The Latest News in Rheumatology
1/24/2003
Treatment Cards for Patients on Anti-TNF Therapy
Arthritis Drugs May Help the Heart
High Vitamin A Intake and Increased Fracture Risk
Progranulin Identified as a Probable Growth Factor in
Wound Repair
Doctors Stuck in Time Warp
Patients
With Hip Fracture Discharged Too Soon?
Belfast, Northern Ireland -- Dr. Andrew P. Cairns and Dr. AJ Taggart (Musgrave
Park Hospital, Belfast, Northern Ireland) have designed a biological therapy
treatment card for patients that highlights the risk of infection while they are
taking either Remicade or Enbrel. The cards have been used so far in 100
patients with severe inflammatory arthritis who are receiving anti-TNF-alpha
drugs, and according to the two aforementioned rheumatologists, they are
"convinced of their value" to patients. Dr. Cairns and Dr. Taggart
chronicled their experiences in a letter to the journal Rheumatology this
month.
Prior to the idea of using a treatment card, the two doctors always
instructed their patients about potential risks of anti-TNF-alpha therapy before
beginning treatment, and they were told to consult their doctor if they
developed any signs of infection. Those receiving Enbrel were also told to stop
their self-injections immediately if they felt unwell. Dr. Cairns and Dr.
Taggart note, "In spite of this, a number of patients have failed to
discontinue anti-TNF therapy while receiving antibiotic therapy for intercurrent
infection because of a concern that their joint symptoms might return."
Patients receiving long-term corticosteroids are often asked to carry a card
to remind themselves and their physicians of the risk of suddenly stopping
treatment, so Dr. Cairns and Dr. Taggart decided to apply the same principle to
TNF inhibitors.
The anti-TNF-alpha card emphasizes the important of stopping the medication
and seeking help immediately if the patient develops symptoms suggestive of
infection. It is the size of a credit-card that can easily be carried in a
wallet or purse, and also contains a 24-hour telephone help line available to
patients and healthcare professionals who may be unfamiliar with these new
therapies.
There was no mention of other countries currently using a uniform treatment
card for TNF inhibitors.
Dallas, TX -- According to a small study from the Journal of American Heart
Association, anti-inflammatory drugs used to treat arthritis may also benefit
people with heart disease by improving blood vessel flexibility and reducing
inflammation.
COX-2 inhibitors, such as celecoxib (brand name Celebrex) are
second-generation nonsteroidal anti-inflammatory drugs (NSAIDs) used for
arthritis and other inflammatory conditions. COX-2 inhibitors supposedly are
associated with a lower incidence of stomach irritation than other NSAIDs, such
as aspirin or ibuprofen.
Swiss researchers studied 14 male patients aged 46 to 77, with severe heart
disease. Every participant had a standard cardiovascular therapy that included
blood-thinning aspirin and lipid-lowering statin drugs. The patients either
received 200 milligrams of Celebex or a placebo
for two weeks. Afterwards, the groups switched treatments.
Atheroschlerosis is a buildup of plaque deposits in the arteries. Build up in
the neck's carotid arteries can prevent blood flow to the brain, possibly
resulting in a stoke. There is increasing evidence indicating that
atherosclerosis is an inflammatory disease. Frank Ruschitzka, MD of the
department of cardiology at University Hospital in Zurich, Switzerland,
explains: "Anti-inflammatory agents used to treat arthritis, such as COX-2
inhibitors, may not only reduce inflammation in the joints, but could possibly
have that same anti-inflammatory benefit in the vessel wall. This is the first
study to show that relationship."
The study's authors suggest that COX-2 inhibition with Celebrex has
potential as an add-on therapy to standard treatment, such as statins and ACE
inhibitors, for people with heart disease. They note that additional
well-designed large-scale clinical trials must be conducted to find the
overall effect of COX-2 inhibitors on cardiovascular events.
Uppsala, Sweden -- Another recent study has suggested that high intake
of vitamin A increases the risk of fractures, reigniting concerns that the
routine use of vitamin supplements and the fortification of foods such as
cereals and dairy products with vitamin A may be harmful in Western countries
where the prevalence of osteoporosis is increasing. This research appears in a
recent New England Journal of Medicine.
Dr. Karl Michaelsson and colleagues from the University Hospital, Uppsala,
Sweden, note that their study is the first to use a biological marker of vitamin
A called serum retinol, whereas previous studies have used food questionnaire
data to estimate vitamin A exposure. They found a direct link between serum
retinol levels and the risk of fracture, with high levels substantially
increasing the overall risk of fracture. Dr. Michaelsson and colleagues suggest
that this may explain, at least in part, the high incidence of hip fractures in
Scandinavia and the U.S. where vitamin supplements are commonly used.
The investigators looked at serum retinol levels in blood samples taken on
enrollment into the Uppsala Longitudinal Study of Adult Men, which began during
the years of 1970 through 1973 with 2322 men aged 49 to 50 years of age. During
the 30 years of follow-up, they found fractures in 266 men. The increased risk
of fracture was mainly concentrated in men with the highest levels of serum
retinol -- men with retinol levels in the 99th percentile had an overall
increased risk of fracture that was seven times the risk of men with lower
levels, the researchers note.
Dr. Michaelsson says that the results of their study could be used by doctors
to recommend a balanced diet to their patients, not an unbalanced diet with a
high proportion of foods containing retinol. The main dietary sources of
retinoids are fish, liver, and dairy products, together with fortified foods. A
small proportion of carotenoids from vegetables and fruits converts to retinol.
They also suggest that food agencies or multivitamin supplement products
consider a lower amount of retinol addition by food fortification or in
supplements in Western countries.
Dr. Robert Heaney (Osteoporosis Research Center, Creighton University, Omaha,
NE) notes that the increased risk of fractures in this study was confined to a
small proportion of participants with the highest serum retinol concentrations,
and "most people don't have levels this high. There is a danger in calling
for a restriction on vitamins that people at the other end of the spectrum, who
have very low levels of vitamin A, may cut their intake to the point where they
develop a deficiency and symptoms...such as night blindness, skin dryness,
corneal ulceration, etc."
Yet Dr. Heaney says that it is something that doctors should bear in mind
when caring for people at risk of osteoporosis. "It may be worthwhile
asking about their use of vitamin supplements and in particular about any
products they may be taking that contain vitamin A. If someone is taking two
multivitamin pills a day, that's too much."
As published in the recent issue of Nature Medicine, Dr. Andrew Bateman and
and colleagues from McGill University in Montreal have shown that
a growth factor involved in the development of tumors speeds up the healing of
wounds. The factor, progranulin, speeds up the body's ability to clean up and
repair wounds, a process that is particularly difficult for people with poor
circulation such as the elderly and diabetics. Researchers suggest that
continued studies into progranulin's role in the body will advance the
understanding and perhaps the treatment of acute and chronic wounds,
inflammatory joint conditions, and tumor-stromal interactions. Specific
inflammatory joint condition names were not mentioned in the article.
Their study on mice showed that progranulin concentration soared in tissue
from wounds, as opposed to "normal" mouse tissue. Researchers added
progranulin directly to the injured skin tissue, and it dramatically increased
the number of blood vessels entering the tissue to help heal the wound.
Increased blood flow to the wound is something that people with wound healing
problems (like poor circulation) lack. After kick-starting the process, however,
progranulin levels subsided - a fact Bateman and his colleagues conclude means it
is crucial in the first phase of healing but not the final stages.
They agree that more work is needed to ensure their interpretation of their
findings is correct. Additional tests for any unforeseen adverse consequences is
also crucial before being tested in humans.
According to Dr. Bateman: "One day, it may be possible to heal these
wounds very, very rapidly," he said. "It would shorten people's
hospitalization, it would decrease their risk of infection. So it could be a
tremendous advance if you could heal these things in days rather than weeks to
months."
A new study shows that millions of people with chronic diseases are not
getting the care they need because of outdated systems. Patients with ongoing
health problems aren't getting state-of-the-art care, but this study claims that
the reason is not because the doctors aren't qualified to practice medicine. It
suggests that most doctors work in a system of two- or three-doctor medical
practices that are not keeping pace with new treatment guidelines. As a result,
many patients end up in emergency rooms for medical crises that could have
easily been prevented.
The report was published in the Jan. 22/29 issue of The Journal of the
American Medical Association. Lead researcher Lawrence Casalino, MD, PhD,
and colleagues surveyed the heads of more than 1,000 medical groups and
independent practices. They only looked at medical practices with 20 or more
doctors, so the following results underestimate the problem, says Dr. Casalino.
They found that 7 out of 10 group practices don't keep a list of patients
with serious ongoing problems, and half of the medical groups/practices surveyed
don't have computerized systems to track patients' illnesses, medications, and
lab results
"We know how to treat patients better, but we are not practicing in
organized systems to do that very well," says study researcher Stephen M.
Shortell, PhD, dean of the school of public health at the University of
California, Berkeley. He says that nearly all of the systems work best when
doctors use computer technology --"Yet doctors' practices are woefully
behind the times in using this technology." These researchers agree that
there must be financial incentives from businesses and government to help
improve the quality of medical care.
Kenneth E. Thorpe, PhD, chairman of health policy and management at Emory
University's Rollins School of Public Health, believes that patient care does
not focus on prevention issues surrounding getting patients to comply with their
treatment. "This adds cost and inefficiency to the healthcare system."
What can patients do?
Dr. Shortell says that "A large part of this means patients should get more
involved in their care. These are competent doctors working in outmoded systems.
They are working with one hand tied behind their backs. So patients need to be
assertive in talking with their healthcare team to make sure their care is
managed in a 21st century way. Tell your doctor, "Make sure my name is on
your list of patients with my condition, that I get a reminder of when I need
follow-up care, that you have my medical records on hand, that I participate in
my care, and that I can access you by Internet with questions about my
care."
Patients with hip fractures are being discharged from hospitals much sooner
than they used to be. In the U.S., the average length of stay was 20.1 days in
1981, but only 6.5 days in 1999.
A new study has shown that more than half of the patients with hip fracture discharged
from four hospitals in the New York area from 197 to 1998 had serious clinical
problems that substantially increased the risk of death or readmission. Results
are published in a recent Archives of Internal Medicine.
Dr. Ethan Halm (Mount Sinai School of Medicine, NY) and colleagues followed
559 consecutive patients hospitalized for hip fracture (average age 81.9 years).
The overall mean length of hospital stay was 8.5 days.
They focused on two main classes of medical problems:
- Active Clinical Issues (ACIs),-- which included acute potentially dangerous
problems that doctors would want addressed before discharge, like basic
indicators of clinical instability (i.e. vital sign abnormalities, altered
mental state, inability to eat) as well as worrisome symptoms, such as acute
chest pain or shortness of breath, which could reflect serious
complications.
- New Impairements (NIs) -- functional impairements that may not be quickly
resolved, such as bowel and bladder incontinence, inability to get out o
fbed, and the presence of decubitus ulcers. These would not necessarily
delay discharge, but they may carry a worse prognosis and dictate a higher
level of post treatment.
In the 559 patients studied, 94 (16.8%) had one or more ACIs on discharge
(most common: diastolic blood pressure, altered mental state, higher
temperature). 229 patients (41%) had one or more NIs on discharge (most common:
bladder incontinence, decubitus ulcer, bed-bound status)
"Leaving the hospital with these active problems had important clinical
consequences because the greater the number of problems, the greater the risk of
death or readmission," claims Dr. Halm. Patients with one or more ACIs on
discharge had 80% increased odds of death or readmission in the 60 days after
discharge, even after adjusting for other variables that could contribute to
death. Patients with any NIs on discharge had 200% increased odds of death or
readmission.
They urge clinicians to consider carefully whether patients are truly ready
for discharge. If they are discharged, "it seems prudent that these
patients receive close post-hospital monitoring and treatment." However,
whether patients with only one ACI following hip surgery should have a discharge
delayed is less clear since the risk associated with a single unstable factor
was more modest in their opinion.
To the surprise of the researchers, discharge to an acute rehabilitation
facility or nursing home did not improve the consequences of ACI and NI on
discharge in this study. They say that hip fracture patients with active
problems following surgery may benefit from more intense observation and
treatment than they currently receive in traditional post-acute-care settings.