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Bringing Stem Cells to War: Meet the Blood Pharmers
New research from DARPA could open the door to on-demand blood-cell manufacturing on battlefields and in hospitals. All
medics need is a machine that uses a nanofiber that mimics bone marrow to turn a handful of stem cells into gallons of
blood. Who needs blood donations when you have blood pharming?
By Michael Milstein
Published on: December 16, 2008
Fresher blood is better than stale: It carries more oxygen and, when transfused into patients, speeds recovery.
Military medics are all too familiar with this problem in the field, where donated blood may take two or more weeks to
reach soldiers who need it immediately. But medical researchers—also known as blood pharmers—are working on
manufacturing the red stuff on the spot.
With a machine the size of a few refrigerators, the Defense Department's advanced research arm, the Defense Advanced
Research Projects Agency (DARPA) envisions liter upon liter of fresh blood churning out, destined for the veins of injured soldiers. It
doesn't get any fresher than that. And if it works for the military, it should also work for domestic hospitals that are paying
increasingly pricey bills for blood that's in short supply, says DARPA project scientist Jon Mogford, who was awarded nearly $2
million to Cleveland-based Arteriocyte for blood-pharming research.
The company's key ingredient is umbilical-cord stem cells, the Houdini of human cells, that can transform into whatever other cells
the body might need to repair or replace injured ones. Arteriocyte researchers were trying to grow big batches of stem cells when
they realized that the growing conditions they used—such as temperature and levels of oxygen and carbon dioxide —caused the
stem cells to turn into an early stage of red blood cell. At first they were frustrated because they wanted stem cells. Then they
realized that they may have unintentionally found a clever way to produce new blood.
Blood is in extremely short supply, and not only on the battlefield. Americans today do not donate blood as often as they used to and
many are ineligible to donate because of the risk of hepatitis and other diseases tied to ubiquitous tattoos and piercings. The
shortage has driven the cost of blood up and hospitals are having a hard time getting the kind that they need when they need it.
Even when they do, it may be several days old. On battlefields, the blood may be even older: "It often takes seven to 14 days to get
from my arm to a staging center," said Arteriocyte CEO Donald Brown.
The trick isn't producing red blood cells—the company has that figured out—it is producing them in enough volume to do patients
some good. The cells can be finicky: they need just the right environment to grow. For that, Arteriocyte is relying on a technique
developed at Johns Hopkins University that uses nanofibers to mimic the three-dimensional structure of bone marrow, which
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manufactures blood in the body. Parent stem cells readily multiply in the matrix. "You're trying to replicate what goes on in human
bone marrow," Brown says.
The DARPA award gives Arteriocyte three years to scale up to a self-contained system that could turn out 100 units of universal
blood (which could be transfused into people with any blood type) a week for eight weeks. The system can measure no more than
47 cu ft and must stand up to the rigors of frontline military deployment. DARPA then wants to submit the system to the FDA for
approval. In the end, if the system works, soldiers and civilian patients could have all the blood they need available on tap.
Thursday, December 18, 2008
Wednesday, December 17, 2008
ZYVOX INDICATIONS
http://www.zyvox.com/index.asp?hcp=true
ZYVOX INDICATIONS
ZYVOX® (linezolid) is indicated in the treatment of the following infections caused by susceptible strains of the designated microorganisms:
Nosocomial pneumonia caused by Staphylococcus aureus(methicillin-susceptible and -resistant strains) or Streptococcus pneumoniae(including multidrug-resistant strains [MDRSP]). MDRSP refers to isolates resistant to 2 or more of the following antibiotics: penicillin, second-generation cephalosporins, macrolides, tetracycline, and trimethoprim/sulfamethoxazole.
Complicated skin and skin structure infections, including diabetic foot infections, without concomitant osteomyelitis, caused by Staphylococcus aureus (methicillin-susceptible and -resistant strains), Streptococcus pyogenes, or Streptococcus agalactiae. ZYVOX has not been studied in the treatment of decubitus ulcers.
IMPORTANT SAFETY CONSIDERATIONS
ZYVOX formulations are contraindicated for use in patients who have known hypersensitivity to linezolid or any of the other product components.
ZYVOX should not be used in patients taking any medicinal product which inhibits monoamine oxidases A or B (e.g. phenelzine, isocarboxazid) or within 2 weeks of taking any such medicinal product.
Unless patients are monitored for potential increases in blood pressure, ZYVOX should not be administered to patients with uncontrolled hypertension, pheochromocytoma, thyrotoxicosis and/or patients taking any of the following types of medications: directly and indirectly acting sympathomimetic agents (e.g. pseudoephedrine), vasopressive agents (e.g. epinephrine, norepinephrine), and dopaminergic agents (e.g. dopamine, dobutamine).
Unless patients are carefully observed for signs and/or symptoms of serotonin syndrome, ZYVOX should not be administered to patients with carcinoid syndrome and/or patients taking any of the following medications: serotonin re-uptake inhibitors, tricyclic antidepressants, serotonin 5-HT1 receptor agonists (triptans), meperidine, or buspirone.
Myelosuppression (including anemia, leukopenia, pancytopenia, and thrombocytopenia) has been reported in patients receiving ZYVOX. In cases where the outcome is known, when ZYVOX was discontinued, the affected hematologic parameters have risen toward pretreatment levels. Complete blood counts should be monitored weekly in patients who receive ZYVOX, particularly in those who receive ZYVOX for longer than 2 weeks, those with preexisting myelosuppression, those receiving concomitant drugs that produce bone marrow suppression, or those with a chronic infection who have received previous or concomitant antibiotic therapy. Discontinuation of therapy with ZYVOX should be considered in patients who develop or have worsening myelosuppression.
ZYVOX is not approved and should not be used for the treatment of patients with catheter-related bloodstream infections or catheter-site infections.
In an open-label investigational study in seriously ill patients with intravascular catheter-related infections, an imbalance in mortality was seen in patients treated with ZYVOX compared with vancomycin/dicloxacillin/oxacillin. While causality has not been established, mortality was higher in patients treated with ZYVOX who were infected with Gram-negative organisms alone, with both Gram-positive and Gram-negative organisms, or who had no infection when they entered the study. Patients with Gram-positive infections had no difference in mortality.
ZYVOX has no clinical activity against Gram-negative pathogens and is not indicated for the treatment of Gram-negative infections. It is critical that specific Gram-negative therapy be initiated immediately if a concomitant Gram-negative pathogen is documented or suspected.
Lactic acidosis has been reported with the use of ZYVOX. In reported cases, patients experienced repeated episodes of nausea and vomiting. Patients who develop recurrent nausea or vomiting, unexplained acidosis, or a low bicarbonate level while receiving ZYVOX should receive immediate medical evaluation.
Spontaneous reports of serotonin syndrome associated with the coadministration of ZYVOX and serotonergic agents, including antidepressants such as selective serotonin reuptake inhibitors (SSRIs), have been reported. Where administration of ZYVOX and concomitant serotonergic agents is clinically appropriate, patients should be closely observed for signs and symptoms of serotonin syndrome such as cognitive dysfunction, hyperpyrexia, hyperreflexia, and incoordination. If signs or symptoms occur, physicians should consider discontinuation of either one or both agents.
Peripheral and optic neuropathy have been reported in patients treated with ZYVOX, primarily those patients treated for longer than the maximum recommended duration of 28 days. In cases of optic neuropathy that progressed to loss of vision, patients were treated for extended periods beyond the maximum recommended duration. Visual blurring has been reported in some patients treated with ZYVOX for less than 28 days.
If patients experience symptoms of visual impairment, such as changes in visual acuity, changes in color vision, blurred vision, or visual field defect, prompt ophthalmic evaluation is recommended. Visual function should be monitored in all patients taking ZYVOX for extended periods (3 months) and in all patients reporting new visual symptoms regardless of length of therapy with ZYVOX. If peripheral or optic neuropathy occurs, the continued use of ZYVOX in these patients should be weighed against the potential risks.
Convulsions have been reported in patients when treated with ZYVOX. In some of these cases, a history of seizures or risk factors for seizures was reported.
The most commonly reported adverse events in adults across clinical trials were nausea, headache, and diarrhea.
To reduce the development of drug-resistant bacteria and maintain the effectiveness of ZYVOX and other antibacterial drugs, ZYVOX should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria. When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy. In the absence of such data, local epidemiology and susceptibility patterns may contribute to the empiric selection of therapy.
Clostridium difficile –associated diarrhea (CDAD) has been reported with the use of nearly all antibacterial agents, including ZYVOX, and may range in severity from mild diarrhea to fatal colitis. Treatment with antibacterial agents alters the normal flora of the colon leading to overgrowth of C difficile . C difficile produces toxins A and B, which contribute to the development of CDAD. Hypertoxin-producing strains of C difficile cause increased morbidity and mortality, as these infections can be refractory to antimicrobial therapy and may require colectomy. CDAD must be considered in all patients who present with diarrhea following antibiotic use. Careful medical history is necessary since CDAD has been reported to occur more than 2 months after the administration of antibacterial agents. If CDAD is suspected or confirmed, ongoing antibiotic use not directed against C difficile may need to be discontinued. Appropriate fluid and electrolyte management, protein supplementation, antibiotic treatment of C difficile , and surgical evaluation should be instituted as clinically indicated.
ZYVOX INDICATIONS
ZYVOX® (linezolid) is indicated in the treatment of the following infections caused by susceptible strains of the designated microorganisms:
Nosocomial pneumonia caused by Staphylococcus aureus(methicillin-susceptible and -resistant strains) or Streptococcus pneumoniae(including multidrug-resistant strains [MDRSP]). MDRSP refers to isolates resistant to 2 or more of the following antibiotics: penicillin, second-generation cephalosporins, macrolides, tetracycline, and trimethoprim/sulfamethoxazole.
Complicated skin and skin structure infections, including diabetic foot infections, without concomitant osteomyelitis, caused by Staphylococcus aureus (methicillin-susceptible and -resistant strains), Streptococcus pyogenes, or Streptococcus agalactiae. ZYVOX has not been studied in the treatment of decubitus ulcers.
IMPORTANT SAFETY CONSIDERATIONS
ZYVOX formulations are contraindicated for use in patients who have known hypersensitivity to linezolid or any of the other product components.
ZYVOX should not be used in patients taking any medicinal product which inhibits monoamine oxidases A or B (e.g. phenelzine, isocarboxazid) or within 2 weeks of taking any such medicinal product.
Unless patients are monitored for potential increases in blood pressure, ZYVOX should not be administered to patients with uncontrolled hypertension, pheochromocytoma, thyrotoxicosis and/or patients taking any of the following types of medications: directly and indirectly acting sympathomimetic agents (e.g. pseudoephedrine), vasopressive agents (e.g. epinephrine, norepinephrine), and dopaminergic agents (e.g. dopamine, dobutamine).
Unless patients are carefully observed for signs and/or symptoms of serotonin syndrome, ZYVOX should not be administered to patients with carcinoid syndrome and/or patients taking any of the following medications: serotonin re-uptake inhibitors, tricyclic antidepressants, serotonin 5-HT1 receptor agonists (triptans), meperidine, or buspirone.
Myelosuppression (including anemia, leukopenia, pancytopenia, and thrombocytopenia) has been reported in patients receiving ZYVOX. In cases where the outcome is known, when ZYVOX was discontinued, the affected hematologic parameters have risen toward pretreatment levels. Complete blood counts should be monitored weekly in patients who receive ZYVOX, particularly in those who receive ZYVOX for longer than 2 weeks, those with preexisting myelosuppression, those receiving concomitant drugs that produce bone marrow suppression, or those with a chronic infection who have received previous or concomitant antibiotic therapy. Discontinuation of therapy with ZYVOX should be considered in patients who develop or have worsening myelosuppression.
ZYVOX is not approved and should not be used for the treatment of patients with catheter-related bloodstream infections or catheter-site infections.
In an open-label investigational study in seriously ill patients with intravascular catheter-related infections, an imbalance in mortality was seen in patients treated with ZYVOX compared with vancomycin/dicloxacillin/oxacillin. While causality has not been established, mortality was higher in patients treated with ZYVOX who were infected with Gram-negative organisms alone, with both Gram-positive and Gram-negative organisms, or who had no infection when they entered the study. Patients with Gram-positive infections had no difference in mortality.
ZYVOX has no clinical activity against Gram-negative pathogens and is not indicated for the treatment of Gram-negative infections. It is critical that specific Gram-negative therapy be initiated immediately if a concomitant Gram-negative pathogen is documented or suspected.
Lactic acidosis has been reported with the use of ZYVOX. In reported cases, patients experienced repeated episodes of nausea and vomiting. Patients who develop recurrent nausea or vomiting, unexplained acidosis, or a low bicarbonate level while receiving ZYVOX should receive immediate medical evaluation.
Spontaneous reports of serotonin syndrome associated with the coadministration of ZYVOX and serotonergic agents, including antidepressants such as selective serotonin reuptake inhibitors (SSRIs), have been reported. Where administration of ZYVOX and concomitant serotonergic agents is clinically appropriate, patients should be closely observed for signs and symptoms of serotonin syndrome such as cognitive dysfunction, hyperpyrexia, hyperreflexia, and incoordination. If signs or symptoms occur, physicians should consider discontinuation of either one or both agents.
Peripheral and optic neuropathy have been reported in patients treated with ZYVOX, primarily those patients treated for longer than the maximum recommended duration of 28 days. In cases of optic neuropathy that progressed to loss of vision, patients were treated for extended periods beyond the maximum recommended duration. Visual blurring has been reported in some patients treated with ZYVOX for less than 28 days.
If patients experience symptoms of visual impairment, such as changes in visual acuity, changes in color vision, blurred vision, or visual field defect, prompt ophthalmic evaluation is recommended. Visual function should be monitored in all patients taking ZYVOX for extended periods (3 months) and in all patients reporting new visual symptoms regardless of length of therapy with ZYVOX. If peripheral or optic neuropathy occurs, the continued use of ZYVOX in these patients should be weighed against the potential risks.
Convulsions have been reported in patients when treated with ZYVOX. In some of these cases, a history of seizures or risk factors for seizures was reported.
The most commonly reported adverse events in adults across clinical trials were nausea, headache, and diarrhea.
To reduce the development of drug-resistant bacteria and maintain the effectiveness of ZYVOX and other antibacterial drugs, ZYVOX should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria. When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy. In the absence of such data, local epidemiology and susceptibility patterns may contribute to the empiric selection of therapy.
Clostridium difficile –associated diarrhea (CDAD) has been reported with the use of nearly all antibacterial agents, including ZYVOX, and may range in severity from mild diarrhea to fatal colitis. Treatment with antibacterial agents alters the normal flora of the colon leading to overgrowth of C difficile . C difficile produces toxins A and B, which contribute to the development of CDAD. Hypertoxin-producing strains of C difficile cause increased morbidity and mortality, as these infections can be refractory to antimicrobial therapy and may require colectomy. CDAD must be considered in all patients who present with diarrhea following antibiotic use. Careful medical history is necessary since CDAD has been reported to occur more than 2 months after the administration of antibacterial agents. If CDAD is suspected or confirmed, ongoing antibiotic use not directed against C difficile may need to be discontinued. Appropriate fluid and electrolyte management, protein supplementation, antibiotic treatment of C difficile , and surgical evaluation should be instituted as clinically indicated.
North American breakthrough for dialysis patients
http://www.physorg.com/printnews.php?newsid=147001312
North American breakthrough for dialysis patients
Suffering from end-stage renal disease (ESRD), a growing number of patients at the Centre hospitalier de l'Université de Montréal (CHUM), have become the beneficiaries of a North American breakthrough: high efficacy hemodiafiltration (HDF).
An extracorporeal blood purification technique, HDF is indicated for ESRD patients. Since the HDF unit was introduced in CHUM's Nephrology section, preliminary results show a clear advantage of high efficacy HDF over conventional hemodialysis in several areas, including the following:
-- Improved removal of uremic toxins;
-- Decreased number of hospitalization days;
-- A better tolerance for patients;
-- Minimizes the state of chronic inflammation that too often may lead to complications over a long course of dialysis;
-- Diminished need for certain medications.
-- Increased biocompatibility across the blood-dialysis system interface.
"Conventional hemodialysis continues to save lives, but we now have the technology to improve the lot of dialysis patients," says Dr. Rénee Lévesque, nephologist and lead physician in the HDF program at CHUM, and a professor with the medical faculty of the Université de Montréal. "At CHUM, we're proud to soon be accepting a cohort of forty patients undergoing HDF." Dr. Lévesque added that the CHUM Nephrology section is putting much efforts behind the new process, and hopes that one day soon all dialysis patients will be treated in this fashion.
Recent retrospective clinical data indicate that HDF reduces the mortality rates of dialysis patients and randomized studies are under way to provide clear proof of increased survival rates for patients. Among these, the CONTRAST study compares hemodialysis with online hemodiafiltration HDF in overall performance relative to cardiovascular morbidity and mortality. The study seeks to recruit seven hundred test subjects and follow them over a three-year period. CHUM is the only medical centre in North America to take part in this study, currently the largest in terms of the size of the randomized cohort.
Hemodiafiltration : the best of both worlds
HDF combines the elements of two processes, conventional hemodialysis (HD) and hemofiltration (HF). Renal replacement therapy for ESRD is based on two processes: diffusion and convection.
Conventional HD is diffusive; blood is circulated in an artificial kidney machine on one side of a semi-permeable membrane, while a special dialysis fluid is circulated on the other side. Small molecules of metabolic waste seep out into a dialysis solution flowing in the opposite direction on the other side of the membrane, mimicking the kidneys and washing wastes and toxins out of the bloodstream. One major toxin is urea. HD is the most widely used renal replacement function technology for ESRD.
Hemofiltration (HF) or ultrafiltration is exclusively convective, forcing blood through a filter under high pressure. The principle consists of applying a hydrostatic pressure gradient (high pressure on one side, low pressure on the other) across the membrane or filter. This results in an ultrafiltrate (water and electrolytes) on the other side. The quantity of ultrafiltrate lost in this process must be compensated by a matching infusion of replacement fluid. HF is used primarily in continuous mode and in acute care or intensive care.
In HDF, the diffusive component of HD is combined with the convective component of HF. As is the case in HF, the excessive loss of liquid must be compensated by the reinfusion of a sterile and apyrogenic (not producing fever) fluid. Recent developments have led to the "on-line" production of large volumes of ultrapure liquid of high quality. This has led to higher quality physicochemical and microbiological properties in these solutions, in comparison with HD.
Some statistics on the treatment of end-stage renal disease:
-- At the end of 2003, there were 29,551 Canadians undergoing renal substitution treatment and that number is expected to double over the next ten years;
-- Among that number, 61 % were in dialysis. Of these patients, 81 % were in hemodialysis and 19 % followed a regiment of peritoneal dialysis, e.g. from the abdomen.
Source: Université de Montréal Hospital Centre
North American breakthrough for dialysis patients
Suffering from end-stage renal disease (ESRD), a growing number of patients at the Centre hospitalier de l'Université de Montréal (CHUM), have become the beneficiaries of a North American breakthrough: high efficacy hemodiafiltration (HDF).
An extracorporeal blood purification technique, HDF is indicated for ESRD patients. Since the HDF unit was introduced in CHUM's Nephrology section, preliminary results show a clear advantage of high efficacy HDF over conventional hemodialysis in several areas, including the following:
-- Improved removal of uremic toxins;
-- Decreased number of hospitalization days;
-- A better tolerance for patients;
-- Minimizes the state of chronic inflammation that too often may lead to complications over a long course of dialysis;
-- Diminished need for certain medications.
-- Increased biocompatibility across the blood-dialysis system interface.
"Conventional hemodialysis continues to save lives, but we now have the technology to improve the lot of dialysis patients," says Dr. Rénee Lévesque, nephologist and lead physician in the HDF program at CHUM, and a professor with the medical faculty of the Université de Montréal. "At CHUM, we're proud to soon be accepting a cohort of forty patients undergoing HDF." Dr. Lévesque added that the CHUM Nephrology section is putting much efforts behind the new process, and hopes that one day soon all dialysis patients will be treated in this fashion.
Recent retrospective clinical data indicate that HDF reduces the mortality rates of dialysis patients and randomized studies are under way to provide clear proof of increased survival rates for patients. Among these, the CONTRAST study compares hemodialysis with online hemodiafiltration HDF in overall performance relative to cardiovascular morbidity and mortality. The study seeks to recruit seven hundred test subjects and follow them over a three-year period. CHUM is the only medical centre in North America to take part in this study, currently the largest in terms of the size of the randomized cohort.
Hemodiafiltration : the best of both worlds
HDF combines the elements of two processes, conventional hemodialysis (HD) and hemofiltration (HF). Renal replacement therapy for ESRD is based on two processes: diffusion and convection.
Conventional HD is diffusive; blood is circulated in an artificial kidney machine on one side of a semi-permeable membrane, while a special dialysis fluid is circulated on the other side. Small molecules of metabolic waste seep out into a dialysis solution flowing in the opposite direction on the other side of the membrane, mimicking the kidneys and washing wastes and toxins out of the bloodstream. One major toxin is urea. HD is the most widely used renal replacement function technology for ESRD.
Hemofiltration (HF) or ultrafiltration is exclusively convective, forcing blood through a filter under high pressure. The principle consists of applying a hydrostatic pressure gradient (high pressure on one side, low pressure on the other) across the membrane or filter. This results in an ultrafiltrate (water and electrolytes) on the other side. The quantity of ultrafiltrate lost in this process must be compensated by a matching infusion of replacement fluid. HF is used primarily in continuous mode and in acute care or intensive care.
In HDF, the diffusive component of HD is combined with the convective component of HF. As is the case in HF, the excessive loss of liquid must be compensated by the reinfusion of a sterile and apyrogenic (not producing fever) fluid. Recent developments have led to the "on-line" production of large volumes of ultrapure liquid of high quality. This has led to higher quality physicochemical and microbiological properties in these solutions, in comparison with HD.
Some statistics on the treatment of end-stage renal disease:
-- At the end of 2003, there were 29,551 Canadians undergoing renal substitution treatment and that number is expected to double over the next ten years;
-- Among that number, 61 % were in dialysis. Of these patients, 81 % were in hemodialysis and 19 % followed a regiment of peritoneal dialysis, e.g. from the abdomen.
Source: Université de Montréal Hospital Centre
Wednesday, December 10, 2008
Diabetes causes more amputations than landmines
December 8, 2008
The condition now accounts for 70 per cent of all lower limb amputations
Dr Thomas Stuttaford
Mohandas Gandhi was known as Mahatma, or “great soul”, because he combined patriotism with moral teaching, reform and a horror of violence, consumerism and class, caste or racial discrimination.
Gandhi would have welcomed the support given to the World Diabetes Foundation (WDF) and the World Health Organisation (WHO) by Handicap International. That is the French charitable organisation that has been awarded a Nobel prize for its work with people left crippled and handicapped in Vietnam, Cambodia and other countries by landmines.
Exploding hidden landmines remain a considerable danger, but one that has been overtaken by diabetes as a reason for the amputation of younger people's legs around the world. Diabetes now accounts for 70 per cent of all lower limb amputations. Hence the decision of Handicap International, while continuing to work in Vietnam, Cambodia and other former war zones, to add to its agenda the WDF campaign to reduce the incidence and improve the treatment of diabetes in developing countries.
The loss of a lower limb in a working man usually heralds the loss of the family's livelihood so that poverty becomes inevitable. Locally made artificial lower limbs are satisfactory for walking but rarely adequate for hard manual work.
RELATED LINKS
Temporary castration for prostate cancer sufferers
Back pain causing a lack of sleep
Are injectable self-tans safe?
The WDF's expertise helps in the formation of partnerships to deal with diabetes in the developing world. It unites the various people and organisations interested in raising the awareness of the lifestyle changes needed to prevent diabetes and the need for prompt diagnosis and treatment. Earlier treatment of diabetic foot complications would prevent 85 per cent of amputations.
Currently 40,000 legs are amputated in India each year. Last week doctors, health workers and journalists gathered in Bangalore and Madras. In Bangalore they visited the vascular surgical unit at the Bhagwan Jain hospital. The unit, led by Dr Kalkunte Suresh, is financed by the WDF, the WHO, Handicap International and several local philanthropists. It runs a footcare division that organises local clinics that screen people in surrounding villages for diabetes and the first signs of nerve damage that could desensitise their feet so that they become vulnerable to minor injury.
The clinics also raise public awareness of the lifestyle changes needed to reduce the incidence of diabetes and its complications. Dr Suresh, the director of the scheme and of the hospital's vascular surgical unit, said that diabetic foot complications were increasing and that someone with diabetes in India was 25 times more likely to have a leg amputated than someone without it.
Dr Suresh added that doctors trained in the developed world associate foot complications including gangrene and amputation with elderly or obese, under-exercised patients. This is not so in India. There, the most common cause for a crisis leading to gangrene and amputation was more likely to be precipitated by diabetic nerve damage than deteriorating arterial blood flow.
The Indian patients who need amputation are often aged only around 35 to 45, a time in the manual worker's life when he has maximal domestic responsibilities and is probably providing for several generations. Most of Dr Suresh's patients who had leg amputations were not overweight but lean, tough and muscular agricultural workers.
Gandhi, delegates were reminded, taught that India lives in its villages, and in order to bring about change it was necessary to change the way that village people think.
Dr Suresh and his team, when spreading the message about diabetic prevention and treatment, rely on well -respected local people - popular village postmen or bus drivers are ideal - to educate their fellow villagers about the signs and symptoms of early diabetes, the need for foot care, and the importance of wearing shoes in and out of the house (more feet are injured indoors than in the fields).
All these aspects of diabetes can be taught in the villages by troupes of enthusiastic street performers acting out short plays and singing traditional folk songs, modified to spell out the methods of prevention and treatment of diabetes.
While India watched and mourned the atrocities in Mumbai, the delegates moved to Madras. There they visited the projects the WDF has established with the Pabolu Ogirala and Sriram Charitable Trust. It aims to combat eye problems in diabetic patients, who are twice as likely to develop them as non-diabetic people. Fifty per cent of all diabetic people develop some degree of diabetic eye disease.
www.worlddiabetesfoundation.org
The condition now accounts for 70 per cent of all lower limb amputations
Dr Thomas Stuttaford
Mohandas Gandhi was known as Mahatma, or “great soul”, because he combined patriotism with moral teaching, reform and a horror of violence, consumerism and class, caste or racial discrimination.
Gandhi would have welcomed the support given to the World Diabetes Foundation (WDF) and the World Health Organisation (WHO) by Handicap International. That is the French charitable organisation that has been awarded a Nobel prize for its work with people left crippled and handicapped in Vietnam, Cambodia and other countries by landmines.
Exploding hidden landmines remain a considerable danger, but one that has been overtaken by diabetes as a reason for the amputation of younger people's legs around the world. Diabetes now accounts for 70 per cent of all lower limb amputations. Hence the decision of Handicap International, while continuing to work in Vietnam, Cambodia and other former war zones, to add to its agenda the WDF campaign to reduce the incidence and improve the treatment of diabetes in developing countries.
The loss of a lower limb in a working man usually heralds the loss of the family's livelihood so that poverty becomes inevitable. Locally made artificial lower limbs are satisfactory for walking but rarely adequate for hard manual work.
RELATED LINKS
Temporary castration for prostate cancer sufferers
Back pain causing a lack of sleep
Are injectable self-tans safe?
The WDF's expertise helps in the formation of partnerships to deal with diabetes in the developing world. It unites the various people and organisations interested in raising the awareness of the lifestyle changes needed to prevent diabetes and the need for prompt diagnosis and treatment. Earlier treatment of diabetic foot complications would prevent 85 per cent of amputations.
Currently 40,000 legs are amputated in India each year. Last week doctors, health workers and journalists gathered in Bangalore and Madras. In Bangalore they visited the vascular surgical unit at the Bhagwan Jain hospital. The unit, led by Dr Kalkunte Suresh, is financed by the WDF, the WHO, Handicap International and several local philanthropists. It runs a footcare division that organises local clinics that screen people in surrounding villages for diabetes and the first signs of nerve damage that could desensitise their feet so that they become vulnerable to minor injury.
The clinics also raise public awareness of the lifestyle changes needed to reduce the incidence of diabetes and its complications. Dr Suresh, the director of the scheme and of the hospital's vascular surgical unit, said that diabetic foot complications were increasing and that someone with diabetes in India was 25 times more likely to have a leg amputated than someone without it.
Dr Suresh added that doctors trained in the developed world associate foot complications including gangrene and amputation with elderly or obese, under-exercised patients. This is not so in India. There, the most common cause for a crisis leading to gangrene and amputation was more likely to be precipitated by diabetic nerve damage than deteriorating arterial blood flow.
The Indian patients who need amputation are often aged only around 35 to 45, a time in the manual worker's life when he has maximal domestic responsibilities and is probably providing for several generations. Most of Dr Suresh's patients who had leg amputations were not overweight but lean, tough and muscular agricultural workers.
Gandhi, delegates were reminded, taught that India lives in its villages, and in order to bring about change it was necessary to change the way that village people think.
Dr Suresh and his team, when spreading the message about diabetic prevention and treatment, rely on well -respected local people - popular village postmen or bus drivers are ideal - to educate their fellow villagers about the signs and symptoms of early diabetes, the need for foot care, and the importance of wearing shoes in and out of the house (more feet are injured indoors than in the fields).
All these aspects of diabetes can be taught in the villages by troupes of enthusiastic street performers acting out short plays and singing traditional folk songs, modified to spell out the methods of prevention and treatment of diabetes.
While India watched and mourned the atrocities in Mumbai, the delegates moved to Madras. There they visited the projects the WDF has established with the Pabolu Ogirala and Sriram Charitable Trust. It aims to combat eye problems in diabetic patients, who are twice as likely to develop them as non-diabetic people. Fifty per cent of all diabetic people develop some degree of diabetic eye disease.
www.worlddiabetesfoundation.org
Salt 'as bad as cigarettes'
12/10/08 7:01 PM
AAPDecember 03, 2008 03:36pm
Health & Lifestyle
AUSTRALIANS are consuming too much salt, say nutritionists who blame not only fast food but also
healthier alternatives such as canned vegetables and baked beans.
Less than 5 per cent of all sausages and beef burgers sold in the nation's supermarkets contained
acceptable levels of salt, a Nutrition Society of Australia conference has also heard.
Jacqui Webster, a senior project manager based at Sydney's The George Institute for International
Health, said Australians were consuming well over the maximum recommended intake of six grams
of salt a day.
"Despite being aware of the adverse health effects of salt, most Australian consumers are taking little
action to reduce their intake,'' Ms Webster told the conference.
"Consuming too much salt, or sodium, can lead to serious health problems including high blood
pressure, cardiovascular disease, stroke, osteoporosis and stomach cancer.
"There is also some evidence that it adds to the severity of asthma symptoms.''
Ms Webster said the 2007 Australian National Children's Nutrition and Physical Activity Survey
showed boys were consuming around 9g of salt daily, while girls came in at the maximum 6g.
She said it was also likely that many adults consumed in excess of the 9g of salt each day.
Ms Webster said foods contributing to high salt diet included bread, processed meats, baked beans,
canned vegetables, table sauces, some breakfast cereals and fast food.
Research in the UK showed processed foods accounted for 75 per cent of salt in a person's diet, with
10 per cent from natural foods like fish and vegetables.
The remaining 15 per cent was salt added at the table or during cooking.
Given the dire health consequences, Ms Webster said reducing salt in the diet should be "considered
on the same level of importance as reducing obesity, alcohol and tobacco consumption''.
Leading nutritionists from around Australia and the world are attending the conference in Adelaide.
AAPDecember 03, 2008 03:36pm
Health & Lifestyle
AUSTRALIANS are consuming too much salt, say nutritionists who blame not only fast food but also
healthier alternatives such as canned vegetables and baked beans.
Less than 5 per cent of all sausages and beef burgers sold in the nation's supermarkets contained
acceptable levels of salt, a Nutrition Society of Australia conference has also heard.
Jacqui Webster, a senior project manager based at Sydney's The George Institute for International
Health, said Australians were consuming well over the maximum recommended intake of six grams
of salt a day.
"Despite being aware of the adverse health effects of salt, most Australian consumers are taking little
action to reduce their intake,'' Ms Webster told the conference.
"Consuming too much salt, or sodium, can lead to serious health problems including high blood
pressure, cardiovascular disease, stroke, osteoporosis and stomach cancer.
"There is also some evidence that it adds to the severity of asthma symptoms.''
Ms Webster said the 2007 Australian National Children's Nutrition and Physical Activity Survey
showed boys were consuming around 9g of salt daily, while girls came in at the maximum 6g.
She said it was also likely that many adults consumed in excess of the 9g of salt each day.
Ms Webster said foods contributing to high salt diet included bread, processed meats, baked beans,
canned vegetables, table sauces, some breakfast cereals and fast food.
Research in the UK showed processed foods accounted for 75 per cent of salt in a person's diet, with
10 per cent from natural foods like fish and vegetables.
The remaining 15 per cent was salt added at the table or during cooking.
Given the dire health consequences, Ms Webster said reducing salt in the diet should be "considered
on the same level of importance as reducing obesity, alcohol and tobacco consumption''.
Leading nutritionists from around Australia and the world are attending the conference in Adelaide.
The Pain May Be Real, but the Scan Is Deceiving
Cheryl Weinstein’s left knee bothered her for years, but when it started clicking and hurting when she straightened it, she told her internist that something was definitely wrong.
The Evidence Gap
Diagnosing the Wrong Problem
Articles in this series, are exploring medical treatments used despite scant proof that they work and are examining steps toward medicine based on evidence.
Previous Articles in the Series »
Multimedia
Dartmouth-Hitchcock Medical Center
It was the start of her medical odyssey, a journey that led her to specialists, physical therapy, Internet searches and, finally, an M.R.I. scan that showed a torn cartilage and convinced her that her only hope for relief was to have surgery to repair it. But in fact, fixing the torn cartilage that was picked up on the scan was not going to solve her problem, which, eventually, she found was caused by arthritis.
Scans — more sensitive and easily available than ever — are increasingly finding abnormalities that may not be the cause of the problem for which they are blamed. It’s an issue particularly for the millions of people who go to doctors’ offices in pain.
The scans are expensive — Medicare and its beneficiaries pay about $750 to $950 for an M.R.I. scan of a knee or back, for example. Many doctors own their own scanners, which can provide an incentive to offer scans to their patients.
And so, in what is often an irresistible feedback loop, patients who are in pain often demand scans hoping to find out what is wrong, doctors are tempted to offer scans to those patients, and then, once a scan is done, it is common for doctors and patients to assume that any abnormalities found are the reason for the pain.
But in many cases it is just not known whether what is seen on a scan is the cause of the pain. The problem is that all too often, no one knows what is normal.
“A patient comes in because he’s in pain,” said Dr. Nelda Wray, a senior research scientist at the Methodist Institute for Technology in Houston. “We see something in a scan, and we assume causation. But we have no idea of the prevalence of the abnormality in routine populations.”
Now, as more and more people have scans for everything from headaches to foot aches, more are left in a medical lurch, or with unnecessary or sometimes even harmful treatments, including surgery.
“Every time we get a new technology that provides insights into structures we didn’t encounter before, we end up saying, ‘Oh, my God, look at all those abnormalities.’ They might be dangerous,” said Dr. David Felson, a professor of medicine and epidemiology at Boston University Medical School. “Some are, some aren’t, but it ends up leading to a lot of care that’s unnecessary.”
That was what almost happened with Mrs. Weinstein, an active, athletic 64-year-old who lives in New London, N.H. And it was her great fortune to finally visit a surgeon who told her so. He told her bluntly that her pain was caused by arthritis, not the torn cartilage.
No one had told her that before, Mrs. Weinstein said, and looking back on her quest to get a scan and get the cartilage fixed, she shook her head in dismay. There’s no surgical procedure short of a knee replacement that will help, and she’s not ready for a knee replacement.
“I feel that I have come full circle,” she said. “I will cope on my own with this knee.”
In fact, Mrs. Weinstein was also lucky because her problem was with her knee. It’s one of only two body parts — the other is the back — where there are good data on abnormalities that turn up in people who feel just fine, indicating that the abnormalities may not be so abnormal after all.
But even the data on knees comes from just one study, and researchers say the problem is far from fixed. It is difficult to conduct scans on people who feel fine — most do not want to spend time in an M.R.I. machine, and CT scans require that people be exposed to radiation. But that leaves patients and doctors in an untenable situation.
“It’s a concern, isn’t it?” said Dr. Jeffrey Jarvik, a professor of radiology and neurosurgery at the University of Washington. “We are trying to fix things that shouldn’t be fixed.”
As a rheumatologist, Dr. Felson saw patient after patient with knee pain, many of whom had already had scans. And he was becoming concerned about their findings.
Often, a scan would show that a person with arthritis had a torn meniscus, cartilage that stabilizes the knee. And often the result was surgery — orthopedic surgeons do more meniscus surgery than any other operation. But, Dr. Felson wondered, was the torn cartilage an injury causing pain or was the arthritis causing pain and the tear a consequence of arthritis?
That led Dr. Felson and his colleagues to do the first and so far the only large study of knees, asking what is normal. It involved M.R.I. scans on 991 people ages 50 to 90. Some had knee pain, others did not.
On Sept. 11, Dr. Felson and his colleagues published their results in The New England Journal of Medicine: meniscal tears were just as common in people with knee arthritis who did not complain of pain as they were in people with knee arthritis who did have pain. They tended to occur along with arthritis and were a part of the disease process itself. And so repairing the tears would not eliminate the pain.
“The rule is, as you get older, you will get a meniscal tear,” Dr. Felson said. “It’s a function of aging and disease. If you are a 60-year-old guy, the chance that you have a meniscal tear is 40 percent.”
It is a result that paralleled what spine researchers found over the past decade in what is perhaps the best evidence on what shows up on scans of healthy people. “If you’re going to look at a spine, you need to know what that spine might look like in a normal patient,” said Dr. Michael Modic, chairman of the Neurological Institute at the Cleveland Clinic.
After Dr. Modic and others scanned hundreds of asymptomatic people, they learned abnormalities were common.
“Somewhere between 20 and 25 percent of people who climb into a scanner will have a herniated disk,” Dr. Modic said. As many as 60 percent of healthy adults with no back pain, he said, have degenerative changes in their spines.
Those findings made Dr. Modic ask: Why do a scan in the first place? There are some who may benefit from surgery, but does it make sense to routinely do scans for nearly everyone with back pain? After all, one-third of herniated disks disappear on their own in six weeks, and two-thirds in six months.
And surgeons use symptoms and a physical examination to identify patients who would be helped by operations. What extra medical help does a scan provide? So Dr. Modic did another study, this time with 250 patients. All had M.R.I. scans when they first arrived complaining of back pain or shooting pains down their leg, which can be caused by a herniated disc pressing on a nerve in the spine. And all had scans again six weeks later. Sixty percent had herniated disks, the scans showed.
Dr. Modic gave the results to only half of the patients and their doctors — the others had no idea what the M.R.I.’s revealed. Dr. Modic knew, though.
In 13 percent of the patients, the second scan showed that the herniated disk had become bigger or a new herniated disk had appeared. In 15 percent, the herniated disk had disappeared. But there was no relationship between the scan findings at six weeks and patients’ symptoms. Some continued to complain of pain even though their herniated disk had disappeared; others said they felt better even though their herniation had grown bigger.
The question, though, was whether it helped the patients and their doctors to know what the M.R.I.’s had found. And the answer, Dr. Modic reported, is that it did not. The patients who knew recovered no faster than those who did not know. However, Dr. Modic said, there was one effect of being told — patients felt worse about themselves when they knew they had a bulging disk.
“If I tell you that you have a degenerated disk, basically I’m telling you you’re ugly,” Dr. Modic said.
Scans, he said, are presurgical tools, not screening tools. A scan can help a surgeon before he or she operates, but it does not help with a diagnosis.
“If a patient has back or leg pain, they should be treated conservatively for at least eight weeks,” Dr. Modic said, meaning that they take pain relievers and go about their normal lives. “Then you should do imaging only if you are going to do surgery.”
That message can be a hard sell, he acknowledged. “A lot of people are driven by wanting to have imaging,” Dr. Modic said. “They are miserable as hell, they can’t work, they can’t sit. We look at you and say, ‘We think you have a herniated disk. We say the natural history is that you will get better. You should go through six to eight weeks of conservative management.’ ”
At the Partners Healthcare System in Boston, spine experts have the same struggle to convince patients that an M.R.I. scan is not necessarily desirable, said Dr. Scott Gazelle, director of radiology there.
“The consensus is that you are a surgical candidate or not based on your history and physical findings, not on imaging findings,” he said.
Dr. Gazelle had a chance last year to test his own convictions. He had the classic symptoms of a herniated disk — shooting pains down his left leg, a numb foot and difficulty walking.
Dr. Gazelle went to see his primary-care doctor but, he said, “I didn’t get an M.R.I.” That decision, he added, “was the right thing to do.”
About three months later, he had recovered on his own.
In 1998, two medical scientists, writing in The Lancet, proposed what sounded like a radical idea. Instead of simply providing patients and their doctors with the results of an X-ray or an M.R.I. scan, he said, radiologists should put the findings in context. For example, they wrote, if a scan showed advanced disk deterioration, the report should say, “Roughly 40 percent of patients with this finding do not have back pain so the finding may be unrelated.”
It is an idea that only would work for back pain, because that is the one area where radiologists have enough data. But it made eminent sense to Dr. Jarvik. “It gives referring physicians some sort of context,” he said.
So, a few years ago, with some trepidation, his radiology group starting including epidemiological data in their reports. “We thought, ‘What’s going to be the reaction among referring physicians?’ ” Dr. Jarvik said. Their fear was that doctors would start choosing other places for M.R.I.’s and that Dr. Jarvik’s group would lose business.
Because of the way the university’s records are kept, it’s hard to know whether the new reporting system had that effect, Dr. Jarvik said. But he was heartened by the responses of some doctors, like Dr. Sohail Mirza, who recently moved to Dartmouth Medical School.
“We often see patients who have already had M.R.I. scans,” Dr. Mirza said. “They are fixated on the abnormality and come to a surgeon to try to get the abnormality fixed. They’ll come in with the report in hand.”
The new sort of report, Dr. Mirza said, was “very helpful information to have when talking to patients and very helpful for patients to help them understand that the abnormalities were not catastrophic findings.”
Others, like Dr. Modic, are hesitant about reporting epidemiology along with a patient’s scan findings.
“It’s an interesting idea,” he said. But, he added: “The problem isn’t what happens after they get their imaging. It’s that they get the imaging in the first place.”
That was what happened with Mrs. Weinstein.
When she started looking up her symptoms on the Internet, she decided she probably had a meniscus tear. “I was very forceful in asking for an M.R.I.,” she said.
And when the scan showed that her meniscus was torn, she went to a surgeon expecting an operation.
He X-rayed her knee and told her she had arthritis. Then, Mrs. Weinstein said, the surgeon looked at her and said, “Let me get this straight. Are you here for a knee replacement?”
She said no, of course not. She skis, she does aerobics, she was nowhere near ready for something so drastic.
Then the surgeon told her that there was no point in repairing her meniscus because that was not her problem. And if he repaired the cartilage, her arthritic bones would just grind it down again.
For now, Mrs. Weinstein says she is finished with her medical odyssey.
“I continue to live with this, whatever they call it, this arthritic knee,” she said.
The Evidence Gap
Diagnosing the Wrong Problem
Articles in this series, are exploring medical treatments used despite scant proof that they work and are examining steps toward medicine based on evidence.
Previous Articles in the Series »
Multimedia
Dartmouth-Hitchcock Medical Center
It was the start of her medical odyssey, a journey that led her to specialists, physical therapy, Internet searches and, finally, an M.R.I. scan that showed a torn cartilage and convinced her that her only hope for relief was to have surgery to repair it. But in fact, fixing the torn cartilage that was picked up on the scan was not going to solve her problem, which, eventually, she found was caused by arthritis.
Scans — more sensitive and easily available than ever — are increasingly finding abnormalities that may not be the cause of the problem for which they are blamed. It’s an issue particularly for the millions of people who go to doctors’ offices in pain.
The scans are expensive — Medicare and its beneficiaries pay about $750 to $950 for an M.R.I. scan of a knee or back, for example. Many doctors own their own scanners, which can provide an incentive to offer scans to their patients.
And so, in what is often an irresistible feedback loop, patients who are in pain often demand scans hoping to find out what is wrong, doctors are tempted to offer scans to those patients, and then, once a scan is done, it is common for doctors and patients to assume that any abnormalities found are the reason for the pain.
But in many cases it is just not known whether what is seen on a scan is the cause of the pain. The problem is that all too often, no one knows what is normal.
“A patient comes in because he’s in pain,” said Dr. Nelda Wray, a senior research scientist at the Methodist Institute for Technology in Houston. “We see something in a scan, and we assume causation. But we have no idea of the prevalence of the abnormality in routine populations.”
Now, as more and more people have scans for everything from headaches to foot aches, more are left in a medical lurch, or with unnecessary or sometimes even harmful treatments, including surgery.
“Every time we get a new technology that provides insights into structures we didn’t encounter before, we end up saying, ‘Oh, my God, look at all those abnormalities.’ They might be dangerous,” said Dr. David Felson, a professor of medicine and epidemiology at Boston University Medical School. “Some are, some aren’t, but it ends up leading to a lot of care that’s unnecessary.”
That was what almost happened with Mrs. Weinstein, an active, athletic 64-year-old who lives in New London, N.H. And it was her great fortune to finally visit a surgeon who told her so. He told her bluntly that her pain was caused by arthritis, not the torn cartilage.
No one had told her that before, Mrs. Weinstein said, and looking back on her quest to get a scan and get the cartilage fixed, she shook her head in dismay. There’s no surgical procedure short of a knee replacement that will help, and she’s not ready for a knee replacement.
“I feel that I have come full circle,” she said. “I will cope on my own with this knee.”
In fact, Mrs. Weinstein was also lucky because her problem was with her knee. It’s one of only two body parts — the other is the back — where there are good data on abnormalities that turn up in people who feel just fine, indicating that the abnormalities may not be so abnormal after all.
But even the data on knees comes from just one study, and researchers say the problem is far from fixed. It is difficult to conduct scans on people who feel fine — most do not want to spend time in an M.R.I. machine, and CT scans require that people be exposed to radiation. But that leaves patients and doctors in an untenable situation.
“It’s a concern, isn’t it?” said Dr. Jeffrey Jarvik, a professor of radiology and neurosurgery at the University of Washington. “We are trying to fix things that shouldn’t be fixed.”
As a rheumatologist, Dr. Felson saw patient after patient with knee pain, many of whom had already had scans. And he was becoming concerned about their findings.
Often, a scan would show that a person with arthritis had a torn meniscus, cartilage that stabilizes the knee. And often the result was surgery — orthopedic surgeons do more meniscus surgery than any other operation. But, Dr. Felson wondered, was the torn cartilage an injury causing pain or was the arthritis causing pain and the tear a consequence of arthritis?
That led Dr. Felson and his colleagues to do the first and so far the only large study of knees, asking what is normal. It involved M.R.I. scans on 991 people ages 50 to 90. Some had knee pain, others did not.
On Sept. 11, Dr. Felson and his colleagues published their results in The New England Journal of Medicine: meniscal tears were just as common in people with knee arthritis who did not complain of pain as they were in people with knee arthritis who did have pain. They tended to occur along with arthritis and were a part of the disease process itself. And so repairing the tears would not eliminate the pain.
“The rule is, as you get older, you will get a meniscal tear,” Dr. Felson said. “It’s a function of aging and disease. If you are a 60-year-old guy, the chance that you have a meniscal tear is 40 percent.”
It is a result that paralleled what spine researchers found over the past decade in what is perhaps the best evidence on what shows up on scans of healthy people. “If you’re going to look at a spine, you need to know what that spine might look like in a normal patient,” said Dr. Michael Modic, chairman of the Neurological Institute at the Cleveland Clinic.
After Dr. Modic and others scanned hundreds of asymptomatic people, they learned abnormalities were common.
“Somewhere between 20 and 25 percent of people who climb into a scanner will have a herniated disk,” Dr. Modic said. As many as 60 percent of healthy adults with no back pain, he said, have degenerative changes in their spines.
Those findings made Dr. Modic ask: Why do a scan in the first place? There are some who may benefit from surgery, but does it make sense to routinely do scans for nearly everyone with back pain? After all, one-third of herniated disks disappear on their own in six weeks, and two-thirds in six months.
And surgeons use symptoms and a physical examination to identify patients who would be helped by operations. What extra medical help does a scan provide? So Dr. Modic did another study, this time with 250 patients. All had M.R.I. scans when they first arrived complaining of back pain or shooting pains down their leg, which can be caused by a herniated disc pressing on a nerve in the spine. And all had scans again six weeks later. Sixty percent had herniated disks, the scans showed.
Dr. Modic gave the results to only half of the patients and their doctors — the others had no idea what the M.R.I.’s revealed. Dr. Modic knew, though.
In 13 percent of the patients, the second scan showed that the herniated disk had become bigger or a new herniated disk had appeared. In 15 percent, the herniated disk had disappeared. But there was no relationship between the scan findings at six weeks and patients’ symptoms. Some continued to complain of pain even though their herniated disk had disappeared; others said they felt better even though their herniation had grown bigger.
The question, though, was whether it helped the patients and their doctors to know what the M.R.I.’s had found. And the answer, Dr. Modic reported, is that it did not. The patients who knew recovered no faster than those who did not know. However, Dr. Modic said, there was one effect of being told — patients felt worse about themselves when they knew they had a bulging disk.
“If I tell you that you have a degenerated disk, basically I’m telling you you’re ugly,” Dr. Modic said.
Scans, he said, are presurgical tools, not screening tools. A scan can help a surgeon before he or she operates, but it does not help with a diagnosis.
“If a patient has back or leg pain, they should be treated conservatively for at least eight weeks,” Dr. Modic said, meaning that they take pain relievers and go about their normal lives. “Then you should do imaging only if you are going to do surgery.”
That message can be a hard sell, he acknowledged. “A lot of people are driven by wanting to have imaging,” Dr. Modic said. “They are miserable as hell, they can’t work, they can’t sit. We look at you and say, ‘We think you have a herniated disk. We say the natural history is that you will get better. You should go through six to eight weeks of conservative management.’ ”
At the Partners Healthcare System in Boston, spine experts have the same struggle to convince patients that an M.R.I. scan is not necessarily desirable, said Dr. Scott Gazelle, director of radiology there.
“The consensus is that you are a surgical candidate or not based on your history and physical findings, not on imaging findings,” he said.
Dr. Gazelle had a chance last year to test his own convictions. He had the classic symptoms of a herniated disk — shooting pains down his left leg, a numb foot and difficulty walking.
Dr. Gazelle went to see his primary-care doctor but, he said, “I didn’t get an M.R.I.” That decision, he added, “was the right thing to do.”
About three months later, he had recovered on his own.
In 1998, two medical scientists, writing in The Lancet, proposed what sounded like a radical idea. Instead of simply providing patients and their doctors with the results of an X-ray or an M.R.I. scan, he said, radiologists should put the findings in context. For example, they wrote, if a scan showed advanced disk deterioration, the report should say, “Roughly 40 percent of patients with this finding do not have back pain so the finding may be unrelated.”
It is an idea that only would work for back pain, because that is the one area where radiologists have enough data. But it made eminent sense to Dr. Jarvik. “It gives referring physicians some sort of context,” he said.
So, a few years ago, with some trepidation, his radiology group starting including epidemiological data in their reports. “We thought, ‘What’s going to be the reaction among referring physicians?’ ” Dr. Jarvik said. Their fear was that doctors would start choosing other places for M.R.I.’s and that Dr. Jarvik’s group would lose business.
Because of the way the university’s records are kept, it’s hard to know whether the new reporting system had that effect, Dr. Jarvik said. But he was heartened by the responses of some doctors, like Dr. Sohail Mirza, who recently moved to Dartmouth Medical School.
“We often see patients who have already had M.R.I. scans,” Dr. Mirza said. “They are fixated on the abnormality and come to a surgeon to try to get the abnormality fixed. They’ll come in with the report in hand.”
The new sort of report, Dr. Mirza said, was “very helpful information to have when talking to patients and very helpful for patients to help them understand that the abnormalities were not catastrophic findings.”
Others, like Dr. Modic, are hesitant about reporting epidemiology along with a patient’s scan findings.
“It’s an interesting idea,” he said. But, he added: “The problem isn’t what happens after they get their imaging. It’s that they get the imaging in the first place.”
That was what happened with Mrs. Weinstein.
When she started looking up her symptoms on the Internet, she decided she probably had a meniscus tear. “I was very forceful in asking for an M.R.I.,” she said.
And when the scan showed that her meniscus was torn, she went to a surgeon expecting an operation.
He X-rayed her knee and told her she had arthritis. Then, Mrs. Weinstein said, the surgeon looked at her and said, “Let me get this straight. Are you here for a knee replacement?”
She said no, of course not. She skis, she does aerobics, she was nowhere near ready for something so drastic.
Then the surgeon told her that there was no point in repairing her meniscus because that was not her problem. And if he repaired the cartilage, her arthritic bones would just grind it down again.
For now, Mrs. Weinstein says she is finished with her medical odyssey.
“I continue to live with this, whatever they call it, this arthritic knee,” she said.
Study: 4 Out of 5 Doctors Don’t Get Enough Exercise
By Amanda MacMillan
As a health writer, people often ask me if I’ve changed my lifestyle to become a healthier person. Do I eat healthier, work out more, and actually put to use any of those nifty tips I learn about every day?
For a long time, my response was, “No—I still have all the same bad habits; now I just feel guiltier about them.”
I did eventually get involved in fitness and running, partially thanks to my job. But I still find it hard to squeeze in a workout most days, even though I know how important it is to my long-term health.
Turns out, I’m probably not the only health-related professional who feels that way. Most doctors, who know the dangers of inactivity more than anyone, don’t get enough exercise, according to a study published this month in the British Journal of Sports Medicine.
Almost 80% of doctors fall short
Researchers at the United Kingdom’s Bedford Hospital NHS Trust surveyed 61 hospital physicians and found that only 21% get the recommended 30 minutes of moderate exercise at least five days a week—that’s less than half of the 44% of the overall population in the same age group who claim to meet this goal. Those who didn’t blamed lack of time, lack of motivation, or lack of workout facilities. (Doctors with an on-site gym at their hospital didn’t fare any better than those without, however. In fact, a third of them didn’t even know it existed!)
Other good habits had seemed to rub off on the junior doctors, who had an average age of 27 and an average BMI of 23.5 (considered normal weight): They weighed less and smoked less than the national average, and only 7% drank more than the recommended weekly amount of alcohol. As for their abysmal exercise habits, many had been more active in school—and had only become couch potatoes after they started their jobs.
What does it mean for us?
While the study was done on British hospital doctors (as opposed to, say, American primary-care physicians), coauthor Lampson Fan, MBBS, is willing to bet that findings would be similar elsewhere: “In both the U.K. and U.S., doctors are under the influence of the same stresses,” he says. “In many ways, it’s probably worse in the U.S. as the doctors there are working on average 30 hours more [a week] than those in the U.K.”
While I can’t say I’m shocked at these results, the numbers are quite disheartening. If doctors, whose responsibility it should be to promote good health, can’t find time to exercise, what hope is there for others out there with demanding schedules—lawyers, truck drivers, working moms, or people who have taken on a second job?
Previous research has shown that doctors who exercise are more likely to counsel their patients to do the same, and that patients are more willing to try exercising when their doctors disclose their own personal workout habits. Think about it: If an out-of-shape doctor pleaded with you to get more exercise, how seriously could you take him knowing that he’s not getting enough himself?
Dr. Lampson recommends that health-care institutions do more to promote physical activity among employees, such as sponsoring organized exercise classes, team sports, and discounts with local gyms. If doctors can get passionate about exercise, hopefully they’ll pass on that excitement to their patients—or at least set a good example.
Does the physical fitness of your doctor matter to you? Have you ever been motivated—or discouraged—by the health of a physician?
As a health writer, people often ask me if I’ve changed my lifestyle to become a healthier person. Do I eat healthier, work out more, and actually put to use any of those nifty tips I learn about every day?
For a long time, my response was, “No—I still have all the same bad habits; now I just feel guiltier about them.”
I did eventually get involved in fitness and running, partially thanks to my job. But I still find it hard to squeeze in a workout most days, even though I know how important it is to my long-term health.
Turns out, I’m probably not the only health-related professional who feels that way. Most doctors, who know the dangers of inactivity more than anyone, don’t get enough exercise, according to a study published this month in the British Journal of Sports Medicine.
Almost 80% of doctors fall short
Researchers at the United Kingdom’s Bedford Hospital NHS Trust surveyed 61 hospital physicians and found that only 21% get the recommended 30 minutes of moderate exercise at least five days a week—that’s less than half of the 44% of the overall population in the same age group who claim to meet this goal. Those who didn’t blamed lack of time, lack of motivation, or lack of workout facilities. (Doctors with an on-site gym at their hospital didn’t fare any better than those without, however. In fact, a third of them didn’t even know it existed!)
Other good habits had seemed to rub off on the junior doctors, who had an average age of 27 and an average BMI of 23.5 (considered normal weight): They weighed less and smoked less than the national average, and only 7% drank more than the recommended weekly amount of alcohol. As for their abysmal exercise habits, many had been more active in school—and had only become couch potatoes after they started their jobs.
What does it mean for us?
While the study was done on British hospital doctors (as opposed to, say, American primary-care physicians), coauthor Lampson Fan, MBBS, is willing to bet that findings would be similar elsewhere: “In both the U.K. and U.S., doctors are under the influence of the same stresses,” he says. “In many ways, it’s probably worse in the U.S. as the doctors there are working on average 30 hours more [a week] than those in the U.K.”
While I can’t say I’m shocked at these results, the numbers are quite disheartening. If doctors, whose responsibility it should be to promote good health, can’t find time to exercise, what hope is there for others out there with demanding schedules—lawyers, truck drivers, working moms, or people who have taken on a second job?
Previous research has shown that doctors who exercise are more likely to counsel their patients to do the same, and that patients are more willing to try exercising when their doctors disclose their own personal workout habits. Think about it: If an out-of-shape doctor pleaded with you to get more exercise, how seriously could you take him knowing that he’s not getting enough himself?
Dr. Lampson recommends that health-care institutions do more to promote physical activity among employees, such as sponsoring organized exercise classes, team sports, and discounts with local gyms. If doctors can get passionate about exercise, hopefully they’ll pass on that excitement to their patients—or at least set a good example.
Does the physical fitness of your doctor matter to you? Have you ever been motivated—or discouraged—by the health of a physician?
Half-Dose Flu Shots Work In Adults, Study Finds
Half-Dose Flu Shots Work In Adults, Study Finds
By Lindsey Tanner, AP Medical Writer
posted: 09 December 2008 03:59 pm ET
CHICAGO — Half-dose flu shots are effective in adults, especially in women and those younger than 50, and offer a viable way to stretch supplies during vaccine shortages, a government study found.
The strategy also might be an option during hard economic times since lower doses likely would mean cheaper shots, said Vanderbilt University vaccine expert Dr. Kathryn Edwards, who wasn't involved in the study. And the lower dosage could open doors to vaccinating people in poor countries where flu shots are little used, she said.
Even so, Edwards said giving half-dose flu shots isn't ready for prime time. It's still experimental and hasn't been approved by federal authorities.
The study involved 1,114 adults aged 18 to 64. It's the first to test half-dose flu shots in those aged 50 and older during a single flu season, 2004-05. The results among younger adults echo previous research, said lead author Dr. Renata Engler of Walter Reed Army Medical Center.
The government-funded study appears in Monday's Archives of Internal Medicine.
"Traditionally, vaccine programs have followed a 'one-size-fits-all' approach," Engler said. That means everyone gets the same dose and during shortages, supplies are more likely to run out.
If the study results are confirmed through additional research, Engler said, half-doses could be given to large numbers of adults, enabling more people to get vaccinated.
That's important because while influenza is often underestimated, the federal Centers for Disease Control and Prevention says each year the disease is responsible for about 36,000 deaths and 200,000 hospitalizations nationwide.
In the study, participants were randomly chosen to get full- or half-dose flu shots in late 2004 in the Washington D.C. area. The researchers measured blood levels of antibodies to flu virus before vaccination and 21 days afterward.
After the shots, similar numbers of adults of all ages, including men and women, had antibody levels considered adequate to protect against the flu.
The 18-to-49 age group and women had the highest antibody levels. That adds to evidence that women may be more sensitive to some vaccines than men.
Dr. Ronald Hershow, an infectious disease specialist at the University of Illinois's Chicago campus, noted that while half-doses produced an adequate immune response, full doses produced a stronger response. And there's evidence that stronger immune responses provide better protection against disease, he said.
Still, the study authors argued that from a public health standpoint, it would be better to vaccinate many people with lower doses than fewer people with full doses when vaccine supplies are scarce.
There were few reports of flu-like illnesses among the study volunteers, but the number of people of all ages with those symptoms was similar in both the full-dose and half-dose groups.
Engler noted that because adults in their 60s and older are more vulnerable to flu complications, more research is needed to be sure that half-doses are adequate for them.
The study was done during the vaccine shortage in the winter of 2004-05 when contamination was found at a major vaccine supplier's plant in Britain.
Now, there are five licensed flu vaccine manufacturers, making shortages in the near future unlikely. Still, Dr. Joseph Bresee, the CDC's flu chief, said the study provides useful information just in case.
Flu season starts in the fall and this year is off to a pretty typical start, with low levels of disease nationwide, Bresee said.
"It's still a good time to get a vaccine," Bresee said.
By Lindsey Tanner, AP Medical Writer
posted: 09 December 2008 03:59 pm ET
CHICAGO — Half-dose flu shots are effective in adults, especially in women and those younger than 50, and offer a viable way to stretch supplies during vaccine shortages, a government study found.
The strategy also might be an option during hard economic times since lower doses likely would mean cheaper shots, said Vanderbilt University vaccine expert Dr. Kathryn Edwards, who wasn't involved in the study. And the lower dosage could open doors to vaccinating people in poor countries where flu shots are little used, she said.
Even so, Edwards said giving half-dose flu shots isn't ready for prime time. It's still experimental and hasn't been approved by federal authorities.
The study involved 1,114 adults aged 18 to 64. It's the first to test half-dose flu shots in those aged 50 and older during a single flu season, 2004-05. The results among younger adults echo previous research, said lead author Dr. Renata Engler of Walter Reed Army Medical Center.
The government-funded study appears in Monday's Archives of Internal Medicine.
"Traditionally, vaccine programs have followed a 'one-size-fits-all' approach," Engler said. That means everyone gets the same dose and during shortages, supplies are more likely to run out.
If the study results are confirmed through additional research, Engler said, half-doses could be given to large numbers of adults, enabling more people to get vaccinated.
That's important because while influenza is often underestimated, the federal Centers for Disease Control and Prevention says each year the disease is responsible for about 36,000 deaths and 200,000 hospitalizations nationwide.
In the study, participants were randomly chosen to get full- or half-dose flu shots in late 2004 in the Washington D.C. area. The researchers measured blood levels of antibodies to flu virus before vaccination and 21 days afterward.
After the shots, similar numbers of adults of all ages, including men and women, had antibody levels considered adequate to protect against the flu.
The 18-to-49 age group and women had the highest antibody levels. That adds to evidence that women may be more sensitive to some vaccines than men.
Dr. Ronald Hershow, an infectious disease specialist at the University of Illinois's Chicago campus, noted that while half-doses produced an adequate immune response, full doses produced a stronger response. And there's evidence that stronger immune responses provide better protection against disease, he said.
Still, the study authors argued that from a public health standpoint, it would be better to vaccinate many people with lower doses than fewer people with full doses when vaccine supplies are scarce.
There were few reports of flu-like illnesses among the study volunteers, but the number of people of all ages with those symptoms was similar in both the full-dose and half-dose groups.
Engler noted that because adults in their 60s and older are more vulnerable to flu complications, more research is needed to be sure that half-doses are adequate for them.
The study was done during the vaccine shortage in the winter of 2004-05 when contamination was found at a major vaccine supplier's plant in Britain.
Now, there are five licensed flu vaccine manufacturers, making shortages in the near future unlikely. Still, Dr. Joseph Bresee, the CDC's flu chief, said the study provides useful information just in case.
Flu season starts in the fall and this year is off to a pretty typical start, with low levels of disease nationwide, Bresee said.
"It's still a good time to get a vaccine," Bresee said.
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