The Latest News in Rheumatology
7/18/2002
Charting the Course of AS Using X-Rays
Coxibs
Safer on GI Tract Than Older NSAIDS
Medical Residents Face New Restricted Workweeks
Ultrasounds Are Superior to X-rays When Diagnosing
Crohn's Disease
Study Shows That More Physicians Are Surfing the Web
New
Book Explores Causes, Effects, and Prevention of Medical Errors
Combined Rheumatolgy / Orthopedic Clinics are "Way Forward"
Bath, UK-- According to a study published in the June 2002 issue of the Journal
of Rheumatology, x-rays show that AS is a chronic and progressive disease,
but individuals with the disease experience a great deal of variation. They note
that variation may be accounted for by presence of hip disease, iritis, and sex
of the patient.
Researchers studied 2284 radiographs from 1975-2001 for AS patients attending the Royal
National Hospital for Rheumatic Diseases in the UK. Because the damage is
irreversible, x-rays are a particularly reliable reflection of the natural
history of the disease.
They found that AS begins in the SI joints and moves up the spine in most
patients. Thus, spinal involvement seems to be largely an expression of disease
duration. Accordingly, the researchers comment: "It is possible that the
majority of variation in severity of radiological change may be accounted for by
genetic factors, as has been suggested for disease activity and functional
measures."
Iritis and hip involvement may also be associated with severity. Hip
involvement occurs in 20% to 30% of patients, and is a predictor of a more
severe outcome for the cervical spine. Patients with hip involvement usually
have a younger age of onset and more severe disease radiologically.
Study author Dr. Sinead Brophy and colleagues say that, "Patients with
severe disease in the initial 10 years will continue to have progressive and
severe disease in the future."
It should be noted that these patients were from a hospital session, and as a
result, might have had more severe and rapidly progressing disease that could
differ from the general population of people with AS.
A panel of experts examined in detail all available clinical data on two
COX-2 inhibitors--celecoxib (Celebrex®, Pharmacia & Pfizer) and rofecoxib (Vioxx®,
Merck & Co)--and have come to a consensus statement supporting the greater
GI safety of the two inhibitors when compared with traditional NSAIDS. They
published their conclusions from the "Consensus Conference Report" in the July
2002 issue of the Journal of Rheumatology.
The panel included 24 rheumatologists, gastroenterologists, nephrologists,
cardiologists, epidemiologists, and pharmacologists from North America and
Europe. At the time of the panel meeting in February 2001, Celebrex® and Vioxx®
were the only two COX-2 inhibitors available, which explains why new COX-2
inhibitors are not mentioned in this article.
From day one, claims that coxibs offer GI safety advantages over the older
and less-expensive traditional NSAIDS have been questioned and debated.
Recently, they faced further scrutiny when FDA-approved changes to the U.S.
labeling were different for each drug, fueling questions on whether Celebrex®,
in particular, offers any advantage.
Yet this panel estimates that Celebrex® and Vioxx® cause only half the number of
upper-GI complications than that of traditional NSAIDS. And even though data
from clinical trials suggest differences amid the two coxibs, this panel says
that "clinically relevant differences" have not yet been
confirmed.
The Accreditation Council for Graduate Medical Education (ACGME), which
oversees 7,800-plus U.S. teaching hospitals, announced new regulations for
medical residents that will take effect July 2003. ACGME is restricting
residents' workweeks to 80 hours, and limiting their duty to no more than 24
consecutive hours with at least 10 hours of rest between shifts.
However, enforcement of a set of similar structures in New York has become
relaxed through the years. New York State Code 405 has been in place since 1989,
following the Bell Commission report, which implicated the intense training
schedule as one problem leading to a patient's death.
Groups lobbying for a restricted workweek, such as the American Medical
Students Association, believe that the restrictions will reduce the risk of
errors caused by fatigued junior doctors.
Yet teaching hospitals rely on residents as a source of cheap labor, so some
of these hospitals fear that compliance with the new rules may increase costs by
millions of dollars, or lead to chronic staff shortages.
Results of a prospective trial published in the April issue of Gut
suggest that bowel ultrasound is accurate in identifying complications,
location, and extent of Crohn's disease.
F. Parente and colleagues from L. Sacco University Hospital in Milan, Italy,
studied 296 patients with Crohn's disease. They concluded that, "In
experienced hands, bowel ultrasound is an accurate technique for assessing
Crohn's disease extent and location, and is very helpful in detecting small
bowel strictures, especially in very severe cases that are candidates for
surgery."
Although recent studies show that bowel ultrasound is useful in
assessing bowel diseases, this study's researchers are quick to point out that
uncertainty persists to its diagnostic capabilities in patients with complicated
Crohn's disease. But they believe that bowel ultrasounds should be used initially in Crohn's
disease patients with suspected complications, even before performing
conventional x-ray studies.
Benefits of ultrasound include lack of radiation
exposure, ready availability, repeatability, and low cost. Yet the researchers
note that it takes a highly-skilled ultrasound operator to achieve accuracy
rates comparable to those published in their study.
A new study conducted by the American Medical Association (AMA) reveals that
almost half of physicians feel that the Internet has had a huge impact on the
way they practice medicine. The increasing influence of the Internet on clinical
medicine has greatly effected frequency and duration of web use among the 78% of
physicians who currently make use of cyberspace.
The findings come from the 2002 AMA Study on Physicians' Use of the World
Wide Web, in which they interviewed 977 physicians in the U.S.
They found the following trends:
- Physician use of the Internet is becoming more frequent. Two-thirds of
online physicians access the Internet daily, which is an increase of 24%
since 1997.
- Physicians are spending more hours online, with the average number of
hours a week jumping from 4.3 in 1997 to 7.1 in 2001. The doctors even
expect to use the Internet an average of 9.6 hours per week during the next
6 months.
- Approximately 3 of 10 physicians using the Internet have a web site.
- Web site development has been most prevalent among physicians in
obstetrics/gynecology and internal medicine.
Ann Arbor, MI-- Back in 1999, the Institute of Medicine issued a
scathing report on medical errors and their deadly toll. It opened many eyes to
the potential dangers that patients face from health care mistakes and mishaps,
and spawned a movement to increase patient safety. Now a new book picks up where
the previous left off by discussing new ways to think about the causes of
medical errors from top experts.
Authors Marilynn M. Rosenthal, Ph.D., and Kathleen M. Sutcliffe, Ph.D.,
collected essays from doctors, nurses, health care administrators, researchers
and organizational therapists to produce the new book, titled "Medical
Error: What Do We Know? What Do We Do?" (Joseey-Bass/Wiley).
The authors hope that the book will become a great resource for anyone
involved in health care. It addresses ways in which certain health care
approaches are outdated, examples of data on medical errors that has been
misinterpreted, critiques of the Institute of Medicine report, and new insights
and innovations concerning medical practices.
For anyone interested in purchasing this book, it is available by special
order in bookstores nationwide and online at all major bookseller web sites.
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Stockholm, Sweden-- A team of doctors from Wales feel that combined
rheumatology and orthopedic clinics "are definitely the right way
forward." They explained their findings in a poster session at the EULAR
meeting in Stockholm last month that these specialized clinics are very
effective.
According to Rheumatologist Dr. Margaret O'Sullivan (Wrexham Maelor Hospital,
Wrexham, Wales), the combined clinics work well because the rheumatologist often
knows the patient well from ongoing appointments. "It's very traumatic for
a patient to see a surgeon, but a lot of them have told me that when they know I
am going to be there, it's helpful."
The clinics are also useful for a second opinion from an orthopedic surgeon
when a patient does not accept the view of the rheumatologist. Patients can
discuss their concerns and hear input at the same time from the surgeon and
rheumatologist.
When asked whether she ever disagreed with the surgeon's decision at a
combined clinic, Dr. O'Sullivan commented, "It doesn't happen that
often--we are all there to try and make the right decisions. But if we can't
come to a compromise, we will carry out more investigations to help us
decide."
Although the U.S. does not have combined clinics, they are nothing new to the
medical world, and fairly accepted throughout the UK.