The Latest News in Rheumatology
8/23/2002
Reliability of Self Assessed Joint Counts in Ankylosing
Spondylitis
Food For Thought on Whether Traditional Chinese
Medicine Works
Short-Term Effects on Linear Growth and Bone Turnover
in Children Randomized to Receive Prednisolone or Dexamethasone
New Book Evaluates the Risks and Benefits of
Volunteering for Clinical Trials
Study: Benefits of Exercise Overlooked by
Rheumatologists
Editorial on U.S. Healthcare: "It's a Jungle Out
There, and You're on Your Own"
A. Spoorenberg and colleagues conducted a study to determine the reliability
of self reported joint counts to assess pain or swelling in ankylosing
spondylitis (AS). The results were published in a recent article for the Annals
of the Rheumatic Diseases.
217 AS patients marked their painful joints and swollen joints on mannequins.
A doctor or research nurse assessed the same joints for pain and swelling on the
same day (after mannequin completion by the patient) without information on the
results of the patient's assessment.
Twenty-one percent of the patients reported one or more swollen joints, and
the doctors found one or more swollen joints in 25% of the patients. The overall
agreement on the number of swollen joints between patients and doctor was
moderate. Agreement on individual swollen joints was poor to moderate.
Sixty percent of the patients reported tender joints, and the doctors
reported one or more tender joints in 50% of the patients. Again, the overall
agreement was moderate, and the agreement on individual tender joints was poor
to moderate.
The only area that both doctors and patients highly agreed upon was the
absence of swollen joints (82%).
Spoorenberg and colleagues say that joint counts in AS assessed by doctors
cannot be replaced by joint counts reported by the patients because there is a
high discrepancy in assessment of individual joints and the total number of
affected joints. Furthermore, this study suggests that patients are only able to
judge if their joints are not swollen.
A continuous topic for debate concerns whether popular "alternative
medicines", such as Chinese herbal remedies and spiritual therapies,
actually help or harm patients using the treatment.
Xiaorui Zhang, who is from China and a World Health Organization coordinator
on traditional medicine policy, states: "Western medicine came to China
about 100 years ago. That Chinese people survived for thousands of years without
Western medicine shows that it (traditional medicine) works."
Gerald Weissmann, M.D. counters Zhang's claims by offering the following
timeline of life expectancy statistics.
Fact #1:
Xinhua, the official propaganda press agency of the People's Republic of China,
details how "beneficial" China's occupation has been for the Tibetans:
"The life expectancy in Tibet has almost doubled in the past half century,
from an average of 35.5 years to 67 years."
http://www.tibet.ca/wtnarchive/2002/4/8_6.html
Fact #2
According to the People's Daily, 10/10/200:
The Chinese average life expectancy has risen to 71 from just over 30 years old
at the beginning of the 1900's. Zhao Baohua, vice-director of the China
Association for Aged People, attributes the rise to the advancement of science
and technology, especially in medical science.
http://www.lai-aib.org/lai/article_lai.phtml?section=A3ABAA&object_id=7553
Fact #3:
From the U.S. Census Bureau -
Life expectancy at birth in China in 1949 35 years*
Life expectancy at birth in U.S. in 1949 67 male,
73 female
Life expectancy at birth in China in 2000 69.6 male, 73.3
female
Life expectancy at birth in U.S. in 2002 74.2
male, 79.9 female
* first year of nationwide record-keeping; no separate gender data
http://www.census.gov/ftp/pub/ipc/www/idbsum.html
Dr. Weissmann comments that the life expectancy in China seems to have doubled
since the introduction of Western medicine, which include sanitation,
vaccination, antibiotics, etc.
He says that Chinese traditional medicine may have worked for thousands of
years, "but if one judges by the only end-point that really counts,
longevity, it seems to have worked only half as well as Western Medicine--You
don't double a country's life expectancy with herbs and acupuncture."
A recent study published in the August 2002 issue of Clinical
Endocrinology compared the potency of prednisolone and dexamethasone on
short-term growth and bone turnover in children with acute lymphoblastic
leukemia.
Results: Nineteen children from the Royal Hospital for Sick Children
in Yorkhill, Glasgow participated in the study. Researchers S. F. Ahmed and
colleagues found that both prednisolone and dexamethasone affected short-term
growth and bone turnover, but conclude that the mechanism of the effect on bone
formation may be different between the two drugs.
Dexamethasone appeared to be 18 times more potent than prednisolone at
suppressing short-term linear growth and stimulating weight gain, and nine times
more potent at suppressing bone turnover.
The study did not mention children with Juvenile Ankylosing Spondylitis
(JAS), although short-term growth and bone turnover are also of concern in
children with JAS.
In 2002, more than one million individuals will participate in 80,000
clinical trials in the U.S., most of which are sponsored by pharmaceutical
companies. These trials are critical for screening new drugs' effectiveness, and
many people enroll for access to new medications not yet available to the
public. But participation is not always beneficial to the patient.
David Shimm, MD, FACP, reviews a new book titled Informed Consent: The
Consumer's Guide to the Risks and Benefits of Volunteering for Clinical Trials,
written by Kenneth Getz and Deborah Borfitz.
Getz is the president of CenterWatch, an Internet clearinghouse for clinical
trials, so Shimm feels the books is particularly impressive because it does not
shy away from discussing potential financial conflicts of interest (which could
lead the investigator to pressure a patient to enter a trial).
The authors stress that people should ask questions, such as whether
clinical investigators are being paid by the sponsor to enroll patients in a
clinical trial, and to discuss alternatives to entering the trial with the
investigator and with their personal physician to make sure that this is the
best action for the patient.
Overall, Shimm believes that Informed Consent offers a valuable guide
to patients considering entering clinical trials, and "provides a wealth of
the background material that underpins current human subject protection
regulations."
For further information and a listing of current trials, visit the FDA
Clinical Trials web site at www.fda.com/clinical_trialsA-D.htm.
According to an editorial article published in the August issue of the Annals
of Rheumatic Diseases, rehabilitation expert Dr.
Mike V. Hurley (King's College, London) states that rheumatologists and other
healthcare professionals are not emphasizing the benefits of exercise enough to
people suffering from osteoarthritis and other rheumatic conditions.
He wants physicians to place a higher priority on exercise in the management
of rheumatic conditions: "Failing to recommend exercise to our patients is
professional negligence."
Hurley says that doctors and the public generally regard osteoarthritis as an
inevitable, untreatable consequence of life. Although reputable medical
organizations endorse exercise for people with arthritis, "less than half
of patients with rheumatic conditions report receiving exercise advice."
Furthermore, "it is incumbent on all healthcare professionals not to
give uninterested, half-hearted exercise advice but to convince people of the
benefits of regular exercise and physical activity, and ensure they can follow
our advice by demanding that appropriate facilities and resources are available
that will enable people to remain physically active."
He emphasizes that 30 minutes of accumulated physical exercise (such as
gardening, housework, brisk walks) a day can be just as beneficial as strenuous
sessions in a gym. People may be more likely to incorporate smaller chunks of
exercise in their schedule than "going for the burn" at a gym.
Hurley does not believe that exercise is the "miracle remedy" for
rheumatic conditions, but he would like rheumatologists to ensure that their
patients are following their exercise advice.
In a recent Washington Post editorial, author Melody Simmons
discusses the current U.S. health care system and how it affects consumers.
People who defend the U.S. health care system often argue that those who do
not have health insurance can always buy policies in the individual market.
Simmons discusses an article published in the magazine Consumer Reports to
demonstrate how expensive and difficult it can be to obtain policies in
individual markets. Some problems with these policies include:
- They are designed to screen out people who most likely need medical
coverage, and welcome those who are unlikely to need care.
- Coverage is often offered at an initial rate, and followed by a steep hike
in price.
- Treatment for maternity care/delivery, mental health, and substance abuse
are generally not covered.
- There is almost never prescription drug coverage.
What can consumers do?
The magazine's authors say there is very little the public can do because
people are at the mercy of the insurance companies.
However, Larry Levitt, vice president of the Kaiser Family Foundation, urges
consumers to shop around for individual policies on the Internet or through an
insurance broker. Unfortunately, he believes that as the economy continues to
slump, more people will find themselves relying on this market.
Twenty-nine states do offer a program to try and help the people most in need
of medical insurance.
Nearly 150,000 Americans get health insurance through their state's high-risk
pool--the only place where those in the worst health can find a policy. The
participating states are listed, along with this article, online at www.consumerreports.org.