Medicare Regional Analysis Masks Substantial Local Variation In Health Care Spending

Main Category: Medicare / Medicaid / SCHIP
Also Included In: Public Health
Article Date: 02 Nov 2012 – 0:00 PDT

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Reforming Medicare payments based on large geographic regions may be too bluntly targeted to promote the best use of health care resources, a new analysis from the University of Pittsburgh Graduate School of Public Health suggests. The analysis will be published in the Nov. 1 issue of the New England Journal of Medicine.

“Much policy attention has been drawn to the large geographic variation in health care spending across regions, and for good reason – because regional variation points to inefficient use of resources,” said lead author Yuting Zhang, Ph.D., associate professor of health economics at Pitt Public Health. “But it is important to effectively target these policies to reduce overutilization while maintaining access to high-quality care.”

Policies that are too widely focused, such as at the larger regional level, could leave many high-spending locales untouched while inadvertently penalizing some low-spending locales. However, policies that are too finely focused, such as at the physician-level, could miss system-level factors that account for high utilization in some areas, Dr. Zhang said.

Previous geographic variation analyses primarily focused on regional areas, such as the hospital referral regions (HRRs) described in the Dartmouth Atlas of Health Care. The United States can be divided into 306 HRRs, which are areas served by large tertiary hospitals where patients are referred for major cardiovascular surgical procedures and for neurosurgery.

The HRRs can be further divided into 3,436 Dartmouth hospital-service areas (HSAs), where residents receive most of their hospital care from the hospitals in the area.

Dr. Zhang and her colleagues used enrollment, pharmacy claims and medical claims data from 2006 through 2009 from the Centers for Medicare and Medicaid Services for a 5 percent random sample of Medicare beneficiaries enrolled in stand-alone Part D plans. The study sample included about 1 million beneficiaries each year.

“We found substantial misalignment of high-spending HSAs and HRRs, after adjusting for population difference across regions,” Dr. Zhang said. “Many low-spending HSAs are located within high-spending HRRs, and many high-spending HSAs are located within low-spending HRRs.”

Only about half of the HSAs located within the highest-spending fifth of HRRs are themselves in the highest spending fifth of HSAs. Conversely, only about half of the highest-spending fifth of HSAs were located within the highest-spending fifth of HRRs.

For example, Manhattan was one of the HRRs with the highest drug spending in the nation, while Albuquerque was one of the lowest, after adjusting for population difference in the regions. However, the lowest-spending HSA in Manhattan had lower spending than about a quarter of the HSAs within Albuquerque.

“If a reform policy targeted the Manhattan HRR for lower Medicare payments, it would penalize low-spending local hospitals while missing the higher-spending local hospitals within the Manhattan HRR,” Dr. Zhang said.

Using their analysis, Dr. Zhang and her colleagues could not determine the “right” level to target policy reforms, but suggest that focusing exclusively on the regional level is too blunt.

The study was funded by the Institute of Medicine grant no. HHSP22320042509X, National Institute of Mental Health grant no. RC1 MH088510 and the Agency for Healthcare Research and Quality grant no. R01 HS018657.
Co-authors include Seo Hyon Baik, Ph.D., of GSPH’s Department of Health Policy and Management; A. Mark Fendrick, M.D., of the University of Michigan School of Medicine; and Katherine Baicker, Ph.D., of the Harvard University School of Public Health.
University of Pittsburgh Schools of the Health Sciences
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Why Women Tend to Rise Earlier

By Colleen Oakley
WebMD the Magazine – Feature

Jeri Solomon is a morning person. Jim, her husband of 11 years, is not. Early in their relationship, it posed quite a problem. “When we were planning our wedding, I wanted to have these big discussions at 8 a.m., when I had been up for two hours and was fresh, but Jim would just be getting out of bed,” says the 46-year-old floral designer from Melrose, Mass. “We ended up getting into a lot of arguments because I took his shrugs to be disinterest, when really he was just still half-asleep.”

The couple learned to work around their differences over the years, but their situation is not uncommon, says Katherine Sharkey, MD, PhD, assistant professor of internal medicine and psychiatry and human behavior at Brown University and associate director of the Sleep for Science Research Lab. “More women tend to be larks, while men lean toward being night owls,” she says.

Recommended Related to Sleep Disorders

The Link Between Sleep Position and Sleep Quality

Stacey Sanner, 51, a PR consultant in Seattle and avid runner, is partial to sleeping on her right side. In her 20s, following a knee injury, she switched her primary sleep position from her stomach to her side and added a pillow between her legs. “I have never been able to sleep on my back,” she says. “When I started having lower back trouble, my doctor told me, ”One of the best things to do is sleep on your side with a pillow between your knees.'” Can sleep posture affect the quality of your…

Read the The Link Between Sleep Position and Sleep Quality article > >

What Causes Sleep Patterns

The question is: Why? The answer lies in each individual’s biological internal clock — or circadian rhythm, as scientists call it. “The human clock is about 24 hours, thanks to Earth’s 24-hour light-dark cycle,” Sharkey says. “But some people have a slightly longer natural cycle, and some are slightly shorter.” If your circadian rhythm is on the long side, you’re more likely to be a night owl. If it runs short, you’re probably an early riser.

But your circadian rhythm can change over your lifetime. “There’s a developmental piece to this puzzle — school-age children are generally early birds, while teenagers tend to be night owls, and then as they age, adults gradually transition back into morning people,” Sharkey says. 

Besides the obvious problems with being a night owl if you have a day job, “night owls tend to be more depressed, have a higher dependence on caffeine, and use alcohol more,” Sharkey says. But the news isn’t all bad. A recent study in Belgium found that night owls are able to stay more focused as the day goes on, compared with early risers.

Morning people, however, also have advantages. “Larks generally sleep better, have more regular sleep patterns, and have more flexible personalities,” Sharkey says. They also tend to be happier and feel healthier than night owls, according to a recent study from the University of Toronto.

Q&A on Teen Sleep

Q: “All her life my daughter has been a morning person. But since high school, she’s a night owl, not going to bed until 1 or 2 a.m. each night. Is there a reason she’s changed?”

Kim Olen, 45, marketing and public relations manager, Knoxville, Tenn.

 A: “Ah, teenagers. Her late nights are partly biologically driven. Hormonal changes during puberty affect the body’s internal clock, which means most high schoolers — even ones who used to be early risers — tend to stay up well after dark and sleep until noon. But fortunately, their clocks can be adjusted. Some tips to try: Have them stick to a schedule, and ban bright lights such as smartphones before bed.”

Katherine Sharkey, MD, PhD assistant professor of medicine, Brown University, and associate director, Sleep for Science Research Lab

Find more articles, browse back issues, and read the current issue of “WebMD the Magazine.”

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What to Know About Triglyceride-Lowering Meds

If you have high triglycerides, your doctor may prescribe medicine to help you keep your levels in check. That’s okay — sometimes, diet and exercise alone can’t do the trick. Your cholesterol levels need an extra nudge — in the form of medicine.

What Your Numbers Mean

A common triglycerides goal is to have less than 150 mg/dL, but goals can be different. Your doctor will review your risks for heart disease, such as high blood pressure, diabetes, and obesity, and set a goal that works best for you.

Sometimes a healthy lifestyle can’t lower triglycerides enough to protect your health. In those cases, the next step is to add medicine. You may also be put on meds if you: 

  • Have very high triglycerides — over 500 mg/dL
  • Have both high triglycerides and high “bad” LDL cholesterol levels

Choose the Right Triglyceride Medicine

Your doctor will consider many factors when choosing the right medicine for you. For instance, are you taking other meds? What is your overall health?  

There are three main medication classes:

  • Fibrates: Atromid-S (clofibrate), Gemcor or Lopid (gemfibrozil), Tricor (fenofibrate)
  • Niacin: Niaspan (niacin)
  • Prescription-strength omega-3 fatty acids: Lovaza (omega-3-acid ethyl Esters) and Vascepa (icosapent ethyl)

Cholesterol-Lowering Medicine

High triglycerides and high cholesterol often go hand in hand. If you have both conditions, your doctor might also want you to take a cholesterol-lowering medicine. These meds can slightly lower triglycerides, too. There are three main classes:

  • Cholesterol absorption inhibitors: Zetia (ezetimibe)
  • Statins: Crestor (rosuvastatin), Lipitor (atorvastatin), Zocor (simvastatin)
  • Statin combination drugs: Advicor (niacin extended-release and lovastatin), Simcor (niacin extended-release and simvastatin)

Get What You Need From Follow-up Visits

After you get your prescription, you’ll probably see your doctor every six weeks until your triglyceride levels drop. Use these check-ins to talk about any side effects you find bothersome.

Once you reach your goal level, you’ll see your doctor every six to 12 months. At these follow-up visits, they’ll take blood to make sure your triglycerides are still under control. Keep these appointments — they’re a key part of lowering your risk of heart attack and stroke.

If you’re taking fibrates or niacin, your doctor may use these follow-up visits to take blood to check your liver.

Take Your Pills

“Studies show that about 50% of patients stop taking their medicines after about a year,” says Michael Miller, MD, director of the Center for Preventive Cardiology at the University of Maryland Medical Center.  

That means 50% keep taking them — make a choice to be one of them.

These meds lower your risk of heart attack and stroke. Don’t risk your health by stopping medicine without your doctor’s approval. If something is making you want to quit, think about ways to solve it…

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Leukemia Drug Is Highly Effective MS Treatment

Alemtuzumab Lessens Relapses, Improves Disability

Oct. 31, 2012 — Two new trials offer proof that a leukemia drug long used to treat multiple sclerosis works better than a common treatment.

When compared with the widely used drug interferon beta, the leukemia drug alemtuzumab reduced relapse rates by half, researchers say.

Alemtuzumab Reverses Disability in Some

Alemtuzumab has been used to treat MS for close to two decades, but it has never been approved for this use. It is given by IV infusion.

The drug not only reduced relapses, but improved disability associated with MS, such as loss of coordination or difficulty walking, in some patients.

Side effects include infusion reactions, infections, and potentially serious autoimmune disorders. Patients taking it must be followed closely.

“In the menu of treatment choices for MS patients, I think alemtuzumab falls into the ‘high-reward, high-risk’ category,” says Alasdair Coles, MD, of Britain’s University of Cambridge, who led one of the newly published studies.

“No other drug has been shown to offer the benefits in terms of disability improvement that this drug shows,” he says. “It comes with problems, but these problems are manageable.”

400,000 MS Patients in U.S.

The National MS Society estimates that about 400,000 people in the United States have been diagnosed with multiple sclerosis, and most (85%) have the relapsing-remitting form of the disease, in which symptoms come and go.

These symptoms can include loss of feeling, coordination, and mobility, problems with thinking and vision, and depression.

In one of the two newly published studies, University of Cambridge researchers followed 563 previously untreated patients treated with either alemtuzumab or interferon beta.

Two years later, 22% of the alemtuzumab-treated patients had relapsed, compared to 40% of those treated with interferon beta.

In the second study, which included 840 patients whose MS symptoms were not being controlled with other treatments, treatment with alemtuzumab was associated with 35% of patients relapsing over two years, compared to a 51% relapse rate among those treated with interferon beta.

Patients in this study were also less likely to have additional MS-related disabilities after two years when they took alemtuzumab; 13% had disabilities compared to 20% of interferon-treated patients.

1 in 3 Users Develop Autoimmune Disease

In clinical practice, alemtuzumab has most often been used to treat patients who don’t respond to other treatments or are no longer responding to them.

Coles says he believes this is how the drug will continue to be used if it is approved as an MS drug in the U.K. and the U.S.

He adds that about 1 in 3 patients who take the drug for MS develop an autoimmune disorder that affects the thyroid, and about 1 in 100 develop a disorder that involves blood platelets, which are involved in clotting and stopping bleeding.

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More Independence For People With Paraplegia Using Advanced Exoskeleton

Main Category: Rehabilitation / Physical Therapy
Also Included In: Neurology / Neuroscience;  Medical Devices / Diagnostics
Article Date: 01 Nov 2012 – 1:00 PDT

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The dream of regaining the ability to stand up and walk has come closer to reality for people paralyzed below the waist who thought they would never take another step.

A team of engineers at Vanderbilt University’s Center for Intelligent Mechatronics has developed a powered exoskeleton that enables people with severe spinal cord injuries to stand, walk, sit and climb stairs. Its light weight, compact size and modular design promise to provide users with an unprecedented degree of independence.

The university has several patents pending on the design and Parker Hannifin Corporation – a global leader in motion and control technologies – has signed an exclusive licensing agreement to develop a commercial version of the device, which it plans on introducing in 2014.

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According to the National Spinal Cord Injury Statistical Center, somewhere between 236,000 to 327,000 people in the U.S. are living with serious spinal cord injuries. About 155,000 have paraplegia. The average age at injury is 41 and the estimated lifetime cost when it happens to a person of 50 ranges from $1.1 million to $2.5 million.

Until recently “wearable robots” were the stuff of science fiction. In the last 10 years, however, advances in robotics, microelectronics, battery and electric motor technologies advanced to the point where it has become practical to develop exoskeletons to aid people with disabilities. In fact, two companies – Argo Medical Technologies Ltd. in Israel and Ekso Bionics in Berkeley, Calif. – have developed products of this type and are marketing them in the U.S.

These devices act like an external skeleton. They strap in tightly around the torso. Rigid supports are strapped to the legs and extend from the hip to the knee and from the knee to the foot. The hip and knee joints are driven by computer-controlled electric motors powered by advanced batteries. Patients use the powered apparatus with walkers or forearm crutches to maintain their balance.

“You can think of our exoskeleton as a Segway with legs,” said Michael Goldfarb, the H. Fort Flowers Chair in Mechanical Engineering and professor of physical medicine and rehabilitation. “If the person wearing it leans forward, he moves forward. If he leans back and holds that position for a few seconds, he sits down. When he is sitting down, if he leans forward and holds that position for a few seconds, then he stands up.”

Goldfarb developed the system with funding from the National Institutes of Health and with the assistance of research engineer Don Truex, graduate students Hugo Quintero, Spencer Murray and Kevin Ha, and Ryan Farris, a former student who now works for Parker Hannifin.

“My kids have started calling me ‘Ironman,'” said Brian Shaffer, who was completely paralyzed from the waist down in an automobile accident on Christmas night 2010. He has been testing the Vanderbilt apparatus at the Nashville-area satellite facility of the Shepherd Center. Based in Atlanta, Shepherd Center is one the leading hospitals for spinal cord and brain injury rehabilitation in the U.S. and has provided the Vanderbilt engineers with the clinical feedback they need to develop the device.

“It’s unbelievable to stand up again. It takes concentration to use it at first but, once you catch on, it’s not that hard: The device does all the work. I don’t expect that it will completely replace the wheelchair, but there are some situations, like walking your daughter down the aisle at her wedding or sitting in the bleachers watching your son play football, where it will be priceless,” said Shaffer, who has two sons and two daughters.

“This is an extremely exciting new technology,” said Clare Hartigan, a physical therapist at Shepherd Center who has worked with the Argo, Ekso and Vanderbilt devices. “All three models get people up and walking, which is fantastic.”

According to Hartigan, just getting people out of their wheelchairs and getting their bodies upright regularly can pay major health dividends. People who must rely on a wheelchair to move around can develop serious problems with their urinary, respiratory, cardiovascular and digestive systems, as well as getting osteoporosis, pressure sores, blood clots and other afflictions associated with lack of mobility. The risk for developing these conditions can be reduced considerably by regularly standing, moving and exercising their lower limbs.

The Vanderbilt design has some unique characteristics that have led Hartigan and her colleagues at Shepherd Center to conclude that it has the most promise as a rehabilitative and home device.

None of the exoskeletons have been approved yet for home use. But the Vanderbilt design has some intrinsic advantages. It has a modular design and is lighter and slimmer than the competition. As a result, it can provide its users with an unprecedented degree of independence. Users will be able to transport the compact device on the back of their wheelchair. When they reach a location where they want to walk, they will be able to put on the exoskeleton by themselves without getting out of the wheelchair. When they are done walking, they can sit back down in the same chair and take the device off or keep it on and propel the wheelchair to their next destination.

The Vanderbilt exoskeleton weighs about 27 pounds, nearly half the weight of the other models that weigh around 45 pounds. The other models are also bulkier so most users wearing them cannot fit into a standard-sized wheelchair.

From a rehabilitation perspective the Vanderbilt design also has two potential advantages, Hartigan pointed out:

  • The amount of robotic assistance adjusts automatically for users who have some muscle control in their legs. This allows them to use their own muscles while walking. When a user is totally paralyzed, the device does all the work. The other designs provide all the power all of the time.
  • It is the only wearable robot that incorporates a proven rehabilitation technology called functional electrical stimulation. FES applies small electrical pulses to paralyzed muscles, causing them to contract and relax. FES can improve strength in the legs of people with incomplete paraplegia. For complete paraplegics, FES can improve circulation, change bone density and reduce muscle atrophy.

There is also the matter of cost. The price tags of other rehabilitation model exoskeletons have been reported to be as high as $140,000 apiece, plus a hefty annual service fee. Parker Hannifin hasn’t set a price for the Vanderbilt exoskeleton, but Goldfarb is hopeful that its minimalist design combined with Parker Hannifin’s manufacturing capability will translate into a more affordable product. “It would be wonderful if we could get the price down to a level where individuals could afford them and insurance companies would cover them,” he said.

Meanwhile, Hartigan has advice for potential users: “These new devices for walking are here and they are getting better and better. However, a person has to be physically fit to use them. They have to keep their weight below 220 pounds, develop adequate upper body strength to use a walker or forearm crutches and maintain flexibility in their shoulder, hip, knee and ankle joints … which is not that easy when a person has relied on a wheelchair for months or even years.”

by David Salisbury
The research was funded by a grant from the National Institute of Child Health and Human Development numbered R01HD059832.
Vanderbilt University
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Arthritis Patients’ Lives Improved By Complementary And Alternative Therapy

Main Category: Arthritis / Rheumatology
Also Included In: Complementary Medicine / Alternative Medicine
Article Date: 31 Oct 2012 – 3:00 PDT

Arthritis Patients’ Lives Improved By Complementary And Alternative Therapy
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Nearly a quarter of patients with rheumatoid arthritis and osteoarthritis used complementary and alternative therapy (CAT) to help manage their condition, according to a study in the November issue of the Journal of Clinical Nursing.
Researchers interviewed 250 patients aged between 20 and 90 years of age. More than two-thirds (67%) had rheumatoid arthritis and the remainder had osteoarthritis.
They found that 23% used CAT in addition to prescribed drugs and that just under two-thirds of those (64%) felt that the therapy was beneficial, reporting improvements in pain intensity, sleeping patterns and activity levels. “Our study underlines the importance of healthcare professionals being knowledgeable about the potential use of CAT when providing medical care to patients with arthritis” says lead author Professor Nada Alaaeddine, Head of the Regenerative and Inflammation Lab in the Faculty of Medicine, University of St Joseph, Beirut, Lebanon.
“Although CAT might have beneficial effects in rheumatoid arthritis and osteoarthritis, patients should be cautious about their use and should tell their healthcare providers that they are using them to make sure they don’t conflict with their existing treatment.”
Key findings of the survey included:

  • CAT users had an average age of 45 years, significantly younger than the average non CAT user, who was aged 57 years.
  • CAT use was higher in patients with osteoarthritis (29%) than rheumatoid arthritis (20%).
  • The most common CAT used was herbal therapy (83%), followed by exercise (22%), massage (12%), acupuncture (3%), yoga and meditation (3%) and dietary supplements (3%).
  • Just under a quarter of the patients using CAT (24%) sought medical care because of possible side effects, but they were not serious and were reversible. The most common side effects included skin problems (16%) and gastrointestinal problems (9%).
  • The majority did not tell their healthcare provider about their CAT use (59%).
  • CAT users were asked to rate the amount of pain they felt and the percentage who said that they experienced no pain rose from 12% to 43% after CAT use. The number who slept all night rose from 9% to 66%.
  • CAT users also reported an improvement in daily activities. The percentage who said that their pain did not limit them at all rose from 3% to 12% and the percentage who said they could do everything, but with pain, rose from 26% to 52%.

“CAT use is increasing and this study shows that it provided self-reported benefits for patient with rheumatoid arthritis and osteoarthritis” says Professor Alaaeddine.
“It is, however, important that patients discuss CAT use with their healthcare practitioner and that they are made aware of possible side effects, in particular the possible interactions between herbal and prescribed drugs.”

Article adapted by Medical News Today from original press release. Click ‘references’ tab above for source.
Visit our arthritis / rheumatology section for the latest news on this subject.
“Use of complementary and alternative therapy among patients with rheumatoid arthritis and osteoarthritis.” Alaaeddine et al.Journal of Clinical Nursing. 21, pp3198-3204. (November 2012). doi: 10.1111/j.1365-2702.2012.04169.x
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31 Oct. 2012. <http://www.medicalnewstoday.com/releases/252181.php>
n.p. (2012, October 31). “Arthritis Patients’ Lives Improved By Complementary And Alternative Therapy.” . Retrieved fromhttp://www.medicalnewstoday.com/releases/252181.php.

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Rheumatoid arthritis, sometimes referred to as rheumatoid disease, is a chronic (long lasting), progressive and disabling autoimmune disease that causes inflammation (swelling) and pain in the joints, the tissue around the joints, and other organs in… Read more…

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Water Workouts Offer Same Aerobic Benefits With Less Wear And Tear

Main Category: Sports Medicine / Fitness
Also Included In: Arthritis / Rheumatology;  Obesity / Weight Loss / Fitness
Article Date: 31 Oct 2012 – 1:00 PDT

Water Workouts Offer Same Aerobic Benefits With Less Wear And Tear
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Biking, running and walking are all good for you. But the strain can be tough if you’re overweight, have arthritis or suffer from other joint problems or injuries. What to do? Just add water.
A study presented today at the Canadian Cardiovascular Congress found that people who used an immersible ergocycle – basically an exercise bike in a pool – had just about the equivalent workout to using a typical stationary bike.
“If you can’t train on land, you can train in the water and have the same benefits in terms of improving aerobic fitness,” says Dr. Martin Juneau, director of prevention at the Montreal Heart Institute.
He says people might assume that exercising in the water can’t be as valuable as exercising on land. Because of the resistance of the water when you move, it doesn’t seem like you can work as hard. This new study indicates otherwise.
Healthy participants did exercise tests on both the land and water cycling machines (with water up to chest level). They increased their intensity minute by minute until exhaustion.
Dr. Juneau reports that the maximal oxygen consumption – which tells you whether it was a good workout – was almost the same using both types of cycles.
His study colleague Dr. Mathieu Gayda, a clinical exercise physiologist at the Montreal Heart Institute, adds: “Exercise during water immersion may be even more efficient from a cardiorespiratory standpoint.”
Another finding, says Dr. Juneau, is that the heart rate of the participants was a little lower in the water.
“You pump more blood for each beat, so don’t need as many heartbeats, because the pressure of the water on your legs and lower body makes the blood return more effectively to the heart. That’s interesting data that hasn’t been studied thoroughly before,” says Dr. Juneau.
Considering the number of people who can find it difficult to exercise on land, the water option is promising, says Dr. Juneau. He says that swimming may be the best exercise of all but not everyone can swim. With the workout benefits, the low stress of moving in the water and the reduced chance of injury, “this is a great alternative,” he says.
Heart and Stroke Foundation spokesperson Dr. Beth Abramson notes that 85 per cent of Canadians do not accumulate the recommended 150 minutes per week of moderate- to vigorous-intensity physical activity.
“Inactive people who become physically active can reduce their risk of heart attack risk by 35 to 55 per cent, plus lower their chance of developing several other conditions, cut stress levels and increase energy,” says Dr. Abramson. “Even if you have difficulty moving more, there are always solutions, as this study shows. This is encouraging given the aging population – it’s never too late or too difficult to make a lifestyle change.”

Article adapted by Medical News Today from original press release. Click ‘references’ tab above for source.
Visit our sports medicine / fitness section for the latest news on this subject.
The Canadian Cardiovascular Congress 2012 is co-hosted by the Heart and Stroke Foundation and the Canadian Cardiovascular Society.Heart and Stroke Foundation of Canada
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31 Oct. 2012. <http://www.medicalnewstoday.com/releases/252169.php>
n.p. (2012, October 31). “Water Workouts Offer Same Aerobic Benefits With Less Wear And Tear.” . Retrieved fromhttp://www.medicalnewstoday.com/releases/252169.php.

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Research revealed on a BBC TV Horizon programme broadcast in February 2012, suggests it is possible to improve some measures of fitness with just 3 minutes of exercise a week. Read more…
High profile events like the Olympics look to inspire young people into sport. But, if they don’t take appropriate measures, young athletes can end up in pain and on a path to poor health, due to avoidable sport injury. Read more…

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Cartilage Engineered From Pluripotent Stem Cells

Main Category: Stem Cell Research
Also Included In: Arthritis / Rheumatology;  Bones / Orthopedics
Article Date: 31 Oct 2012 – 0:00 PDT

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A team of Duke Medicine researchers has engineered cartilage from induced pluripotent stem cells that were successfully grown and sorted for use in tissue repair and studies into cartilage injury and osteoarthritis.
The finding is reported online in the journal the Proceedings of the National Academy of Sciences, and suggests that induced pluripotent stem cells, or iPSCs, may be a viable source of patient-specific articular cartilage tissue.
“This technique of creating induced pluripotent stem cells – an achievement honored with this year’s Nobel Prize in medicine for Shimya Yamanaka of Kyoto University – is a way to take adult stem cells and convert them so they have the properties of embryonic stem cells,” said Farshid Guilak, PhD, Laszlo Ormandy Professor of Orthopaedic Surgery at Duke and senior author of the study.
“Adult stems cells are limited in what they can do, and embryonic stem cells have ethical issues,” Guilak said. “What this research shows in a mouse model is the ability to create an unlimited supply of stem cells that can turn into any type of tissue – in this case cartilage, which has no ability to regenerate by itself.”
Articular cartilage is the shock absorber tissue in joints that makes it possible to walk, climb stairs, jump and perform daily activities without pain. But ordinary wear-and-tear or an injury can diminish its effectiveness and progress to osteoarthritis. Because articular cartilage has a poor capacity for repair, damage and osteoarthritis are leading causes of impairment in older people and often requires joint replacement.
In their study, the Duke researchers, led by Brian O. Diekman, PhD., a post-doctoral associate in orthopaedic surgery, aimed to apply recent technologies that have made iPSCs a promising alternative to other tissue engineering techniques, which use adult stem cells derived from the bone marrow or fat tissue.
One challenge the researchers sought to overcome was developing a uniformly differentiated population of chondrocytes, cells that produce collagen and maintain cartilage, while culling other types of cells that the powerful iPSCs could form.
To achieve that, the researchers induced chondrocyte differentiation in iPSCs derived from adult mouse fibroblasts by treating cultures with a growth medium. They also tailored the cells to express green fluorescent protein only when the cells successfully became chondrocytes. As the iPSCs differentiated, the chondrocyte cells that glowed with the green fluorescent protein were easily identified and sorted from the undesired cells.
The tailored cells also produced greater amounts of cartilage components, including collagen, and showed the characteristic stiffness of native cartilage, suggesting they would work well repairing cartilage defects in the body.
“This was a multi-step approach, with the initial differentiation, then sorting, and then proceeding to make the tissue,” Diekman said. “What this shows is that iPSCs can be used to make high quality cartilage, either for replacement tissue or as a way to study disease and potential treatments.”
Diekman and Guilak said the next phase of the research will be to use human iPSCs to test the cartilage-growing technique.
“The advantage of this technique is that we can grow a continuous supply of cartilage in a dish,” Guilak said. “In addition to cell-based therapies, iPSC technology can also provide patient-specific cell and tissue models that could be used to screen for drugs to treat osteoarthritis, which right now does not have a cure or an effective therapy to inhibit cartilage loss.”

Article adapted by Medical News Today from original press release. Click ‘references’ tab above for source.
Visit our stem cell research section for the latest news on this subject.
In addition to Guilak and Diekman, study authors include Nicolas Christoforou; Vincent P. Willard; Alex Sun; Johannah Sanchez-Adams; and Kam W. Leong.
The National Institutes of Health (AR50245, AR48852, AG15768, AR48182, Training Grant T32AI007217) and the Arthritis Foundation funded the study.
Duke University Medical Center
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n.p. “Cartilage Engineered From Pluripotent Stem Cells.” Medical News Today. MediLexicon, Intl., 31 Oct. 2012. Web.
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n.p. (2012, October 31). “Cartilage Engineered From Pluripotent Stem Cells.” . Retrieved fromhttp://www.medicalnewstoday.com/releases/252149.php.

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ACR Supports Best Practices For Ultrasonography Use In Rheumatology

Main Category: Arthritis / Rheumatology
Also Included In: Lupus;  Gout
Article Date: 31 Oct 2012 – 0:00 PDT

ACR Supports Best Practices For Ultrasonography Use In Rheumatology
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More rheumatologists are embracing musculoskeletal ultrasound (MSUS) to diagnose and manage rheumatic diseases. In response, the American College of Rheumatology (ACR) assembled a task force to investigate and determine best practices for use of MSUS in rheumatology practice. The resulting scenario-based recommendations, which aim to help clinicians understand when it is reasonable to integrate MSUS into their rheumatology practices, now appear online in Arthritis Care & Research.
In Europe, more than 100 million individuals are affected by rheumatic diseases, according to the European League Against Rheumatism (EULAR). The ACR estimates that nearly 50 million Americans are burdened by arthritis and more than 7 million individuals suffer from inflammatory rheumatic diseases such as systemic lupus erythematosus, rheumatoid arthritis and gout.
“With so many people affected by rheumatic diseases, including arthritis, a diagnostic tool such as MSUS that is minimally invasive and with little risk to patients is an important tool for rheumatologists,” explains lead researcher Dr. Tim McAlindon from Tufts Medical Center in Boston, Mass. “Our task force goal was to establish when use of MSUS was ‘reasonable’ in a number of medical situations.”
The task force reviewed medical literature to come up with scenario-based recommendations for how MSUS could be used in rheumatology practice. These recommendations include a rating by type of evidence, with Level A supported by at least two randomized clinical trials or one or more meta-analyses of randomized trials; Level B backed by one randomized trial, non-randomized studies or meta-analyses of non-randomized studies; and Level C confirmed by consensus expert opinion, case studies, or standard clinical care.
The complete list of 14 recommendations of the reasonable use of MSUS in rheumatology, along with level of evidence, is published in the article. Partial list of recommendations includes:

  • For a patient with articular pain, swelling or mechanical symptoms, without definitive diagnosis on clinical exam, it is reasonable to use MSUS to further elucidate the diagnosis at the following joints: glenohumeral, acromioclavicular, sternoclavicular, elbow, wrist, metacarpophalangeal, interphalangeal, hip, knee, ankle, midfoot and metatarsophalangeal. Level of evidence: B.
  • For a patient with diagnosed inflammatory arthritis and new or ongoing symptoms without definitive diagnosis on clinical exam, it is reasonable to use MSUS to evaluate for inflammatory disease activity, structural damage or emergence of an alternate cause at the following sites: glenohumeral, acromioclavicular, elbow, wrist, metacarpophalangeal, interphalangeal, hip, knee, ankle, midfoot and metatarsophalangeal, and entheseal. Level B.
  • For a patient with shoulder pain or mechanical symptoms, without definitive diagnosis on clinical exam, it is reasonable to use MSUS to evaluate underlying structural disorders; but not for adhesive capsulitis or as preparation for surgical intervention. Level B.
  • It is reasonable to use MSUS to evaluate the parotid and submandibular glands in a patient being evaluated for Sjögren’s disease to determine whether they have typical changes as further evidence of the disorder. Level B.
  • For a patient with symptoms in the region of a joint whose evaluation is obfuscated by adipose or other local derangements of soft tissue, it is reasonable to use MSUS to facilitate clinical assessment at the glenohumeral, acromioclavicular, elbow, wrist, hand, metacarpophalangeal, interphalangeal, hip, knee, ankle/foot, and metatarsophalangeal joints. Level C.
  • For a patient with regional neuropathic pain without definitive diagnosis on clinical exam, it is reasonable to use MSUS to diagnose entrapment of the median nerve at the carpal tunnel; ulnar nerve at the cubital tunnel; and posterior tibial nerve at the tarsal tunnel. Level B.
  • It is reasonable to use MSUS to guide articular and peri-articular aspiration or injection at sites that include the synovial, tenosynovial, bursal, peritendinous and perientheseal areas. Level A.

The benefits of MSUS use include a faster, more accurate diagnosis, better measurement of treatment success, reduced procedural pain, and improved patient satisfaction. However, the authors highlight that economic impact was not part of this study. Dr. McAlindon concludes, “Further study of the cost-effectiveness and long-term outcomes of MSUS is necessary to determine its value compared to other interventions.”

Article adapted by Medical News Today from original press release. Click ‘references’ tab above for source.
Visit our arthritis / rheumatology section for the latest news on this subject.
Full citation: American College of Rheumatology Report on Reasonable Use of Musculoskeletal Ultrasonography in Rheumatology Clinical Practice.” Timothy McAlindon, Eugene Kissin, Levon Nazarian, Veena Ranganath, Shraddha Prakash, Mihaela Taylor, Raveendhara R Bannuru, Sachin Srinivasan, Maneesh Gogia, Maureen A McMahon, Jennifer Grossman, Suzanne Kafaja, John FitzGerald. Arthritis Care and Research; Published Online: October 29, 2012 (DOI: 10.1002/acr.21836).Wiley
Please use one of the following formats to cite this article in your essay, paper or report:

n.p. “ACR Supports Best Practices For Ultrasonography Use In Rheumatology.” Medical News Today. MediLexicon, Intl., 31 Oct. 2012. Web.
31 Oct. 2012. <http://www.medicalnewstoday.com/releases/252173.php>
n.p. (2012, October 31). “ACR Supports Best Practices For Ultrasonography Use In Rheumatology.” . Retrieved fromhttp://www.medicalnewstoday.com/releases/252173.php.

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