Physical Therapy as Effective as Surgery for Meniscal Tear

April 9th, 2013

Physical Therapy as Effective as Surgery for Meniscal Tear

Kathleen Louden

Mar 20, 2013

CHICAGO, Illinois — Patients with knee osteoarthritis and a meniscal tear who received physical therapy without surgery had good functional improvement 6 months later, and outcomes did not differ significantly from patients who underwent arthroscopic partial meniscectomy, a new clinical trial shows.

In the Meniscal Tear in Osteoarthritis Research (METEOR) trial, both groups of patients improved substantially in function and pain.

This finding, presented here at the American Academy of Orthopaedic Surgeons 2013 Annual Meeting and published online simultaneously in the New England Journal of Medicine, provides “considerable reassurance regarding an initial nonoperative strategy,” the investigators report.

Patients with a meniscal tear and osteoarthritis pose a treatment challenge because it is not clear which condition is causing their symptoms,” principal investigator Jeffrey Katz, MD, from Brigham and Women’s Hospital in Boston, Massachusetts, told Medscape Medical News.

“These data suggest that there are 2 reasonable pathways for patients with knee arthritis and meniscal tear,” Dr. Katz explained. “We hope physicians will use these data to help patients understand their choices.”

In an accompanying editorial, clinical epidemiologist Rachelle Buchbinder, PhD, from the Monash University School of Public Health and Preventive Medicine in Victoria, Australia, said that “these results should change practice. Currently, millions of people are being exposed to potential risks associated with a [surgical] treatment that may or may not offer specific benefit, and the costs are substantial.”

 

These results should change practice.

 

The METEOR trial enrolled 351 patients from 7 medical centers in the United States. Eligible patients were older than 45 years, had osteoarthritic cartilage change documented with magnetic resonance imaging, and had at least 1 symptom of meniscal tear, such as knee clicking or giving way, that lasted at least 1 month despite drug treatment, physical therapy, or limited activity.

In this intent-to-treat analysis, investigators randomly assigned 174 patients to arthroscopic partial meniscectomy plus postoperative physical therapy and 177 to physical therapy alone.

The physical therapy in both regimens was a standardized 3-stage program that allowed patients to advance to the next intensity level at their own pace, Dr. Katz explained. The program involved 1 or 2 sessions a week for about 6 weeks and home exercises. The average number of physical therapy visits was 7 in the surgery group and 8 in the nonsurgery group.

Investigators evaluated patients 6 and 12 months after randomization. The primary outcome was the between-group difference in change in physical function score from baseline to 6 months, assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). At baseline, demographic characteristics and WOMAC physical function scores were similar in the 2 groups.

At 6 months, improvement in the WOMAC function score was comparable in the 2 groups. The mean between-group difference of 2.4 points was not statistically significant after analysis of covariance. There was also no significant difference between groups in pain improvement or frequency of adverse events.

METEOR: Mean Improvement in Osteoarthritis Index at 6 Months

Treatment Group Mean Improvement (Points) 95% Confidence Interval
Surgery plus physical therapy 20.9 17.9–23.9
Physical therapy 18.5 15.6–21.5

 

 

There was 1 death in each group, and 8 patients in the nonsurgery group and 13 in the surgery group withdrew in the first 6 months of the study.

Patients in the nonsurgery group were allowed to cross over to the surgical group at any time. Within 6 months, 30% of patients did so.

“They were not doing very well,” Dr. Katz said. His team is still analyzing the reasons these patients did not benefit from intensive physical therapy.

The 12-month results were similar to the 6-month results. In addition, by 12 months, outcomes for the crossover patients and for those in the original surgery group were similar.

Meeting delegate John Mays, MD, an orthopaedic surgeon practicing in Bossier City, Louisiana, who was asked by Medscape Medical News to comment on the findings, said most patients don’t choose physical therapy. “In the real world, most people want a quick fix” and choose surgery, he noted.

 

Dr. Mays said he would have liked to have seen a group of patients who underwent surgery but did not receive postoperative physical therapy. He explained that his patients with osteoarthritis and meniscal tear rarely get physical therapy after arthroscopic meniscectomy; they most often do home-based exercises.

He added that “most insurance plans have limits on the number of physical therapy sessions they allow.”

This study is funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Dr. Katz, Dr. Buchbinder, and Dr. Mays have disclosed no relevant financial relationships.

N Engl J Med. Published online March 19, 2013. Abstract, Editorial

American Academy of Orthopaedic Surgeons (AAOS) 2013 Annual Meeting: Abstract SE67. Presented March 19, 2013.

 

Gerry Gajadharsingh writes: I liked this one. When a patient is in a lot of pain and discomfort form an acute injury the tendency is to want to do as much as possible and sometimes this includes surgery. Interesting to know that actually waiting and following a conservative pathway can be as effective in certain conditions. ( By the way we are talking about knees)

 

Posted in Exercise & Rehabilitation | Comments Off

Bad posture may give you headaches and even high blood pressure.

April 9th, 2013

Bad posture may give you headaches and even high blood pressure.

By Chloe Lambert

The Daily Mail 19 March 2013

Modern man is born to slouch. While our ancestors moved constantly as they hunted for food, we spend the vast majority of our time in static positions — either sitting or standing — when the temptation to slump and sag is just too great. ‘We fight against gravity the whole time,’ explains Robert McCoy, a lecturer on anatomy at the British School of Osteopathy. ‘It takes about ten minutes of sitting or standing before the muscles in the spine and abdomen that hold us up start to get tired, and we start to lean forward.’ Most of us know from experience that sitting hunched in front of a computer or driving wheel can lead to a stiff, painful back and shoulders. But poor posture can lead to other health problems . . .

IT CAN RAISE YOUR BLOOD PRESSURE The usual risk factors for high blood pressure are age, being overweight, smoking and chronic diseases such as type 2 diabetes. But scientists now think slouching may trigger it, too. This is because there is a link between neck muscles and the area of the brain that helps regulate blood pressure. In a study published in 2007, neuro-scientists at the University of Leeds found that when cells in the neck muscles sense the neck is moving, they send a signal to that area of the brain. The theory is that this helps ensure adequate blood supply when we change posture, for example from sitting to standing. But if the neck muscle cells become damaged or pressured through stooping and slumping, this could trigger problems with blood pressure, suggests Professor Jim Deuchars, the scientist who led the study.  ‘It’s possible that poor posture, which compresses the neck muscles, may be involved in high blood pressure, too, but more research is needed.’

 

. . AND LEAD TO DISTRESSING LEAKS Around half of all women suffer from bladder problems at some point, with many developing from stress incontinence, urine leaks when they laugh or cough. Poor posture may be partly to blame. When you stand correctly, your spine should form a slight S-shape, with a small curve near the neck and one at the lower spine.

Studies by physiotherapist Ruth Sapsford, at the University of Queensland, have shown that women with stress incontinence and who’ve suffered from a prolapse have less curves in their lower spine than women without these conditions. Sitting upright — with the spine adopting its natural curve at the bottom — engages more of the pelvic floor muscles, which support the bladder. If you’re sitting in a slumped, C-shaped posture, there’s more weight bearing down on your bladder and pelvic floor muscles, which will weaken them over time and make you more likely to leak,’ explains Sammy Margo, of the Chartered Society of Physiotherapy. ‘Apart from this, good posture can enhance your enjoyment of your sex life, as strong pelvic floor muscles are associated with more and better orgasms.’

…SLUMPING MAKES YOU SAD AND SHY A study of 110 students by San Francisco State University last year found those who walked with a slouched body posture reported feeling more depressed and having lower energy levels than those who were more upright.

Study leader Erik Peper, a professor of health education at the university, says sitting or standing up straight with shoulders back does not just give other people a good impression, but also sends a message to the brain that makes us feel better about ourselves.  Meanwhile, in a 2007 study at Colorado College, students with the best sitting posture felt more confident and scored significantly higher on tests than those who sat slumped. Interestingly, though, the trend was only true for male students. Women felt more confident if they’d slouched, possibly because men tend to determine how they feel according to internal cues, while women think more about how they look to others for them an upright posture made them feel pressured and self-conscious.

….IT MAY TRIGGER HEARTBURN. According to some experts, one of the consequences can be heartburn where stomach acid travels into the oesophagus, causing chest pain. ‘The pelvis is like a bowl, and when we stand up straight we hold it flat,’ says Robert McCoy. ‘But as you shift forward, the bowl tips forward and the contents, such as the stomach and digestive organs, shift, too.’

 

….AND ASTHMATICS MIGHT STRUGGLE ‘You’ll notice that people don’t sigh when they sit slumped they have to sit up to take a deep breath,’ observes Professor Stephen Spiro of the British Lung Foundation. ‘That’s because the lungs work best when we’re vertical. If you’re slumped forward you don’t fully breathe and ventilate the lungs, because they’re compressed and the diaphragm is coming up into the chest — so you won’t breathe as easily and efficiently. If you’re an asthmatic you probably don’t have bad posture because people are quite clever at correcting themselves,’ says Professor Spiro.

….IT CAN TRIGGER HEADACHES If you find you suffer headaches while at work, it might be the way you sit, rather than the stress of your workload that’s the source of the problem.‘When sitting at a desk, as the muscles in the back and stomach start to tire and the spine starts to slump, we tend to stick the neck and chin forward to keep the eyes in a good position, so we can still see the screen,’ says osteopath Robert McCoy.‘Tension in the muscles at the base of the skull, caused by the spine rounding and the neck sticking forward, can pinch the trigeminal nerve in that area, leading to something called cervicogenic headache. It tends to be characterised by pain that starts at the back of the head and travels up and over and ends just above the forehead.’

…..AND LEAVES YOU BLOATED One in seven Britons is thought to suffer from irritable bowel syndrome, and even more find they feel bloated after eating. Dr Michael Mendall, a gastroenterologist at Croydon University Hospital, says stooping can make feelings of bloatedness worse because it squashes the abdomen — so after a big meal, sit up straight to avoid discomfort. Interestingly, he says bloating is a common side-effect of osteoporosis, the brittle-bone disease affecting three million people in the UK, which can alter posture. ‘As your spine crumbles you slump and lose volume in the abdominal cavity, so people find even though they are eating normally they feel full and bloated.

Gerry Gajadharsingh writes: As an Osteopath I know all of this but I guess it is news to many patients and its good to see it highlighted in the mainstream press. I remember having conversations with BUPA as to why a GIT specialist had been referring me patients, they simply couldn’t get it, c’est la vie.

Posted in Exercise & Rehabilitation | Comments Off

Handing out steroid cream can leave children in pain: How GPs are adding to the agony of eczema

April 9th, 2013

Handing out steroid cream can leave children in pain: How GPs are adding to the agony of eczema

By Maria Lally  

The Daily Mail 19 March 2013

 

Looking down at my 20-month-old daughter Sophia’s feet, my heart nearly broke.The skin was angry, cracked and bloody. She had similar patches on her legs, tummy, back and arms and was frantically scratching any area she could reach until the skin split.

The next day I took her to our GP — again. He took a brief look at her feet (by now so red and scabbed they looked burnt), said he’d seen worse, then handed me yet another prescription for steroid cream, even though I told him we had several half-used tubs at home.

Then, just after her second birthday, she suffered a vomiting bug and for two days had just water and dry toast. Her skin became beautifully clear.

When she was better she had a beaker of milk and her eczema came back immediately. I told my GP, who scoffed at the idea of a food allergy — even though my husband Dan is allergic to milk and eggs and had eczema as a child.At this point Dan and I had had enough — we decided to get private treatment and, at a cost of £760 and with a change of diet, Sophia’s skin is finally clear.

But all that expense — and months of misery — could have been avoided if the GPs we saw had done the right thing.‘GPs often don’t know how to handle eczema,’ says Dr Susan Mayou, a dermatologist from the paediatric department at the Chelsea and Westminster Hospital. ‘It’s not life-threatening, there’s no one-cure-fits-all and they often don’t have enough training.’

While there is no single cause of eczema, experts agree that it is largely inherited. If a parent has or had it, their child is 60 per cent more likely to get it. This rises to 80 per cent if both parents have it. As many as two-thirds of children with eczema (but especially those who develop it before the age of one) will also have a food allergy, according to the NHS. Under guidelines from the National Institute for Health and Clinical Excellence (NICE), GPs are meant to ask parents to ‘consider a diagnosis of food allergy’ if children under 12 have eczema that isn’t responding to treatment. ‘If food allergy is suspected, GPs should refer the child to a dietitian or dermatologist.GPs are also meant to advise parents on how to prevent and spot infected eczema.It’s clear that too many GPs don’t know about these guidelines, or stick to them if they do.

‘I worked on putting the NICE guidelines together and it’s frustrating that some GPs just don’t follow them,’ says Dr Adam Fox, the private dermatologist whom we ended up seeing. Parents feel fobbed off and see specialists like me — or, worse, they start to self-treat their children by cutting out foods or using steroid creams without proper advice.’

Margaret Cox from the National Eczema Society adds: ‘Your GP will be lucky if they’ve had six days’ training in dermatology.Many see eczema as a minor complaint, know little about it and have no idea of the challenges faced by families living with it.’

Bad eczema is the condition Dr Fox says he would least like his own child to have. ‘It’s horrendous. I meet teary-eyed parents who are exhausted and struggling,’ he says. ‘Their child has been up all night scratching for weeks, even years. The family doesn’t sleep properly and are miserable, yet their GP treats them the same as somebody with a small patch of dry skin. Many dermatologists would love to get their hands on some GPs and teach them about eczema.’

On our two family holidays, the sand and seawater made her cry out in pain and sun cream caused flare-ups so she barely spent time outside. Or she sat in her pushchair watching other children build sandcastles or play in the waves. Bath time was torturous. Eczema needs to be clean (split skin allows bacteria to enter and becomes infected) and moisturised. But water and cream sting raw skin, causing screams during flare-ups. Anyone who thinks toddlers are a handful should try looking after a sleep-deprived one who has a burning sensation all over their body.

Research published in the journal Psychology Today, found that 83 per cent of children with eczema have trouble sleeping. They are also more likely to ‘suffer from behavioural disturbances’ caused by broken sleep, according to the Journal of Clinical Sleep Medicine.

Desperate, we paid £580 to see Dr Fox. He asked about my and Dan’s health and ran allergy tests.We quickly discovered that Sophia, like her father, was allergic to milk and eggs.

Dr Fox said diet would help but also prescribed a week’s course of Elocon, a strong steroid cream, to control her eczema while the diet kicked in. He explained that eczema — which means to bubble and boil over in Greek — is like a bush fire: when it takes hold, it rages.You need to put out the fire with strong steroids, and then keep it out with suitable treatment.

A dietitian (a further £180) created an egg- and milk-free diet for Sophia and we started using Aveeno twice a day — a fantastic cream that contains finely milled oats (an anti-irritant) and leaves a protective barrier on the skin.Within three days the red patches had softened and after a week Sophia’s skin was clear. She hasn’t had eczema since. She sleeps better, behaves better and our family life is transformed.

‘Sixty to 70 per cent of children who get eczema in the first year of life have a food allergy,’ Dr Fox told me. ‘And children with eczema that doesn’t respond to standard treatment with steroid creams tend to have food allergies.’ In fact, the same applies for adults. GPs see an enormous number of children with eczema as it affects 20 per cent at some point. Most have it mildly and steroid cream works fine. But some don’t respond and alarm bells should ring. GPs should refer them to a specialist.’

Dr Mayou adds: ‘If your child’s eczema isn’t improving, ask your GP why. Push for a referral to a dermatologist and flag up any family history. Give your child regular baths that are warm, never hot, and apply Aveeno several times a day.’

 

Gerry Gajadharsingh writes: Finally a Dermatologist is saying what it really is, don’t just treat the symptoms of skin conditions look at what is the underlying cause, for children and in my opinion many adults food may be the culprit, the question is does the person what to give up what they are reacting badly to?

Posted in Exercise & Rehabilitation | Comments Off

Skimmed milk ‘doesn’t stop toddlers getting fat’

April 9th, 2013

Skimmed milk ‘doesn’t stop toddlers getting fat’

Jenny Hope Medical Correspondent

The Daily Mail 19 March 2013

 

 

Parents who give their toddlers skimmed milk to prevent them from gaining weight may be wasting their time. A study found that two year olds who drank full fat milk put on fewer pounds than those on low fat. Academics believe this is because full fat keeps them fuller for longer, and they eat less as a result.

The US study concluded that the type of milk given to children ‘may not matter that much’ despite fears the obesity epidemic is being fuelled by diets high in fat.

Researchers at the University Of Virginia School Of Medicine found two-year-olds who drank mainly low-fat and skimmed milk were 57 per cent more likely to become overweight by the age of four. But the average weight of children drinking full-fat milk was lower over the same period.

Professor Mark DeBoer, who led the research, said: ‘We assumed the study would show that children drinking low-fat and skimmed milk would be helped to keep their weight down, but this was not the case.

‘If you are going to drink milk, and we strongly back the importance of drinking milk at a young age, it doesn’t seem to matter that much which type it is.’

In the US, the American Academy of Pediatrics and the American Heart Association recommend all children drink low-fat or skimmed milk after the age of two to ward off obesity.In contrast, British children under five are not advised to drink skimmed milk – which has virtually all the fat removed – because they need the extra energy for growth.The US study asked 11,000 parents what type of milk their children drank at aged two and four: skimmed; one per cent semi-skimmed; two per cent milk fat; full-fat, or soy.

Heavier children were more likely to drink skimmed and semi-skimmed milk, with 14 per cent of heavy two-year-olds and 16 per cent of heavy four-year-olds drinking it, compared with nine per cent of normal weight two-year-olds and 13 per cent of normal weight four-year-olds.

Professor DeBoer said parents may be acting from the best motives by choosing low-fat milks, but milk fat may increase a feeling of fullness so reduce the appetite for other high calorie foods. He said: ‘Physicians don’t have much time to advise parents worried about their children putting on weight, so they may be better off sticking to advice we know works.

 

Gerry Gajadharsingh writes: When are the powers to be going to come clean and advise patients that following low fat diets are NOT what you need to do? Actually the title should be eating low fat makes you put on weight!

Posted in Blog, Metabolic Balance, News | Comments Off

Sugary Drinks May Explain 180,000 Deaths Worldwide Each Year

April 9th, 2013

Sugary Drinks May Explain 180,000 Deaths Worldwide Each Year

Marlene Busko

Mar 20, 2013

 

NEW ORLEANS — A large, international epidemiologic study reports that slurping back large amounts of sugary beverages was associated with an increased body-mass index (BMI), which in turn was linked with BMI-related deaths from diabetes, cardiovascular disease (CVD), and cancer.

Specifically, the researchers found that in 2010, 132,000 deaths from diabetes, 44,000 deaths from CVD, and 6000 deaths from cancer in the world could be attributed to drinking sugar-sweetened soft drinks, fruit juice, or sports beverages.

The study byGitanjali Singh, PhD, from Harvard School of Public Health, Boston, Massachusetts, and colleagues was reported at EPI|NPAM 2013, the Epidemiology and Prevention/Nutrition, Physical Activity and Metabolism 2013 Scientific Sessions.

“It is a [surprisingly] large number of deaths — tens of thousands of deaths — that are being caused by consuming sugary beverages,” Dr. Singh commented to Medscape Medical News. Three quarters of these BMI-related deaths were from diabetes, which “suggests that limiting sugary-beverage intake is an important step in reducing diabetes deaths,” she noted.

“Uphill Battle” to Change Patient Habits, Public Policy

The study reinforces the need for clinicians to encourage patients to drink fewer sugary beverages, Dr. Singh said. In addition, even though “it’s certainly an uphill battle [to change public policy] — it’s one that…physicians, cardiologists, public-health scientists, [and] policy makers…really need to advocate for and show support for,” she noted.

As part of the Global Burden of Disease study, the researchers obtained data from 114 national dietary surveys, representing more than 60% of the world’s population.

Based on data from large prospective cohort studies, they determined how changes in consumption of sugary drinks affected BMI, and next, how elevated BMI affected CVD, diabetes, and 7 obesity-related cancers (breast, uterine, esophageal, gallbladder, colorectal, kidney, and pancreatic cancer). Using data from the World Health Organization, they calculated the number of deaths from BMI-related CVD, diabetes, and cancer for men and for women aged 20 to 44, 45 to 64, and 65 years and older.

Average sugary-drink consumption varied tremendously — from less than 1 drink (8 oz) a day in elderly Chinese women to more than 5 drinks (40 oz) a day in younger Cuban men.

Most deaths (78%) from excess sugary drinks were in low- and middle-income countries.

Mexico, which has one of the world’s highest per capita rates of drinking sweetened drinks, had the greatest number of deaths related to this risk factor: 318 deaths per million adults.

In contrast, Japan, with one of the lowest per-capita rates of imbibing these beverages, had the smallest number of deaths attributable to this risk factor: about 10 deaths per million adults.

In 2010, drinking sugar-sweetened beverages was associated with about:

  • 38,000 deaths from diabetes in Latin American and Caribbean countries.
  • 11,000 deaths from CVD in Eastern- and Central-Eurasian countries.
  • 25,000 deaths in the United States.

“Sugar-sweetened beverages are a major cause of preventable deaths due to chronic diseases, not only in high-income countries, but also in low and middle-income countries,” the group concludes.

Bottom Line: Advise Patients to Avoid Sugary Drinks

“The evidence base that sugar-sweetened beverages are associated with excess weight gain is well established; what these investigators have done is to take it a step further by saying the excess weight gain that is attributable to sugary drinks actually increases the risk of death from diabetes, CVD, and cancer,” American Heart Association(AHA) spokesperson Rachel K. Johnson, PhD, from the University of Vermont, Burlington, commented.

Study strengths include its large scope, but since it was an epidemiologic study, it does not demonstrate cause and effect, Johnson noted. Nevertheless, “it is certainly a [biologically] plausible association, and we should take it seriously,” she added.

According to Dr. Johnson, “The bottom line is to [advise patients to] avoid sugar-sweetened drinks, [since we have] more and more evidence that it’s not a good choice.”

 

It is “particularly problematic” that satiety mechanisms don’t kick in with beverages in the same way as with solid foods. “If you have a sugary drink at 4 o’clock, you’re not as likely to cut back on what you eat for dinner in the same way you would if you’d had a snack of solid food at 4 o’clock,” she said.

The AHA recommends that adults don’t exceed 450 calories a day or 36 oz a week from sugar-sweetened beverages. In a 2012 statement position statement, the AHA and American Diabetes Association stated that nonnutritive artificial sweeteners can be a tool to help people lower their added sugar and calorie intake, as long as they don’t eat extra calories to compensate for the lower calories in the diet drinks.

The authors have disclosed no relevant financial relationships.

EPI|NPAM 2013. March 19–22, 2013. Abstract MP22.

 

Gerry Gajadharsingh writes:

Note this research includes fruit juices, whilst a little fruit is good for you, that means the whole fruit including the fibre which helps to slow down the fructose (fruit sugar) release, drinking fruit juices and smoothies is not what we recommend!

Posted in Blog, Metabolic Balance, News | Comments Off

Multivitamins May Lower Cancer Risk in Men

November 1st, 2012

Multivitamins May Lower Cancer Risk in Men

Medscape Today News

17th October 2012

11th Annual American Association for Cancer Research (AACR) International Conference on Frontiers in Cancer Prevention Research

 

The daily use of multivitamins may reduce the risk for cancer in men, according to the results of a very large randomized trial.

After about 11 years, multivitamin use resulted in a modest but statistically significant reduction — specifically, an 8% reduction in total cancer incidence.

In an analysis that separated prostate cancer from all other cancers, “we did not see an effect for prostate cancer, but there was a 12% reduction in total cancers which was significant,” said lead author John Michael Gaziano, MD, MPH. He was speaking at a press briefing ahead of a presentation at the Annual American Association for Cancer Research (AACR) Frontiers in Cancer Prevention Research meeting.

The study has also been published early online in the Journal of the American Medical Association to coincide with the meeting.

“Cancer mortality also went in the right direction — a 12% reduction which wasn’t quite statistically significant but certainly a consistent finding,” said Dr. Gaziano, a researcher at Brigham and Women’s Hospital, Center for Older Adult Health, Boston, Massachusetts.

“Our main message is that the main reason to take a multivitamin is for nutritional deficiencies but it certainly appears that there may be a modest benefit in preventing cancer in men over the age of 50,” he said.

A number of trials of individual vitamins, administered at high doses, have not shown any effect at preventing cancer, Dr. Gaziano explained.

Observational studies have also not provided evidence of an association between multivitamin use and a reduction in cancer incidence or mortality.

However, the current study is unique in a number of ways, the first being that it is the only large-scale placebo-controlled trial evaluating a multivitamin in the prevention of cancer.

It is also of long duration, he said. “This effort was 17 years in the making, from the time we wrote the first protocol and we have 11 years of follow up, with up to 14 years of treatment for some of the participants.”

In addition, Dr. Gaziano pointed out that this study was well controlled. The participants who were randomized to the multivitamin arm were all taking the exact same brand and formulation (Centrum Silver), which has not necessarily been the case in other studies.

Conflicting Results

Previous studies have reported conflicting results. As reported by Medscape Medical News, 2 studies evaluating the association of multivitamins and breast cancer found opposite results — one study found an increased risk while the other found that multivitamins decreased the risk.

Another study reported more neutral results, in that multivitamin use had no influence on the risk for common cancers, cardiovascular disease, or overall mortality.

The lead author of that study, Marian L Neuhouser, MD, commented at that time that the “main message of our study is that postmenopausal women who take a multivitamin don’t increase their risk for cancer or cardiovascular disease, but they don’t decrease it either.

“These multivitamins are having no effect with regard to these particular disease outcomes,” said Dr. Neuhouser, who is from the Fred Hutchinson Cancer Research Center, Seattle, Washington.

Reduction in Total Cancers

The data in the current study was drawn from the Physicians’ Health Study II, a large-scale, randomized, double-blind, placebo-controlled trial that included 14, 641 male US physicians who were 50 years or older when the study began. The cohort included 1312 men with a history of cancer. The multivitamin study began in 1997, with treatment and follow-up that continued through June 1, 2011.

The cohort included a large proportion of former smokers (40.0%) and a very low proportion of current smokers (3.6%) with a high rate of current aspirin use (77.4%).

“This was a population of healthy physicians,” Dr. Gaziano said. “Over two thirds of them exercised regularly and only 4% smoked.”

Adherence to the protocol was high in both the multivitamin and placebo group. At 4 years, it was 76.8% (vitamin) and 77.1% (placebo), P = .71; and at 8 years, adherence was 72.3% (vitamin) and 70.7% (placebo), P = .15. It remained high even at the end of the follow-up period, at 67.5% and 67.1%, respectively (P = .70).

During the study period, a total of 2669 men developed cancer, including 1373 cases of prostate cancer and 210 cases of colorectal cancer. A total of 2757 participants (18.8%) died during follow-up, and this included 859 (5.9%) from cancer.

Their results showed that men taking a daily multivitamin had a statistically significant reduction in the incidence of total cancer, as compared with placebo (17.0 and 18.3 events, respectively, per 1000 person-years; hazard ratio [HR], 0.92; P = .04).

However, when the cancers were considered separately, there was no significant effect. There was no effect of the daily multivitamin on prostate cancer (multivitamin and placebo groups, 9.1 and 9.2 events per 1000 person-years; HR, 0.98; P = .76), colorectal cancer (1.2 and 1.4 events per 1000 person years; HR, 0.89; P = .39), or any other site-specific cancers.

Dr. Gaziano and colleagues noted that the total cancer rates in this cohort were probably influenced by the increased surveillance for prostate-specific antigen (PSA) and subsequent diagnoses of prostate cancer during the last 1990s.

“We had included participants with a prior history of cancer and we had prespecified an analysis that we would do, and there is an appearance of a stronger effect in those with a prior cancer,” he said.

Among men with a baseline history of cancer, daily multivitamin use was associated with a reduction in total cancer (HR, 0.73; P = .02). However, this reduction was not significantly different from the cohort without a cancer history (HR, 0.94; P = .15; P for interaction = .07).

“We are continuing more analyses, looking at the nutritional status of the individuals,” Dr. Gaziano said. “We hope to be able to continue following this cohort, some of whom we have been following for 30 years, so we can see the long term effects.”

Researchers from the Linus Pauling Institute at Oregon State University, Corvallis, who have been studying related issues, commented that this data “conclusively shows that multivitamins are safe to take, help fill important nutritional gaps, reduce cancer risk and in turn will help cut health care costs.”

“An 8 percent drop in overall cancer rates is not small,” said Balz Frei, PhD, professor and director of the Linus Pauling Institute, in a statement.

“Given that more than 1.6 million new cancer cases are diagnosed in the U.S. each year, this translates into about 130,000 cancers prevented every year, and with it all the health care costs and human suffering,” commented Dr. Frei, who was not involved in the study.

Dr. Frei also pointed out that the effect might be even higher in other population groups than seen in this study. “And it’s worth noting that the research was done with 14,600 physicians,” Dr. Frei said. “This highly-educated group has a better diet, knowledge base and health habits than the average person, so it’s reasonable to believe that the impact of multivitamin use in the general population will be even greater.”

11th Annual AACR International Conference on Frontiers in Cancer Prevention Research, Presented October 17, 2012.

The study was supported by grants from the National Institutes of Health and the BASF Corporation. Dr. Gaziano reports investigator-initiated research funding from the NIH, the Veterans Administration, and the BASF Corporation; assistance with study agents and packaging from BASF Corporation and Pfizer (formerly Wyeth, American Home Products, and Lederle); and assistance with study packaging provided by DSM Nutritional Products Inc. (formerly Roche Vitamins). Several other coauthors also report relationships with industry as noted in the paper.

JAMA. 2012. Published online October 17, 2012.

 

Gerry Gajadharsingh writes:

 

So you see the problems of research! Sometimes conflicting research comes up. The American Physicians Health Study is a study following a very large group of American Physicians over many years, I also present some of this research to back up the science behind Metabolic Balance. Interestingly the multivitamin /mineral complex used was a standard OTC low dose following Recommended Daily Allowance (RDA), for example Vitamin C at 60mg (100% RDA), Magnesium (13% RDA) and Zinc (73% RDA), amongst others.

 

RDA was developed to ward of deficiency disease, if you take in less than 60mg of Vitamin C a day eventually you will develop scurvy, the plague of sailors in times gone by. This is vastly different to saying that 60mg is all you need! I am amazed that even at this low dose the reduction in overall male cancer (>50 years) was 12% (excluding prostate cancer). I expect that in years to come research will become more convincing with the use of optimal levels of nutritional supplementation (not just vitamins and minerals) in decreasing the incidence of diseases, not just cancer. Of course the main stay of keeping healthy should be great nutrition, with supplements doing just that, supplementing your diet.

Posted in Metabolic Balance, News | Comments Off

Simvastatin: updated advice on drug interactions – updated contraindications

October 17th, 2012

The Medicines and Healthcare products Regulatory Agency (MHRA)

 Drug Safety Update

 Simvastatin: updated advice on drug interactions – updated contraindications

 

Article date: August 2012

 

We have previously communicated on the increased risk of myopathy associated with use of high-dose simvastatin (80 mg daily) – see Drug Safety Update May 2010.

Considering the risk of myopathy associated with simvastatin, recent analysis of clinical trial data, spontaneously reported cases and drug- drug interaction studies has resulted in further changes to the simvastatin prescribing information.

The changes include contraindications to concomitant use with certain medicines and maximum dose recommendations when simvastatin is taken with a number of other medicines, as these interactions may increase plasma concentrations of simvastatin which is associated with an increased risk of myopathy and/or rhabdomyolysis. Key points to note are that:

  • Simvastatin is now contraindicated with ciclosporine, danazol and gemfibrozil
  • The maximum recommended dose for simvastatin in conjunction with amlodipine or diltiazem is now 20 mg/day

A full updated listing of all the interactions is provided in the table below.

Drug interactions associated with increased risk of myopathy/rhabdomyolysis
Interacting agents Prescribing recommendations
Itraconazole

Ketoconazole

Posaconazole

Erythromycin

Clarithromycin

Telithromycin

HIV protease inhibitors (eg, nelfinavir)

Nefazodone

Ciclosporin

Danazol

Gemfibrozil

 Contraindicated with simvastatin
Other fibrates (except fenofibrate) Do not exceed 10 mg simvastatin daily
Amiodarone

Amlodipine

Verapamil

Diltiazem

 Do not exceed 20 mg simvastatin daily
Fusidic acid Patients should be closely monitored. Temporary suspension of simvastatin treatment may be considered.
Grapefruit juice Avoid grapefruit juice when taking simvastatin

 

 

Gerry Gajadharsingh writes:

 

This is slightly worrying, Many of my male musculoskeletal patients concurrently take statins. It is difficult to know sometimes if the statin they are taking contributes to their pain, certainly elevation of the muscle enzyme creatine kinase (CK) requested as a blood test may be helpful. However data is now emerging that this common statin is causing increasing problems, hence the guidance to make sure you are not taking more than 20mg especially if you are taking other medications for blood pressure and even common antibiotics such as Erythromycin. Patients also find it amazing that even grapefruit is contraindicated!

 

Posted in Blog, Metabolic Balance, News | Comments Off

Sitting down increases risk of Type 11 Diabetes, CVS events and death

October 17th, 2012

Sitting down increases risk of Type 11 Diabetes, CVS events and death

Medscape News

October 15, 2012 (Leicester United Kingdom) — The more time people spend sitting, the greater their risk of diabetes, cardiovascular events, and death, a new meta-analysis has shown [1]. This is the first research to systematically quantify the strength of association between sedentary behavior–beyond just TV viewing–and health outcomes and shows a particularly consistent relationship for diabetes, say Dr Emma G Wilmot (University of Leicester, UK) and colleagues in their paper in the November 2012 issue of Diabetologia.

Wilmot says that a number of important messages have emerged from the research. “People don’t think about sitting as being dangerous, and it’s quite a change, having to think, ‘how can I reduce my sitting?’ rather than just ‘how much exercise can I do?’ We’ve traditionally been focused on making sure we meet the physical-activity guidelines of 30 minutes per day, but with that approach we’ve overlooked what we do with the other 23 and a half hours in the day. If you sit for the rest of the day, that is going to have an impact on health, and that’s essentially what our meta-analysis shows,” she told heartwire .

She stresses, however, that this does not mean that exercise is not important. “That’s obviously not the case. There’s a wealth of data showing that physical activity is important, but if people are spending a large percentage of their time sitting, they need to start thinking about how they can reduce this.”

And this message applies across the world, says Wilmot, who says she has had journalists calling her from as far afield as Canada, Chile, India, Russia, South Africa, and the US.

She and her colleagues add that much more research is needed to figure out how best to quantify and standardize measures of sedentary behavior and to formulate guidelines. “At the moment, we don’t have enough of an evidence base to be able to give very specific recommendations about how much to reduce sitting time by. We need intervention studies to give us some guidance on what approach we should take.” She and her colleagues are now running a study in 200 young people at increased risk of diabetes, which they expect to report next year and which they hope will add to this evidence base.

Greatest vs Least Sedentary Time Doubles Risk of Diabetes

Wilmot and colleagues say the hazards of high levels of sitting were first highlighted in the 1950s, when a twofold increase in the risk of an MI was identified in London bus drivers compared with active bus conductors. But since then, the “potentially important distinction” between sedentary (sitting) and light-intensity physical activity has been “largely overlooked” in research, they observe.

“The opportunities for sedentary behavior in modern society, such as watching television, sitting in a car, or using the computer, are ubiquitous,” they add, stating that estimates have put the time the average adult spends in sedentary pursuits at around 50% to 60% of their day.

For their review, the researchers searched for terms related to sedentary time and health outcomes. They combined the results of 18 studies including a total of 794 577 participants. The data were adjusted for baseline event rate and pooled using a random-effects model.

The greatest sedentary time compared with the lowest was associated with a doubling of diabetes (relative risk 2.12), around a 2.5-fold increase in the risk of cardiovascular events (RR 2.47), a 90% rise in risk of cardiovascular death (hazard ratio 1.90) and a 49% higher risk of all-cause mortality (HR 1.49). Based on the pooled effects, all of these findings were significant.

Further statistical analysis showed that the predictive effects were significant only for diabetes, which means the reproducibility of the diabetes finding was greater, suggesting this is the “most robust” result, Wilmot noted.

“People don’t realize that doing just small amounts of activity–it doesn’t even need to be a proper walk–are important,” she says. “If you are having a chat with a friend at your desk or the phone rings, stand up and chat. Just these small changes could make a big difference.”

Specific Reasons Why Sitting Ups Risk of Diabetes

Wilmot explained to heartwire that there appear to be specific reasons why sitting too long can be particularly deleterious in terms of diabetes. “Sitting seems to have an immediate effect on how our bodies metabolize glucose. When we sit, our muscles are not used, and we quickly become more insulin resistant.” Studies have shown that people who sit after eating have 24% higher glucose levels than people who walk very slowly after a meal, she says.

It is also known that there are some individuals who are genetically predisposed to the adverse effects of sitting, including those who are susceptible to diabetes, “so it might be especially important for these people to avoid prolonged sitting,” she observes. The exact metabolic pathways involved are not known, “but what we do know is that when rats have their hind legs immobilized, there is a reduction in lipoprotein lipase, a key regulator of metabolic health.”

Further studies in this area are required, she says, and future diabetes-prevention programs should consider promoting reduced sedentary behavior–including environmental restructuring to promote less sitting–alongside more traditional lifestyle behaviors such as increased physical activity and dietary change.

Also needed is research on how best to quantify sitting using devices called accelerators–which can calculate how long people sit for–as well as work on how to standardize measures of sedentary time. This will include looking at the feasibility of reducing sitting time too, by employing simple concepts such as standing or “walking” desks with treadmills or gadgets that people wear on their waist and that vibrate when the user has been sitting continuously for 40 minutes.

 

Gerry Gajadharsingh writes:

Here’s a good tip, do 5 minutes of resistance based exercise to activate your glucose receptors before eating followed by a short (gentle and slow) walk after eating. Be aware that lots of cardio exercise may also counter productive as it keeps us in carb burning energy pathways and pushes up our insulin response.

 

Posted in Blog, Exercise & Rehabilitation, Metabolic Balance, News | Comments Off

Poor sleep patterns affects Insulin sensitivity

October 17th, 2012

Poor sleep patterns affects Insulin sensitivity

Medscape News

October 16, 2012 — Sleep restriction may be associated with reduced insulin sensitivity in human adipocytes, according to the findings of a crossover clinical trial.

Josiane L. Broussard, PhD, from Cedars-Sinai Medical Center in Los Angeles, California, and colleagues published their findings in the October 16 issue of the Annals of Internal Medicine.

The authors note that although humans sleep for up to one third of their lives, the function of sleep has yet to be definitely clarified. “Although evidence supports a role for sleep in learning, memory, and other central nervous system functions, prospective epidemiologic studies have found that insufficient sleep may increase the risk for metabolic disturbances, including insulin resistance, obesity, and type 2 diabetes,” the authors write. “Consistent with the epidemiologic evidence, well-controlled laboratory studies in healthy adults have shown that repeated partial sleep restriction has adverse effects on systemic insulin sensitivity and glucose tolerance, further supporting the hypothesis that sleep may be important for peripheral metabolism.”

In this study, the authors recruited 7 healthy adults (6 men and 1 woman; mean age, 23.7 ± 3.8 years; mean body mass index, 22.8 ± 1.6 kg/m2) to randomly undergo 4 nights of regular sleep (8.5 hours in bed) and 4 nights of restricted sleep (4.5 hours in bed) separated by an interval of at least 4 weeks. Adipocytes collected from biopsied abdominal fat tissue from each participant were exposed to different concentrations of insulin to assess the response of total Akt (tAkt) and phosphorylated Akt (pAkt) to insulin after normal and restricted sleep. Among the 7 participants, the total area under the curve (AUC) of the pAkt-tAkt response to insulin was 30% lower after sleep restriction (893.00 ± 208.00 vs 1280.00 ± 190.00; P = .01).

None of the patients exhibited abnormal glucose tolerance or current or previous sleep disorders. The exclusion criteria included chronic medical conditions, shift work, depressed mood, the use of any medication or supplement that interfered with normal sleep, smoking, substantial alcohol consumption, and abnormal physical or laboratory examination findings.

The change in the AUC of the pAkt-tAkt response was caused by changes in pAkt levels, as sleep restriction consistently reduced the response of pAkt to insulin, whereas tAkt levels were unaffected. The insulin concentration corresponding to the half-maximal pAkt-tAkt response was nearly 3-fold higher after sleep restriction (0.71 ± 0.27 nM vs 0.24 ± 0.24 nM; P = .01), and the maximum insulin-induced pAkt-tAkt response was 29% lower after sleep restriction (106 ± 23 vs 150 ± 23; P = .02).

Moreover, total body insulin sensitivity was 16% lower after sleep restriction (3.77 ± 1.06 [mU/L]−1/minute−1 vs 3.22 ± 1.38 [mU/L]−1/minute−1; P = .02).

The limitations of the study included the small number of participants, inclusion of only 1 woman, the interindividual variation in insulin response, and the single-institution design of the study.

The authors conclude that their findings revealed additional roles of sleep in metabolic homeostasis. “From a clinical standpoint, our study provides additional evidence that insufficient sleep may contribute to the development of or exacerbate metabolic disorders,” the authors write. “Future studies are needed to determine whether optimizing sleep duration may delay the development or reduce the severity of metabolic alterations in persons who are at increased risk for diabetes and whether maintaining sufficient sleep duration may be an important behavioral modification, in conjunction with a healthy diet and exercise, to prevent and treat obesity and diabetes.”

In a related commentary, Francesco P. Cappuccio, MD, DSc, and Michelle A. Miller, PhD, both from the University of Warwick in Coventry, United Kingdom, indicated that the findings of this study challenge the notion that the primary role of sleep is confined to restorative effects on the central nervous system. “These results point to a much wider influence of sleep on bodily functions, including metabolism, adipose tissue, cardiovascular function, and possibly more,” Dr. Cappuccio and Dr. Miller write. “These observations support the quest for ways to reduce the external threats to sleep duration and quality as a strategy to improve the health of both individuals and society.”

This study was funded by the National Institutes of Health. Dr. Broussard received grant and travel funding from the National Institutes of Health as well as support from the Society in Science—The Branco Weiss Fellowship award. Complete conflict-of-interest information is available in the article. Dr. Miller received royalties from a textbook on sleep. Dr. Cappuccio received royalties for a textbook on sleep and travel funding from the World Health Organization, and he holds a chair at the University of Warwick that is endowed by Cephalon.

Ann Intern Med. 2012;157:549-557. Abstract

 

Gerry Gajadharsingh writes:

 

Although only a small clinical study, given that the poor subjects had to have their abdominal fat biopsied I am not surprised! What we know about visceral adipose tissue (VAT- the fat around your stomach) is that the produce more than their fair share of adipocytes (many of which are inflammatory cytokines- not good for health as all health problems have an inflammatory component). Coupled with a sedentary lifestyle allows excess deposition of VAT. Increased levels of cortisol (part of the stress response), also allows increasing VAT. Sleep disturbance, almost always caused by an anxiety/stress response can only make this worse. Current UK guidelines are that having a waist circumference above 94cm for men (>90cm for Asians) and 80cm for women puts you at increased risk of type 11 diabetes and associated cardiovascular risk.

 

 

Posted in Blog, Metabolic Balance | Comments Off

Use of Complementary & Alternative Medicine (CAM) in Cancer Patients

October 17th, 2012

Use of Complementary & Alternative Medicine (CAM) in Cancer Patients

October 16, 2012 (Albuquerque, New Mexico) — A large percentage of cancer patients use complementary and alternative medicine (CAM) for a wide variety of reasons. Because some of these therapies can interfere with conventional treatments, such as chemotherapy, it is imperative that healthcare providers know everything their patients are using.

Oncology nurses tend to underestimate their patients’ use of CAM, according to a study presented here at the 9th International Conference of the Society for Integrative Oncology.

“From multiple surveys, we know that the primary reason that patients aren’t sharing information about CAM use is because nobody has asked them,” said Lorenzo Cohen, PhD, professor and director of the integrative medicine program at the University of Texas M.D. Anderson Cancer Center in Houston.

Dr. Cohen presented the results of a study designed to evaluate the effect of a brief intervention for nurses on communication about CAM. The primary aim of the study was to make nurses aware of the importance of asking their patients about CAM. A secondary aim was to assess the use of CAM in community settings; most research to date has been done in academic settings,” he explained.

Concern About Interactions

Cancer patients often use over-the-counter medications and are increasingly using CAM, as previously reported by Medscape Medical News. This is particularly true in older adults, who make up the largest population of cancer patients and have high rates of polypharmacy.

Interactions between drugs and CAM are a real concern, William Douglas Figg Sr., PharmD, MBA, senior scientist and head of the clinical pharmacology program and molecular pharmacology section at the Center for Cancer Research, National Cancer Institute (NCI), in Bethesda, Maryland, previously explained. “We know that some [CAM] agents can increase metabolism or decrease metabolism,” he said. “Some can alter absorption. These might alter the anticancer agents we are giving.”

Patient and Nurse Perspectives

Dr. Cohen and colleagues conducted their multisite randomized trial through the Community Clinical Oncology Program (CCOP) Research Base at the M.D. Anderson Cancer Center. This NCI-funded program prepares cancer control and prevention trials, which are then made available to a national network of CCOP sites and independent Main Member sites.

Initially, 175 nurses were recruited to the trial, as were 699 patients who completed a questionnaire about CAM use, communication, and knowledge (preintervention patients). Two months later, another 650 patients were recruited and completed the questionnaire (postintervention patients).

Nurses in the intervention group viewed a weekly 20-minute video that discussed the definitions of CAM, issues of patient use, the importance of discussing CAM, and the legal ramifications of not doing so. A resource list on how to access information about CAM was provided to the nurses in the intervention group and to those in the control group.

About 40% of patients reported that they used some type of CAM (excluding spiritual practices such as prayer) after their cancer diagnosis. “This number is somewhat low,” Dr. Cohen noted. “We are still doing analyses to really be sure about it, but it does seem that in community settings and in the regions where the study was conducted, it is somewhat lower.”

The main reasons patients gave for using CAM was that they found it beneficial (70%) and it addressed emotional and spiritual aspects (62%) related to their disease. Some patients also reported that it helped their immune system and alleviated adverse effects.

The main reasons patients gave for not using CAM given were a lack of information about it and skepticism about its benefits.

At 2-month follow-up, more nurses in the intervention group reported asking about CAM use than nurses in the control group (odds ratio [OR], 4.2; P < .005), and reported asking more of their last 5 patients about CAM use (P =.003).

However, when preintervention and postintervention patients reported on being asked about CAM use, there was no significant difference (OR, 1.6; P > .010)

Underestimation of CAM Use

There was a huge misperception when nurses were asked what percentage of their patients used CAM. “The majority thought that it was 1% to 25%, so no more than a quarter. In fact, we know that close to one half of patients reported using some type of CAM,” Dr. Cohen noted.

Interestingly, the researchers found that there was a high degree of personal CAM use among nurses.

CAM use in community-based oncology patients is relatively high, but there was an underestimation of its use by the oncology nurses, he concluded. Although more nurses in the intervention group reported asking about CAM use than in the control group, when the same element was assessed in patients, the effect was more modest, Dr. Cohen reported.

This is something that needs to be better understood, he added, and future studies should include other members of the healthcare team, including physicians.

9th International Conference of the Society for Integrative Oncology (SIO). Presented October 10, 2012.

 

Gerry Gajadharsingh writes:

 

A diagnosis of cancer is always traumatic for patients and their families. It is good to know that of almost 50% of all cancer patients using CAM, 70% found it beneficial, with 62% finding the emotional support offered by CAM very useful. The diagnostic procedures necessary to confirm cancer can sometimes be painful and traumatic to some patients, especially biopsy, receiving the dreaded diagnosis traumatic enough, never mind the treatment offered which may include surgery, radiotherapy or chemotherapy. CAM clinicians experienced in helping patients as an adjunct to their medical intervention can often help with the “non-medical factors”, nutritional, management of anxiety, overall well-being, pain control and general support. Many oncology centres are welcoming adjunct therapies but I think it only sensible that patients inform their cancer specialists of CAM treatment they are receiving, especially OTC nutritional and herbal supplements which may effect any potential medical interventions. Lifestyle factor modification, such as alcohol, smoking, caffeine, high glycaemic load carbohydrate diets, stress management etc., can sometimes play its part in cancer care and preventive strategies.

Posted in Blog, Metabolic Balance, News | Comments Off

« Older Entries
 

London

4th Floor North, 25 Wimpole Street,
London W1G 8GL

+44 (0)20 7631 1414

Buckinghamshire

Bowers Cottage, Magpie Lane, Coleshill,
Amersham, Buckinghamshire HP7 0LU

+44 (0)1494 431 293

Appointments

Request an Appointment