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BOSTON -- Researchers from Hebrew SeniorLife's Institute for Aging Research, and Boston Medical Center have reported that one-third of people 40-59 years have image-based evidence of moderate to severe degenerative disc disease and more than half had moderate to severe spinal osteoarthritis. Beyond that, the prevalence of disc height narrowing and joint osteoarthritis increased 2 to 4 fold in those aged 60-69 and 70-89 respectively. Furthermore, scientists observed that progression of these conditions occurred 40 - 70% more frequently in women than men.

To uncover these results, scientists used CT scans taken six years apart to evaluate the severity of disc disease and spinal osteoarthritis in 1200 cohort members of the Framingham Study - a collection of data from Framingham, MA residents and their offspring dating back to the 1940s. The results of this study were published recently in The Spine Journal.

Elizabeth Samelson, Ph.D., Associate Scientist at the Institute for Aging Research and author of this study said, "Spinal degenerative conditions, including disc height narrowing and joint osteoarthritis are common causes of pain, reduced function, and health care costs in older adults. Despite the clinical importance, little is known about the frequency and progression of spinal degenerative disease in the general population. Therefore, we conducted a study to describe the prevalence and progression in a population-based cohort."

PHILADELPHIA - A targeted therapy that has shown its power in fighting ovarian cancer in women including those with BRCA1 and BRCA2 mutations may also help patients with aggressive pancreatic cancer who harbor these mutations and have few or no other treatment options. An international team of researchers led by the Perelman School of Medicine and the Basser Center for BRCA at the University of Pennsylvania reported their findings this week in JCO Precision Oncology.

The drug, PARP inhibitor rucaparib, which was approved by the U.S. Food and Drug Administration (FDA) last month for the treatment of women with ovarian cancer who have recurrent disease or received prior therapies, showed its clinical benefit in previously treated pancreatic patients with BRCA mutations in a phase II clinical trial. Of the 19 patients treated, four had responses and two additional patients had stable disease.

"These results not only point us in a new treatment direction to further investigate for patients with pancreatic cancers, but it also reinforces the clinical significance of the BRCA genes beyond ovarian and breast cancer and the utility of PARP inhibitors in other cancers," said Susan M. Domchek, MD, executive director of the Basser Center for BRCA at the Abramson Cancer Center of the University of Pennsylvania.

PARP - poly (ADP-ribose) polymerase - is an enzyme used by healthy cells to repair themselves. However, cancer cells also use PARP to repair DNA damage, thus extending their growth and possible lethality. Preliminary results from the study, which included patients from seven centers around the globe, were presented at the annual meeting of the American Society of Clinical Oncology in 2016. These latest findings represent the full study.

Pancreatic cancer, which is often caught in later, more aggressive stages, is projected to become the second leading cause of cancer death by 2020, emphasizing the need for a larger and more effective arsenal of treatments to combat the disease. Only about 32 percent of patients respond to a first line of chemotherapy, and less than 20 percent who don't respond to a first line of chemotherapy end up responding to a second.

This underscores the importance of looking outside of chemotherapy options, the authors said, particularly in patients with targetable mutations, like BRCA.

Importantly, Domchek said, none of the patients who benefited from rucaparib had tumors that had progressed on a prior platinum-based chemotherapy, suggesting a potential role for rucaparib as an earlier treatment for patients whose tumors are not resistant to such treatments.

Rucaparib is a PARP inhibitor shown to be an effective therapy in ovarian cancers with BRCA 1/2 mutations. In 2016, the drug was approved by the FDA for women with BRCA-associated ovarian cancer who received two or more prior chemotherapies. And in April 2018, the approval was extended to women with recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer who are having a complete or partial response to platinum-based chemotherapies.

The success of rucaparib in ovarian cancers is what prompted the clinical study in pancreatic patients with the same mutation. About nine percent of pancreatic patients have BRCA/2 mutation associated pancreatic cancer.

Overall, a clinical benefit was observed in 32 percent of patients (6/19) treated with rucaparib, and 45 percent in patients (4/9) who had received only one prior chemotherapy for locally advanced or metastatic disease. Nine patients had progressive disease, and three were not evaluable for response. The objective confirmed response rate, the primary endpoint for the study, was 16 percent (3/19).

The trial included 11 men and eight women, with a median age of 57. Twenty-one percent of the patients had BRCA1mutation-associated pancreatic cancer, while 79 percent were associated with BRCA2 mutations.

"Consideration should be given to use of this therapy for treatment of patients whose tumors have not progressed on prior platinum therapy," the authors wrote. "Future studies should focus on better understand the sequencing of PARP inhibitor treatment and potential maintenance therapy, as well as potential predictors of resistance to therapy."

A new study shows that a kind of E. coli most associated with "travelers' diarrhea" and children in underdeveloped areas of the world causes more severe disease in people with blood type A.

The bacteria release a protein that latches onto intestinal cells in people with blood type A, but not blood type O or B, according to a study led by researchers at Washington University School of Medicine in St. Louis. A vaccine targeting that protein could potentially protect people with type A blood against the deadliest effects of enterotoxigenic E. coli (Escherichia coli) infection.

"We think this protein is responsible for this blood-group difference in disease severity," said senior author James Fleckenstein, MD, an associate professor of medicine at Washington University. "A vaccine targeting this protein would potentially protect the individuals at highest risk for severe disease."

The study is published May 17 in The Journal of Clinical Investigation. The work was conducted in collaboration with investigators at Johns Hopkins University, the National Institutes of Health (NIH), and the Naval Medical Research Center.

Enterotoxigenic E. coli are responsible for millions of cases of diarrhea and hundreds of thousands of deaths every year, mainly of young children. It primarily infects people living in or visiting developing countries. Some people infected with the bacterium develop severe, cholera-like, watery diarrhea that can be lethal. Others experience unpleasant symptoms but recover easily, while some don't get sick at all.

Enterotoxigenic E. coli are not the cause of the current romaine lettuce-related outbreak. That outbreak involves a different kind of E. coli known as Shiga toxin-producing E. coli O157:H7.

Years ago, doctors noted that children naturally infected with enterotoxigenic E. coli in Bangladesh seemed to get sicker if they had blood type A, but the reason for this was never tested. Fleckenstein, instructor in medicine Matthew Kuhlmann, MD, postdoctoral researcher Pardeep Kumar, PhD, and colleagues investigated whether blood type influences disease severity by looking at what happened to people of different blood types who drank a cup of water laced with E. coli.

In controlled human infection clinical trials, researchers at Johns Hopkins University gave healthy volunteers a dose of an E. coli strain originally isolated from a person in Bangladesh with severe, cholera-like diarrhea. Then, they observed the volunteers for five days. Those who developed moderate to severe diarrhea were treated with antibiotics. The disease comes on quickly, so anyone who was still healthy at the end of five days was unlikely to get sick later. Nonetheless, any remaining healthy participants also were given antibiotics to clear the bacteria before going home.

Kuhlmann and colleagues obtained data and blood samples from 106 people, each of whom participated in one of four such studies. They found that people with blood type A got sick sooner and more seriously than those of other blood types. More than eight out of 10 (81 percent) of blood group A people developed diarrhea that required treatment, as compared with about half of people with blood group B or O.

Blood groups are based on the sugars that decorate the surface of red blood cells and other cells. People with group A blood have sugars that are distinct from those present in either B or O blood groups. People with blood group AB carry both A- and B-type sugars on their cells.

The researchers found that the bacteria produce a specific protein that sticks to A-type sugars - but not B- or O-type sugars - on intestinal cells. Since the protein also sticks to E. coli, it effectively fastens the bacteria to the intestinal wall, making it easy for them to deliver diarrhea-causing toxins to intestinal cells.

The effect of blood group in people infected with this strain of E. coli was striking and significant, but it doesn't mean people should change their behavior based on blood type, the researchers said.

"I don't want anyone to cancel their travel plans to Mexico because they have type A blood," Kuhlmann said. "Or the converse: I don't want anyone to think they're safe because their blood group is not A. There are a lot of different species of bacteria and viruses that can cause diarrhea, so even though this blood-group association is strong, it doesn't change your overall risk. You should continue taking the same precautions whatever your blood type."

Basic hygiene - washing hands and purifying water - is the best protection against diarrheal diseases because it works against all kinds of organisms. But the people who suffer most from diarrhea are small children. For them, and others who don't have reliable access to basic sanitation or clean water, a vaccine could be lifesaving.

There are many strains of enterotoxigenic E. coli, and developing a vaccine that protects against all of them has been a challenge because no single protein is found in all strains. To defend against as many strains as possible, scientists are studying dozens of proteins - but they still haven't found a way to cover all strains. The protein identified in this study is found in many strains, so adding it to the mix could provide broader protection, especially for people at the highest risk for severe disease.

New research indicates that when pregnant women take certain rheumatoid arthritis (RA) drugs that may cause immunosuppression, their children do not have a marked excess risk of developing serious infections. The Arthritis & Rheumatology findings are potentially encouraging for women with RA who are or wish to become pregnant.

In North America, infections are the leading cause of mortality in children less than 5 years. There are concerns that tumor necrosis factor inhibitors (TNFis), which are used to treat RA and are transported across the placenta, may cause immunosuppression and compromise young children's ability to fight infections; however, there are limited data on the risk of serious infection in children whose mothers used the drugs during pregnancy.

To investigate, Évelyne Vinet MD, PhD, of the Research Institute of the McGill University Health Centre (RI-MUHC) in Montreal, Quebec, and her colleagues used US claim data from 2011 to 2015 to identify 2,989 offspring of women with rheumatoid arthritis and a randomly selected group of 14,596 control children, matched ?4:1 for maternal age, year of delivery, and state of residence. The researchers defined TNFi exposure based on at least one filled prescription during pregnancy. Children were followed from birth until 12 months of age, first indication of serious infection, end of commercial insurance eligibility, death, or end of study period (December 30, 2015), whichever came first.

Among offspring of women with RA, 380 (12.7 percent) were exposed to TNFis during pregnancy. The percent of serious infections in those with no TNFi exposure was similar (2.0 percent) to control offspring (1.9 percent), while the percent of serious infections in offspring with TNFi exposure was 3.2 percent. After adjusting for maternal demographics, co-morbidities, pregnancy complications, and medications, however, the investigators were unable to establish an increased risk of serious infections in offspring exposed to TNFis versus both control offspring and offspring of mothers with RA who did not use TNFis.

"Our study provides new evidence to counsel RA women contemplating pregnancy," said Dr. Vinet. "Within the largest cohort of RA offspring exposed to TNFis ever assembled, we did not observe a marked excess risk for serious infections versus unexposed RA offspring and children from the general population. Our data are potentially reassuring, however, we could not exclude a differential risk according to specific TNFi characteristics, with infliximab potentially resulting in a 3-fold increase in the risk of serious infections compared with other TNFis."

Dr. Vinet emphasized that until further studies are conducted to address this issue, it is very important to follow current recommendations when treating women during pregnancy. The European League Against Rheumatism recommends discontinuing infliximab and adalimumab before 20 weeks of gestation and etanercept before 31 to 32 weeks to minimize the risk of infections in offspring, while certolizumab can be continued throughout pregnancy.

An automated system for identifying patients at risk for complications associated with the use of mechanical ventilators provided significantly more accurate results than did traditional surveillance methods, which rely on manual recording and interpretation of individual patient data. In their paper published in Infection Control & Hospital Epidemiology, a Massachusetts General Hospital (MGH) research team report that their system - using an algorithm developed through a collaboration among the hospital's Division of Infectious Diseases, Infection Control Unit, and the Clinical Data Animation Center (CDAC) - was 100 percent accurate in identifying at-risk patients when provided with necessary data.

"Ventilator-associated pneumonia is a very serious problem that is estimated to develop in up to half the patients receiving mechanical ventilator support," says Brandon Westover, MD, PhD, of the MGH Department of Neurology, director of CDAC and co-senior author of the report. "Many patients die each year from ventilator-associated pneumonia, which can be prevented by following good patient care practices, such as keeping the head of the bed elevated and taking measures to prevent the growth of harmful bacteria in patients' airways."

Traditional surveillance of patients receiving mechanical ventilation involves manual recording every 12 hours, usually by a respiratory therapist, of ventilator settings - which are adjusted throughout the day to accommodate the patient's needs. Those settings, which reflect the pressure required to keep a patient's lungs open at the end of a breath and the percentage of oxygen being delivered to the patient, are reviewed by an infection control practitioner for signs that indicate possible ventilator-associated pneumonia.

Lead and corresponding author Erica Shenoy, MD, PhD, of the MGH Division of Infectious Diseases, the Infection Control Unit and hospital epidemiology lead for CDAC says, "In our study, manual surveillance made many more errors than automated surveillance - including false positives, reporting cases that on review, did not meet criteria for what are called ventilator-associated events; misclassifications, reporting an event as more or less serious than it really was; and failure to detect and report cases that, on closer inspection, actually met criteria. In contrast, so long as the necessary electronic data were available, the automated method performed perfectly."

Updated surveillance standards issued in 2013 by the National Health and Safety Network of the U.S. Centers for Disease Control and Prevention (CDC) specified three levels of ventilator-associated events, which can be thought of as corresponding to yellow, orange and red alerts to the risk or presence of ventilator-associated pneumonia:

Ventilator-associated condition (VAC) - an increase in a patient's need for oxygen without evidence of infection,

Infection-related ventilator-associated complication (IVAC) - increased oxygen need accompanied by signs of infection, such as fever, elevated white blood cell count or an antibiotic prescription,

Possible ventilator-associated pneumonia (PVAP) - evidence of bacterial growth in the respiratory system, along with the factors listed above.

The CDC specifications were designed to enable large-scale, automated surveillance for ventilator-associated pneumonia, allowing efficient monitoring of infection rates throughout a hospital or a hospital system. To reduce the time required to manually record and review ventilator settings and medical charts, along with the possibility of human error, members of the MGH research team developed an algorithm to provide automated, real-time monitoring of both ventilator settings and information from the electronic health record. Based on that data, the algorithm determined whether criteria were met for a ventilator-associated event and, if so, which level of event: VAC, IVAP, or PVAP.

Initial testing and debugging of the automated system was carried out from January through March of 2015 in four MGH intensive care units. During that time 1,325 patients were admitted to the units, 479 of whom received ventilator support. A retrospective analysis comparing manual versus automated surveillance of data gathered from patients cared for during this development period revealed that the automated system was 100 percent accurate in detecting ventilator-associated events, distinguishing patients with such events from those without, and predicting the development of ventilator-associated pneumonia. In contrast, the accuracy of manual surveillance for each of those measures was 40 percent, 89 percent and 70 percent.

A validation study to further test the algorithm was conducted using data from a similar three-month period in the subsequent year, during which 1,234 patients were admitted to the ICUs, 431 of whom received ventilator support. During that period, manual surveillance produced accuracies of 71 percent, 98 percent and 87 percent, while results for the automated system were 85 percent, 99 percent and 100 percent accurate. The drop-off in accuracy of the automated system during the validation period reflects a temporary interruption of data availability while software was being upgraded, and the team subsequently developed a monitoring system to alert staff to any future interruptions.

Westover says, "An automated surveillance system could relieve the manual effort of large-scale surveillance, freeing up more time for clinicians to focus on infection prevention. Automated surveillance is also much faster than manual surveillance and can be programmed to run as often as desired, which opens the way to using it for clinical monitoring, not just retrospective surveillance. Real-time, automated surveillance could help us design interventions to prevent, halt or shorten the course of an infection, something we hope to explore as we continue developing this project."

Ann Arbor, May 17, 2018 - The US mental health system faces considerable challenges in delivering behavioral healthcare to populations in need. In a special supplement to the American Journal of Preventive Medicine, experts focus on the key issue of behavioral health human resources for which substantial investment is needed to effect change. Articles in this issue cover research on workforce planning, service delivery and practice, and workforce preparation, and advocate for intelligent allocation of resources to ensure all clients have access to behavioral healthcare.

More than 44 million American adults have a diagnosable mental health condition, and rates of severe depression are worsening among young people. Mental health and disability are well-established drivers of substance use, and drug overdose deaths fueled by opioid misuse have more than tripled from 1999 to 2016.

A 2016 report by the Health Resources and Services Administration (HRSA) on the projected supply and demand for behavioral health practitioners through 2025 indicated significant shortages of psychiatrists, psychologists, social workers, mental health counselors, and marriage and family therapists. The magnitude of provider shortages, however, is not the only issue when considering access to behavioral health services. Another major concern is maldistribution, since parts of the US have few or no behavioral health providers available, and access to mental health services is especially critical in areas of poverty.

"It is imperative that a plan be developed to address the resource limitations inhibiting the delivery of behavioral health services," says Angela J. Beck, PhD, MPH, of the University of Michigan School of Public Health, Behavioral Health Workforce Research Center, Ann Arbor, MI, USA, one of the supplement's Guest Editors. "This set of articles collectively proposes strategies and best practices to guide success of the current and future behavioral health workforce."

A contribution from C. Holly A. Andrilla, MS, and colleagues from the WWAMI Rural Health Research Center, Department of Family Medicine, University of Washington School of Medicine, Seattle, WA, USA, summarizes the supply challenges of the behavioral health workforce, including severe shortages in rural areas. Using National Plan and Provider Enumeration System National Provider Identifier data, researchers examined the supply of psychiatrists, psychologists, and psychiatric nurse practitioners across the US. Providers were classified into three geographic categories based on their practicing county (metropolitan, micropolitan, and non-core). US population data were used to calculate provider-to-population ratios for each provider type.

Results revealed substantial variations across Census Divisions in the supply of psychiatrists, psychologists, and psychiatric nurse practitioners and showed that rural populations have far less access to behavioral health providers than populations in the cities. The New England Census Division had the highest supply, and the West South Central Census Division had among the lowest supply of all three provider types. There was a more than tenfold difference in the percentage of counties lacking a psychiatrist between the New England Census Division (6 percent) and the West North Central Census Division (69 percent).

"Understanding this unequal distribution is necessary for developing approaches to improving access to behavioral health services for underserved populations," explains Ms. Andrilla. "Given the dramatic shortages of behavioral health providers, particularly in certain geographic regions and in most rural areas, innovative solutions must be explored to expand access to behavioral health services for underserved populations."

Disparities in access to behavioral health services are particularly significant in New Mexico, where 56 percent of adults with mental illness receive no treatment, according to Deborah B. Altschul, PhD, from the Division of Community Behavioral Health, Department of Psychiatry and Behavioral Sciences, the University of New Mexico Health Sciences Center, Albuquerque, NM, USA. Dr. Altschul and colleagues focus on legislation enacted in New Mexico in 2011 to survey all healthcare professionals systematically in an effort to inform policies to address shortage issues.

In 2015, almost 4,500 behavioral health providers completed a survey as a mandatory component of license renewal. Findings indicated a dearth of licensed behavioral health providers representative of the populations served, limited access to services via Medicaid and Medicare payer sources, limited access to providers working in public health settings, and limited access to health information technology. Medicaid is the single largest payer for mental health services in the US and increasingly plays a significant role in the reimbursement of substance use disorder services. Therefore, the finding that more than a quarter of providers surveyed did not have a single Medicaid patient enrolled in services was alarming.

Based on this survey, researchers recommend effective recruitment and retention of professionals representative of the populations served, policy reforms to enhance the training environment and reduce unnecessary barriers to practice, post-licensure programs to encourage students from diverse backgrounds to participate in training opportunities in areas of high need, and increasing access to supervision for clinicians working in rural and underserved communities. They highlight telehealth as an innovative strategy for quickly expanding access to supervision and propose permitting interdisciplinary supervision from a variety of behavioral health professionals to increase access. Medicaid is examining reimbursement for services provided by trainees under the oversight of an independently licensed Medicaid provider.

"The statewide licensure survey has provided real-time data for decision making and strategic planning that continues to be invaluable as the healthcare system and related financing strategies evolve," note Dr. Altschul and colleagues. "It provides data on the real status of New Mexico's healthcare workforce, such as knowing which professionals are engaging in service delivery rather than working in administration or academia or are retired or living in another state but keeping active New Mexico licenses. Other states would benefit from considering similar legislative initiatives aimed at better addressing issues related to the adequacy of their behavioral health workforce."

Individuals who work in a variety of settings, including psychiatric hospitals, clinics, jails and prisons, and supportive housing, and have lived experience, are increasingly employed to support those who are recovering from mental illness or substance use disorders. Susan A. Chapman, PhD, MPH, RN, of the Healthforce Center, University of California, San Francisco, CA, USA, and colleagues report on emerging roles for peer providers in supporting clients' long-term recovery.

Researchers conducted three- to five-day site visits in in four states that have developed innovative peer support roles, including Pennsylvania's program in which peer providers support those in re-entry programs from county jails; Arizona's peer provider program working with tribal organizations and on reservations; and in peer organizations in Georgia and Texas. Data collection included document review and interviews with state policymakers, directors of training and certification bodies, peer providers, and other staff in mental health and substance use treatment and recovery organizations. They found that a favorable policy environment along with individual champions and consumer advocacy organizations were positively associated with robust programs. Medicaid billing for peer services was an essential source of revenue in both Medicaid expansion and non-expansion states. States' peer provider training and certification requirements varied.

"While peers often face stigma, low wages, and unsustainable employment, they are consistently valued by the organizations in which they work," comments Dr. Chapman. "They are uniquely positioned to prevent acute crises and support long-term recovery, especially for clients in underserved populations and rural areas. We need greater awareness of peer providers, in addition to standards for training and certification, billing and reimbursement, so that the role can be more widely adopted in states that are further behind the ones we studied. We must remove the policy barriers that prevent peer providers from helping the people who need it most.

An article by Rebecca L. Haffajee, JD, PhD, MPH, and colleagues from the University of Michigan highlights some of the policy considerations important in trying to address the opioid crisis workforce and overcoming barriers to the provision of buprenorphine, a highly effective medication-assisted treatment for opioid use disorders.

"At least 2.3 million people in the US have an opioid use disorder, less than 40 percent of whom receive evidence-based treatment," explains Dr. Haffajee. "Buprenorphine has high potential to address this gap because of its approval for use in non-specialty outpatient settings, effectiveness at promoting abstinence, and cost-effectiveness. However, significant obstacles to expanding access remain. Less than four percent of licensed physicians are approved to prescribe buprenorphine for opioid use disorder, and almost half of counties lack a buprenorphine-waivered physician."

Dr. Haffajee and colleagues propose specific policies to address workforce barriers in several domains such as insufficient training and experience; lack of institutional and peer support; poor care coordination; stigma; and burdensome reimbursement and regulatory procedures.

Significant recommendations include eliminating the national waiver process for qualified buprenorphine prescribers, replacing it instead with robust training from graduate education throughout practice. They also recommend incentives for providers to regularly prescribe buprenorphine, especially in rural areas of high need, such as loan repayment programs. Finally, they suggest that reimbursement models adjust to comprehensively cover buprenorphine and related treatment.

"These proposals are critical given our current opioid epidemic, which claimed over 42,000 lives in 2016," says Dr. Haffajee. "There is increasing political will to devote resources towards treating opioid addiction. But the resources need to be allocated intelligently to truly mitigate the epidemic and improve the lives of people with opioid use disorders and their communities."

The 2016 HRSA report projected that the supply of workers in selected behavioral health professions would be some 250,000 workers short of the projected demand by 2025. These shortages, along with the maldistribution of behavioral health providers, further complicate the behavioral health landscape by limiting access to essential care and treatment for millions of individuals with mental illness or substance use disorders.

"The barriers to strengthening behavioral health workforce capacity and improving service delivery will not be easily overcome," caution the Guest Editors, Angela J. Beck, PhD, MPH, Ronald W. Manderscheid, PhD, The National Association of County Behavioral Health and Developmental Disability Directors, Washington, DC, USA, and Peter Buerhaus, PhD, RN, Center for Interdisciplinary Health Workforce Studies, Montana State University, Bozeman, MT, USA. "But with challenge comes opportunity. The increased national and state focus on mental health and addiction services has mobilized the field. The portfolio of efforts highlighted throughout this publication are strong evidence of this energy and enthusiasm. The vision for the future of the behavioral health workforce is one of real hope!"

Last year, a record number of heart transplants were performed in the U.S., but analyses of the data show a dark reason behind this good news: A sharp rise in organ donations is largely driven by the U.S. drug-abuse epidemic. A new study published in The New England Journal of Medicine by investigators from Brigham and Women's Hospital and University of Utah, examines survival outcomes for patients who have received organs from donors who died of drug intoxication. The team reports no significant difference in survival outcomes among patients who received heart and lung transplants from donors who died of drug intoxication, despite these organs being especially sensitive to restrictions in blood supply.

The study also compares donations in the U.S. and Europe. The team saw a jump in the number of organ donors in the U.S. who had died from intoxication - from 59 in the year 2000 to 1,029 in 2016. Over the same span of time, there was no significant change in the number of organ donor deaths from intoxication in Europe.

"We wanted to understand the impact of the drug abuse epidemic on the most vulnerable segments of organ transplants, which include heart and lung organs," said Mandeep R. Mehra, MD, FACC, FESC, FHFSA, FRCP, executive director of the Center for Advanced Heart Disease and medical director of the Heart & Vascular Center at BWH. "Importantly, we were curious to understand if the drug-abuse epidemic is affecting organ donations globally or if this effect is restricted to the United States. We were surprised to find that this is a U.S. issue and not at all seen in the European transplant experience."

Survival rates one year after heart or lung transplantation were similar for recipients who received organs from donors who died from drug intoxication and for those who received organs from donors who died of other causes.

"It's important to remember that while more people are receiving the gift of life, other lives are being lost," said Mehra. "Instead of scientific advancements driving an increase in the pool of available organs, this increase is driven by a crisis, and we cannot rely on this as a source indefinitely. As efforts in health policy to overcome this crisis take root, the transplant community must turn to sustainable ways to increase organ donor recovery."

Investigators at BWH and elsewhere are currently exploring ways to recover organs from current donors considered less suitable. Some of the novel sources being considered are high-risk organs from donors infected with treatable diseases such as hepatitis C or those from donors who experienced cardiac death.

Cannabidiol (CBD), a compound derived from the cannabis plant that does not produce a "high" and has been an increasing focus of medical research, was shown in a new large-scale, randomized, controlled trial to significantly reduce the number of dangerous seizures in patients with a severe form of epilepsy called Lennox-Gastaut syndrome.

In the new study comparing two doses of CBD to a placebo, the researchers reported a 41.9 percent reduction in "drop seizures" - a type of seizure that results in severe loss of muscle control and balance - in patients taking a 20 mg/kg/d CBD regimen, a 37.2 percent reduction in those on a 10 mg/kg/d CBD regimen, and a 17.2 percent reduction in a group given a placebo.

The phase III trial was led by principal investigator and study first co-author Orrin Devinsky, MD, a professor of neurology, neurosurgery, and psychiatry at NYU School of Medicine and director of NYU Langone's Comprehensive Epilepsy Center, and was published online May 17 in The New England Journal of Medicine.

"This new study adds rigorous evidence of cannabidiol's effectiveness in reducing seizure burden in a severe form of epilepsy and, importantly, is the first study of its kind to offer more information on proper dosing," says Dr. Devinsky. "These are real medications with real side effects, and as providers we need to know all we can about a potential treatment in order to provide safe and effective care to our patients."

The study included an investigational liquid, oral formulation of CBD called Epidiolex. The product is manufactured by GW Pharmaceuticals, which operates in the U.S. as Greenwich Biosciences; GW Pharmaceuticals funded the clinical trial.

Safety of Two CBD Doses Studied

Lennox-Gastaut syndrome is a rare and severe form of epilepsy characterized by frequent drop seizures and severe cognitive impairment. Six medications are approved to treat seizures in patients with the syndrome, but disabling seizures occur in most patients despite these treatments.

Researchers enrolled 225 patients (age 2 to 55) with Lennox-Gastaut syndrome across 30 international sites in a randomized, double-blind, placebo-controlled trial to assess the efficacy and safety of two doses of CBD: Seventy-six patients received 20 mg/kg/d CBD, 73 received 10 mg/kg/d CBD, and 76 were given a placebo. All medications were divided into two doses per day for 14 weeks. The number of seizures were monitored beginning four weeks prior to the study for baseline assessment, then tracked throughout the 14-week study period and afterwards for a four-week safety check.

Side effects occurred in 94 per of patients in the 20 mg CBD group, 84 percent in the 10 mg CBD group, and 72 percent of those taking placebo. Side effects were generally reported as mild or moderate in severity and those that occurred in more than 10 percent of patients included: sleepiness, decreased appetite, diarrhea, upper respiratory infection, fever, vomiting, nasopharyngitis, and status epilepticus. Fourteen patients taking CBD experienced dose-related, elevated liver enzymes that were reversible. Seven participants from the CBD group withdrew from the trial due to side effects compared to one participant in the placebo group.

"This landmark study provides data and evidence that Epidiolex can be an effective and safe treatment for seizures seen in patients with Lennox Gastaut Syndrome, a very difficult to control epilepsy syndrome," adds study co-first author, Anup Patel, MD, chief of Neurology at Nationwide Children's Hospital.

A study led by Dr. Devinsky published in last May's New England Journal of Medicine showed a 39 percent drop in seizure frequency in patients with a different rare form of epilepsy, Dravet syndrome. Those findings represented the first large-scale, randomized clinical trial for the compound. Open label CBD studies led by Dr. Devinsky also have shown positive results for treatment-resistant epilepsies.

In April, a U.S. Food and Drug Administration advisory panel unanimously voted to recommend approval of a new drug application for Epidiolex cannabidiol oral solution, following a meeting where researchers, including Dr. Devinsky, presented their findings. The FDA will decide whether to approve the medication in late June.

"While the news gives hope for a new treatment option to the epilepsy community, more research remains imperative to better determine the effects of CBD and other similar cannabis-derived compounds on other forms of the disease and in more dosing regimens," says Dr. Devinsky.

Boston, MA - Organ transplantation is often a last treatment available to many patients facing end-stage diseases. More than 125,000 patients are currently on the wait list for an organ transplant, according to the U.S. Department of Health & Human Services. But, based on currently practiced approaches of accepting organs, the availability remains limited. Consequently, the health of these patients deteriorates and UNOS estimates that, on average, 20 people die each day while waiting for a transplant.

In a new review article, published in The New England Journal of Medicine, investigators from Brigham and Women's Hospital highlight a largely untapped, existing opportunity: the use of deceased-donor organs that are currently excluded from potential transplant due to old age, a hepatitis C infection, or cardiac death. The team notes that newly developed approaches and treatments could allow for the successful transplantation of these organs that were previously considered unusable.

"We see a potential opportunity to narrow the gap between the current supply and demand by utilizing available organs" said Stefan G. Tullius, MD, PhD, chief of transplant surgery at Brigham and Women's Hospital and lead author of the study. Tullius also thinks that novel methods of preserving organs may facilitate assessment and reconditioning of organs that are considered 'suboptimal'".

Dr. Tullius also adds, that while we see the potential benefit to expanding the potential donor pool, "the specific risk that would be acceptable in using these organs will need to be defined, and the risk-benefit analysis will need to be made explicitly clear to patients."

If you've had a minor stroke or a transient ischemic stroke (TIA), taking the clot-preventing drug clopidogrel along with aspirin may lower your risk of having a major stroke within the next 90 days, according to new research published in The New England Journal of Medicine.

An international study of 4,881 adults in 10 countries who either had a minor stroke or a TIA showed that people who took clopidogrel plus aspirin had a 25 percent lower risk of a major stroke, heart attack or death from blood clots within the three months after the first incident, compared with those who took aspirin alone.

"The study gives us solid evidence that we can use this drug combination to prevent strokes in the highest-risk people, but not without some risk of bleeding," said lead author Clay Johnston, M.D., Ph.D., dean and professor of neurology at Dell Medical School at The University of Texas at Austin.

Both minor stroke and TIA are warning signs that a person has a 3 to 15 percent chance of having a more severe stroke within the next three months. Minor stroke is one that results in mild, nondisabling symptoms. TIA, often called a warning stroke or mini-stroke, is caused by a temporary blockage in a blood vessel to the brain that often dissolves or dislodges on its own to stop symptoms. More than a third of U.S. adults have had TIA symptoms, according to the American Stroke Association.

The study also showed a small increase in the risk of hemorrhage in the clopidogrel-aspirin group compared with the aspirin alone group. For every 1,000 patients treated with the combination, an extra five major bleeds would be expected but with 15 fewer strokes and other major ischemic events. Because the bleeding events are generally reversible, the overall benefit outweighs the risk for most patients, Johnston said.

"Of the 33 major hemorrhages that occurred in these 4,881 patients, more than half involved the gastrointestinal tract, and none of them was fatal. These largely preventable or treatable bleeding complications of the treatment have to be balanced against the benefit of avoiding disabling strokes," said co-author J. Donald Easton, M.D., professor of neurology at the University of California, San Francisco School of Medicine.

One previous trial in this area showed that clopidogrel plus aspirin was effective in lowering risks but did not find the risk of hemorrhage.

"The results of this large international trial, when added to the results of previous research, provide evidence to support the use of clopidogrel plus aspirin for 90 days among patients with minor ischemic stroke and high-risk TIA treated within 12 hours," said Ralph Sacco, M.D., M.S., professor of neurology at Miller School of Medicine at the University of Miami. "This trial is likely to change practice since most clinicians and patients are usually willing to accept the increased risk of hemorrhage to offset the disabling impact of a stroke."

The research was part of the Platelet-Oriented Inhibition in New TIA and minor ischemic stroke (POINT) trial -- a randomized, double-blind, placebo-controlled trial conducted between May 2010 and December 2017. It included patient information from 269 sites in 10 countries throughout North America, Europe and Australia. Patients were included if they had a minor stroke or a transient ischemic stroke and were at high risk of having a major stroke.

"It's likely we will see more patients who have had a TIA or a minor stroke receiving the combination of clopidogrel and aspirin in the future," Johnston said. "If you've suffered from a minor stroke or TIA, it's important to see a physician immediately, even in the emergency room, to ensure you're taking steps to avoid a potentially debilitating stroke later on," he said. "There are several tests that need to be done right away to determine the cause of the event and to make sure the best treatments are started as soon as possible."

Clopidogrel, known by the brand name Plavix, is a platelet inhibitor commonly prescribed to people who have peripheral artery disease or who have had a recent heart attack or stroke to prevent future cardiac or stroke events.

Patients with stroke caused by bleeding on the brain (intracerebral haemorrhage) may benefit from receiving a drug currently used to treat blood loss from major trauma and bleeding after childbirth, an international trial has revealed.

The study, led by experts at The University of Nottingham and funded by the National Institute for Health Research (NIHR) Health Technology Assessment Programme, found that giving tranexamic acid (TXA) to people who had experienced intracerebral haemorrhage reduced the number of deaths in the early days following the stroke.

It also found that both the amount of bleeding in the brain and number of associated serious complications were lower in the patients who had received the TXA treatment.

However, the trial found no difference in the number of people who were left disabled or had died at three months after their stroke (the study's primary outcome). The researchers believe further study is needed on larger groups of patients to enable them to fully understand the potential benefits.

The research is published in the medical journal The Lancet and was presented at the 4th European Stroke Conference in Gothenburg, Sweden on 16th May.

Nikola Sprigg, Professor of Stroke Medicine at the Stroke Trials Unit in the University's Division of Clinical Neuroscience, led the trial. She said: "Tranexamic acid is cheap - costing less than £15 per patient - and widely available so has the potential for reducing death and disability across the world."

"While we failed to show significant benefits three months after stroke, the reduction in early deaths, amount of bleeding on the brain and serious complications are signs that this drug may be of benefit in the future. More trials are needed, particularly focusing on giving treatment as soon as possible after the start of bleeding in this emergency condition.

"TICH-2 cements the position of the NIHR and the UK as key players in the world of stroke research. A study of this scale would simply not have been possible without support of the NIHR infrastructure. Alongside the large stroke centres, the contribution made by the network of smaller sites across the UK has been crucial to the success of TICH-2."

Around 150,000 people in the UK suffer a stroke every year -- the majority of these are ischaemic strokes caused by a blocked blood vessel on the brain which can be treated very successfully in many cases with the use of clot-busting drugs (thrombolysis) administered within 4.5 hours of the stroke.

However, 15 per cent of all strokes -- affecting around 22,000 people every year -- are caused by haemorrhagic stroke when a blood vessel in the brain bursts, leading to permanent damage. While all people with acute stroke benefit from treatment on a stroke unit, there is currently no specific treatment for haemorrhagic stroke and unfortunately many people affected will die within a few days. Those who do survive are often left with debilitating disabilities including paralysis and an inability to speak.

A previous small pilot study by The University of Nottingham and funded by both the university and the charity the Stroke Association, concluded that a larger study was needed to accurately assess the effectiveness of the drug tranexamic acid. The drug was chosen for the study after previous research showed that it was successful in stopping bleeding in people involved in road traffic accidents.

For the latest trial, people who were diagnosed as having had bleeding on the brain -- confirmed by CT scan -- were offered the chance to take part in the study. Where the person was too ill to decide, permission was asked of their family or close friends. Where no family were available a doctor unconnected with the study decided if the patient should take part.

The five-year TICH-2 trial recruited more than 2,000 patients from 124 hospitals in 12 countries between 2013 and 2017. They were randomly sorted into two patient groups - one received TXA within eight hours of their stroke and another was given a saline placebo. In the UK, more than 80 hospitals took part in the study with support from the NIHR clinical research network.

CT scans of the patients' brains were performed 24 hours after their stroke and their progress was monitored and measured at day two and day seven after their stroke. The final follow up was performed at 90 days.

The study revealed that TXA did not improve the outcome for patients after 90 days as there was no significant difference in the number of patients who had subsequently died or had been left with disabilities between the TXA and placebo groups at three months.

However, in the TXA group there were fewer deaths by day seven following the stroke and, at day two, fewer people on TXA experienced a worsening of the bleed on their brain and had smaller amounts of blood in the brain compared to their control group counterparts. Also, the number of patients who experienced associated serious complications (such as pneumonia and brain swelling) were lower in the patients who had received the TXA treatment compared to those who had control.

The trial also found evidence that TXA might be more effective in patients with lower blood pressure as those with blood pressure lower than 170 mmHg had a more favourable outcome that those with 170mmHg and above. Other studies have confirmed that the sooner TXA is given, the more effective it is, and ideally it needs to be given within less than 3 hours of bleeding onset. In this study only one third of patients were given treatment within 3 hours of stroke onset.

As a result, the researchers have highlighted the need for further studies to find out whether giving an earlier dose of TXA might be beneficial for patients.

Pediatric asthma takes a heavy toll on patients and families alike. Affecting more than 7 million children in the U.S., it's the most common nonsurgical diagnosis for pediatric hospital admission, with costs of more than $570 million annually. Understanding how to care for these young patients has significantly improved in the last several decades, leading the National Institutes of Health (NIH) to issue evidence-based guidelines on pediatric asthma in 1990. Despite knowing more about this respiratory ailment, overall morbidity--measured by attack rates, pediatric emergency department visits or hospitalizations--has not decreased over the last decade.

"We know how to effectively treat pediatric asthma," says Kavita Parikh, M.D., M.S.H.S., a pediatric hospitalist at Children's National Health System. "There's been a huge investment in terms of quality improvements that's reflected in how many papers there are about this topic in the literature."

However, Dr. Parikh notes, most of those quality-improvement papers do not focus on inpatient discharge, a particularly vulnerable time for patients. Up to 40 percent of children who are hospitalized for asthma-related concerns come back through the emergency department within one year. One-quarter of those kids are readmitted.

"It's clear that we need to do better at keeping kids with asthma out of the hospital. The point at which they're being discharged might be an effective time to intervene," Dr. Parikh adds.

To determine which interventions hold promise, Dr. Parikh and colleagues recently performed a systematic review of studies involving quality improvements after inpatient discharge. They published their findings in the May 2018 edition of the journal, Pediatrics. Because May is National Asthma and Allergy Awareness month, she adds, it's a timely fit.

The researchers combed the literature, looking for research that tested various interventions at the point of discharge for their effect on hospital readmission anywhere from fewer than 30 days after discharge to up to one year later. They specifically searched for papers published from 1991, the year after the NIH issued its original asthma care guidelines, until November 2016.

Their search netted 30 articles that met these criteria. A more thorough review of each of these studies revealed common themes to interventions implemented at discharge:

Nine studies focused on standardization of care, such as introducing or revising a specific clinical pathway

Nine studies focused on education, such as teaching patients and their families better self-management strategies

Five studies focused on tools for discharge planning, such as ensuring kids had medications in-hand at the time of discharge or assigning a case manager to navigate barriers to care and

Seven studies looked at the effect of multimodal interventions that combined any of these themes.

When Dr. Parikh and colleagues examined the effects of each type of intervention on hospital readmission, they came to a stunning conclusion: No single category of intervention seemed to have any effect. Only multimodal interventions that combined multiple categories were effective at reducing the risk of readmission between 30 days and one year after initial discharge.

"It's indicative of what we have personally seen in quality-improvement efforts here at Children's National," Dr. Parikh says. "With a complex condition like asthma, it's difficult for a single change in how this disease is managed to make a big difference. We need complex and multimodal programs to improve pediatric asthma outcomes, particularly when there's a transfer of care like when patients are discharged and return home."

One intervention that showed promise in their qualitative analysis of these studies, Dr. Parikh adds, is ensuring patients are discharged with medications in hand--a strategy that also has been examined at Children's National. In Children's focus groups, patients and their families have spoken about how having medications with them when they leave the hospital can boost compliance in taking them and avoid difficulties is getting to an outside pharmacy after discharge. Sometimes, they have said, the chaos of returning home can stymie efforts to stay on track with care, despite their best efforts. Anything that can ease that burden may help improve outcomes, Dr. Parikh says.

"We're going to need to try many different strategies to reduce readmission rates, engaging different stakeholders in the inpatient and outpatient side," she adds. "There's a lot of room for improvement."

DALLAS - May 15, 2018 - Imagine millions of depressed Americans getting their brain activity measured and undergoing blood tests to determine which antidepressant would work best. Imagine some of them receiving "brain training" or magnetic stimulation to make their brains more amenable to those treatments.

A national research trial initiated by UT Southwestern in 2012 is generating the first set of results this year that provides an early glimpse into how such high-tech strategies may change the field of mental health.

Treating Depression

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The first study - to be published in the June edition of the Journal of the American Medical Association Psychiatry - found that measuring electrical activity in the brain can help predict a patient's response to an antidepressant. In the coming months, at least four more studies evaluating the effectiveness of other predictive tests are expected to derive from the EMBARC trial, a major thrust of a national effort to establish biology-based, objective strategies to remedy mood disorders.

"When the results from these tests are combined, we hope to have up to 80 percent accuracy in predicting whether common antidepressants will work for a patient. This research is very likely to alter the mindset of how depression should be diagnosed and treated," said Dr. Madhukar Trivedi, who oversees EMBARC and is founding Director of UT Southwestern's Center for Depression Research and Clinical Care, a cornerstone of the Peter O'Donnell Jr. Brain Institute.

Finding solutions

Dr. Trivedi organized EMBARC with several other academic centers after the world's largest depression study that he led more than a decade ago detailed shortcomings in patient care. Among other major findings, the STAR*D studies found that up to two-thirds of patients do not adequately respond to their first antidepressant.

Dr. Trivedi sought to improve this situation by spearheading the 16-week EMBARC trial at four U.S. sites in which more than 300 patients with major depressive disorder were evaluated through brain imaging and various DNA, blood, and other tests.

The project's first published study focuses on how electrical activity in the brain can indicate whether a patient is likely to benefit from an SSRI (selective serotonin reuptake inhibitor), the most common class of antidepressant. Researchers used an electroencephalogram, or EEG, a noninvasive test that measured activity in the brain's rostral anterior cingulate cortex. Patients with higher activity were more likely to respond to the SSRI within about two months.

Dr. Trivedi said EEGs have the potential to be used in combination with brain imaging and blood tests to help patients who don't respond to SSRIs find effective treatments more quickly. He also suggested that more studies may yield useful methods to boost neural activity and make the brain more responsive to SSRIs - perhaps either through psychotherapy or magnetic stimulation on the cortex.

"Like STAR*D, I expect these studies will have a widespread effect on how we design and plan treatment approaches," Dr. Trivedi said. "My goal is to establish blood tests and brain imaging as standard strategies in the treatment of depression."

Benchmark research

Dr. Trivedi's work is becoming increasingly critical in the U.S. as the depression rate continues to soar. According to data from the National Health and Nutrition Examination Survey, more than 34 million adults took antidepressants in 2013-14 - more than double the number in the 1999-2000 survey.

Some depressed patients have been diagnosed with other mood disorders such as schizophrenia or bipolar disorder - conditions that have also lacked biological markers and objective treatment strategies. UT Southwestern faculty have received national accolades for helping the field progress in this area. The recognitions include receiving the American Psychiatric Association's top research award for two consecutive years, largely for STAR*D and for creating a new system of classifying various forms of psychosis based on biological indicators.

Understanding mood disorders

Meanwhile, Dr. Trivedi has initiated other large research projects to further understand the underpinnings of mood disorders, among them D2K, a study that will enroll 2,000 patients with depression and bipolar disorders and follow them for 20 years. In addition, RAD is a 10-year study of 1,500 participants (ages 10-24) that will uncover factors that reduce the risk of developing mood or anxiety disorders.

Utilizing some of these enrollees, Dr. Trivedi's research team will study the results from a battery of other tests to augment EEGs and more accurately assess patients' biological signatures and determine the most effective treatment. Dr. Trivedi has had preliminary success developing a blood test but acknowledges it may only benefit patients with a specific type of inflammation.

Combining blood and brain tests, he said, will improve the chances of choosing the right treatment the first time.

"Although we continue to study brain imaging and blood biomarkers, I do recommend patients ask for these tests when seeking an antidepressant," Dr. Trivedi said. "Your performance on them, when appropriate, will tell you to try this or avoid that. The bottom line is to reduce the trial-and-error process that can be so devastating to patients."

ROCHESTER Minn. - A team of researchers including investigators from Mayo Clinic has identified a technology to address the problem of false positives in CT-based lung cancer screening. The team's findings are published in the current issue of PLOS One.

"As physicians, one of the most challenging problems in screening patients for lung cancer is that the vast majority of the detected pulmonary nodules are not cancer," says Tobias Peikert, M.D., a pulmonologist at Mayo Clinic. "Even in individuals who are at high risk for lung cancer, up to 96 percent of nodules are not cancer."

Dr. Peikert says false-positive test results cause significant patient anxiety and often lead to unnecessary additional testing, including surgery. "False-positive lung cancer screening results also increase health care costs and may lead to unintentional physician-caused injury and mortality," Dr. Peikert says.

To address the problem of false positives in lung cancer screening Dr. Peikert and Fabien Maldonado, M.D., from Vanderbilt University, along with their collaborators used a radiomics approach to analyze the CT images of all lung cancers diagnosed as part of the National Lung Cancer Screening Trial. Radiomics is a field of medicine that involves extracting large amounts of quantitative data from medical images and using computer programs to identify disease characteristics that cannot be seen by the naked eye.

Researchers tested a set of 57 variables for volume, nodule density, shape, nodule surface characteristics and texture of the surrounding lung tissue. They identified eight variables which enabled them to distinguish a benign nodule from a cancerous nodule. None of the eight variables were directly linked to nodule size and the researchers did not include any demographic variables such as age, smoking status and prior cancer history as part of their testing.

Dr. Peikert says that while the technology looks very promising and has the potential to change the way physicians evaluate incidentally detected lung nodules, it still requires additional validation.

Older adults with mild cognitive impairment (MCI), often a precursor to Alzheimer's, showed significant improvement with certain complex thinking and memory skills after exergaming, according to a new study.

The results could encourage seniors, caregivers and health care providers to pursue or prescribe exergames (video games that also require physical exercise) in hopes of slowing the debilitating effects of those with MCI, sometimes a stage between normal brain aging and dementia.

"It's promising data," said Cay Anderson-Hanley, associate professor of psychology at Union College and the study's lead author. "Exergaming is one more thing that could be added to the arsenal of tools to fight back against this cruel disease."

The study appears in the current issue of Frontiers in Aging Neuroscience.

Previously published research by Anderson-Hanley and others found that seniors who exercise using the features of interactive video games experienced greater cognitive health benefits than those who rely on traditional exercise alone.

For the latest study, researchers wanted to target older adults diagnosed with or at risk for MCI. MCI is most common in people over age 55. By age 65, approximately 15 to 20 percent of the population shows signs of MCI, according to the Alzheimer's Association.

Researchers initially enrolled more than 100 seniors for the study, which was funded through a grant from the National Institute on Aging. Over six months, 14 (evenly split between men and women) persisted with regular exergaming. The average age was 78.

The first group of seven was assigned to pedal along a scenic virtual reality bike path several times a week. The second group was given a more challenging task for the brain: pedal while playing a video game that included chasing dragons and collecting coins.

The special bikes were placed at a number of sites, including hospitals, community centers and independent living centers.

The results were compared against data collected from a separate group of eight seniors who played video games on a laptop but did not pedal, and also a group from the previous research who only rode a traditional stationary bike with no gaming component.

At the end of the randomized clinical trial, participants in both the group that pedaled along a virtual bike path and those that chased dragons and collected coins experienced significantly better executive function, which controls, in part, multi-tasking and decision making.

"Executive function is like the CEO of the brain. It is key to remaining independent in later life," said Anderson-Hanley. "For example, it allows you to cook two things on the stove at once. It makes sure you don't forget that you are boiling water while also having something in the oven."

Benefits for both groups were also seen for verbal memory and physical function, suggesting it may be worth the effort for seniors to incorporate exergaming into a daily exercise regime.

Anderson-Hanley acknowledged that further research with a larger sample size is needed to confirm the team's findings. One of the challenges faced was getting older adults in the habit of going to the gym or another venue to exergame. The team is working on a way to have seniors stay home and upload a video game to an iPad that can be used with a stationary bike.

In the meantime, the research suggests benefits of exercising while also stimulating the brain with some mental challenge, such as navigating a scenic bike path or interactively playing a video game.

"The goal is to explore even more effective ways to prevent or ameliorate cognitive decline in older adults by tailoring accessibility and level of mental engagement in interactive cognitive and physical exercise," she said. "The results suggest that the best outcome for brain health may result when we do both: move it and use it."