The Latest News in Rheumatology
8/30/2002
Exercise Habits Among Patients with Ankylosing Spondylitis: A Questionnaire Based Survey in the County of Vasterbotten, Sweden
Does a Regular Exercise Program for Ankylosing
Spondylitis Influence Body Image?
Anti-Tumor
Necrosis Factor Treatment Restores the Gut Barrier in Crohn's Disease
Traumatic Spinal Cord Injury as a Complication to
Ankylosing Spondylitis: An Extended Report
Total Hip Arthroplasty in Ankylosing Spondylitis: An Analysis of 181 Hips
Survival and Potential Years of Life Lost After Hip
Fracture in Men and Age-Matched Women
Juvenile Spondyloarthropathies and Related Arthritis
Beneficial
Effect of Climatic Therapy on Inflammatory Arthritis at Tiberias Hot Springs
Government to Consider Bar Code System for
Prescription Medication
Medical Students to Use Role-Play
In a recent article published in the Scandinavian Journal of Rheumatology,
researchers studied exercise habits among patients with AS to evaluate the
main restraints that keep these patients from exercising.
Results: B. Sundstrom and colleagues at the Department of Community
Medicine and Rehabilitation, Physiotherapy, Umea University of Sweden, studied
189 patients.
A majority of the patients reported that they performed exercises, the most
popular of which was walking. The participants rated water exercises in a pool
as the most enjoyable form of exercise, and it was perceived to relieve the
symptoms of AS more than any other exercise.
The main obstacle to exercise was lack of time, followed by fatigue. A small
group of patients experienced aggravated symptoms with exercise.
Researchers concluded that the majority of AS patients exercise, although the
frequency of exercise was low for many patients, mainly based on lack of time or
fatigue.
S. Hider and colleagues investigated whether participation in a regular
exercise program had a positive impact on body image for people with AS. The
study's results were published in a recent Scandinavian Journal of
Rheumatology issue.
Results: The researchers did not find a correlation between exercise
and body image. However, body image was affected by a person's acceptance of illness,
and whether they felt depressed.
Based on previous studies of individuals participating in exercise programs,
regular exercise normally improves a person's body image.
For this reason, S. Hider and colleagues expected to see the same results for
people with AS. Yet this study shows that a recommended exercise
program does not influence body image in AS, and a person's mood seems to better
impact his/her idea of body image.
In order to improve a person with AS' compliance to participate in
therapeutic exercise programs, the researchers want further studies to
investigate possible influences of body image on people with AS.
In the August issue of the American Journal of Gastroenterology, researchers
P. Suenaert and colleagues at the University Hospital Gasthuisberg in Leuven,
Belgium studied whether taking the anti-TNF medication infliximab (Remicade®) had
any effect on inflammation related to Crohn's disease.
Results: 23 patients with active Crohn's disease were evaluated before
and after a single 5 mg/kg. Remicade® infusion.
The researchers concluded that the medication dramatically reduced gut
inflammation and largely restored the gut barrier in Crohn's disease.
People with AS are reported to be at greater risk for fracture and a spinal
cord injury (SCI).
H. Alaranta and colleagues from the Kapyla Rehabilitation Centre of the
National Association of the Disabled in Helsinki, Finland studied whether this
higher risk in AS patients could also be detected among patients with traumatic
SCI rehabilitated at Kapyla Rehabilitation Centre. They also wanted to evaluate
characteristics of patients with traumatic SCI as a complication to AS in order
to develop prevention of SCI for patients with AS.
Results: The researchers studied 20 AS patients and compared their
data to that of the other SCI patients (1,103) in the rehabilitation centre.
They found that the rate of patients with AS for traumatic SCI was 11.4 times
greater than expected for the national population at large.
Neurologic injury was at the cervical level in 84% of the patients with AS,
but only in 48% of the patients with traumatic SCI in general.
Among patients with AS, the SCI was caused by slipping in 53% of the cases,
whereas slipping was the reason for SCI in only 7% of the cases in general.
The researchers concluded that patients with AS seem to run a higher risk of
traumatic SCI than the general population at large, and the injury levels are
higher.
H. Alaranta and colleagues particularly encourage male AS patients to take
precautions by installing preventive devices, such as night lights
and handrails, support or head rests when driving a car, and they should avoid
walking on slippery surfaces, loose carpets, etc. They also suggest avoiding
excessive use of alcohol and activities involving the risk of physical injury,
such as contact sports.
When a hip is severely damaged, chronic deterioration in qualify of life can
result. After exhausting other treatment options (such as medications, exercise,
and physical therapy), a person may undergo cemented total hip arthroplasty (THA)
to replace a malfunctioning, painful joint with a brand-new, long-lasting artificial
hip--a prosthesis.
A.B. Joshi and
colleagues at the Centre for Hip Surgery, Wrightington Hospital in Wigan, UK
sought to determine the utility of THA in patients with AS. They published their findings in the June issue of the Journal of Arthroplasty.
Results: 103 AS patients underwent 181 THA's (72
patients--69.9%--had bilateral surgery). The mean age of patients undergoing
surgery was 47 years old, and 23.2% of the hips were ankylosed (fused).
Revision surgery was carried out in 13.8% of the hips. Over 11% of the hips
had heterotopic ossification, which is when extra bone forms around the prosthesis. However, no patients had
functional impairment or re-ankylosis.
At the final follow-up examination, 96% of the hips had an excellent (low)
pain score, and 29.2% had a normal or near-normal function score.
Probability of survival of the implant was 71% at 27 years after the original
surgery date.
In conclusion, the researchers believe that THA provides long-term
hip-function improvement for patients with AS.
Hip fracture is associated with a higher mortality rate for men than in
women, yet the average age of men and women with hip fractures is drastically
different. In order to avoid the influence of age on gender-specific outcome,
Dr. A. Trombetti and colleagues analyzed men and women of the same age. The
study was published in a recent issue of the Osteoporosis International.
Results: Researchers studied 106 men (average age: 80.3 years old) and
264 age-matched women (average age: 81.4) with hip fractures to evaluate
mortality rate, survival, years of potential life lost, and modification of
housing conditions.
Overall, men with hip fractures differed from age-matched women with hip
fractures by a higher alcohol and tobacco consumption, greater frequency of
living in couple, and by less prevalent fractures.
Mortality rate after hip fracture was much higher in men. Since mortality is
also higher in the general male population, the researchers compared reduction in
life expectancy while taking into account the gender-specific mortality rate.
The estimate of death attributable to fracture did not differ between
genders.
Reduction in life expectancy due to hip fracture was similar in both genders,
but the proportion of the years of life lost was higher in men (5.9 years give
or take 4.5 years based on study parameters) than in women (5.8 years give or
take 4.8 years).
They conclude that for the same age, mortality rate after hip fracture was
higher in men than in women. Even though reduction in life expectancy was
similar in both genders, the proportion of years lost was higher in men. This
suggests a worse impact of hip fracture on survival in men, even after
consideration of the higher mortality rate in the general male population.
H. Bukulmez and R.A. Colbert reviewed recent articles related to juvenile
spondyloarthropathies, and highlighted the following:
- Diagnostic criteria for identifying undifferentiated spondyloarthropathies
in adults have been developed, and while separate criteria have been
proposed for juvenile onset disease, they remain to be validated.
- The most significant recent advances in juvenile spondyloarthropathies
involve treatment.
- Several studies using anti-TNF inhibitors (Remicade® and Enbrel®) suggest that
these medications hold great promise for lessening symptoms and improving
function. Long-term effects on disease progression remain to be evaluated.
According to a recent article in the Scandinavian Journal of Rheumatology,
P.J. Hashkes examined the beneficial effect of climatic therapy at the Tiberias
Hot Springs in Israel on patients with inflammatory arthritis.
As reported in SAA's Spondylitis Plus Fall issue, people throughout
history have believed in hot springs' special healing properties. Now springs
are generally believed to be therapeutic because the warm water provides
benefits to muscles and joints. But, medical experts have never found any proof
that rheumatic conditions (AS included) can be controlled by water treatments.
Results: 136 patients from Sweden with inflammatory arthritis
underwent climatic therapy for four weeks. Of the 83 patients with rheumatoid
arthritis (RA), 57% were considered "great responders" to the hot
springs treatment. For the 53 AS patients, 60% were "great
responders."
Shorter disease duration and more active disease were associated with greater
response in RA, while AS males responded more often than AS females.
In conclusion, the researchers note that most patients benefited from
climatic therapy. Long-term follow-up is necessary to see whether improvement is
sustained, and if work ability and hospitalizations are also improved.
An article written in Medscape Money & Medicine by Christine Wiebe
discusses the story of a late nurse, Sue Kinnick, who was struck one day by the
efficiency of her rental car process. The rental transaction was complete in a few simple
steps because the company used bar-codes.
Kinnick convinced fellow administrators at the Easter Kansas Veterans Affairs (VA) Medical
Center that a hospital bar-code
would streamline the process for delivering prescription drugs to patients and
reduce medical errors. She worked with pharmacists to develop a prototype that was adopted by the
entire VA system, and is now being studied by private hospitals as well.
Bar-code technology (a familiar site in supermarkets) is used in many
industries to manage inventory and document transactions. However, it is still
relatively rare in healthcare. Analysts say that pharmaceutical companies have
been reluctant to label products with bar codes until more hospitals have
scanners to read the bar-codes, and many hospitals have been waiting to invest
in proper scanning technology until more coded products are available.
The government is now considering a requirement that would end the waiting
game and produce a uniform labeling system throughout the healthcare
industry.
Each year, approximately 770,000 medication errors occur in U.S. hospitals, a
number which could be reduced significantly with the use of bar coding.
At the Topeka VA hospital, errors involving the wrong medication or dosage
have been cut by 66% since implementing the bar-codes. Errors involving the
wrong patient or the wrong time for a medication to be given have been reduced
by more than 90%.
Patients at the VA hospitals are given a bar-coded wristband. When a nurse
scans the wristband with a handheld device, the patient's information (such as
prescribed medications, drug allergies, or other relevant health information)
appears on a portable laptop computer. Then the nurse scans the bar code of the
drug dose that he/she wishes to administer, and an alert appears on screen if
the medicine, dosage, or timing is wrong.
A bar-code system benefits patients and hospitals in other ways, such as in
the case of a hospital ward where the rate of late medications dropped
significantly when a nurse went on vacation. When the rate went up again after
the nurse returned, it signaled a need for supervisors to focus their efforts on
that one individual.
But it takes a large commitment and increased costs from pharmaceutical
companies and hospitals alike to implement such a widespread program. Proponents
of the bar-code system are hoping that government intervention could help speed
the process and reassure company executives that their efforts will pay off in
the long run.
Since 1998, graduates of foreign medical schools requesting licenses in the
U.S. have had to pass a clinical skills test to determine whether they can
effectively deal with patients.
Now the National Board of Medical Examiners wants to ensure that all doctors
(including graduates of American medical schools) have good "bedside
manner" by making the clinical skills assessment test a part of the
national medical licensing exam.
The clinical tests takes place in one day and consist of 10 to 12 personal
meetings with actors who are carefully trained to feign illnesses and explain
symptoms. Each student must gather medical history, conduct a physical
examination, and provide feedback or counseling-- all within 15 minutes. They
then get 10 minutes to record their findings (which are graded by a senior
physician) before moving on to the next patient. Once the student finishes an
examination, the fake patient grades his/her performance using checklists and
rating scales.
"Most people assume that this bedside manner comes automatically to
doctors in training. But we know that's not true," said Dr. Peter V. Scoles,
senior vice president of the medical examiners board. He believes that this
licensing exam will provide the public with the assurance that doctors have at
least basic competency in bedside manner. It will also help weed out the small
number of medical students who do not have adequate interpersonal and clinical
skills from practicing medicine.
Most medical schools already use actors to test students' clinical skills.
But if the new test is adopted, it will create a national standard. Some medical
students think that the exam will help reduce the number of medical malpractice
suits which could result from poor communication between doctor and patient.
Yet medical students will need to pay for the cost of the new test if
implemented, which runs about $950 plus travel expenses to one of the five to
seven sites nationwide that will administer it.
Dr. Jordan Cohen, president of the Association of American Medical Colleges,
endorses the exam but notes that over 80% of medical students are already
heavily in debt. According to Cohen, "There should be an alternative that
accomplishes the same goal without such heavy costs."