Diet and exercise reduce pain in osteoarthritis

According to a study by researchers at Wake Forest University in Winston-Salem, North Carolina, intensive diet and exercise can dramatically reduce the amount of pain in older adults with osteoarthritis of the knee and improve function and gait speed .

The study Intensive Diet and Exercise on Arthritis (IDEA, for its acronym in English) of 18 months was intended to assess the impact of intense weight loss with or without exercise in the progression of the disease. The results presented here at the 2011 Annual Meeting of the American College of Rheumatology is the first study and focus only on pain and function.

The researchers randomly distributed to 454 individuals with pre-obesity and obesity (72% women) with a mean body mass index of 33.6 kg / m ² and an average age of 65.6 years, one of three groups: intensive diet designed to achieve a weight loss of 10% or more, only moderate exercise (two marches of 15 minutes and 20 minutes of exercise to reduce weight three times a week), or both. Participants were served each week during the first six months and every two weeks thereafter. Eighty-eight percent of participants reached the final 18 months study.

At study end, participants in the diet-only group had an average loss of 9.5% of their initial weight and group exercise conducted only reached an average loss of 2.2%.However, diet and exercise group had a combined average of 11.4% loss. None of the participants returned to the initial figures, even after 18 months.

While all groups reported less pain at six months, the difference between groups was not significant. However, at 18 months, the group combined with diet and exercise showed a 51% reduction in pain compared with 27% and 28% in the groups that received only diet and exercise only, respectively ( p  <0, 0004), said lead author Dr. Stephen P. Messier, PhD, JB Snow Biomechanics Director of Laboratory at Wake Forest University . He said that 40% of patients in the combined group rated their pain at 0 or 1 to 18 s's, compared with 20% of groups with only exercise and diet alone.

In addition, participants in the group with diet / exercise improved their functional status 47%, compared with 30% in the diet-only group and 26% in the exercise only group. The combination group also increased walking speed by 12%, compared with 10% and 6% in the groups that received only diet or only exercise, respectively ( p = 0.004).

Dr. Messier said: "Surely our cohort has reversed the trend of decreasing mobility observed in older adults." In fact, the combination group had a faster walking speed than women in healthy middle-aged 40 to 62, and an equivalent of middle-aged healthy men.

Dr. Eric L. Matteson, chairman of the Department of Rheumatology at the Mayo Clinic in Rochester, Minnesota, said the most interesting finding of this study is that even patients who did not exercise had less pain.

He said: "Both exercise and diet are a formidable method to improve pain and function, but what was unique in this study was the observation that patients who lost weight had less pain associated with weight loss, even with some exercise. " This could be the result of a lower burden on the joints, he said, and could enable patients to postpone joint replacement operations.

It is also possible that patients can reduce the amount of analgesics taken if lose weight, noted Dr. Messier, something his group hopes to show by further analysis. He said: "We hope that from the standpoint of public health decreases medication use."

The key message, he said, is that "Doctors can tell patients that have a great improvement in pain and function in six months or so." The fact that no significant differences appeared between the groups until 18 months, however, "underscores the need for long-term studies to detect clinically and statistically significant results.

Knee Pain - Common Causes of Knee Pain

Knee Pain - Common Causes of Knee Pain

Lower Back Pain - Common Causes of Lumbar Pain

Lower Back Pain - Common Causes of Lumbar Pain

Medications to treat blood pressure are more effective when administered at night

In patients with chronic kidney disease (NC) and hypertension, taking at least one antihypertensive drug at bedtime significantly improved control of blood pressure (BP) with a concomitant reduction in the risk of cardiovascular complications, according to new research.

Dr. Ramon C. Hermida, PhD and colleagues at the Laboratory of Bioengineering and Chronobiology at the University of Vigo, University Campus, Spain, published their findings recently in the online version  of Journal of the American Society of Nephrology .

According to investigators, have documented the effectiveness before taking antihypertensive night but "the potential reduction in risk of cardiovascular disease (CVD) inherent to specifically lower blood pressure during sleeping hours is still a debated issue."

In the present prospective study was investigated in hypertensive patients with chronic kidney disease if antihypertensive treatment administered at bedtime improved BP control and reduce the risk of CVD compared with treatment on waking.

The study included 661 patients with chronic kidney disease who were randomly assigned to take all prescribed antihypertensive drugs on awakening or at least take one of them at bedtime. Ambulatory BP was determined at 48 hours at least once a year or three months after any adjustment in treatment.

The combined endpoint of cardiovascular death was used understood, myocardial infarction, angina pectoris, revascularization, heart failure, arterial obstruction of the lower extremities, retinal artery blockage and stroke. The researchers made the adjustment of the results with respect to factors such as gender, age and diabetes.

Was performed followed patients for a median of 5.4 years in this period patients taking at least one antihypertensive drug at bedtime were about one third the risk of CVD compared with those taking all drugs waking (hazard ratio [HR] adjusted 0.31, confidence interval [95% CI]: 0.21 to 0.46, p <0.001).

There was a similar significant reduction in risk with the administration of the drug at bedtime when combined ECVD variable included only cardiovascular death, myocardial infarction and stroke (adjusted HR: 0.28, 95% CI: 0, 13 to 0.61, p <0.001)  

Patients taking their drugs at bedtime also had a mean BP during sleep was significantly lower and a higher proportion of them gained control of ambulatory BP (56% vs. 45%, p= 0.003).  

Researchers estimate that for every decrease of 5 mmHg in mean systolic BP during sleep, there was a 14% reduction in risk of cardiovascular events at follow up ( p <0.001).

According to Dr. Hermida and colleagues' treatment at bedtime is a simple cost-effective strategy to achieve satisfactory therapeutic goals for an appropriate reduction in BP during sleep and to maintain or restore the pattern of intense reduction BP normal in 24 hours. "

The authors note that a possible explanation of the usefulness of treatment at night may be related to the treatment effect on levels of overnight urinary albumin excretion. They note: "previously demonstrated that urinary albumin excretion was significantly reduced after bedtime, but not after treatment with valsartan in the morning." Furthermore, this reduction was independent of changes in BP for 24 hours, but was correlated with a decrease in BP during sleep.

The study had no commercial funding. The article's authors and the publisher have disclosed no relevant financial conflicts of interest.

References:

 J Am Soc Nephrol . Published online October 24, 2011.  Abstract

A new treatment shows good prospects in severe schizophrenia

New research indicates that the reinforcement with a new cognitive therapy program can improve outcomes in patients with schizophrenia dysfunction.

A small study,  published recently in the online version of Archives of General Psychiatry, showed that patients with severe schizophrenia and major cognitive impairment who participated in a cognitive therapy program for 18 months in addition to normal treatment, which comprised antipsychotic drug, ratings were improving the overall functionality significantly higher than those who received standard treatment. 

Patients who received cognitive therapy also had more improvement in schizophrenic symptoms 'positive' hallucinations and delusions, as well as negative symptom apathy.

Lead author Dr. Paul M. Grant, PhD, assistant professor at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, told Medscape Medical News : "We were able to help those who were assigned to group cognitive therapy to improve their functional outcome, which helped to do a little more to get out more, to make friends, that sort of thing. "

He said: "It is a group of patients who really has not received satisfactory treatment.And they responded to it with respect to their negative symptoms and positive symptoms. Decreased the voices and delusions. "

Dr. Grant added that the main key message for clinicians is that these patients have more potential than you seem to have.

Dr. Grant said: "There are psychosocial treatments that work in this group, to which many have given up, including themselves. Not believe they can improve their lives.However, this is proof that something can be done satisfactory. "

"We created a protocol and ultimately what we're trying to do is see how domain can acquire their own lives and how patients can achieve recovery."

Difficult to treat

According to investigators, two to three million American adults currently suffer from schizophrenia. Of these, nearly two thirds have a chronic form of the disorder.

Report: "Patients with chronic schizophrenia have dysfunctional represent high direct and indirect costs for treatment due to loss of employment and productivity and a low quality of life."

Dr. Grant said: "These patients are the most costly psychiatric services. For example, in Philadelphia are up to 5% to 10% of patients with Medicare, but they represent over 25% of costs. "

Unfortunately, researchers say, "antipsychotic medication and psychosocial interventions have shown limited effectiveness in promoting better functional outcomes."

Although previous research has shown that cognitive therapy has been successful to help a "wide range" of psychiatric disorders has not been focused on patients with schizophrenia who have poor performance and cognitive disorders.

The researchers note in their paper: "By adapting cognitive therapy to patients with schizophrenia have poor performance, we changed the emphasis from predominantly oriented approach in symptoms, which is characteristic of the protocols in the UK, a therapeutic approach aimed highlighting the person's interests, strengths and positive factors of the patients. "

"We focus our treatment methods to identify and promote specific goals to improve the quality of life and reintegration into society."

A 'right step'

For this study, 60 outpatients between 18 and 65 years of age with dysfunction who had schizophrenia and neurocognitive disorders (65% black, 31% white) were built between January 2007 and August 2009 at the University of Pennsylvania. The average the duration of schizophrenia was 15.5 years. Neurocognitive impairment was defined as "difficulty in information processing tasks of memory, attention and executive function."

All participants were randomly assigned to receive cognitive therapy protocol adapted by the researcher rather the standard treatment (n = 31, 67.8% male, mean age 34.3 years) or just the normal treatment for 18 months (n = 29, 65.5% male, mean age 42.9 years).

The primary endpoint was improvement of psychosocial functioning, as shown in the global rating scale after 18 months. Secondary endpoints included improvements in the Scale for the Assessment of Positive Symptoms and the four subscales of the Scale for the Assessment of Negative Symptoms.

Positive symptoms of schizophrenia were measured consisted of hallucinations, delusions, and disorganization. The subscales included abolition of negative symptoms-apathy, anhedonia-asocial, alogia and affective indifference.

The results showed that the group receiving cognitive therapy showed more improvement in global functioning at 18 months than the group that received only standard treatment ( p  = 0.03).

The scale of negative symptoms was significantly greater for the group with cognitive therapy in the abolition-apathy compared with the group that received only standard therapy ( p = 0.01), as well as significantly greater improvements in symptom scale positive ( p = 0.04).

There were no significant differences between groups for emotional indifference, the alogia or anhedonia-asocial.

The researchers note in their paper: "Age was adjusted in the analysis and no significant group differences in initial antipsychotic drugs (class or level) or medication changes during the course of study."

They note that this is the first time that patients with schizophrenia "selected from the end of the range of dysfunction" has shown clinically relevant improvements after receiving a psychosocial intervention.

Dr. Grant said, "Some of the patients who were referred for this study had not really changed in 15 or even 20 years and psychiatrists said they were not going to change.However, we show that this was wrong. " "This is an appropriate step to actually improve their lives."

Report to be published later this year, a manual that describes in detail the cognitive therapy program. In addition, researchers are currently exploring how to adapt the protocol of cognitive therapy in hospitalized patients with schizophrenia.

Hope of negative symptoms

Dr Douglas Turkington, FRCPsych, Department of Psychiatry at Newcastle University , UK, and Dr. Anthony P. Morrison, PhD, School of Psychological Sciences of the University of  Manchester , UK, in an accompanying editorial noted: "So far, treatments have offered little hope for persistent negative symptoms [schizophrenia].

However, the study by Dr. Grant and colleagues suggests that cognitive therapy, "which is based on a cognitive model that involves fear of failure and corresponding behaviors aimed at avoiding it, may improve negative symptoms in a population clinically difficult. "

The editorial authors note that previously most of the attention has focused on the positive symptoms of the disorder in which hallucinations and delusions, yet debilitating negative symptoms, such as reduced motivation and alogia, are some major problems for patients and their families.

Although they note that the study is "very welcome", he concludes that "research is needed based on more models for this group of disabled patients."

The study was funded by a grant for Distinguished Research from the National Alliance for Research on Schizophrenia and Depression and by grants from the Heinz Foundation and the Barbara and Henry Jordan Foundation. Three of the authors, including Dr. Grant, report having received royalties from Guilford Press. The authors of the editorial have disclosed no relevant financial conflicts of interest.

FDA Approves an inhalation aerosol in patients with COPD

The U.S. Food and Drug Administration (FDA) has granted approval to an aerosol by inhalation of ipratropium bromide and albuterol sulfate       ( Combivent Inhalation Spray Respimat , Boehringer Ingelheim) in patients with chronic obstructive pulmonary disease (COPD) who used a bronchodilator aerosol suspension, but still have signs of bronchospasm and requires a second bronchodilator.

It is considered that the combination inhaler is an appropriate alternative in patients who are currently using ipratropium bromide and albuterol sulfate ( Combivent Inhalation Aerosol ), which soon will retire from the trade. The aerosol suspension product is gradually being withdrawn because it contains chlorofluorocarbons (CFCs) and trade will be removed after December 31, 2013.

In April, the FDA announced that phase out seven different dosimetric inhalers containing CFCs which are used to treat patients with asthma, COPD, or both. The reason for the phasing out of CFC inhalers is the Montreal Protocol on Substances that Deplete the Ozone Layer, an international agreement signed United States, along with most other countries. Chlorofluorocarbons, like other substances, damage to the environment by reducing the ozone layer and the signatories of the agreement are committed to remove these compounds from trade after the designated dates. Most inhalers containing CFCs have been phased out as part of this protocol.

Aerosol dispensers Phasing

The general use of CFCs in consumer aerosols was banned for decades in the United States eliminated the production of CFCs from January 1, 1996, except for certain limited uses, such as aerosol dispensers.

Badrul Chowdhury Dr, PhD, director of the Division of Pulmonary Products, Allergy and Rheumatology, Center for Drug Evaluation and Research, FDA, said in a statement: "During this transition, the FDA wants to ensure that patients have access to safe and effective alternative medications to treat their asthma or COPD. "

Currently we are working with professional associations and patient organizations to make sure they know which products are no longer available and have information regarding which alternative medication might work better. "

The decision to remove these products is the latest in a series of decisions concerning the withdrawal of trade in CFC inhalers, as forcing the Clean Air Act. The FDA proposed to phase out the remaining seven products in 2007 and reached its final decision after reviewing more than 4000 public comments and information that was sent as part of a public meeting.

The aerosol inhaler containing ipratropium bromide and albuterol sulfate combined, which is produced by Boehringer Ingelheim Pharmaceuticals, will provide patients with COPD and another treatment option when a suitable alternative is not available in aerosol suspension.

Author: Roxanne Nelson

Overuse of Antibiotics in children with Asthma

According to findings from two new studies, may be prescribed antibiotics over the asthmatic children.

A study  was conducted by Dr. Ian M. Paul, Department of Pediatrics and Public Health Sciences, Penn State College of Medicine , Hershey, Pennsylvania, and the other was led by Dr. Kris De Boeck, PhD, Department of Pediatric Pulmonology and Infectious Diseases, University Hospital of Leuven in Belgium. The two studies were released recently in the online version and the print version of Pediatrics .

According to Dr. Paul and his colleagues, the guidelines of the National Program for Education and Asthma Prevention specify that "antibiotics should not be used as part of chronic treatment of asthma or acute exacerbations with the exception of patients who have concomitant bacterial infections such as pneumonia or sinusitis. "

It is believed that macrolide antibiotics have anti-inflammatory actions and ketolides, but the results of studies related to its use in asthmatics have been ambivalent and "neither the U.S. nor international guidelines for asthma treatment currently recommended antibiotic therapy in exacerbations of the disease, "say the authors.

Dr. Paul and his colleagues determined how often doctors were prescribing antibiotics for U.S. pediatric visits for asthma in the absence of a documented comorbidity. Evaluated the data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care, collected between 1998 and 2007, for consultations for asthma in the office and in the emergency department for children (<18 years).

The authors note: "It is estimated to have occurred 60.4 million visits for asthma without other code ( Classification  of Diseases, Ninth Edition)  to justify the prescription of antibiotics. " However, nearly 16% of these visits were prescribed antibiotics to patients.

The antibiotic most often prescribed was a macrolide (48.8%). In a multivariate analysis, factors associated with an increased chance of antibiotic prescriptions were concomitant prescribing of systemic corticosteroids (odds ratio [OR] 2.69, confidence interval [CI] 95% CI 1.68 to 4.30) and treatment during the winter (OR: 1.92, 97% CI 1.05 to 3.52).

In contrast, treatment in an emergency department was associated with less chance of antibiotic prescription (OR 0.48, 95% CI 0.26 to 0.89). In addition, during consultations at clinics, information about asthma was associated with fewer antibiotic prescriptions (OR 0.46, 95% CI 0.24 to 0.86).

In a second large study led by Dr. De Boeck, we evaluated a database of health insurance that included prescription of antibiotics and asthma drugs during the course of a year to 892,841 Belgian children under 18 years of age.

Antibiotics were prescribed for 44.21% of the children, while asthma drugs were prescribed to 16.04%. The highest proportion of patients who received either of the two treatments was less than three years old.

In general, prescribed an antibiotic to 73.50% of children who also received an anti-asthmatic drug compared to 38.62% of those receiving only one antibiotic ( p <0.0001). Overall, regardless of age, children were about twice as likely to receive an antibiotic and also received asthma treatment (OR 1.90, 95% CI 1.89 to 1.91), p <0 , 0001). On more than one third of children who received an anti-asthmatic drug was prescribed an antibiotic the same day.

Dr. Rita Mangione-Smith, MPH and Dr. Paul Krogstad, authors of a related commentary, observed: "A major strength of these studies is the great power that provided the extensive series of databases that were assessed." Mangione-Smith Dr. in the Department of Pediatrics at the University of Washington in Seattle, and Dr. Krogstad in the Department of Pediatrics and Molecular and Medical Pharmacology at the David Geffen School of Medicine, University of California, Los Angeles .

According to commentators, "the results indicate that Belgian and American physicians prescribe antibiotics to patients with a presumptive diagnosis of asthma or bronchospasm to a previously unsuspected level: with a frequency of up to one in six American children consultations, which million or more is a dubious recipe for years. "

Mangione-Smith Dr. and Dr. Krogstad note that some of these recipes may be due to diagnostic uncertainty and medicolegal concerns, and to pressure or influence exerted by parents who want a prescription for an antibiotic for your child .

They add: "The new battle to stop the unjustified use of antibiotics in the pediatric outpatient setting requires that we focus on reducing inappropriate bacterial diagnoses and decreasing the use of broad-spectrum antimicrobial."

None of the studies had trade finance. Researchers and commentators have disclosed no relevant financial conflicts of interest.

References

Pediatrics . 2011, 127:1014-1021, 1022 to 1026 from 1174 to 1176