Donor Kidneys More Likely to Be Discarded on Weekends: Study

By Dennis Thompson
HealthDay Reporter

SATURDAY, Nov. 7, 2015 (HealthDay News) — Kidneys from deceased donors tend to be discarded more often over the weekend than on weekdays, a new study shows.

A deceased donor kidney procured on Friday or Saturday was 20 percent more likely to be discarded than if it became available on other days, said study author Dr. Sumit Mohan, a kidney expert and an assistant professor at Columbia University Department of Medicine, in New York City.

With donor organs always in short supply, this waste may cause some transplant candidates to miss valuable opportunities for a new kidney, Mohan said.

“We’ve gotten to a point where we’re discarding 17 percent of kidneys in the United States. That’s almost one in five,” he said. “We could increase the transplantation rate just by removing the bottlenecks in our process, without the public stepping up and increasing the donation rate.”

Mohan was to present his findings Saturday at the American Society of Nephrology’s annual meeting, in San Diego. Research presented at medical meetings is typically considered preliminary, because it is not subject to the same scrutiny as that in published journals.

For this study, Mohan and his team examined data from the Scientific Registry of Transplant Recipients.

About 80 percent of kidneys from deceased donors are transplanted over the weekend and are procured either Friday or Saturday. Given that, the researchers compared the use of deceased donor kidneys procured on those days to the organs procured for weekday use.

They found that about 18.6 percent of deceased donor kidneys that come in on Friday and Saturday are discarded, compared with a discard rate of 16.4 percent the rest of the week.

The issue does not seem to be the quality of the donated organs. While kidneys procured on Friday and Saturday did tend to be slightly older and of slightly lower quality, the researchers found that kidneys discarded over the weekend were of higher quality than those discarded during the rest of the week.

Mohan says the “weekend effect” may come down to the way hospitals allocate resources on Saturdays and Sundays.

Hospitals around the world tend to operate with less staff on weekends. “Usually what happens, the only things that happen on the weekends are emergencies,” Mohan said. “Elective procedures are never scheduled for Saturday or Sunday. Because we have a skeletal staff on the weekends, it gets much harder to do things and it takes longer to do things, in general.”

Transplant hospitals are required to be ready to take a donated organ every day of the week, but it can be difficult to assemble the required team to procure an organ or implant it, he said.

“If you have fewer resources on the weekends, if the operating rooms are closed and you have to get an entire team to come in, the hurdle is much higher to accept a kidney and get everything up and running,” Mohan said.

Dr. David Klassen, chief medical officer of the United Network for Organ Sharing, said the new study raises interesting points. But he is skeptical of Mohan’s staffing theory and noted there wasn’t a huge difference in discard rates between the weekend and weekdays.

“I wouldn’t say this is any sort of definitive analysis of that concept,” he said.

The study also found lower kidney procurement on Friday and Saturday, but it was only 89.5 percent compared with 90.2 percent on weekdays, Klassen pointed out.

However, Klassen said UNOS is concerned about the percentage of donated organs that are discarded, and is trying to find ways to minimize the discard rate.

He said one way might be to change how transplant centers are monitored and rated, so they might be more likely to try transplanting organs of good-but-not-sterling quality.

Older transplant candidates might be willing to take a donated organ that isn’t expected to function for decades longer, Klassen said.

Mohan said regulators also could limit weekend waste by allowing transplant centers to place themselves on bypass for short periods, when their resources are stretched. That way, an organ could be forwarded to a center that is actually ready to use it, rather than languishing in the process.

More information

To learn more about organ donation, visit the U.S. National Institutes of Health.

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Kidney Disease Rates Have Stabilized in U.S., Study Finds

By Maureen Salamon
HealthDay Reporter

SATURDAY, Nov. 7, 2015 (HealthDay News) — The rate of chronic kidney disease among Americans has leveled off over the last decade after climbing for many years, a new study found.

Researchers compared nationwide data for 2003-2004 and 2011-2012. Their study showed that the number of people with chronic kidney disease had stabilized or even decreased over the period. The plateau mirrors that found in U.S. cases of permanent kidney failure, also known as end-stage renal disease.

“High blood pressure and diabetes are two major reasons for developing kidney disease, and I think treatments for these are actually getting better,” said study author Dr. Chi-yuan Hsu, professor and division chief of nephrology at the University of California, San Francisco.

“Kidney disease takes years to decades to develop, and several decades ago, we started developing better ways of halting or slowing kidney disease,” Hsu added. “Control is much better than it used to be.”

The study was to be presented Saturday at the American Society of Nephrology’s annual meeting, in San Diego. Research presented at scientific meetings typically hasn’t been peer-reviewed or published and the results are considered preliminary.

Chronic kidney disease, which causes reduced kidney function over time, remains a major public health problem. It affects more than 20 million Americans and is the ninth-leading cause of death in the United States, according to the U.S. National Institute of Diabetes and Digestive and Kidney Diseases.

Because of the threat, the U.S. Department of Health and Human Services’ Healthy People 2020 initiative has aimed for a 10 percent reduction in chronic kidney disease cases in the United States over the next five years.

Many chronic kidney disease patients eventually develop end-stage renal disease, which requires treatment with dialysis or a kidney transplant. Hsu’s study is consistent with prior research indicating that new diagnoses of end-stage renal disease have also leveled off.

He said better blood sugar control for people with diabetes and drugs that help patients better manage high blood pressure have contributed to the gains.

“Every few years, there’s some new class of drugs available for diabetes,” Hsu said. “The whole area of blood pressure treatment has [also] made a lot of progress.”

Dr. Uptal Patel, an associate professor of nephrology and pediatric nephrology at Duke University School of Medicine in Durham, N.C., agreed with Hsu on the reasons why kidney disease rates have stabilized.

“It’s actually very exciting, promising data from a public health perspective,” Patel said. “And, this result [also] suggests potentially more widespread effectiveness in public health strategies” that have raised awareness of kidney disease.

Aside from diabetes and high blood pressure, several other health conditions can put people at risk for kidney disease, Patel noted. These include autoimmune diseases such as lupus or scleroderma, advanced heart disease, or a history of cancer. A family history of kidney disease should also be considered.

Symptoms of chronic kidney disease range from nausea and vomiting to lower urine output and swelling of the ankles and feet. But many symptoms are non-specific, meaning they could be caused by a variety of health problems.

Being overweight can also raise the risk, because it increases the odds for high blood pressure and diabetes, Hsu and Patel said.

“We do need to combat obesity, because that’s the origin of a lot of problems,” Hsu said. “But it’s encouraging … that obesity is no longer increasing [nationally] at the rate it was.”

More information

Learn more about chronic kidney disease at the National Kidney Foundation.

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45-Minute Class Helps Middle Schoolers Master CPR Basics

SATURDAY, Nov. 7, 2015 (HealthDay News) — Just one 45-minute class can help middle school students master lifesaving CPR skills, researchers report.

The students in the study were taught both manual CPR (chest compressions) and the use of an automated external defibrillator (AED), a device available for emergency use in many public spaces.

“If schools across the United States invested one 45- to 60-minute period a year for each school year, this would ensure widespread CPR and AED knowledge with minimal cost and loss of school time,” study authors Dr. Kae Watanabe and Dr. Joseph Philip, of the University of Florida, in Gainesville, wrote in a news release from the American Heart Association (AHA).

The findings were to be presented Sunday at the AHA’s annual meeting in Orlando, Fla. Studies presented at medical meetings are typically considered preliminary until published in a peer-reviewed journal.

The study included 41 eight graders who received one 45-minute session on basic life support during a physical education class. Half the students received a repeat session two months later, while the others did not.

The students’ CPR skills and knowledge of responding to a heart that has stopped beating were tested before and immediately after the first session, and then two and four months later.

There was considerable improvement in the students’ CPR skills and knowledge after the first session, and they retained the information two and four months later, the researchers said.

Watanabe and Philip also found no difference in knowledge between students who received the repeat session and those who did not, although those who took the repeat session were somewhat better at using an AED.

Two experts in public health were heartened by the findings.

“According to the AHA’s research, bystander CPR can as much as triple a victim’s chance of survival,” noted Rosemarie Ennis, director of community education and health at North Shore-LIJ Health System in Great Neck, N.Y.

“Four out of five times a cardiac arrest will occur within one’s home environment, so there is a good chance a rescuer will help his own loved one,” she said.

Ennis believes that “schools are an excellent place to offer CPR training, giving opportunity to improve cardiac survival rates. When you teach students CPR, you are strengthening their community’s safety and giving them skills they can carry into the future.”

Beth Oliver is a nurse and senior vice president of clinical operations at Mount Sinai Heart in New York City. She agreed that “CPR saves lives,” and “taking 45 to 60 minutes of a student’s time is a very small investment — with a potentially huge benefit of saving lives.”

More information

The American Academy of Family Physicians has more about CPR.

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Many Who Survive Cardiac Arrest Don’t Suffer Brain Damage

SATURDAY, Nov. 7, 2015 (HealthDay News) — Most adults who survive cardiac arrest away from a hospital don’t end up with brain damage, a new study finds.

Researchers analyzed data from about 3,800 attempted resuscitations of people whose hearts stopped beating in urban or suburban areas.

Of the 12 percent who survived, nearly 84 percent didn’t suffer significant brain damage. They had either normal function or slight disabilities that didn’t prevent them from living on their own and working.

About 90 percent of those who had little or no brain damage were resuscitated in 35 minutes or less. The other 10 percent took longer than 35 minutes, Dr. Jefferson Williams, from Wake County EMS in Raleigh, N.C., and colleagues said.

In general, those who ended up with little or no brain damage had their cardiac arrest witnessed by a bystander, and their hearts started beating again while emergency medical personnel were on the scene of the cardiac arrest, rather than while riding in an ambulance or at the hospital.

A related study found that hospital patients who suffer cardiac arrest at night tend to suffer more brain damage than those who had cardiac arrest during the day.

In this study, a team led by Dr. Luca Marengo at the University Hospital Basel reviewed the outcomes for 270 people who had cardiac arrest while in a teaching hospital in Switzerland. One-third of the cardiac arrests occurred during the night, the study found.

The reaction times of rapid response teams were similar during the day and night, the researchers said. But, patients who had cardiac arrest during the day were more likely than those who had cardiac arrest at night to be noticed. They were also more likely to have the type of heartbeat that responds to a shock from a defibrillator, and to have less brain damage, the study found.

The findings suggest that the higher risk of brain damage in patients who have cardiac arrest at night may be due to the fact that their condition is not noticed as quickly, the researchers said.

Both studies are to be presented Monday at the American Heart Association annual meeting in Orlando, Fla.

Research presented at meetings is viewed as preliminary because it has not been subjected to the scrutiny of a peer-reviewed publication.

More information

The U.S. National Heart, Lung, and Blood Institute has more about cardiac arrest.

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Lifesaving Defibrillators Often Behind Locked Doors, Study Finds

By Amy Norton
HealthDay Reporter

SATURDAY, Nov. 7, 2015 (HealthDay News) — Public defibrillators can help anyone save the life of someone suffering cardiac arrest, but the devices are often kept behind locked doors, a new study finds.

At issue is the accessibility of devices called automated external defibrillators, or AEDs. They are portable, layperson-friendly versions of the devices doctors use to “shock” the heart out of cardiac arrest.

It’s now routine for paramedics to carry AEDs, and the devices are often available in large venues, such as airports and sports stadiums, as well as schools and private businesses.

To live up to their full potential, though, those devices have to be readily available, said study author Timothy Chan, a researcher at the University of Toronto.

However, his team found, that’s often not the case.

The researchers looked at the cases of 451 Toronto residents who went into cardiac arrest within 100 meters of an AED — about a football field’s distance. One-quarter of the time, the devices were behind locked doors.

“If the AED isn’t accessible, it’s as if it’s not there at all,” Chan said.

The study found that AEDs in schools, office buildings, industrial sites and recreational facilities were most likely to be locked up, particularly at night or on weekends — which is not surprising, Chan noted, since such buildings are not open 24/7.

Unfortunately, two-thirds of the cardiac arrests in this study occurred at night or over the weekend, Chan said.

He was to present the findings Sunday at the annual meeting of the American Heart Association, in Orlando, Fla. The data and conclusions should be considered preliminary until published in a peer-reviewed journal.

The findings “ring true,” according to Dr. Clifton Callaway, an AHA spokesperson and a professor of emergency medicine at the University of Pittsburgh.

“One of our longstanding concerns is that AEDs are not always in locations that are clearly marked, or that people are aware of,” Callaway said. It makes sense, he added, that AEDs would also frequently be inaccessible — particularly those owned by private businesses.

“A lot of businesses would buy these with their employees in mind, and not for the general public to use,” Callaway said.

He said local communities need to come up with “novel ideas” on how to make AEDs broadly available, and make sure that people know where the devices are located.

There is work being done, both Callaway and Chan said. The PulsePoint Foundation, for example, has developed a smartphone app that allows users to locate local AEDs.

Chan said companies are also working on ways to make AEDs available outdoors, in weatherproof, vandalism-proof containers.

But more innovation is needed, according to Chan. One possibility, he said, would be to bring banks on board and have AEDs available in ATM lobbies.

In Japan, Chan noted, there are AED vending machines.

AEDs can be used to restore a normal heart rhythm in some cases of cardiac arrest. Most often, cardiac arrest occurs when the heart’s main pumping chamber stops contracting and begins to quiver chaotically — depriving the body of blood and oxygen. Without prompt treatment, it’s fatal within minutes.

Each year in the United States, about 360,000 people suffer cardiac arrest outside of a hospital, according to the AHA. Less than 10 percent of those people survive.

The odds of survival do improve, however, if bystanders perform chest compressions or use an AED while waiting for paramedics to arrive.

Chan said it’s not clear how AED availability might have affected the survival of patients in his study.

Callaway also pointed out that increasing AED availability is just one piece of the picture. The public also needs to know that the devices exist, and be comfortable using them.

Local CPR courses now include AED training, Chan said.

But even without training, he added, anyone can use an AED: The devices automatically analyze the heart’s rhythm, then deliver a shock only if it’s appropriate.

Chan pointed to a widely reported study of “mock” cardiac arrests, where researchers found that untrained sixth-graders used AEDs almost as well as medical professionals did.

More information

The American Heart Association has more on cardiac arrest.

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What You Need to Know When Your Child Gets a Rash

FRIDAY, Nov. 6, 2015 (HealthDay News) — When children develop a rash, parents might think it’s simply due to a skin irritation. But viruses are also a common cause of rashes in children, an expert says.

“Causes of rashes vary immensely and it can be difficult for parents to know if they should be concerned,” Dr. Heidi Renner, a pediatrician at Loyola Medicine and assistant professor at Loyola University Chicago Stritch School of Medicine, said in a university news release.

“Rashes can be caused by anything from an allergic reaction to viral illness to something more serious,” she explained.

“Most childhood rashes are no cause for concern, but it’s always best to talk to your pediatrician,” Renner added.

In most cases, childhood rashes get better on their own or are easily treated. But rashes can be a symptom of another illness or virus, and a child with a rash should be seen by a doctor, Renner said.

Common viruses that can cause rashes include roseola, chickenpox and measles. These rashes are highly contagious, and children with a rash and high fever should not be around other kids. Thorough hand-washing is also critical to preventing transmission of the virus to others, according to the news release.

Contact your doctor if your child also has symptoms of dehydration, including low fluid intake, dry lips and decreased urination, because “this scenario may indicate a more serious illness and the child should be evaluated by a pediatrician,” Renner said.

Rashes come in many forms — including flat red areas, raised bumps, welts, blisters or combinations — and can last from a couple of days to several weeks.

If a child has a fever and a rash that is bright red or purple with spots or bruises that don’t turn white when you press on them, seek immediate medical help. These could be signs of a meningococcal infection, which can cause lifelong disability or death, Renner said.

More information

The American Academy of Pediatrics has more about rashes and skin conditions.

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13 Famous Women on Why Turning 40 Is Actually Awesome

Photo: Getty Images

Turning the big 4-0 can be a little daunting. All of a sudden, you’re officially in the “midlife” stage, and—there’s no way around it—some things are just different than they were in your 20s and 30s. But that’s not a bad thing, necessarily. Your 40s can end up being the best years of your life. Just take it from these famous women who’ve been there.

RELATED: 6 Things That Happen When You Turn 40

It’s not as bad as you might expect (yes, seriously)

“I was really worried about it, leading up to the day, but now I feel really happy and content with my life. I’m excited to move into the next phase. It’s much more exciting than I thought it would be.”
—Gwyneth Paltrow, US Weekly, October 2012

“What a great time in a woman’s life. I wasn’t sure what was going to happen or how I was going to feel about it. But now having turned the corner, it’s really empowering.”
—Jennie Garth, People, April 2012

“It really feels fantastic actually. I mean I have to say, I was gearing up to it. I was getting ready for it and I feel like I’ve earned these 40 stripes. I made it.”
—Kate Winslet, The Ellen DeGeneres Show, October, 2015

RELATED: 20 Celebrities on Losing the Baby Weight

You find new confidence

“When I turned 40, I was like, huh. I accept myself more now. It was much more comforting.”
—Jennifer Lopez, Harper’s Bazaar, February 2013

“There’s a confidence and sense of self that comes with age that I didn’t anticipate. I don’t feel the need to prove myself now, which I did for a very long time. And there is a peace that I didn’t have in my 30s. I no longer feel this urgency to make impulsive decisions.”
—Jillian Michaels, Health, November 2014

“I’m so happy to be in my 40s and not be in my 20s and worried if I fit into my skinny jeans or whether I will be able to get into that club.”
—Charlize Theron, E! Online, July 2015

“I embraced it. There’s something freeing about 40. There’s something that allowed me to walk the walk and talk the talk of being the woman that I always wanted to be.”
—Gabrielle Union, People, May 2013

You learn to let the little things go

“Every time I get stressed out or anxious, I say to myself, Just live and love. Feel love. I think that’s what I took away from my turning-40 meltdown. I have been operating out of fear, and I just don’t want to do it anymore.”
—Amy Adams, Vogue, December 2014 

RELATED: 7 Famous Women on Not Having Kids

You prioritize your health

“I wish I had known more about nutrition and exercise and how really good it could affect you at a younger age. Then I would have kicked it up a lot sooner.”
—Queen Latifah, People StyleWatch, February 2010

“I also notice that even though you do your best to stay in shape and keep your butt as tight as possible, there is not much you can do about skin. If I could take back all those spring break years in Daytona Beach, Florida, I would. What the heck was I thinking, lying out on top of tin foil with baby oil all over my delicate Irish skin? I was nuts!”
—Jenny McCarthy, Splash, November 2012

And finally, you understand these will be the best years of your life

“For the first time in my life I’m content. I’m so excited. Getting older is the best part of life. Like, I know more than I’ve ever known. I have gratitude. I know myself better. I feel more capable than ever. And as far as the physicality of it—I feel better at 40 than I did at 25.”
—Cameron Diaz, Esquire UK, November 2012

“When am I supposed to freak out? When am I supposed to feel like, ‘Oh, my knee! Oh, ouch!’ I don’t feel any of those things! … I’ve had more fun post-40 than I can remember. From a work point of view, a physical point of view, a psycho-therapeutic point of view.”
—Jennifer Aniston, Harper’s Bazaar, November 2014

“It’s the first time in my life that my age has met up with where my life is and it’s perfect. I love being 40.”
—Drew Barrymore, The Ellen DeGeneres Show, May 2015

RELATED: 9 Celebrities With Lupus

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5 Ways to Say Goodbye to Dark Circles and Puffy Eyes

Celebrities—they’re just like us. Their skin isn’t perfect. They’re often just as sleep-deprived (try 4 a.m. call times) and they, too, are faced with puffy eyes and dark circles as a result. So what’s the star secret to looking wide-eyed and gorgeous when going from red eye to red carpet? Eye masks. The single-use patches blanket the contours under the eye to deliver potent ingredients faster and deeper than your standard eye cream. Here, five of our favorites that smooth and soothe. (They make for a great Instagram post, too.)

Herbal remedy

Photo: courtesy of Sephora.com

Sephora Green Tea Eye Mask ($5 a pair; sephora.com)
Inside: Two silky sheets (one for each eye) infused with antioxidant-rich green tea to ease puffiness and reduce the appearance of dark circles, plus soothing aloe vera leaf extract. They’re comfortable to wear and won’t slide down your face, so pop on a pair for fifteen minutes while you blow-dry your hair or pick out an outfit to fake awake fast.

RELATED: 8 Best Overnight Beauty Products to Wake Up Gorgeous

Quick fix

Photo: courtesy of Amazon.com

Patchology FlashPatch Eye Gels ($50 for 60 sets; amazon.com)
These wonderfully cooling gels offer instant relief—okay, near to, requiring only five minutes. Packed with hyaluronic acid to amp up hydration and hydrolyzed collagen to improve elasticity and lessen the look of lines, they’re choice for prepping the eye area before makeup or in lieu of your morning eye cream. Keep them in the refrigerator for an extra-cooling sensation.

One-for-all

Photo: courtesy of Sephora.com

Karuna Renewal + Eye Mask ($36 for 4 sets; sephora.com)
Stash a set of these individually sealed masks at your desk or in your car for on-the-go application. Each sheet is saturated in hydrating hyaluronic acid, calming chamomile, plumping peptides and brightening Chinese licorice–which means you get a mask that hydrates, depuffs, and reduces fine lines all in one tiny package. Leave them on for ten minutes, then massage any leftover serum into skin for noticeably revived eyes.

The detoxifier

Photo: courtesy of Sephora.com

Klorane Smoothing and Relaxing Patches ($21 for 7 sets; sephora.com)
Made with cornflower, which is known for its anti-inflammatory benefits, these soothing patches are a must after a long night of drinking or a super-salty dinner (sushi and saké, anyone?). Apply for 20 minutes to eliminate puffiness.

RELATED: The Anti-Aging Products Derms Love

At-home facial

Photo: courtesy of Ultra.com

Bliss Triple Oxygen Instant Energizing Eye Mask ($54 for 4 sets; ulta.com)
We consider these the next best thing to spa-like experience. The concentrated oxygen helps deliver brightening vitamin C and calming cucumber deeper in the skin to quickly alleviate puff and shadows. To apply, start by pressing the liquid chamber until it releases the fluid into the pad. Once saturated, place one under each eye and relax for 15 to 30 minutes.

 

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Doctors Often Flub Achilles Tendon Diagnosis, Review Finds

FRIDAY, Nov. 6, 2015 (HealthDay News) — Achilles tendon problems are often misdiagnosed, but many patients still have good outcomes, a new study suggests.

For example, about one-quarter of Achilles tendon ruptures are missed during doctors’ initial examinations, according to the authors of the clinical review published in the November issue of The Journal of the American Osteopathic Association.

The Achilles tendon, which connects calf muscles at the back of the lower leg to the heel, is the largest tendon in the body and plays a vital role in walking, running and jumping.

The researchers found that most patients healed better with conservative treatment and said surgery should be limited to acute tears in young or very active patients.

“As an osteopathic physician, we approach treating injuries with the least amount of surgical intervention possible,” Dr. Joseph Daniel, clinical associate professor of orthopedic surgery at Jefferson Medical College in Philadelphia, said in a journal news release.

“Injuries of the Achilles are no different, and this study validates that most patients are better off with conservative treatment,” he added.

However, surgery in younger, athletic patients is associated with a lower risk of re-rupture and a faster return to activity, Daniel said.

The researchers also said that diagnostic imaging, such as MRI or ultrasound, is not recommended for people with Achilles tendon problems unless a rupture is suspected.

“Mismanaged or neglected injuries will markedly decrease a patient’s quality of life,” Daniel said. “In all but a select few cases, we can resolve the issue with rest, over-the-counter medication, physical therapy, or a few weeks in a walking boot.”

More information

The American College of Foot and Ankle Surgeons has more about Achilles tendon problems.

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The Physically Active Less Prone to Post-Heart Attack Depression

FRIDAY, Nov. 6, 2015 (HealthDay News) — Heart attack survivors who exercised for years prior to the event have a lower risk of developing depression, according to a new study.

Researchers looked at 189 people in Norway after their first heart attack. People who were physically active for 10 years before their heart attack were 20 percent less likely to be depressed after the event than those who were inactive, the investigators found.

The study also revealed that those who had been inactive but started exercising before their heart attack were less likely to be depressed than those who had been active but stopped exercising.

The findings were published recently in the American Journal of Medicine.

“Our results add strength to the evidence of a causal link between physical activity and mental health,” study first author Linda Ernstsen, of the Center for Exercise in Medicine at the Norwegian University of Science and Technology, said in a university news release.

“In fact, we do not know if the heart attack itself is related to the prevalence of depression or if it is the change in physical activity level that is the driving force behind our findings. More research is definitely needed in this area,” she added.

The findings reinforce the link between physical activity and depression, and highlight the need for people with or at risk for heart disease and/or depression to boost their physical activity levels, the researchers said.

More information

The American Heart Association has more about depression after heart attack.

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