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Saturday, December 29, 2018

Vintage Secrets to Being a Good Conversationalist


Editor’s note: The following is an excerpt from Our Deportment by John H. Young, an etiquette manual published in 1882.
The character of a person is revealed by his conversation as much as by any one quality he possesses, for strive as he may he cannot always be acting.

Importance of Conversing Well

To be able to converse well is an attainment which should be cultivated by every intelligent man and woman. It is better to be a good talker than a good singer or musician, because the former is more widely appreciated, and the company of a person who is able to talk well on a great variety of subjects, is much sought after. The importance, therefore, of cultivating the art of conversation, cannot easily be overestimated. It should be the aim of all intelligent persons to acquire the habit of talking sensibly and with facility upon all topics of general interest to society, so that they may both interest others and be themselves interested, in whatever company they may chance to be thrown.

Training Children

The training for this should be commenced in early childhood. Parents should not only encourage their children to express themselves freely upon everything that attracts their attention and interests them, but they should also incite their faculties of perception, memory, and close observation, by requiring them to recount everything, even to its minutest details, that they may have observed in walking to and from school, or in taking a ride in a carriage or in the cars. By training a child to a close observation of everything he meets or passes, his mind becomes very active, and the habit having once been acquired, he becomes interested in a great variety of objects; sees more and enjoys more than one who has not been so trained.

Cultivating the Memory

A good memory is an invaluable aid in acquiring the art of conversation, and the cultivation and training of this faculty is a matter of importance. Early youth is the proper time to begin this training, and parents and teachers should give special attention to the cultivation of memory. When children are taken to church, or to hear a lecture, they should be required to relate or to write down from memory, such a digest of the sermon or lecture as they can remember. Adults may also adopt this plan for cultivating the memory, and they will be surprised to find how continued practice in this will improve this faculty. The practice of taking notes impairs rather than aids the memory, for then a person relies almost entirely in the notes taken, and does not tax the memory sufficiently. A person should also train himself to remember the names of persons whom he becomes acquainted with, so as to recall them whenever or wherever he may subsequently meet them.

Henry Clay’s Memory of Names

One secret of Henry Clay’s popularity as a politician was his faculty of remembering the names of persons he had met. It is said of him that if he was once introduced to a person, he was ever afterwards able to call him by name, and recount the circumstances of their first meeting. This faculty he cultivated after he entered upon the practice of law in Kentucky, and soon after he began his political life. At that time his memory for names was very poor, and he resolved to improve it. He adopted the practice, just before retiring at night, of recalling the names of all the persons he had met during the day, writing them in a note book, and repeating over the list the next morning. By this practice, he acquired, in time, his wonderful faculty in remembering the names of persons he had become acquainted with.

Writing as an Aid to Correct Talking

To converse correctly—to use correct language in conversation—is also a matter of importance, and while this can be acquired by a strict attention to grammatical rules, it can be greatly facilitated by the habit of writing down one’s thoughts. In writing, strict regard is, or should be, paid to the correct use of language, and when a person, from constant writing, acquires the habit of using correct language, this habit will follow him in talking. A person who is accustomed to much writing, will always be found to use language correctly in speaking.

Requisites for a Good Talker

To be a good talker, then, one should be possessed of much general information, acquired by keen observation, attentive listening, a good memory, extensive reading and study, logical habits of thought, and have a correct knowledge of the use of language. He should also aim at a clear intonation, well chosen phraseology, and correct accent. These acquirements are within the reach of every person of ordinary ability, who has a determination to possess them, and the energy and perseverance to carry out that determination.

Vulgarisms

In conversation, one must scrupulously guard against vulgarisms. Simplicity and terseness of language are the characteristics of a well educated and highly cultivated person. It is the uneducated or those who are but half educated, who use long words and high-sounding phrases. A hyperbolical way of speaking is mere flippancy, and should be avoided. Such phrases as “awfully pretty,” “immensely jolly,” “abominably stupid,” “disgustingly mean,” are of this nature, and should be avoided. Awkwardness of attitude is equally as bad as awkwardness of speech. Lolling, gesticulating, fidgeting, handling an eye-glass or watch chain and the like, give an air of gaucherie, and take off a certain percentage from the respect of others.

Listening

The habit of listening with interest and attention is one which should be specially cultivated. Even if the talker is prosy and prolix, the well-bred person will appear interested, and at appropriate intervals make such remarks as shall show that he has heard and understood all that has been said. Some superficial people are apt to style this hypocrisy; but if it is, it is certainly a commendable hypocrisy, directly founded on that strict rule of good manners which commands us to show the same courtesy to others that we hope to receive ourselves. We are commanded to check our impulses, conceal our dislikes, and even modify our likings whenever or wherever these are liable to give offense or pain to others. The person who turns away with manifest displeasure, disgust, or want of interest when another is addressing him, is guilty not only of an ill-bred, but a cruel act.

Flippancy

In conversation all provincialisms, affectations of foreign accents, mannerisms, exaggerations, and slang are detestable. Equally to be avoided are inaccuracies of expression, hesitation, an undue use of foreign words, and anything approaching to flippancy, coarseness, triviality, or provocation.
Flippancy is as much an evidence of ill-breeding as is the perpetual smile, the wandering eye, the vacant stare, and the half opened mouth of the man who is preparing to break in upon the conversation.

Be Sympathetic and Animated

Do not go into society unless you make up your mind to be sympathetic, unselfish, animating, as well as animated. Society does not require mirth, but it does demand cheerfulness and unselfishness, and you must help to make and sustain cheerful conversation. The manner of conversation is as important as the matter.

Compliments

Compliments which are not sincere are only flattery and should be avoided; but the saying of kind things, which is natural to the kind heart, and which confers pleasure should be cultivated, at least not suppressed. Those parents who strive most for the best mode of training their children are said to have found that it is never wise to censure them for a fault, without preparing the way by some judicious mention of their good qualities.

Flattery

Do not be guilty of flattery. The flattery of those richer than ourselves or better born is vulgar, and born of rudeness and is sure to be received as emanating from unworthy motives. Testify your respect, your admiration, and your gratitude by deeds more than by words. Words are easy but deeds are difficult. Few will believe the former, but the latter will carry confirmation with them.

Scandal and Gossip

Scandal is the least excusable of all conversational vulgarities. Envy prompts the tongue of the slanderer. Jealousy is the disturber of the harmony of all interests. A writer on this subject says: “Gossip is a troublesome sort of insect that only buzzes about your ears and never bites deep; slander is the beast of prey that leaps upon you from its den and tears you in pieces. Slander is the proper object of rage; gossip of contempt.” Those who best understand the nature of gossip and slander, if the victims of both, will take no notice of the former, but will allow no slander of themselves to go unrefuted during their lifetime, to spring up in a hydra-headed attack upon their children.

Satire and Ridicule

Young persons appear ridiculous when satirizing or ridiculing books, people, or things. Opinions to be worth the consideration of others should have the advantage of coming from mature persons. Cultivated people are not in the habit of resorting to such weapons as satire and ridicule. They find too much to correct in themselves, to indulge in coarse censure of the conduct of others, who may not have had advantages equal to their own.

Interruption

Interruption of the speech of others is a great sin against good-breeding. It has been aptly said that if you interrupt a speaker in the middle of a sentence, you act almost as rudely as if, when walking with a companion, you were to thrust yourself before him and stop his progress.

Adaptability in Conversation

The great secret of talking well is to adapt your conversation, as skillfully as may be, to your company. If you really wish to be thought agreeable, sensible, amiable, unselfish, and even well-informed, you should lead the way, in tete-a-tete conversations for sportsmen to talk of their shooting, a mother to talk of her children, a traveler of his journeys and the countries he has visited, a young lady of her last ball and the prospective ones, an artist of his picture, and an author of his book. To show any interest in the immediate concerns of people is very complimentary, and when not in general society one is privileged to do this. People take more interest in their own affairs than in any thing else you can name, and if you manifest an interest to hear, there are but few who will not sustain conversation by a narration of their affairs in some form or another. Thackeray says: “Be interested by other people and by their affairs. It is because you yourself are selfish that that other person’s self does not interest you.”

Speaking One’s Mind

Certain honest but unthinking people often commit the grievous mistake of “speaking their mind” on all occasions and under all circumstances, and oftentimes to the great mortification of their hearers. And especially do they take credit to themselves for their courage, if their freedom of speech happens to give offense to any of them. A little reflection ought to show how cruel and unjust this is. The law restrains us from inflicting bodily injury upon those with whom we disagree, yet there is no legal preventive against this wounding of the feeling of others.

Unwise Expression of Opinion

Another class of people, actuated by the best of intentions, seem to consider it a duty to parade their opinions upon all occasions, and in all places without reflecting that the highest truth will suffer from an unwise and over-zealous advocacy. Civility requires that we give to the opinions of others the same toleration that we exact for our own, and good sense should cause us to remember that we are never likely to convert a person to our views when we begin by violating his notions of propriety and exciting his prejudices. A silent advocate of a cause is always better than an indiscreet one.

Profanity

No gentleman uses profane language. It is unnecessary to add that no gentleman will use profane language in the presence of a lady. For profanity there is no excuse. It is a low and paltry habit, acquired from association with low and paltry spirits, who possess no sense of honor, no regard for decency and no reverence or respect for beings of a higher moral or religious nature than themselves. The man who habitually uses profane language, lowers his moral tone with every oath he utters. Moreover, the silliness of the practice, if no other reason, should prevent its use by every man of good sense.

Public Mention of Private Matters

Do not parade merely private matters before a public or mixed assembly or to acquaintances. If strangers really wish to become informed about you or your affairs, they will find the means to gratify their curiosity without your advising them gratuitously. Besides, personal and family affairs, no matter how interesting they may be to the parties immediately concerned, are generally of little moment to outsiders. Still less will the well-bred person inquire into or narrate the private affairs of any other family or individual.

Ostentatious Display of Knowledge

In refined and intelligent society one should always display himself at his best, and make a proper and legitimate use of all such acquirements as he may happen to have. But there should be no ostentatious or pedantic show of erudition. Besides being vulgar, such a show subjects the person to ridicule.

Wit

You may be witty and amusing if you like, or rather if you can; but never use your wit at the expense of others.

The Confidence of Others

Never try to force yourself into the confidence of others; but if they give you their confidence of their own free will, let nothing whatever induce you to betray it. Never seek to pry into a secret, and never divulge one.

Dogmatic Style of Speaking

Never speak dogmatically or with an assumption of knowledge or information beyond that of those with whom you are conversing. Even if you are conscious of this superiority, a proper and becoming modesty will lead you to conceal it as far as possible, that you may not put to shame or humiliation those less fortunate than yourself. If they discover your superiority of their own accord, they will have much more admiration for you than though you forced the recognition upon them. If they do not discover it, you cannot force it upon their perceptions, and they will only hold you in contempt for trying to do so. Besides, there is the possibility that you overestimate yourself, and instead of being a wise man you are only a self-sufficient fool.

Fault-Finding

Do not be censorious or fault-finding. Long and close friendship may sometimes excuse one friend in reproving or criticizing another, but it must always be done in the kindest and gentlest manner, and in nine cases out of ten had best be left undone. When one is inclined to be censorious or critical, it is well to remember the scriptural injunction, “First cast the beam out of thine own eye, and then shalt thou see clearly to cast the mote out of thy brother’s eye.”

Hobbies

People with hobbies are at once the easiest and most difficult persons with whom to engage in conversation. On general subjects they are idealess and voiceless beyond monosyllables. But introduce their special hobby, and if you choose you need only to listen. There is much profit to be derived from the conversation of these persons. They will give you a clearer idea of the aspects of any subject or theory which they may have taken to heart, than you could perhaps gain in any other way.
The too constant riding of hobbies is not, however, to be specially recommended. An individual, though he may be pardoned in cultivating special tastes, should yet be possessed of sufficiently broad and general information to be able to converse intelligently on all subjects, and he should, as far as possible, reserve his hobby-riding for exhibition before those who ride hobbies similar to his own.

Things to Be Avoided

If anyone should assume a disagreeable tone of voice or offensive manner toward you, never return it in company, and above all, do not adopt the same style of conversation with him. Appear not to notice it, and generally it will be discontinued, as it will be seen that it has failed in its object.
Never attack the character of others in their absence; and if you hear others attacked, say what you can consistently to defend them.
Do not appear to notice an error in language, either in pronunciation or grammar, made by the person with whom you are conversing, and do not repeat correctly the same word or phrase. This would be as ill-bred as to correct it when spoken.
Sneering at the private affairs of others has long ago been banished from the conversation of well-mannered people.
Never introduce unpleasant topics, nor describe revolting scenes in general company.
Never give officious advice. Even when sought for, give advice sparingly.
Never, directly or indirectly, refer to the affairs of others, which it may give them pain in any degree to recall.
Never hold your companion in conversation by the button-hole. If you are obliged to detain him forcibly in order to say what you wish, you are pressing upon him what is disagreeable or unwelcome, and you commit a gross breach of etiquette in so doing.
Especially avoid contradictions, interruptions, and monopolizing all conversation yourself. These faults are all intolerable and very offensive.
To speak to one person in a company in ambiguous terms, understood by him alone, is as rude as if you had whispered in his ear.
Avoid stale and trite remarks on commonplace subjects; also all egotism and anecdotes of personal adventure and exploit, unless it should be called out by persons you are conversing with.
To make a classical quotation in a mixed company is considered pedantic and out of place, as is also an ostentatious display of your learning.
A gentleman should avoid talking about his business or profession, unless such matters are drawn from him by the person with whom he is conversing. It is in bad taste, particularly, to employ technical or professional terms in general conversation.
Long arguments or heated discussions are apt to be tiresome to others, and should be avoided.
It is considered extremely ill-bred for two persons to whisper in society, or to converse in a language with which all persons are not familiar.
Avoid talking too much, and do not inflict upon your hearers interminably long stories, in which they can have but little interest.

Alzheimer’s Disease Subgroups Identified


Researchers have categorized Alzheimer’s disease into six distinct conditions based on cognitive function at the time of diagnosis and genetic data demonstrating biological differences across groups.
The findings represent “an important result on the road to personalized medicine,” write Dr. Paul Crane of the University of Washington School of Medicine in Seattle and colleagues in a report online December 4 in Molecular Psychiatry.
“Clinicians have noted a lot of variation in the cognitive profiles of people presenting with Alzheimer’s disease for many years,” Dr. Crane told Reuters Health by email. “A ‘relative deficits’ approach to differential diagnosis has characterized typical clinical neuropsychological practice.”
“We were curious as to whether this clinical framework could prove useful in characterizing heterogeneity among people with typical late-onset Alzheimer’s disease,” he said.
In previous studies, the group used cognitive tests to subdivide people with late-onset Alzheimer’s disease into different groups. The current study “looks specifically at genetic data to see whether there is genetic (biological) support for this particular way of categorizing people with typical late-onset Alzheimer’s disease,” Dr. Crane said.
The researchers studied information from five studies involving 4,050 patients with late-onset Alzheimer’s (mean age, 80; 61% women), including 2,431 with single nucleotide polymorphism (SNP) data.
Individuals were assigned to cognitively defined subgroups on the basis of their relative performance in memory, executive functioning, visuospatial functioning, and language at the time of diagnosis. Genotype frequencies for each subgroup were compared with those from cognitively normal elderly controls.
The team focused on the APOE gene and SNPs with more extreme odds ratios than those previously reported for Alzheimer’s disease. They found substantial variation across studies in the proportions of people in each subgroup. However, in each study, higher proportions of people in the subgroup with isolated substantial relative memory impairment had at least one APOE-e4 allele.
Overall, across subgroups, “we found 33 SNPs scattered through the genome with a strong association with one of the cognitively defined subgroups,” Dr. Crane said. “Few of these SNPs had previously been identified as being interesting in Alzheimer’s disease.”
“These data provide strong support for the biological coherence of subgroups produced by our categorization scheme,” the authors state. “Each subgroup we analyzed has extreme ORs at novel SNPs that were consistent across multiple independent samples.”
“Even with the relatively small sample sizes from these studies, the large effect sizes at common SNPs produced p values that are close to genome-wide significance,” they concluded.
“A lot more work needs to happen downstream of our initial findings,” Dr. Crane noted, “but each of these 33 SNPs represents some underlying biology that makes people susceptible to one specific subtype of Alzheimer’s disease,” he said. “Each one thus represents a possible novel target for future work.”
In the future, he said, clinicians “may see different treatments recommended on the basis of cognitively-defined subgroups, but we are not there yet.”
Dr. Keith Fargo, Alzheimer’s Association Director of Scientific Programs and Outreach, commented, “This seems to be a reasonable approach — trying to identify subgroups of people with Alzheimer’s who have different clinical presentations, and associate those with specific genetic variants.”
“Whether it is clinically useful or not remains to be seen,” he said, after the findings have been replicated and additional studies have been done in larger, more diverse populations.
“Looking to the future, it is possible that we may soon be able to treat people with Alzheimer’s disease based on their unique combination of genetics, medical history, risk factors and more,” he said. “This kind of research may be getting us closer to this future of precision medicine for Alzheimer’s and other dementias.”

Melatonin ‘Should Be a Last Resort’ in Tackling Sleep Issues


Experts say that other issues pertaining to poor sleep quality, such as light exposure and certain behaviors, should be tackled ahead of resorting to use of the hormone melatonin to regulate sleep.
But if it is used, an individual’s daily onset of natural melatonin production should be taken into account before deciding on an appropriate dose to supplement, they say.
Melatonin, which is available over-the-counter in the United States but restricted in other developed countries, is typically recommended acutely for sleep schedules thrown off by, for example, jet lag or chronically for certain circadian rhythm disorders.
It has also been touted as something close to a panacea, with some even suggesting it can treat cancer, cognitive dysfunction, and obesity.
However, it is the explosion in the use of melatonin to regulate general sleep in otherwise healthy individuals that has led to US consumers reportedly spending more than $400 million on melatonin supplements in 2018.
This has raised concerns over its safety among healthcare professionals and led to questions as to whether the hormone should be taken for jet lag at all and whether its use should be restricted in children.
This ongoing debate led the American Chemical Society to recently produce a video that debunks many of the myths around melatonin and its effects, including the magnitude of its benefits in improving sleep.
Now, José Cipolla-Neto, MD, PhD, Institute of Biomedical Sciences, University of São Paulo, and Fernanda Gaspar do Amaral, PhD, a professor at the Federal University of São Paulo, Brazil, have conducted an in-depth review of the literature on melatonin and its uses.
Moreover, they have produced a series of recommendations, published in the December issue of Endocrine Reviews, that set out how best to use the hormone, including advice on the most effective dosage and timing.
But others question whether people should look to melatonin to regulate sleep at all, suggesting that, instead, individuals should be looking at controlling night-time light exposure and even regulating light levels in shops.

A Multitude of Effects

The sheer amount of research that has been conducted into melatonin in recent years is staggering. Cipolla-Neto and Amaral point out more than 4000 studies have been published in the last 20 years, of which 200 were randomized controlled trials and 195 systematic reviews.
Melatonin has been shown to affect a number of physiological processes, including downstream effects on the cardiovascular, reproductive, immune, respiratory, and endocrine systems, alongside energy metabolism.
“Melatonin synchronizes our organism’s temporal order both daily and on the seasonal time scale,” Cipolla-Neto commented in a press release from the São Paulo Research Foundation (FAPESP).
He and Amaral therefore argue that these multiple modes of action should be taken into account both when performing laboratory experiments and conducting clinical studies into melatonin’s use as a treatment.
“In this case, above all, it should be kept in mind that melatonin’s effects depend not just on the route of administration and concentration but also on the time of administration, among other factors,” argues Cipolla-Neto.
And crucially, the daily variation in melatonin levels varies between individuals, they say.
For example, so-called early birds, who prefer to get up early, start daily melatonin production earlier than those who prefer to stay up later, while long sleepers tend to produce the hormone for longer periods than those who sleep less.
A given dose of melatonin may, moreover, result in different plasma levels between individuals, owing to pharmacokinetic differences in the way that it is absorbed, distributed, metabolized, and eliminated.
These processes can themselves be affected by an individual’s age and clinical condition, the presence of pathological conditions, and the physiological performance of the gastrointestinal tract, liver, and kidneys, Cipolla-Neto and Amaral point out.
If these factors are not adequately considered, they say that the clinical efficacy of melatonin will be altered.
Indeed, “proper chronic melatonin hormonal replacement therapy is only achieved when dosage and formulation are carefully chosen and individually tailored and controlled to accomplish the desired clinical effect,” Cipolla-Neto observes.

How Should Melatonin Be Best Used?

This led Cipolla-Neto and Amaral to set out a number of recommendations as to how melatonin should be used in clinical practice.
The first is to determine the start of melatonin production, known as the dim light melatonin onset (DLMO), and its duration in each patient, and use that to guide prescribing. This is because, without using the DLMO as an indicator of the timing of administration, melatonin could advance, delay, or even have no effect on the timing of endogenous circadian rhythms, they write.
However, is not typically feasible to determine the DLMO in everyday clinical practice.
Cipolla-Neto and Amaral therefore suggest that a more practical surrogate is to take the time at which the patient usually goes to sleep at night.
With the majority of melatonin formulations requiring approximately 45 minutes to become bioavailable, they recommend that they be taken around an hour before the usual bedtime at exactly the same time every day.
In terms of the dose, however, the authors say that there is no consensus in the literature.
What is known is that young people who take approximately 0.1 to 0.3 mg of melatonin will have a plasma concentration in the range of 100 to 200 pg/mL, which is considered to be within the physiological range.
A dose of 1.0 mg would result in a plasma concentration of approximately 500 to 600 pg/mL, which the authors say is “far higher than the physiological concentration.”
They note that, in reality, a wide range of doses are used, depending on the reason for taking melatonin and the formulation.
“For example, if the outcome is an acute phase displacing, as it is desired for jet lag treatment, a fast-release pulse correctly timed is perfectly adequate,” say Cipolla-Neto and Amaral.
“However, if the desired effect is a sustained phase displacement as, for example, in non-24-hour sleep disorder or circadian dysfunction in totally blind people, the synchronizing effect requires chronic continuous daily intake of melatonin…For this purpose, a slow-release or dual-release formulation is the most appropriate.”

Should Melatonin Be Taken at All?

A question nevertheless remains as to whether melatonin should be taken at all by individuals who do not have a recognized clinical condition, or indeed whether it is the most appropriate treatment in those who do.
Satchidananda Panda, PhD, Salk Institute for Biological Studies, La Jolla, California, and colleagues recently published a study in mice showing how the protein melanopsin in retinal cells continually responds to light.
“Melanopsin, which is tuned to blue light, is essentially checking whether it’s daylight still out there and, if there is daylight, then it will tell the brain to avoid sleeping and stay awake,” Panda told Medscape Medical News.
“It does that by two ways, one is increasing the circadian clock, telling that it’s still daytime, and the second is it tells the pineal gland to slow down production of melatonin.”
While Panda acknowledges that melatonin has a “huge impact” on sleep, he said that it should not be seen as a “panacea,” adding, “if it was, then it should be heavily regulated, which it’s not.”
He continued: “This is the only hormone produced in the human body that’s not heavily regulated, and that says something.”
“That says that the health benefits of melatonin are extremely hyped up beyond what…scientists accept or what is proven. And it’s easy for science writers and commentators to latch onto one hormone and amp up its significance.”
As to whether melatonin itself should be targeted to improve melatonin production or whether, for example, melanopsin would be more appropriate is also open to debate.
While Panda and colleagues were previously able to develop a drug that specifically targets melanopsin and induces a state similar to physiological darkness, he pointed out that “melanopsin has many other effects beyond melatonin.”
Kenneth P. Wright Jr, PhD, Director of the Sleep and Chronobiology Laboratory at the University of Colorado Boulder, agrees.
He notes that melatonin production continues to follow a circadian rhythm even in the absence of exposure to light, thus underlining the fact that there is not a direct relationship between the two proteins.

Not Harmful, But Not That Effective

Wright told Medscape Medical News, “Currently, we don’t have any evidence to say that taking melatonin on a daily basis in that sense is harmful, although there are no large-scale multicenter clinical trials to really test that.”
He added that it has nevertheless been shown in animal studies to be “very safe,” and that some individuals with 24-hour sleep-wake disorder, the majority of whom are blind, “have been taking this for decades, for example.”
However, Wright also points out that taking melatonin at night may help people fall asleep but “there is no evidence that it will help you sustain sleep for long periods of time if your body is already naturally producing it.”
He consequently believes that melatonin “is something that I wouldn’t say should be the first step if you’re trying to help someone improve their sleep.”
Instead, factors that may be disturbing sleep and behaviors around sleep should be examined, so that melatonin doesn’t have to be used “every night.”
Wright explained: “If you’re having a hard time falling asleep and having a hard time waking up in the morning, that could be just down to the fact that either you’re not getting enough sleep…or it could just be that your clock is just timed much later than is conducive to your school or work demands.”
“By using light, we can shift your clock earlier so, that way, your body is prepared to go to sleep earlier and wake up earlier, and that entails getting sunlight exposure in the morning and then reducing your exposure to light at night.”

How to Reduce Light Exposure

To achieve this, Panda says that there are a number of steps that individuals can take.
“Number one is, in the evening, people should switch on their night shift or nightlight features on their phones, laptops, etc, so that the screen becomes dimmer and switches to an orange hue, say around eight or nine o’clock.”
“That also acts as a nice nudge for people to prepare for sleep.”
However, visiting the shops at night could throw an individual’s light exposure, and consequently their sleep preparation, off-kilter.
“Many department stores these days have switched to blue LED light because that looks very bright and then the products look very appealing,” Panda explained.
“That light, at thousands lux of light in many department stores…will definitely reduce melatonin production and will reset the clock, and in some people it can also increase their anxiety levels, etc.”
In situations in which it is not possible to control light, “that’s where maybe having a pair of blue-filtering glasses is handy,” Panda added, saying that even wearing sunglasses could help, “although it sounds very weird.”
Alongside ensuring individuals use low lighting at home in the evenings, he believes that following these steps means “we don’t have to wait for a drug” to help regulate sleep.
“Any drug will have some side effects, and so it’s only in severe cases where people have migraine pain or some other photophobia where it may be better to wait for a drug.”
Wright agrees, noting: “For most people, I wouldn’t recommend using melatonin unless they’d tried other things and worked with the physician to see what might best be the strategy to improve their sleep, if that’s the goal.”
Although he added that, if all else fails, “things like melatonin or even more sophisticated behavioral treatments for sleep problems can be tried.”

Should Light Exposure Be Regulated?

Panda believes a better approach would be to introduce regulations on night-time light exposure, although the evidence on how light affects behavior, sleep, anxiety, and depression is currently not yet strong enough to develop specific guidelines.
He said that, for example, there is currently no advice that recommends stores “to cut down light…at night time, although we know that that amount of light has severe adverse neuroendocrine effects on the human brain and body, and it’s very close to an environmental toxin.”
Cipolla-Neto and Amaral agree, writing that “the present urban society and the industrial production processes as organized should be taken into account” when looking at sleep disturbances, “as both depend on the presence of indoor lights during the night.”
However, Panda notes: “Since we don’t have enough human studies, there is not enough [to] guide these department stores and drug stores on how much light they should have at night.”
“There is much basic science and translational research,” still to be done, he says.
Nevertheless, Panda believes that “in maybe 5 to 10 years we will have smart design in homes, factories, workplaces, shopping places, etc, that will nurture health instead of just lighting up the night.”
The guidelines were supported by Fundação de Amparo à Pesquisa do Estado de São Paulo. The melanopsin study was supported by NIH grants to Panda; a Japan Society for the Promotion of Science fellowship to Megumi Hatori; and Fondation Fyssen and Catharina Foundation fellowships to Ludovic S. Mure. Funding from the Leona M. and Harry B. Helmsley Charitable Trust, Glenn Foundation for Medical Research, and NIH grants facilitated the generation of several viruses and their use in mouse behavioral studies. Panda is the author of The Circadian Code, for which he receives royalties. The authors have reported no other relevant financial relationships.
Endocrine Rev. 2018;39:990-1028. Abstract
Cell Reports. 2018;25:2497-2509. Abstract

Hospitals to list procedure prices under new law: What you need to know


Hospitals already have to make prices for procedures available on request, but a new rule requiring them to post the information online goes into effect on Jan. 1, 2019.
The move toward price transparency sounds like a step in the right direction — part of government efforts to encourage patients to become better educated decision makers in their own care and shop around for the best value for, say, a colonoscopy.
But some health care advocates warn the new requirement is not as straightforward as it appears and may be confusing to consumers.
“This is the list price. When you go to buy a car, you have a manufacturer’s suggested retail price — this is basically what it is,” said NBC News medical contributor Dr. Natalie Azar on TODAY Friday.
“The concern is that there’s a big difference between what the list price is and what the actual transaction price is — the cost the patient is responsible for.”
Almost no one pays the charges indicated on the price list, said Dr. Ira Nash, senior vice president and executive director of Northwell Health Physician Partners in New York. The real prices are the result of negotiations with insurance companies and those are not published, he added.
That list price may also not be that meaningful to patients because they still have to go back to their insurance company and find out what their bottom line — the patient responsibility — is going to be, Azar noted. That can depend on each patient’s co-pays, co-insurance and deductibles.
So the new policy is a nice step forward, but “falls far short of being effective or useful for most people,” said Jeanne Pinder, founder and CEO of ClearHealthCosts.
“Publicizing the list price has the paradoxical effect of causing people to believe that these prices — inflated and fanciful — actually represent what they cost,” she said.
There’s a legitimate concern the new policy is not going to benefit consumers and could confuse patients more than help them, added Benendic Ippolito, research fellow in economic policy at the American Enterprise Institute.
The prices also won’t help people in a crisis who can’t exactly price compare what the hospitals in their area charge as they’re rushed to the ER, Azar pointed out.
She recommended patients who aren’t facing an emergency become informed about the prices, but also consider each hospital’s safety record, quality of care and aspects such as location.
“If you have time to plan for something, I think you can make smart decisions,” Azar said.

US FDA Finalizes Guidance on Breakthrough Medical Device Pathway


  • US FDA has published final guidance on its Breakthrough Medical Device market pathway for novel devices and combination products.
  • The new program incorporates elements of prior FDA programs including the Expedited Access Pathway (EAP) and Priority Review program.
  • Devices that use novel and cutting-edge technologies to address life-threatening or permanently debilitating diseases may qualify for the new program.
The US Food and Drug Administration has finalized details of a new registration route for breakthrough medical devices first announced in 2017.
Final guidance from FDA on its Breakthrough Devices Program covers cutting-edge medical devices as well as combination products with devices as primary components developed to more effectively target life-threatening or debilitating diseases and health conditions. These devices would otherwise undergo Premarket Approval (PMA), 510(k) premarket notification or De Novo classification request review in order to be sold in the US.
As previously reported by Emergo by UL, the Breakthrough Devices Program replaces FDA’s Expedited Access Pathway (EAP), established in 2015, as well as the regulator’s Priority Review Program. In addition, the new program incorporates the agency’s Innovation Pathway pilot program launched in 2011. Devices that previously obtained designation under the EAP now fall under the Breakthrough Devices Program, according to the agency.

Key criteria for program qualification

In order to qualify for participation in the Breakthrough Devices Program, a device must meet two key criteria:
  • The device facilitates more effective treatment or diagnosis of life-threatening or debilitating diseases or conditions.
  • The device represents breakthrough technologies that have no cleared or approved alternatives already available on the US market; offer significant advantages over existing alternative devices; and for which availability is in patients’ best interest.
“One thing it is important for manufacturers to understand is that this program does not take the place of a PMA, 510(k), or De Novo premarket process, but rather it is a means to expedite the device evaluation using whichever premarket pathway is needed,” explains Audrey Swearingen, Regulatory Affairs Manager at Emergo by UL.
“The program is not intended to simply be an expedited review of the submission data, but a partnering with FDA where agency reviewers are more involved early in the development of the device in order to ensure a more streamlined, successful clearance or approval of the submission,” Swearingen adds. “And of course it is only applicable to certain devices that meet the two key criteria, which need to be well supported when a sponsor requests designation as a Breakthrough Device.”

Components of the Breakthrough Devices Program

FDA’s final guidance involves two main phases: a Designation Request phase wherein device manufacturers and sponsors request Breakthrough Device designation, and a second phase that includes processes to expedite device development and prioritize premarket reviews.
Specific features of the Breakthrough Devices Program include interactive and timely communications between FDA and premarket registrants; more flexible clinical study design requirements; and expedited manufacturing inspection regimens depending on registrants’ compliance track records.
Qualifying premarket submissions will also undergo priority review at FDA, but manufacturers should be aware that such reviews may take longer due to novel scientific and technology issues posed by these devices that agency reviewers will have to consider.