Showing posts with label Exercise. Show all posts

PATIENT-ORIENTED MEDICINE: POEMs illustrate the extent of the evolution of clinical practice

POEMs (Patient Oriented Evidence That Matters) are studies that address a relevant clinical question, demonstrate improved patient-oriented outcomes, and have the potential to change clinical practice. This report, featured in the Annals of Family Medicine, identifies POEMs in each of the past 20 years that have driven the most major and lasting change in medical practice.

These POEMs (See list on table below) have all been at the origin of new effective interventions (eg beta-blockers in heart failure or a longer delay between each screening smear in women) or abandonment of practices that have been shown to be ineffective (e.g. intensive glycemic control in patients with type 2 diabetes or even aggressive treatment of low-grade prostate cancer).

These POEMs illustrate the extent of the changes in practice that have taken place in primary care in recent years and the need for general practitioners to be able to “follow” the medical literature.

Ces POEM (Voir liste sur tableau ci-dessous) ont tous été à l’origine de nouvelles interventions efficaces (ex : les bêtabloquants dans l’insuffisance cardiaque ou un délai plus long entre chaque frottis de dépistage chez les femmes) ou de l’abandon de pratiques démontrées comme inefficaces (ex : contrôle intensif de la glycémie chez les patients atteints de diabète de type 2 ou encore traitement agressif du cancer de la prostate de bas grade).

Ces POEM illustrent l'ampleur des changements de pratique intervenus ces dernières années dans les soins primaires et la nécessité pour les médecins généralistes de pouvoir « suivre » la littérature médicale.

HEALTH HOUSES: For pediatrics too!

In the United States, these are the patient-centered medical homes (PCMH) or patient-centered health homes, the equivalent of our multidisciplinary health homes (MSP) with the advantage of multidisciplinarity (doctors, nurses, assistants doctors, nutritionists, psychologists, etc.). And this primary care structure is extremely effective, in pediatrics too, explains this study from the University of Southern California. A health care solution, between the hospital and the home, which would also have a lot to contribute in the follow-up of children with specific health needs and more exposed to inequalities in terms of health care. In short, a local mission not to be neglected.

As in France, in the United States, the “medical house” (or PCMH) approach is essential to offer coordinated care also to the millions of children with special health needs. Two-thirds of children with health problems do not have access to appropriate care and their parents do not yet have the home care reflex, concludes Dr. Mónica Pérez-Jolles, from the University of Southern California. And health inequalities are more common in certain subgroups of pediatric patients, particularly in children with higher functional impairment.

Every child deserves a "medical home" , postulated the American Academy of Pediatrics: medical or health homes therefore have a specific role to play, this role of access to coordinated care already stated but especially for children with special needs: the authors point out that a representative American survey of the general population estimates that approximately 15% of children have special needs in terms of health care and that 23% of families have at least one child with special needs. The “PCMH” approach that focuses on accessible, family-centred, coordinated, comprehensive, culturally consistent, compassionate and high-quality care is tailored and even designed to meet the needs of these children.

This analysis of parent/caregiver experience through nationally representative data from the Medical Expenditure Survey (2003 to 2013) shows the full place of medical and nursing homes. The results suggest that:

only 31% of children with special health care needs receive appropriate care, ie accessible, patient and family centred, comprehensive or multidisciplinary and supportive.
80% of children received comprehensive care and support;
60% benefited from accessible and patient-centered care;
87% of children with these special health needs have at least a moderate functional impairment: these children in particular are less likely to benefit from appropriate care;
children from homes with low income and level of education also have more difficulty accessing this adapted care.

In summary, a little less than a third of children with specific health care needs have access to care such as that provided in medical or health centres.

Thus, despite significant investment in these new structures, "there is still a long way to go to 'reach' all these children in need of care".

EXERCISE: HIIT and high intensity, same benefits!

HIIT (High-intensity interval exercise) is increasingly documented as a form of exercise that is beneficial and suitable for our modern lifestyles. For those short on time, a few minutes of HIIT or a few minutes of sprinting can be just as effective as much longer exercise sessions in boosting certain functions, including mitochondrial function essential for our cellular health (and youthfulness). This is the theme of this small study published in the American Journal of Physiology.

Mitochondria, these small powerhouses of cells, are essential for good health. Previous research has shown that exercise creates new mitochondria and improves the function of existing mitochondria. This change in mitochondrial function in response to a single exercise session generates signals that may induce beneficial changes in cells and reduce the risk of chronic disease. High-intensity interval exercise (HIIT) consists of short periods of high-intensity aerobic exercise, which will increase the heart rate, alternated with brief periods of recovery. Until this study, it was unknown whether the intensity of an intense workout can positively affect

This small study followed 8 young adult volunteers during cycling training, of varying intensity:

moderate intensity: 30 minutes of continuous exercise at a maximum effort of 50%,
HIIT: 5 sessions of 4 minutes at a maximum effort of 75%, each separated by a minute of rest,
sprint: 4 sessions of 30 seconds at maximum effort, each separated by 4.5 minutes of recovery.

The research team measured the amount of energy participants expend during each training session and compared mitochondrial changes in thigh muscles before and after each session.

Reactive oxygen levels benefit cells: Researchers have found that levels of hydrogen peroxide – a type of molecule involved in cell signaling called 'reactive oxygen species' containing oxygen and hydrogen- are changed, in different parts of the mitochondria, after exercise. While too much reactive oxygen can be harmful to cells, here researchers find that the levels measured are the right amount to promote cellular responses beneficial to metabolic function.

A few minutes of intense exercise elicits mitochondrial responses similar to longer moderate-intensity activity. “Just two minutes of sprinting is enough to induce responses similar to 30 minutes of moderate-intensity aerobic exercise,” the researchers write.

Data suggesting that exercise can be tailored to individual preferences and constraints with the same benefit of these metabolic adaptations.

Important implications for adapting the practice of exercise to our lifestyles.

ETP: Patients would like to know a little more about their medications

Clinical guidelines are good because "it helps to increase the proper use of medicines", but their impact on patients is not always taken into account, concludes this study from the University of Kent (Canterbury, UK) . The study reveals, in the journal Health and Social Care in the community, that patients want more information about their medications and also want to have a say in the products prescribed.

Professor Janet Krska, an expert in pharmacology, conducts her research on the heaviness of long-term drug use in patients. With her team and for this study, she has developed a questionnaire, the “Living with Medicines Questionnaire” or LMQ, which makes it possible to assess the impact of treatments on quality of life. The questionnaire covers 8 themes, the relationship with the attending physician, the main interferences of the treatments with daily life, the lack of therapeutic efficacy, the side and undesirable effects, the general observations, the cost and the lack of autonomy. Analysis of data from 684 respondents shows that:

P atients who take the greatest number of drugs who are also those who experience the most adverse effects are also those who would like to be better informed ;
Surprisingly, older patients rate the use of regular medications less burdensome than younger patients, even though they use more medications;
more than a quarter of the users questioned wanted to obtain more information about their medicines and to have more say in the medicines prescribed;
a similar proportion are concerned about drug prices;
over 50% are concerned about long-term side effects;
about 11% say they are not satisfied with the effectiveness of their treatment;
between 10 and 16% regret that their treatment interferes with certain aspects of their daily life;
30% even declare that “their life revolves around drugs”;
16% regret that their doctor did not listen to their opinion on medication;
11% say their doctor doesn't take concerns about their side effects seriously.

Clinical guidelines are a good thing, concludes Professor Krska, but there is a huge need for education of patients and health professionals. We note indeed and again , a lack of listening to the doctor when prescribing.

EXERCISE: How it removes toxic proteins from muscles

This study from the University of São Paulo (USP) will certainly contribute to the development of alternatives to treat muscle weakness and atrophy. The Brazilian researchers, in partnership with American and Norwegian colleagues, show here, in Scientific Reports, that the absence of muscle stimulus results in an accumulation of toxic proteins in the cells which leads to muscle weakness or loss. of muscle mass. It is typically this type of muscle dysfunction that affects the elderly or people with sciatic nerve damage, bedridden patients or even workers who spend long hours sitting, specify the authors.

This buildup of toxic proteins is found to be linked to impaired autophagy, the cellular process responsible for identifying and eliminating damaged proteins and toxins. The study deciphers this process on a group of rats subjected to an exercise program preceding an injury and shows that physical exercise can keep the autophagic system working, optimizing its activity if necessary, as in the case of a dysfunction. muscle related to an injury or a temporary lack of exercise.

Without autophagy, a molecular cascade leads to cell death: Here, the demonstration is performed in rats undergoing sciatic nerve ligation surgery, to create an effect equivalent to that of sciatic nerve compression in humans. The pain prevents the human or animal subject from using the affected leg and the muscles involved weaken and atrophy. During the 4 weeks preceding the surgery, the rats had been divided into 2 groups, one sedentary and the other trained to run at 60% of maximal aerobic capacity for 1 hour a day, 5 days a week. The experiment shows that the muscular dysfunction induced by the lesion of the sciatic nerve turns out to be less aggressive in the “aerobic” group than in the sedentary group. The researchers observe that the physical training increases autophagic flow and thus reduces dysfunctional protein levels in the muscles. At the same time, exercise improves the contractility of muscle tissue.

Thus, daily exercise sensitizes the autophagic system , facilitates the elimination of proteins and organelles that are not or no longer functional in the muscles. Elimination of these dysfunctional components is essential, because when built up, they become toxic and contribute to the breakdown and death of muscle cells.

Muscles work like a refrigerator , which needs electricity to operate. If this signal ceases because you remove the plug from the refrigerator or block the neurons that innervate the muscles, the foods, such as the proteins in the muscles, will start to “spoil”. Initially, an early warning mechanism present in the cells activates the autophagic system, which identifies, isolates and eliminates faulty material but if the mechanism ceases to function properly, the cells also malfunction. The proteins that then form toxic aggregates begin to damage and cause cell death.

Exercise is a transient stress that leaves a memory in the body, here via the autophagic system. When the body is subjected to other stresses, it is then better prepared to react and combat the effects.

The idea, at the end of this work, would be to be able to identify a molecule that selectively keeps the autophagic system on alert, similar to what happens during physical exercise, and to develop a drug to treat muscle dysfunction. . In particular, in bedridden or immobilized patients, or suffering from degenerative muscular diseases.

EXERCISE: It also delays cognitive decline in Alzheimer's

Studies follow one another to reveal the benefits of exercise on the brain or against age-related cognitive decline. This is also done with this German study presented in the journal Alzheimer's & Dementia of the Alzheimer's Association: in people carrying a genetic mutation at the origin of Alzheimer's disease, a physical activity of at least 2.5 hours per week may have beneficial effects on disease markers and delay cognitive decline. But it could also be true for people with more common forms of Alzheimer's disease.

There is indeed a growing body of scientific evidence of the beneficial impact of lifestyle factors on reducing the risk of cognitive decline and dementia. Thus the preliminary results of the Sprint Mind trial reveal that intensive treatment of blood pressure reduces the development of mild cognitive impairment and the risk of cognitive impairment linked to dementia. If here, the demonstration is again made for an autosomal dominant and early genetic form of the disease, representative of less than 1% of Alzheimer's cases, the results confirm the interest of physical activity on the progression of cognition and dementia: the authors explain, in a press release, that their results "show a significant relationship between physical activity, cognition, functional status and Alzheimer's pathology, even in people with this genetic form of the disease. In the study, 70% of all these patients were able to achieve this level of physical activity, so this beneficial lifestyle factor is achievable and may play an important role against disease progression.

Encouraging results, and not only for people with this rare form , explains the Director of the Alzheimer's Association, Dr. Maria C. Carrillo. "If further research confirms this relationship between physical activity and late onset of dementia symptoms in this group of patients, we should attempt to extend our findings to the millions of people with later onset Alzheimer's." ".

Researchers from the University of Tübingen (Germany) analyzed the data of 275 patients carrying the genetic mutation in question, aged on average 38.4 years and looked at the impact of at least 150 minutes of physical activity (walking, running, swimming, aerobics, etc.) per week - the current practice recommendation of the World Health Organization - on participants' cognitive outcomes.

156 participants were considered high physical activity (> 150 minutes of physical activity / week),
68 at low physical activity (<150 minutes of physical activity / week),
the type and frequency of exercise were taken into account, but not the intensity of the exercise.
The analysis confirms that more physical activity leads to better results on the Mini-Mental State Examination (MMSE) and various standard measures of cognition and function;
lower levels of exercise are linked to higher levels of biomarkers (including Tau) of Alzheimer's disease in cerebrospinal fluid.

A physically active lifestyle is an achievable factor that can delay the development and progression of cognitive decline, the researchers conclude.

Thus, patients at genetic risk for dementia should opt for an active lifestyle.

MUSCLE STRENGTHENING: At least 2 sessions per week!

Encouraging new public health approaches to promote the health benefits of muscle-strengthening exercise is the message of this study, which confirms the reduction in the risk of chronic diseases with regular practice of muscle-strengthening exercise. Data presented in the American Journal of Preventive Medicine which reveals that approximately 3 quarters of adults (here Americans) “do not do enough”.

It is therefore a question of respecting the guidelines for the practice of exercise, i.e. 30 minutes of moderate exercise per day, but also of including muscle strengthening exercises which can be practiced using weight machines. , dumbbells, pull-ups. The study shows that while 3 quarters of adults do not do enough, one in 4 adults also do not practice enough aerobic exercise (walking, cycling, running).

At least 2 sessions of muscle-strengthening exercise per week is the authors' recommendation: a light to moderate practice here is associated with a reduction in reported chronic diseases, such as diabetes, obesity and cancer, explains lead author Jason A. Bennie of the Physically Active Lifestyles Research Group at the University of Southern Queensland, Australia. His team analyzed data from more than 397,000 US participants (ages 18-80):

30% practice muscle-strengthening exercises 2 or more times a week, while around 58% report no practice (see diagram below).
black respondents are more likely to meet or exceed minimum muscle building recommendations;
people who don't adhere to the practice tend to be older, female, overweight or obese, also do less aerobics, have lower income and education, and feel that their own health is bad.

While muscle-strengthening exercise is an important contributor to good health , this form of physical exercise has largely been ignored in public health approaches to chronic disease prevention and management. However, underline the researchers, its regular practice makes it possible to increase the force, the power, the endurance and the mass of the skeletal muscle. Previous research has shown that muscle-strengthening exercises have many health benefits, including:

improving glucose and lipid metabolism,
reduction of blood pressure,
increased bone density,
improved balance and physical function,
better self-esteem,
a reduction in anxiety.

Admittedly, this study again demonstrates an association and does not demonstrate causation. Indeed, it could be objected that the reduction in the risk of chronic diseases could be linked to the fact that people with such conditions generally practice muscular exercises less. However, these association data support the findings of previous studies and call for further public health action to support adherence to this type of exercise.

A challenge, more than for encouraging the practice of aerobic exercise, because muscle strengthening exercise requires access to specific structures and facilities as well as the advice of a professional trained in the knowledge large muscle groups and adapted to practice (repetition, duration, etc.).

DOCTOR-PATIENT DIALOGUE: It eases pain and prevents depression

Researchers at the University of Aarhus (Denmark) call this “Talk therapy” and they show how crucial this dialogue with the general practitioner is after the death of a parent or loved one. A full-fledged “prevention” act of the risk of suicide and/or psychiatric disorders which is part of primary care missions, in the same way as the prescription of antidepressant treatments.

Losing a family member or loved one is psychologically extremely painful and generates the highest level of distress and stress. Painful enough to have suicidal thoughts or develop other psychiatric disorders. This broad analysis is conducted on data from 207,000 Danes, aged over 18 who lost a child, spouse, sibling or parent during the period 1996-2013. Among these participants, 4,584 patients (2.2%) were affected by an effect such as suicide, self-harm and admission to a psychiatric ward. Data analysis reveals the benefits of talk therapy:

patients who benefit from it are less likely to develop TS and other psychological disorders
in patients who received antidepressant treatment within 6 months of bereavement, 9.1% experienced severe effects of their bereavement, in patients who received talk therapy, this rate was reduced to 3.2;
the overall risk of serious psychiatric disorders during the grieving process would be reduced by 1.7% if the patient receives talk therapy.

A result that will encourage general practitioners to reserve drug treatment for the most severely depressed patients? However, patients "deprived" of antidepressants could then incur an even higher risk? The researchers are nevertheless convinced, in view of their results, that an early "talk therapy" in response to these grieving patients can prevent, on its own, at least in some patients, the risk of severe psychiatric events.

Unfortunately, the study does not say whether general practitioners are sufficiently prepared and have, in practice, the availability in time for this intervention.

EXERCISE: Only 3% of children reach the daily activity target

Physical activity guidelines state that children should get at least 60 minutes of moderate-to-vigorous physical activity each weekday. This study from the University of Exeter raises a real question: do parents overestimate their children's physical activity time? Because this analysis, certainly carried out in the United Kingdom, reveals that only one child in 30 practices the amount of daily physical activity recommended.

The physical activity guidelines are identical for 5-18 year olds: at least 60 minutes of intense to moderate to vigorous physical activity per day. Assessing compliance with these guidelines should ideally include a 7-day measurement, but most studies do not have data over a typical week and are generally based on an estimate of daily activity time. The study compared activity prevalence estimates from the 2 types of data (daily average vs. a typical 7-day week).

The Exeter researchers analyzed data from the Healthy Lifestyles Program covering several schools. One class from each school was randomized to wear an accelerometer for 8 days. The percentages of children engaging in an average of ≥ 60 minutes of moderate-to-vigorous physical activity per day and every 7 days were estimated.

807 children provided data over 7 days;
based on daily data, 30.6% of children engage in 60 minutes or more of physical activity per day;
based on 7-day data, only 3.2% of children get 60 minutes or more of physical activity per day;
activity levels among girls are even lower: only 1.2% reach the daily goal of 60 minutes, compared to 5.5% of boys.

The conclusion is obvious, most previous studies have most likely overestimated the percentage of children meeting the recommendations. Moreover, this new analysis suggests that only 3.2% of children would reach the goal.

No matter how accurate this percentage is, it shows that most children don't get enough physical activity, and this has consequences not only in childhood, but also in adulthood.

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