Latest News in Rheumatology
2/21/2003
Estrogen Helps
Fight Pain
Falls Cause 90% of Hip Fractures
An
Experimental Study of a Mediterranean Diet Intervention For Patients With
Rheumatoid Arthritis
Hard to Teach an Old
Doc New Tricks
Consent Form Language Too
Complex For Many
New Study Sees Room for 30% Cut in Medicare Costs
Physicians Must Make Their Privacy Policies Public
HealthScoutNews -- A woman's tolerance of pain may have less to do
with the strength of her muscles as it does with the power of her reproductive
hormones. The key to pain response in women may be the hormone estrogen,
according to Dr. Jon-Kar Zubieta (lead researcher and a University of Michigan
neuroscientist) and colleagues.
"Our studies have shown that although pain is influenced by both
genetics and brain chemistry, it is clear that gender and hormones also play a
role in our individual response to pain. When estrogen levels are high, the
brain's natural pain chemicals -- endorphins or enkephalins -- are much more
potent. The response is much greater than when estrogen levels are low,"
explains Zubieta.
For example, Zubieta pregnancy is a situation in which estrogen levels soar
(right before a woman gives birth). He thinks that this is one of the reasons
women can tolerate the pain of childbirth.
According to his new research, hormone activity increases the number of
receptor sites in the brain where natural pain-relieving chemicals as endorphins
can "dock". The more "ports" available to receive the
endorphins, the greater the ability of the brain to control the pain response.
Ultimately, Zubieta says that this allows women to feel less pain.
Pain management expert Allen Lebovits (co-director of the pain management
program at New York University Medical Center) believes that this research makes
sense, and hopes that it will help open the door for better and more efficient
use of anesthesia, particularly in women. "We don't routinely question
women about where they are in their menstrual cycle when we are prescribing pain
medications or even anesthesia. But if these studies prove right, then perhaps
that should be something that doctors should consider when prescribing certain
medications for women."
Zubieta and colleagues spent years using positron-emission topography (PET)
scans to document brain changes linked to hormone activity under varying
conditions.
In their first study (published in the July 2001 issue of Science), researchers
injected volunteers in the jaw with a harmless solution designed to initiate a
painful muscle spasm. Using the PET scan, they documented how within 20 minutes,
the pain response activated endorphins, the brain's natural pain-mediating
chemicals. The rise in endorphin activity correlated with a reduction in the
volunteers' perception of pain.
In the latest study, they used the same techniques to document how women
respond to pain during high and low phases of estrogen production. Jaw pain was
induced during the early phase of the menstrual cycle (a time when estrogen
levels are low). In the second part, women were given an estrogen patch to wear
for one week, and the jaw pain experiment was repeated. Both times, researchers
recorded the women's reactions to the pain, while the PET scans documented brain
activity.
They found under high estrogen conditions that the number of brain receptors
available to receive endorphins increased dramatically, and the women showed a
"remarkable" ability to release endorphins and activate receptor sites
-- as compared to times under low estrogen conditions.
The women reported less pain when estrogen levels were high, even though the
level of pain inflicted was the same as it was during their low estrogen cycle,
says Zubieta. The data is now being confirmed in larger studies, but it hints at
the powerful effects of female hormones on pain and stress response.
New Orleans, LA -- 90% of hip fractures are due to falls, and hip
fractures are one of the most devastating of injuries. It often leads to long-term
hospitalization, which can spell the end of an independent life for many elderly
people.
Dr. Kenneth Koval (New York University Medical School) and colleagues
followed a group of patients, 65 years or older, who had been in good health,
capable of walking (not bedridden), and cognitively intact before their hip
fracture.
After a year, 83% were living, 13% had died, and 4% were lost to follow-up.
However, functional outcomes were significantly reduced. Only 41% of patients
regained prefracture movement, while the remainder showed a decrease in
independent walking ability. About 25% reported losing some ability to perform
basic activities of daily living (like dressing, eating, bathing), while just
over half reported losing some abilities instrumental for daily living
(shopping, cooking, performing housework).
Researchers L. Skoldstam and colleagues from Sweden sought to investigate
whether patients with rheumatoid arthritis (RA) who followed a Mediterranean
diet (MD) versus an ordinary Western diet obtained a reduction in inflammatory
activity, an increase in physical function, and improved vitality. These
findings are published in the March 2003 issue of the Annals of the Rheumatic
Diseases.
People were invited to participate in the study if they had well controlled,
although active RA of at least two years' duration and who were receiving stable
medicine treatment. They were randomly assigned to either the MD or control diet
(CD). For the first three weeks, patients were served either a MD or CD lunch
and dinner at the clinic in order to help insure good compliance with the
prescribed diets. Clinical exams were performed before beginning the diet, and
in the 3rd, 6th, and 12th week to help determine disease activity. None of the
study participants in either group had previously followed the Mediterranean or
a vegetarian-based diet.
The Mediterranean diet included olive and canola oils as the primary dietary
sources of fat -- along with plenty of fish, poultry, produce, and legumes, say
Swedish researchers. The Western diet (also typical in Sweden) included an
abundance of dairy foods and red meat.
Significant improvement was reported by most of the 26 participants who
followed the Mediterranean diet. They first began experiencing relief after six
weeks and improvement continued throughout the study. These participants also
received nutritional counseling on how to cook healthier meals, which perhaps
helped this group lose an average of seven pounds by study's end. Even their
cholesterol levels began dropping by the third week.
Yet no relief was reported by the group of 25 patients who followed a typical
Western diet. They received prepared meals but no counseling. These participants
did not lose weight and reported no measurable symptom relief.
"The results of this intervention program indicate that a Cretan
Mediterranean diet suppresses disease activity in patients who have stable and
modestly active rheumatoid arthritis," write the researchers. "Thus,
by eating a Mediterranean diet for three months, patients with RA can obtain
better physical function and increase their activity. In theory, even a minor
effect that is persistent and accumulates over time might be important."
This is the latest study to suggest arthritis relief may result from eating
the Mediterranean diet, which is typical on Crete and other Greek Islands. Over
two years ago, University of Buffalo researchers found that mice fed high doses
of fish oil and vitamin E (abundant in the two oils studied by this new study)
had reduced levels of a specific protein that can cause joint swelling and pain.
Previous to that, Greek investigators found that a similar Mediterranean diet
reduced the onset of rheumatoid arthritis by nearly three-fold as compared with
people who ate less olive oil and fewer fruits and vegetables.
Results suggest that the ingredients in these key cooking oils may be the key
to relief because they are good sources of heart-healthy fats, and olive and canola
oils are rich in Vitamin E and oleic acid (which has an anti-inflammatory effect
by potentially reducing inflammatory protein levels). Fish and produce are great
sources of other antioxidant phytochemicals believed to reduce inflammation and
inhibit tissue damage. The other foods in the studied diet -- legumes, poultry,
and cereals -- are low in fat, which may further reduce inflammation.
Mary Nettleman, MD, primary care doctor and professor of medicine at Virginia
Commonwealth University in Richmond, and colleagues reviewed several studies
looking at doctors' attitudes about change. Their paper is published in the
February 2003 issue of Clinical Governance: An International Journal.
"Physicians are individualists by nature. If the physician doesn't think
it's important, he or she will ignore it. Whatever it is, it has to clearly
affect the patient's outcome," says Nettleman.
She uses the example of the issue of pain. The Joint Commission on
Accreditation of Hospitals (a regulatory agency) requests that doctors ask the
patient about pain during every hospital visit. If the doctor fails to note this
in a chart, the hospital gets penalized during the annual accreditation process.
Nettleman believes that helping patients is what motivates doctors. "If
it's a new drug for AIDS, doctors are going to be motivated to see if it works.
But when it's something that is not so obviously going to help the patient -- a
form they have to fill out, a question that does not seem relevant -- that's
when doctors are not motivated."
William Bornstein, MD, endocrinologist and chief quality office for Emory
Healthcare Systems in Atlanta, believes that doctors generally have come a long
way in accepting change. He says that physicians are charged by society not to
miss anything or "their feet are held to the fire". In his opinion,
the more data on quality of care that we can provide, the better it is for them
and for the patients. And new technology exists to make routine exams an easy
fix. For example, he explains that in treating a diabetic patient, the doctor
may order 10 very important tests (like blood sugar, thyroid, heart, lung, etc.)
but forget an annual exam of the foot. Now doctors can simply program it into
the patient's chart and a prompt will indicate when the exam is necessary.
Borenstein believes that patients also have a role to play -- "They
should always have a list of medications and allergies with them. If something
seems out of the ordinary, they need to ask a question. They need to be informed
about their own health problems."
Consent forms required of clinical trial volunteers are far too difficult for
most people to understand. At least this is what Johns Hopkins epidemiologists
have confirmed based on a survey of 114 U.S. medical schools. Results were
published in the February 20, 2003 issue of The New England Journal of
Medicine.
Researchers found the average consent form to be written at a 10th-grade
reading level, while an estimated one in two American adults read at or below an
eighth-grade level. The sample text for these forms provided to researchers by
the medical schools' institutional review boards (IRBs) generally failed to meet
the IRB's own standards for reading comprehension.
"Our study suggests that a fourth- to sixth-grade reading level is a
suitable target because text at this level can best convey key concepts simply
and directly, says Michael K. Paasche-Orlow, M.D., M.P.H., lead author of this
study and a postdoctoral fellow in bioethics and internal medicine.
Paasche-Orlow and colleagues plan to revise some of the forms at Johns Hopkins
to develop and validate the improved language.
Philadelphia, Pennsylvania (Reuters) -- According to a recent study, about
30% of Medicare costs (enough to pay for prescription drugs) could be eliminated
without harming the quality of care for Medicare beneficiaries. The study's
researchers believe that these findings come at a critical time for the U.S.
healthcare system, which has been struggling with surging costs and rising
numbers of uninsured patients through the years. In fact, by 2011, the study
said that annual healthcare costs in the U.S. are expected to rise 49% and reach
17% of the U.S. gross domestic product (which is the total value of goods and
services produced by a nation within a year). Study results were published in the
American College of Physicians' Annals of Internal Medicine.
The study examined the cases of 987,000 Medicare beneficiaries hospitalized
in 306 U.S. regions between 1993 and 1995. It looked at health care delivered
during the last six months of life for 615,000 people with hip fractures,
195,000 colorectal cancer patients, and 159,000 heart-attack patients.
Highest-cost regions expended 61% more Medicare resources than regions with
the lowest costs overall. For example, in one year, Medicare costs amounted to
$8,414 per enrollee in the Miami region, but only to $3,341 in Minneapolis. Yet
the researchers did not find a difference in the quality of care between
regions, and suggested that patients in the highest-cost areas received less
access to medicine than those in lowest-cost areas.
"If the U.S. as a whole could safely achieve spending levels comparable
to those of the lowest-spending regions, annual savings of up to 30% of Medicare
expenditures could be achieved," the study concluded. They suggest that
such savings could provide resources to fund important new benefits, such as
prescription drugs or expanded Medicare coverage to younger age groups, or to
extend the life of the Medicare Trust Fund to better cover the health care needs
of future retirees.
The researchers warn that their research offered no guidance on the
potential impact of reducing services that were shown to account for the
differences in healthcare costs between regions.
According to Joel Finkelstein at AMNews (associated with the American Medical
Association), doctors will need to make public their office policies for
protecting patient data. As of April 14, 2003, a new law will require that
doctors hand out notices to their patients (both old and new) describing how
their health information will be used, and explain their rights, such as seeing
their own medical records. The notices must contain a description of office
procedures for protecting patient information, how patients can get more
information, and what privacy practices are required by law.
To be in compliance with this rule (part of the Health Insurance Portability
and Accountability Act -- HIPAA), physicians' offices will have to post their
notices in the office and on their web sites, distribute them to patients, and
"make a good-faith effort" to have patients sign off on the notices.
Since doctors will not be able to get every patient to sign the form, they must
document their efforts and explain why the patient did not sign it.
In emergency situations, this requirement is waived until the patient is
stabilized. And in general, notice requirements should never stand in the way of
administering care. This offers flexibility to help physicians inform their
patients of privacy practices.