of Alzheimer’s disease, even for those who do not have a genetic predisposition for the disease.

Depression and sleeplessness have long been considered symptoms of Alzheimer’s disease. This study indicates that whether in combination with genetic risk factors or on their own, untreated depression and lack of sleep may lead to the onset of Alzheimer’s disease dementia later in life.

“Previous research has attempted to explore the relationship between depression, sleep disturbance and Alzheimer’s disease. Our research is significant in that it is the first to find an increased risk of Alzheimer’s disease due to insomnia and depression independently, as well as in combination with genetic risk factors,” said Shanna L. Burke, assistant professor of social work at the FIU Robert Stempel College of Public Health & Social Work.

Alzheimer’s disease currently affects more than 39.9 million people worldwide. In the United States, it is the most common form of dementia in the elderly, affecting 1 in 10 people over the age of 65.

Although treating the genetic risk factors for Alzheimer’s disease isn’t possible yet, these findings suggest that alleviating depression and sleep disturbance may decrease the chances of a person developing the disease.

Burke served as the primary investigator for the study. She and the other members of the research team—Peter Maramaldi, Tamara Cadet and Walter Kukull—present their findings in Associations between depression, sleep disturbance, and apolipoprotein E in the development of Alzheimer’s disease: dementia, which was recently highlighted as “Paper of the Month” in the journal International Psychogeriatrics. Commentary and associated findings on the study were provided by Dr. David Steffens, chair of the department of psychiatry at the University of Connecticut.

“Future studies are needed to better understand the role of sleep in development of Alzheimer’s Disease, either as an independent risk factor or as a key depressive symptom that might further unlock the link between depression and Alzheimer’s,” said Steffens.

The full paper “Associations between depression, sleep disturbance, and apolipoprotein E in the development of Alzheimer’s disease: dementia” is available free of charge for a limited time here.

The commentary paper “J’accuse! depression as a likely culprit in cases of AD” by David C. Steffens is also available free of charge for a limited time here.

Medicalisation of young minds: new study reveals 28% rise in antidepressant prescribing amongst 6-18 year olds « Swansea University

Antidepressant prescribing amongst children and young people has shown a significant increase of 28% in the past decade, even though recorded diagnoses of depression have gone down, according to new research published today.

One in ten children and young people suffer from some kind of mental health problem, including depression and anxiety. Concerns about under-diagnosis and under-treatment contrast with worries about over-prescribing and the medicalisation of unhappiness in young people.

The research, published in Psychological Medicine, and carried out by a team which included several Swansea University experts, was led by Ann John, associate professor at Swansea University Medical School, who is also a qualified GP. The team looked at data from 358,000 registered patients between 6 and 18 years old, living in Wales, UK, between 2003 and 2013. The data was drawn from GPs and other NHS primary care services.

The research found that:
• Antidepressant prescribing rose significantly, by 28%, mainly in older adolescents
• Depression diagnoses showed a steady decline by just over a quarter, while symptoms of depression more than doubled
• Unlicensed citalopram prescribing occurs outside current guidelines, despite its known toxicity in overdose
• Just over half of new antidepressant prescriptions were associated with depression. The rest were associated with diagnoses such as anxiety and pain

The findings led the researchers to call for new strategies to implement current guidance for managing depression in children and young people.

Dr Ann John, associate professor at Swansea University Medical School, said: “These findings add to the growing debate over increasing prescribing of anti-depressants to children and young people.

The main issue is whether they being prescribed with enough cause. The rise in prescribing may reflect a genuine increase in depression and its symptoms, or increased awareness and better treatment by GPs, or poor access to psychological therapies and specialist care, or even increased help-seeking.

Whatever the explanation it’s important that each individual young person is listened to and gets the right kind of help for their problem. We need to support those who support young people and their families, helping them to act in keeping with current guidance.”

Dr John underlined the importance of responding appropriately to the needs of young people:

“The teenage years are a phase of gaining independence, engaging with the world and testing boundaries. This can result in a normal developmental range of emotional responses- stress, loneliness, sadness and frustration. For others the mental health issues are more serious, and historically they were often not recognised, talked about or treated.

Teenagers may be moving into adulthood without many of the skills necessary to deal with these issues if we don’t manage them well at an early age.

It can be hard to distinguish between what is emotional turmoil and what warrants a mental health diagnosis in a young person.

We need to ensure GPs are trained to really understand the lives and moods of young people, as well as knowing what warning signs they should look out for. For some young people reassurance that this is within the range of normal human experience may be appropriate. For others, talking therapies may be the best option, as they have a proven track record of improving symptoms for those with mild and moderate depression.
In more serious cases, anti-depressants should be used together with talking therapies. Improving access to talking therapies is very important. Otherwise, if waiting times are too long, it’s more likely that a prescription will be given. If an antidepressant is required, fluoxetine should be the first option.”

via Swansea University – Medicalisation of young minds: new study reveals 28% rise in antidepressant prescribing amongst 6-18 year olds

The full paper, published in Psychological Medicine, “Recent trends in primary-care antidepressant prescribing to children and young people: an e-cohort study” by A. John, A. L. Marchant, D. L. Fone, J. I. McGregor, M. S. Dennis, J. O. A. Tan and K. Lloyd has been published Open Access and can be viewed here free of charge.

A centenary of Robert T. Leiper’s lasting legacy on schistosomiasis and a COUNTDOWN on control of neglected tropical diseases

The latest Parasitology Paper of the Month is “A centenary of Robert T. Leiper’s lasting legacy on schistosomiasis and a COUNTDOWN on control of neglected tropical diseases” by J. Russell Stothard, Narcis B. Kabatereine, John Archer, Hajri Al-Shehri, Louis Albert Tchuem-Tchuenté, Margaret Gyapong and Amaya L. Bustinduy. This blog post was written for us by Professor Stothard.

Typically, biomedical research and disease control in general is forward looking in focus. This is often typified in the aspirational goals and targets set by international health agencies, as bundled within progress-specific indicators. In 2012, for example, the WHO formulated the Neglected Tropical Diseases (NTDs) Roadmap which helped to set out future progress to sustain the drive to overcome the global impact of NTDs by 2020. With later formulation of the sustainable development goals (SDGs), this NTD agenda has been expanded but now framed in a 2030 perspective.

While looking to the future, we should not forget to occasionally glance back at the past; for it is here where we review and contextualise previous successes and failures. Indeed, progress is rarely smooth and is often a stuttered march through time. Just over a hundred years ago, the then state-of-the-art biomedical research culminated in clarification of the lifecycle of the African schistosome. With it, precious knowledge was brought forth to the world, opening up a new vista on schistosomiasis, a terrifying waterborne illness, and signposting a cardinal era in future disease control. In some small celebration of this achievement, I thought it time to reflect upon this, placing its significance in today’s world.

I previously had some understanding of the stature that Robert T. Leiper had in parasitology when I was based at the Natural History Museum (NHM) and London School of Hygiene and Tropical Medicine (LSHTM). Although Leiper died the year before I was born, many times did I look at his portrait in oils hanging in the LSHTM’s main stairwell. His face often brought to life by an anecdote retold to me, often either tart or sweet in equal measure, when visiting a senior colleague on the 4th floor who had had first-hand dealings with him.

Upon more detailed investigations into his life, while searching the LSHTM and NHM archives, I was privileged to read his meticulous hand written notes. Moreover, viewing his black and white photographs transported me to China and Egypt of old and delving deeper, I became beset within the melancholies of Antarctic exploration and First World War tragedy. Without doubt, I strongly sensed Leiper’s fiery energy and dogged determination which enabled him to go the extra mile where others would not, and help him solidify the importance of fundamental parasitological research within tropical medicine.

During this exercise, I remembered that control of schistosomiasis in theory is relatively easy; it can be curtailed by very simple water hygiene measures that Leiper himself pioneered. Sadly, putting this into practice is still out of reach for millions in sub-Saharan Africa and in Uganda intestinal schistosomiasis is still rife within lakeshore communities where Leiper once worked. As Director of COUNTDOWN, an implementation research consortium funded by DFID, UK, I hope this article reminds us that ‘old’ advice still needs appropriate tailoring within the control practices of today, and to embellish the aspiration that everyone, child or adult, has the daily right to safe water.

Read the review paper “A centenary of Robert T. Leiper’s lasting legacy on schistosomiasis and a COUNTDOWN on control of neglected tropical diseases” which has been published Open Access here.

The road to depression: understanding the consequences of driving cessation in older women

shutterstock_161784053 credited

The August International Psychogeriatrics Article of the Month is entitled “Moderating effects of social engagement on driving cessation in older women” by Nancy A. Pachana, Janni K Leung, Paul A Gardiner and Deirdre McLaughlin. This blog piece was written for us by one of the paper’s authors, Nancy Pachana.

The ability to drive is considered an important functional skill, as well as a marker of independence, by people in most age groups, including older adults. A variety of physical and /or cognitive issues can require ceasing driving at any age, but this eventuality is perhaps both more common and more concerning later in life. For some older adults, having to cease driving can not only negatively impact participation in a range of activities but can also negatively impact emotional well-being.

A recent study at The University of Queensland examined this important relationship between driving cessation and depression in an older cohort of the Australian Longitudinal Study on Women’s Health (ALSWH). It is important to examine this issue of the consequences of driving cessation in women, because international data suggests that older women are more likely to stop driving, more likely to stop driving pre-maturely, and are also more vulnerable to depression than older men.

Data from over 4000 older women aged 76-87 were analysed over a three year period. In the study driving cessation was indeed associated with poorer self-reported mental health in the sample, congruent with many studies of older men and women, published from a range of countries. However, in our study we were able to identify a protective factor, namely engagement in social activities. In our cohort, older women who remained engaged in social activities despite ceasing driving were able to maintain a higher level of mental health in the face of having ceased driving than those women who were less engaged in such activities.

This is an important finding from an intervention and policy perspective. Driving cessation programs (such as the CarFreeMe ( driving cessation intervention developed at UQ) which help to instruct older drivers about how to stay mobile via public transport, can assist in maintaining access to social activities for those who cease driving. Such interventions are being made available to increasing numbers of older adults who cease driving.

Interventions as well as policies to increase both ease of access as well as facilitate the provision of social engagement opportunities for older adults have an important role in maintaining emotional well-being, facilitating meaningful community engagement, and protecting against social isolation. From our study we suggest that social support acts as a buffer to declining mental health in those women who cease driving later in life. Attention on older women who cease driving is important, as some in this group will be widowed and unable to rely on a spouse for transport if they cannot drive themselves. The maintenance of social networks has been shown to have a wide range of benefits to emotional and physical well-being in later life, and our data shows this list includes well-being for older women who no longer drive.

The full paper “Moderating effects of social engagement on driving cessation in older women” is available free of charge for a limited time here.

The commentary paper “Giving up driving: does social engagement buffer declines in mental health after driving cessation in older women?” by George W. Rebok and Vanya C. Jones is also available free of charge for a limited time here.


Risk factors for dementia diagnosis


The July International Psychogeriatrics Article of the Month is entitled “Risk factors for dementia diagnosis in German primary care practices” by Anke Booker, Louis EC Jacob, Michael Rapp, Jens Bohlken and Karel Kostev. This blog piece was written for us by one of the paper’s authors, Karel Kostev.

A number of factors are associated with the risk of developing dementia, for example, it is well known that the risk of developing this disease is higher in the elderly. Several previous works were controversial and partly focused on a low number of patients. We analyzed the association of different potential risk factors with the risk of developing dementia in German primary care practices.

Based on the large database with electronic medical records we selected 11,956 patients with an initial diagnosis of dementia between January 2010 and December 2014. To have a comparison group, 11,956 controls without dementia were also included and were matched with cases on the basis of age, sex, type of health insurance and physician.
For each patient we selected several disorders potentially associated with dementia based on primary care diagnoses. We used a multivariate regression model and could see that the risk of dementia increased significantly in connection with the following variables: diabetes, lipid metabolism, stroke, Parkinson’s disease, intracranial injury, coronary heart disease, mild cognitive impairment, and mental and behavioral disorders due to alcohol use. Conversely, the risk of dementia decreased with the use of statins, proton-pump inhibitors and antihypertensive drugs.

What are the main strengths of the study? We analyzed the ‘real life’ data from the clinical practice including all possible high risk patients who would be excluded from clinical trials. Further strengths are the high number of patients and the number of primary diagnoses included in the statistical analysis.

Many of these factors are already known so why is this research important? We analyzed patients who visited primary care physicians. The study results clearly highlighted the importance of personalized follow-up by the physicians on patients not only with high risk diagnoses for dementia like mild cognitive impairment but also diabetes or cardiovascular diseases to try to prevent or delay dementia.

The full paper “Risk factors for dementia diagnosis in German primary care practices” is available free of charge for a limited time here.

The commentary paper “Clarifying dementia risk factors: treading in murky waters” by Halima Amjad and Esther S. Oh is also available free of charge for a limited time here.

Researchers find lifestyle link in depression

Researchers following the progress of 1200 people for five years have found strong links between unhealthy lifestyles and depression.

Researchers at the University of Tasmania’s Menzies Institute for Medical Research studied the impact of lifestyle on depression and the impact of depression on lifestyle. This is the first time the association has been looked at from both sides.

The lead author of the study, Dr Seana Gall, said that people with healthier lifestyles at the beginning of the study were significantly less likely (22%) to develop a first episode of depression over the five years, while there was a tendency for those with a history of depression to lose points in a lifestyle assessment over the five years (46% more likely than those without a history of depression at the beginning of the study). Lifestyles were assessed through a score comprising body mass index, smoking, alcohol consumption, leisure time, physical activity and diet.

These associations occurred regardless of other predictive factors such as socio-economic position, parental and marital status, social support, major life events, cardiovascular disease history and self-rated physical health.

Participants were aged 26-36 years at the beginning of the study (2004-2006) and 31-41 years at follow-up (2009-2011).

Dr Gall said the study’s grouping of health behaviours (i.e. the overall lifestyle) rather than looking at individual risk factors was significant. “This is the first study to consider the association between this number of health behaviours and risk of developing depression over time,” Dr Gall said. “Studying individual risk factors and their relationship with depression ignores the fact that risk factors often cluster as unhealthy lifestyles.

“Our findings have implications for reducing the higher risk of cardiovascular disease that is seen in those with depression and also potentially reducing the risk of developing depression in young people” Dr Gall said. “The study highlights the need for holistic management of young adults in terms of their mental and physical health, including health behaviours.

Dr Gall said the results suggested that a healthier lifestyle may protect against the first onset of depression and therefore the findings were relevant for those managing the physical and mental health of younger adults.


via University of Tasmania – Researchers find lifestyle link in depression


The full paper, published in Psychological Medicine, “Bi-directional associations between healthy lifestyles and mood disorders in young adults: The Childhood Determinants of Adult Health Study” by S. L. Gall, K. Sanderson, K. J. Smith, G. Patton, T. Dwyer and A. Venn can be viewed here free of charge until 30th August 2016.


Personal music systems may be hazardous to hearing


Improvements in digital technology have meant that an increasing number of people are listening to music via personal music systems such as MP3 players and mobile phones for prolonged periods of time. These music systems are increasingly small and lightweight with considerable storage capacity and improved sound quality – which has led to prolonged use at higher volume settings, particularly among young people.

A paper published in The Journal of Laryngology & Otology (JLO) finds, alarmingly, that large proportions of young adults are listening to personal music systems at levels higher than safety levels recommended by regulatory bodies. The study finds that listening to music through personal music systems at high volume through ear phones or ear buds may be potentially hazardous to hearing.

The paper’s co-authors – from the All India Institute of Speech and Hearing in Mysore, South India – recruited 60 participants between the ages of 15 and 30 years old for their study, which looked at regular users of personal music systems and non-users of personal music systems. The researchers also used manikins to measure the output of sound pressure levels of personal music systems.

Supported by India’s Department of Science and Technology, the study found that an alarming proportion of young adults were using personal music systems at levels that could potentially damage their hearing. The study found that people who listened to personal music systems at levels higher than 80 decibels had significantly poorer hearing thresholds in high frequencies when compared to other participants. The preferred range for listening to music among participants was 51 to 98 decibels – while workplace noise regulation in the UK, for example, limits the daily exposure levels to 80 decibels.

The study also found that 33 per cent of participants reached the maximum allowable noise level after listening to music for more than four hours, while 20 per cent reached the limit within one hour – with 30 per cent of used personal music systems at levels higher than the permissible limit.

People who listened to personal music systems at levels higher than 80 decibels also showed significant difficulty in perceiving speech in adverse listening conditions, compared to other participants in the study. The authors suggest that this reduced function may be linked to damage to the cochlear structure.

However, all the participants in the study had normal hearing in the conventional frequency range, the study found.

“Our results suggest that listening to music through personal music systems at higher volume levels (over 80 dB LAeq) may not result in clinically significant hearing loss, yet may cause subtle pre-clinical damage to the auditory system, and over the years such behaviour may be hazardous to hearing,” the authors conclude.

The full paper, published in The Journal of Laryngology & Otology, “Personal music systems and hearing” by U A Kumar and S R Deepashree, can be viewed free of charge until 31 August 2016 here.

Early screening spots emergency workers at greater risk of mental illness


Study offers new direction for preventative interventions to increase mental resilience to stress and trauma

Emergency services workers who are more likely to suffer episodes of mental ill health later in their careers can be spotted in the first week of training. That’s the conclusion of a Wellcome Trust funded study carried out with trainee paramedics.

Researchers from the University of Oxford and King’s College London wanted to see if they could identify risk factors that made people more likely to suffer post-traumatic stress (PTSD) or major depression (MD) when working in emergency services. Their results are published in the journal Psychological Medicine.

Dr Jennifer Wild from the University of Oxford explained: ‘Emergency workers are regularly exposed to stressful and traumatic situations and some of them will experience periods of mental illness. Some of the factors that make that more likely can be changed through resilience training, reducing the risk of PTSD and depression. We wanted to test whether we could identify such risk factors, making it possible to spot people at higher risk early in their training and to develop interventions that target these risk factors to strengthen their resilience.’

The researchers followed a group of around 400 new ambulance staff through the first two years of their three-year training period. During the initial six-week classroom phase of the training, the students were given a number of assessments to establish their thinking styles, coping behaviour, psychiatric history and personality traits.

Follow up sessions were carried out every four months for the next two years to see if any of the participants had had PTSD or depression. After two years, a final assessment looked at quality of life, as well as smoking, alcohol and drug use, days off work, weight change, burnout and insomnia.

Professor Anke Ehlers said: ‘While just under one in five experienced PTSD or depression in the two years, most got better by the next four-month follow-up.

‘However, there were still lasting effects. Those who had reported mental ill health were more likely to have sleep problems at 2 years. They were also more likely to have days off work. Paramedics who developed an episode of PTSD were also more likely to report gaining weight and smoking.’

The team found that even accounting for past psychiatric history, people were more likely to experience PTSD and depression if they had lower perceived resilience to trauma, or if they dwelled on stressful events from the past before they started their training.   Significantly, the number of traumatic incidents they experienced could not be used to predict PTSD but was relevant to predicting MD, suggesting a cumulative risk of different exposures to trauma for depression.

Dr Wild said: ‘This is not about screening out particular people in training. Early assessment means that those who are more at risk can be offered training to improve their resilience to stressful and traumatic experiences. That has the potential to reduce episodes of PTSD and major depression and improve the long term health of a valued and essential workforce.’

The full paper has been published Open Access in Psychological Medicine, ‘A prospective study of pre-trauma risk factors for post-traumatic stress disorder and depression’ by  J. Wild et al. can be viewed here free of charge.

Source: Early screening spots emergency workers at greater risk of mental illness- University of Oxford/News

Effectiveness of START psychological intervention in reducing abuse by dementia family carers: randomized controlled trial

shutterstock_310307075 credited

The June International Psychogeriatrics Article of the Month is entitled “Effectiveness of START psychological intervention in reducing abuse by dementia family carers: randomized controlled trial” by Claudia Cooper, Julie Barber, Mark Griffin, Penny Rapaport and Gill Livingston. This blog piece was written for us by one of the paper’s authors, Claudia Cooper.

People with dementia are at increased risk of elder abuse. When we asked family carers of people with dementia whether they had acted in ways that could be abusive, such as screaming or shouting at the person, in a previous study a third said that they had sometimes done so in the last few months. Carers who were more stressed were more likely to act abusively. The START (Strategies for Relatives) intervention for family carers of people with dementia has been shown to reduce the levels of depression and anxiety they report over 2 years. Abusive behavior is associated with depression and anxiety, so we wondered whether START might also be effective in reducing abuse. In this study, we wanted to find out whether family carers who received the START intervention were acting abusively less frequently than carers who did not receive the intervention.

We recruited 260 carers. 173 received the START intervention and 87 did not receive any additional treatment. There was no evidence that those who received START abused less. This is the first randomized controlled trial with abusive behavior towards people with dementia as an outcome. Nearly half of the participants reported significantly abusive behavior at the start of the study and the START intervention did not decrease this compared to those receiving usual treatment. A quarter of carers still reported significant abuse after two years, but those not acting abusively at baseline did not become abusive.

What is the take home message? There was no evidence that START, which reduced carer anxiety and depression, also reduced carer abusive behavior. For ethical reasons we frequently intervened to manage concerning abuse reported in both groups, and may therefore have reduced abuse in the control group, masking any effect of the intervention. Future dementia research should include elder abuse as an outcome, and consider carefully how to manage detected abuse.

The full paper “Effectiveness of START psychological intervention in reducing abuse by dementia family carers: randomized controlled trial” is available free of charge for a limited time here.

The commentary paper “The things that batter” by David Ames is also available free of charge here.

A formula for concern: The boom of milk-based formula sales

PHN Editorial Highlight: ‘Global trends and patterns of commercial milk-based formula sales: is an unprecedented infant and young child feeding transition underway?
Blog by Phillip Baker

To ensure children get the best start in life the World Health Organization recommends that infants are exclusively breastfed to six months of age with ongoing breastfeeding for up to two years of age and beyond. Yet worldwide the prevalence of infants exclusively breast fed to six months hovers at around 37% and has improved only marginally in recent decades.

In contrast, the study of 80 countries demonstrates that global milk-based formula sales are booming. In the five-years between 2008 and 2013 world total milk formula sales grew by 40.8% from 5.5 to 7.8kg per infant/child, a figure projected to increase to 10.8kg by 2018.

This global sales boom applies not only to infant formula (for consumption by infants aged 0-6 months) but also to follow-up (7-12 months) and toddler (13-36 months) formulas, which can displace ongoing breastfeeding if marketed and consumed inappropriately.

We describe this as indicative of a global ‘infant and young child feeding transition’ i.e. a shift from lower to higher formula diets at the population level. Although the idea of such a transition is not new, the rate and scale of change described in the study is potentially unprecedented.

Growth has been especially rapid in several industrialising countries in Asia: China, Indonesia, Malaysia, Vietnam and Thailand. As home to the world’s second largest infant/child population (~41 million aged 0-36 months in 2013) the most significant absolute change has been in China. Other highly-populated countries undergoing significant growth include South Africa, Iran, Turkey, Brazil and Peru.

These results are troubling because formula-fed children experience poorer health and developmental outcomes than breastfed children including an increased risk of death, pneumonia, diarrhoea, obesity and type-2 diabetes, ear infections and asthma. Formula feeding also harms mothers due to the forgone protective effects of breastfeeding against breast and ovarian cancer.

Infant and young child feeding is typically portrayed as an individual behaviour, as a matter of free parental choice. The study offers a counter-view – the observed results are likely to reflect transformations in wider social, economic and social systems that structure infant and young child feeding choices at the population level.

In this view, the global infant and young child feeding transition is driven largely by the expansion of transnational formula companies and more intensive formula marketing, the shift of labour and production out of the home (especially in Asia’s vast manufacturing centres where millions of women have become employed, often with no or limited maternity protections), and the failure of regulations and policies designed to promote, protect and support breastfeeding in these new contexts.

These findings are important for several reasons. The results raise serious concern that the rapid changes observed are not being captured in a timely manner by existing international nutrition monitoring systems.

Existing regulations intended to protect the health of children and mothers and to prevent unethical formula marketing are not working effectively. Renewed efforts towards the implementation, monitoring and enforcement of the International Code of Marketing of Breast-Milk Substitutes, including stronger accountability mechanisms for governments and industry are urgently needed.

Stronger maternity protections that enable breastfeeding (e.g. adequate maternity leave, paid lactation breaks, flexible working hours, and nursing facilities) are also urgently needed for millions of working mothers, especially in Africa and Asia.

This can only come about through greater political priority and strengthened governance mechanisms for infant and young child nutrition.

The paper, ‘Global trends and patterns of commercial milk-based formula sales: is an unprecedented infant and young child feeding transition underway?’ is published in the journalPublic Health Nutrition and is freely available until 12th June 2016.
Authors: Phillip Baker, Julie Smith, Libby Salmon, Sharon Friel, George Kent, Alessandro Iellamo, JP Dadhich, Mary J Renfrew.
Funding: This analysis was unfunded. However, the lead author was employed through an Australian Research Council Discovery Project (number 130101478).

Source: A formula for concern: The boom of milk-based formula sales – Cambridge Journals Blog

The power of two: epigenetics and twins

THG epigenetics blog post

This blog post was written by Jeff Craig

Special Epigenetics issue of Twin Research and Human Genetics

Twins are at the forefront of research into human health and disease. Twin Research and Human Genetics has published a Special Section highlighting how researchers have learned how epigenetics, the molecules that play the symphony of life on our genes, can influence our future health. Never before have such a group of papers been brought together in a single issue.

Papers highlight the power of sampling the same twins over time as their health changes and others detail the ways in which researchers scour the human genome for evidence of epigenetic associations with disease.

Four of the papers focus on the discordant identical twins in which only one twin has an illness. Topics span a wide age range of subjects, from birth weight to hormone replacement therapy (HRT). One even focuses on whether twins are “morning” or “evening” people.

Three papers from the Netherlands Twin Registry highlight the power of collecting biological samples from many hundreds, even thousands, of twin pairs. These are studies of aggressive behaviour, tic disorders and wellbeing and pinpoint specific epigenetic differences linked with each.

The final paper looks at the influences, both genetic and environmental, on how we age epigenetically.

In summary this special section is a clear snapshot of cutting edge twin research that is relevant for our hunt for the genes that influence all of our health.

You can read the articles included in this Special Section free of charge for a limited time here, or using the individual articles linked below.

See below for more details about the papers included in this special issue:

Read the full editorial from Jeff Craig and Richard Saffery, The Power of Two: Epigenetics and Twins

Chiarella et al: “This paper reviews the literature showing how monozygotic twin designs can be used to study epigenetic mechanisms that may explain the impact of early in utero and postnatal environmental factors on the development of psychopathology. “

Tsai et al: “this study of adult identical twins born with different weights found a biological legacy in a gene involved in fetal growth. This suggests that the environment we encounter in the womb can influence us for many year after.”

Bahl et al: “using twins discordant for hormone replacement therapy (HRT) the authors showed that HRT can change the activity of genes in the blood and that many of these genes were associated with sense of smell. This makes sense as HRT is known to improve a woman’s sense of smell.”

Wong et al: “believe it or not, some identical twins are more “day people” while their twin brither or sister are “night people. This study showed that our preference for day or night could be programmed in ‘epigenetic’ factors that stick to our genes and change their activity”

Du et al found an ingenious way to tell which of a pair of identical twins a sample found at a crime scene came from. Identical Twins cannot be distinguished because of their identical DNA but these researchers used “epigenetics”, factors that sit on top of the DNA”.

Bui et al: “identical teenage twins that had separate placentas in the womb may have a greater difference in the activity of their genes than those who shared a placenta. This shows that the environment we encounter in the womb can have long lasting effects”

Zilhao et al and van Dongen et al: “These twin studies of both tic disorders and aggressive behaviour identified changes to gene activity in the blood in genes related to brain function, suggesting that looking at the blood may reveal information about how such disorders are caused.”

Baselmans et al: “study showed that wellbeing in twins is associated with factors that control gene activity.“

Li et al: “study suggests that the variation in methylation acceleration due to unmeasured genetic factors is likely to be even lower that the 40% estimated in previous studies”

More research and regulation needed on e-cigarettes “to protect health of public”

More and more people around the world are switching to electronic cigarettes – known as ‘e-cigarettes’ – as a substitute for conventional cigarettes. An estimated 2.6 million people in the UK alone are using one of the nearly 500 brands of e-cigarettes available from high street shops, petrol stations and via the internet. And yet little is known about the health risks associated with e-cigarettes, which have been in use since they were invented 13 years ago in China.

The authors of a new article point out that – although e-cigarettes are often marketed as using only vapour and nicotine without the carcinogens such as tar found in conventional cigarettes – there have been various chemical compounds found in e-cigarettes that are “either already known to be carcinogens or may well prove to be carcinogenic in the future”. And since e-cigarettes are currently not regulated, users cannot be certain about which chemicals are found within each product.

The three co-authors – who are all experts in the field of respiratory medicine and otolaryngology from hospitals in England – set out to examine the regulations, trends and health risks associated with e-cigarettes, as well as summarising the evidence about the use of e-cigarettes in smoking cessation.

What they found is that many of the elements identified in e-cigarette aerosols are known to cause respiratory distress and disease.  One 2013 study found, for example, that tin, silver, iron, nickel, aluminium and silicate particles have all been found in e-cigarette aerosols. The same study also found that the concentrations of nine out of eleven elements in e-cigarette aerosols were higher than or equal to the corresponding concentrations found in conventional cigarette smoke.

A more recent 2015 study has confirmed that e-cigarettes contain toxic compounds, such as formaldehyde, nitrosamines and nickel, although these were in much lower concentrations than found in conventional cigarettes.

In addition, the authors report that there is limited evidence to prove whether e-cigarettes are an effective method for stopping tobacco smoking. Although several trials suggest that e-cigarettes may be beneficial to some smokers who are looking to quit or reduce smoking, the authors conclude that there is currently not enough long-term data available on the outcomes of using e-cigarettes as smoking cessation devices. At the moment, no e-cigarettes have been approved for smoking cessation purposes by governmental authorities, according to the authors. However, as a result of the European Commission’s Tobacco Products Directive issued in 2014, the Medicines and Healthcare Products Regulatory Agency (MHRA) in the UK is currently considering regulation of e-cigarettes and other nicotine-containing products.

In the meantime, the authors recommend that professionals should not be advocating the use of e-cigarettes as a smoking cessation tool.

“Regulation of e-cigarettes is necessary to establish a scientific basis on which to judge the effects of their use,” they conclude. In addition, they recommend that adequate research is needed on the long-term health effects of e-cigarettes, “firstly so that the public has current and reliable information as to the potential risks and benefits and secondly so that the health of the public is protected.”


The full paper by Miss Nicola Stobbs, Dr Aoife Lillis and Professor Nirmal Kumar is available online in The Journal of Laryngology & Otology (JLO) here.

The dementia difference: Investigating imbalances in the treatment of patients with dementia


The March International Psychogeriatrics Article of the Month is entitled “Healthcare resource utilization and cost in dementia: are there differences between patients screened positive for dementia with and those without a formal diagnosis of dementia in primary care in Germany?” by Bernhard Michalowsky, Tilly Eichler, Jochen René Thyrian, Johannes Hertel, Diana Wucherer, Wolfgang Hoffmann and Steffen Flessa. This blog piece was written for us by one of the paper’s authors, Bernhard Michalowsky.

A precise formal diagnosis of dementia is enormously important to initiate adequate and appropriate treatment and care in dementia. Despite the fact that international standards and evidence based guidelines recommends a precise formal diagnosis, it is well known that dementia is under-diagnosed. Even in high income-countries, fifty to eighty per cent of people with dementia do not receive a formal dementia diagnosis. These persons were unnoticed in most studies, also in cost-of-illness studies. These studies revealed that dementia is associated with substantial and increasing health care costs, which adds to making dementia a serious health care priority. However, are there differences in treatment, in care and in overall healthcare costs between patients formally diagnosed with dementia and those without a formal diagnosis?

We have studied this question in our general-practitioner (GP) based sample of persons who screened positive for dementia and found a significant difference in treatment and care and in medical care cost between patients with and those without a formal dementia diagnosis.

We set out to study this issue within the ongoing DelpHi-MV (Dementia: life- and person-centered help in Mecklenburg-Western Pomerania) trial, a general practitioner-based, cluster-randomized, controlled, intervention trial in the primary care setting. Eligible patients were 70 years or older, living at home and screened in general practitioner (GP) practices for dementia using the DemTect. As published in this month´s issue of the journal we assessed individual data about the utilization of medical and formal health care services of 240 primary care patients. The costs were assessed from the perspective of insurance and the associations between dementia diagnosis and costs were evaluated using multiple linear regression models.

We found that patients formally diagnosed with dementia were treated significantly more often by a neurologist, but less often by all other outpatient specialists, and more often received anti-dementia drugs, but less additional drugs. The higher utilization of anti-dementia drugs and neurologists/ Psychiatrist is in line with the recommendations of evidence-based German guidelines. However, less treatment by outpatient physicians and with additional drugs is out of line with published studies. It is questionable if this corresponds to an inadequate treatment.

Furthermore, we found that diagnosed patients underwent shorter and less frequent planned in-hospital treatments, especially surgeries. This could mean that in hospital a premature discharge is forced and necessary surgeries were possibly omitted or unnecessary surgeries were not conducted because hospitalization is associated with deterioration in health outcomes. Taking all of this into account, dementia diagnosis was significantly associated with less total medical care costs.

What is the take home massage of this research? Actually, it seems to be that there are differences in treatment, care and healthcare cost between persons with dementia and those without a formal dementia diagnosis. Furthermore, dementia diagnosis seems to be beneficial for receiving dementia-specific treatment, but currently insufficient to ensure adequate in-hospital, out-patient specialists and overall medication treatment. This should be validated in further studies and improved in routine care.

The full paper “Healthcare resource utilization and cost in dementia: are there differences between patients screened positive for dementia with and those without a formal diagnosis of dementia in primary care in Germany?” is available free of charge for a limited time here.

The commentary paper “What is the potential for improving care and lowering cost for persons with dementia?” by Karen Davis, Amber Willink and Halima Amjad is also available free of charge here.

Addressing the gender gap in global health leadership – via Global Health, Epidemiology and Genomics

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This post was written by Pascale Allotey andoriginally posted on the Global Health, Epidemiology and Genomics blog – read more at:

In recognition of International Women’s Day 2016, GHEG is inviting submissions for a themed collection on Women in Global Health.

A core mission of global health is to achieve health equity for all people worldwide. Women, particularly in resource-limited settings, experience a disproportionate burden of disease and mortality due to inequities in access to basic health care, nutrition and education.(1) The imbalance in the health burden between genders is therefore a key focus, addressed by both the Millennium Development Goals and more recently, the Sustainable Development Goals.

However, despite this key goal to address gender inequities within the field of global health, women still occupy less than a quarter of global health leadership roles.(1) Ilona Kickbusch’s recent #WGH100 Twitter campaign to identify women leaders working at the forefront of global health, arose from a frustration with the lack of visibility of women in critical public spaces in the field.(2) Like other industries, the reasons for this imbalance include lack of opportunities, family commitments and lack of confidence. Whilst many institutions have attempted to address these issues, tackling the gender gap in leadership still requires a more proactive strategy.

This year’s theme for International Women’s day is Planet 50-50 by 2030: step it up for gender equality. The goal, spearheaded by UN Women, is to achieve gender equality in the next 15 years – by increasing investment in gender equality, striving for parity for women at all levels of decision-making, eliminating discriminatory legislation, and addressing social norms that perpetuate discrimination against women.(3)

The campaign for equality in leadership is important for reasons other than proportional representation. Research in several settings has shown that women in leadership positions are more likely than their male counterparts to invest in infrastructure and programmes that address women’s concerns.(1) Similarly, policies of women in leadership tend to be more responsive to the needs of women and children and recognise women’s responsibility for decision-making when it comes to the health of their families.(1, 2)

In an attempt to address and explore the issues surrounding gender and leadership in global health, GHEG will be publishing a themed collection on Women in Global Health. We invite submissions that explore, among other things, the current landscape, the potential reasons behind the current gender imbalance in global health roles, suggestions for practice and policy that can catalyse change, and descriptions of effective formal partnerships and campaigns on Women in Global Health. The deadline for this call is the 31st May 2016. To find out more visit:

1. Downs JA, Reif LK, Hokororo A, Fitzgerald DW. Increasing women in leadership in global health. Academic medicine : journal of the Association of American Medical Colleges. 2014;89(8):1103-7.
2. Devi S. Twitter campaign highlights top women in global health. Lancet (London, England). 2015;385(9965):318.
3. Press release: World leaders agree: We must close the gender gap [press release]. 2015.

Successful aging at 100 years

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Images: Participants from the PT100 – Oporto Centenarian Study being interviewed

The February International Psychogeriatrics Article of the Month is entitled “Successful aging at 100 years: the relevance of subjectivity and psychological resources” by Lia Araújo, Oscar Ribeiro, Laetitia Teixeira and Constança Paúl. This blog piece was written for us by one of the paper’s authors, Lia Araújo.

Successful aging is a desire that we all aspire for ourselves and for our loved ones. According to Rowe and Kahn’s definition, operationalized through the MacArthur study, individuals who met the three criteria of (i) avoiding disease and disability, (ii) high cognitive and physical functioning and (iii) engagement with life were identified as “successful agers”(1).

Another wish common to many of us is to live longer, why not up to 100!? Indeed, this can be a dream come true for an increasing number of individuals, since the oldest generations are becoming more representative and centenarians are likely to become more common(2).

Both wishes conjointly, a longer and successful aging, motivated the development of the PT100 – Oporto Centenarian Study(3). This population-based study was conducted in the north region of Portugal and included 140 centenarians who were interviewed face-to-face. We began to question ourselves what it means to be “successful” at such an advanced age and quickly got to ask the same question to our study participants. What we found was that sometimes the most relevant outcomes are from the perspective of the subjects themselves; and that together with the concern for problems and needs, we must capitalize on the real strengths of older people.

The criterion of little or no age-related decrements in physiologic function for those aging successfully does not apply to centenarians. However, when considering alternative criteria, based in centenarian´s self-perceptions of health, functional and cognitive capacity, a higher proportion of centenarians might be considered as successful. The paper also presents the influence of the available resources, such as individual strategies and external support, in improving subjective appraisals of successful aging, which confirms that certain internal resources (e.g., self-efficacy and purpose) are not overwhelmed by physical deterioration and may even gain power when corresponding and meaningful perceptions of oneself and one´s life are maintained in late life.

Successful aging at very advanced ages may not mean to stay healthy for even longer but rather to adapt. With that in our minds, as individuals, families, researchers, professionals or policy-makers, longer lives can and will be associated with improved quality of life in all ages and our wishes can become reality for our and next generations.

The full paper “Successful aging at 100 years: the relevance of subjectivity and psychological resources” is available free of charge for a limited time here.

The commentary paper “Success at 100 is easier said than done – comments on Araújo et al: successful aging at 100 years” by Peter Martin and Leonard W. Poon is also available free of charge here.

1. Rowe, J.W., & Kahn, R.L. (1997). Successful aging. Gerontologist, 37, 433-440.
2. Serra, V., Watson, J., Sinclair, D., & Kneale, D. (2011). Living Beyond 100: a report on centenarians. London: International Longevity Centre – UK.

Emotion-processing networks disrupted in sufferers of depression – via UIC News Center

depressed teenage girl

Regions of the brain that normally work together to process emotion become decoupled in people who experience multiple episodes of depression, neuroscientists report. The findings may help identify which patients will benefit from longterm antidepressant treatment to prevent the recurrence of depressive episodes.

The study, led by researchers at the University of Illinois at Chicago, is published in the journal Psychological Medicine.

“Half of people who have a first depressive episode will go on to have another within two years,” says Scott Langenecker, associate professor of psychiatry and psychology at UIC and corresponding author on the study.

Disruptions in the network of areas of the brain that are simultaneously active during problem-solving and emotional processing have been implicated in several mental illnesses, including depression. But in addition, “hyperconnectivity,” or too much connection, within the “resting network,” or areas active during rest and self-reflection, has also been linked to depression.

“If we can identify different network connectivity patterns that are associated with depression, then we may be able to determine which are risk factors for poorer outcomes down the line, such as having multiple episodes, and we can keep those patients on preventive or maintenance medication,” Langenecker explained. “We can also start to see what medications work best for people with different connectivity patterns, to develop more personalized treatment plans.”

In previous research, Langenecker found that the emotional and cognitive brain networks were hyperconnected in young adults who had depression. Areas of the brain related to rumination – thinking about the same thing over and over again – a known risk factor for depression, were also overly connected in adolescents who had experienced depression.

In the new study, Langenecker said he and his coworkers wanted to see if different patterns of network-disruption would show up in young adults who had experienced only one episode of depression versus several episodes.

The researchers used functional magnetic resonance imaging, or fMRI, to scan the brains of 77 young adults (average age: 21.) Seventeen of the participants were experiencing major depression at the time of the scan, while 34 were currently well. Of these 51 patients, 36 had experienced at least one episode of depression in the past, and these individuals were compared  to 26 participants who had never experienced a major depressive episode. None were taking psychiatric medication at the time they were scanned.

All fMRI scans were done in a resting state — to show which areas of the brain are most synchronously active as one relaxes and lets their mind wander.

The researchers found that the amygdala, a region involved in detecting emotion, is decoupled from the emotional network in people who have had multiple episodes of depression. This may cause emotional-information processing to be less accurate, Langenecker said, and could explain “negative processing-bias”  in which depression sufferers perceive even neutral information as negative.

The researchers also saw that participants who had had at least one prior depressive episode — whether or not they were depressed at the time of the scan — exhibited increased connectivity between the resting and cognitive networks.

“This may be an adaptation the brain makes to help regulate emotional biases or rumination,” Langenecker said.

“Since this study provides just a snapshot of the brain at one point in time, longer-term studies are needed, to determine whether the patterns we saw may be predictive of a future of multiple episodes for some patients and might help us identify who should have maintenance treatments and targets for new preventive treatments,” he said.

Rachel Jacobs, Alyssa Barba, Jennifer Gowins, Heide Klumpp, Lisanne Jenkins, Dr. Olusola Ajilore and Dr. K. Luan Phan of the UIC College of Medicine, and Dr. Brian Mickey, Dr. Marta Pecina, Margaret Sikora, Kelly Ryan, David Hsu, Robert Welsh and Jon-Kar Zubieta of the University of Michigan are co-authors on the paper.

This study was funded in part by the UIC Center for Clinical and Translational Science and grants RO1 Q2 601, MH091811 and RO1 MH101487 from the National Institutes of Health. – See more at:

Source: Emotion-processing networks disrupted in sufferers of depression | UIC News Center

The full paper, published in Psychological Medicine, “Decoupling of the amygdala to other salience network regions in adolescent-onset recurrent major depressive disorder” by  S. A. Langenecker et al. can be viewed here free of charge until 31st March 2016.

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