Knee Replacement Often Beneficial for Rheumatoid Arthritis: Study

Patients did as well as those with osteoarthritis, but same did not hold true for hip replacement

By Maureen Salamon

HealthDay Reporter

THURSDAY, June 20 (HealthDay News) -- The common belief that rheumatoid arthritis patients don't benefit from knee replacement surgery as much as those with the more common osteoarthritis has been challenged by the findings from a pair of studies by New York City scientists.

Researchers from the Hospital for Special Surgery also found, however, that rheumatoid arthritis patients who underwent a total hip replacement didn't fare as well as those with osteoarthritis, though they did experience improvements in pain and function.

"One thing that we can clearly pull out of this research is that the levels of pain and function among those with rheumatoid arthritis were so much worse preoperatively at the point they approached joint replacement," explained rheumatologist Dr. Susan Goodman, the lead author of both studies. "They may be postponing or not getting to surgery until they're really in a much worse state. Perhaps that's one of the explanations for the results . . . perhaps it's their generalized disease. We really just don't know yet."

Goodman presented the research last week at the European League Against Rheumatism's annual meeting in Madrid, Spain. Research presented at scientific conferences has typically not been peer-reviewed or published and is considered preliminary.

Affecting one of every five adults, along with 300,000 children, arthritis is the leading cause of disability in the United States, according to the Arthritis Foundation. Osteoarthritis, the most prevalent form, progressively breaks down cartilage in the joints due to wear and tear, while rheumatoid arthritis is an autoimmune disease marked by inflammation of the membranes surrounding joints. Along with bringing chronic pain, both types can result in joint destruction.

Historically, rheumatoid arthritis patients have had worse outcomes after joint replacement surgeries than osteoarthritis patients, according to the study authors, but more effective drugs developed over the last two decades have helped them to better control their disease.

In the first study, Goodman and her team analyzed joint replacement registry data to identify 178 rheumatoid arthritis patients and more than 5,200 osteoarthritis patients who underwent knee replacement surgery. Though rheumatoid arthritis patients had worse pain and function before surgery, patients in both groups had similar satisfaction rates after surgery.

The second study compared outcomes of 202 rheumatoid arthritis patients and more than 5,800 osteoarthritis patients who underwent hip replacement, finding that those with rheumatoid arthritis started out with worse function before surgery and also had worse pain and function scores after surgery. However, rheumatoid arthritis patients were as likely as those with osteoarthritis to experience an overall improvement after hip replacement, though the gains didn't erase the disparity between the two groups.

"The advice to rheumatoid arthritis patients is, really, that you will have significant pain relief [from joint replacement surgery]," Goodman said. "It is an area that needs more study. We're looking forward to assessing more rheumatoid-specific factors."

The research, which looked at participants with active rheumatoid arthritis, is consistent with what Dr. Olivia Ghaw, an assistant professor of medicine in rheumatology at Mount Sinai Medical Center in New York City, sees in her practice.

But Ghaw said she felt the study's two-year follow-up period was perhaps not long enough to confirm if the joint replacement outcomes remained positive for rheumatoid arthritis patients.

"For some of my patients, if their joint is severely destructed, I still do recommend joint replacement," she said. "Ideally, we would love to get their underlying disease under better control. If we can bring their inflammation down, perhaps they can have better results with joint replacement."

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Parents Who Veto Vaccinations Often Seek Like-Minded Opinions

By Amy Norton
HealthDay Reporter

MONDAY, April 15 (HealthDay News) -- Friends and family may be key in parents' decisions on whether to vaccinate their young children, a small study suggests.

The study, of about 200 parents, found that those who had opted not to follow the standard vaccine schedule often sought advice from anti-vaccine friends and family.

Experts said it's not certain that the advice actually steered parents in an anti-vaccine direction: Parents who were already prone to shunning vaccines may have turned to like-minded people for reinforcement.

"It's the chicken-and-egg question," said researcher Emily Brunson, an assistant professor of anthropology at Texas State University, in San Marcos. "The answer is, we don't know which came first."

To be more sure, Brunson said, parents would have to be followed over time, to see whether undecided parents actually base vaccine decisions on advice from other people.

But Brunson said she thinks family, friends and others in parents' "social networks" really are an important influence.

Dr. Douglas Opel, of Seattle Children's Research Institute and the University of Washington, agreed.

"It is unclear how these groups influence parents. Do they simply reinforce the vaccine decisions parents would have made otherwise, or do they actually function as a way that provokes a parent to consider other ideas?" said Opel, who wrote an editorial published with the study, which appears online April 15 and in the May print issue of the journal Pediatrics

Opel said his hunch is that family and friends reinforce parents' existing views. But even if that's true, they are still a big influence by bolstering parents' beliefs.

Experts recommend that babies and young children routinely receive vaccinations against a host of common (or once common) infectious diseases, such as measles, mumps, whooping cough, chickenpox and hepatitis.

But some parents balk at those recommendations, largely because of a purported link between vaccines and autism. More than a decade's worth of studies have failed to confirm that link exists, but anxiety remains: A recent study of U.S. parents found that about one-third thought children receive too many vaccinations in their first two years, and they thought the shots could contribute to autism.

Brunson wanted to see where parents are turning to get their information, so she recruited nearly 200 parents of children 18 months old or younger. About 130 had their child up to date on all vaccines (and were dubbed "conformers") and 70 had opted to skip or delay at least some vaccinations ("nonconformers").

In an online survey, Brunson asked the parents to list the people and other sources -- such as websites and books -- they had gone to for vaccine advice.

She found that nearly all parents had sought advice from other people -- usually several people, including their doctor, spouse, family members and friends. And parents' ultimate decisions generally fell in line with that advice.

Among nonconforming parents, nearly three-quarters of their social circle recommended not vaccinating, on average. That was in sharp contrast to the conformers, whose social circles by and large said they should have their child vaccinated on time.

Brunson found that the more anti-vaccine views parents heard from their circle, the more likely they were to skip or delay vaccinations. And people seemed to matter more than information sources, such as the media.

She noted that the media often "gets a bad rap" as being a well of vaccine misinformation. But in this study, nonconforming parents actually got a more positive view of vaccines from the media than they did from their social circles.

Brunson and Opel said the findings speak to the power of the people in our lives.

"Parents do not make immunization decisions in a vacuum," Opel said. "Parents listen to and are influenced by other parents."

He said parents who vaccinate might try being more "vocal" to other parents about why they made their decision.

Brunson said efforts to encourage parents to vaccinate often focus on the role of pediatricians. "But this study is saying that we probably need to have a much broader approach than that," she said.

Media campaigns and other approaches that reach the general public, not just parents, might work better, Brunson said.

Copyright © 2013 HealthDay. All rights reserved. SOURCES: Emily Brunson, Ph.D., M.P.H., assistant professor, anthropology, Texas State University, San Marcos; Douglas Opel, M.D., M.P.H., assistant professor, bioethics and general pediatrics, University of Washington School of Medicine, Seattle; May 2013 Pediatrics

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Parents Who Veto Vaccinations Often Seek Like-Minded Opinions

Study suggests friends, family may be important sources of advice

By Amy Norton

HealthDay Reporter

MONDAY, April 15 (HealthDay News) -- Friends and family may be key in parents' decisions on whether to vaccinate their young children, a small study suggests.

The study, of about 200 parents, found that those who had opted not to follow the standard vaccine schedule often sought advice from anti-vaccine friends and family.

Experts said it's not certain that the advice actually steered parents in an anti-vaccine direction: Parents who were already prone to shunning vaccines may have turned to like-minded people for reinforcement.

"It's the chicken-and-egg question," said researcher Emily Brunson, an assistant professor of anthropology at Texas State University, in San Marcos. "The answer is, we don't know which came first."

To be more sure, Brunson said, parents would have to be followed over time, to see whether undecided parents actually base vaccine decisions on advice from other people.

But Brunson said she thinks family, friends and others in parents' "social networks" really are an important influence.

Dr. Douglas Opel, of Seattle Children's Research Institute and the University of Washington, agreed.

"It is unclear how these groups influence parents. Do they simply reinforce the vaccine decisions parents would have made otherwise, or do they actually function as a way that provokes a parent to consider other ideas?" said Opel, who wrote an editorial published with the study, which appears online April 15 and in the May print issue of the journal Pediatrics

Opel said his hunch is that family and friends reinforce parents' existing views. But even if that's true, they are still a big influence by bolstering parents' beliefs.

Experts recommend that babies and young children routinely receive vaccinations against a host of common (or once common) infectious diseases, such as measles, mumps, whooping cough, chickenpox and hepatitis.

But some parents balk at those recommendations, largely because of a purported link between vaccines and autism. More than a decade's worth of studies have failed to confirm that link exists, but anxiety remains: A recent study of U.S. parents found that about one-third thought children receive too many vaccinations in their first two years, and they thought the shots could contribute to autism.

Brunson wanted to see where parents are turning to get their information, so she recruited nearly 200 parents of children 18 months old or younger. About 130 had their child up to date on all vaccines (and were dubbed "conformers") and 70 had opted to skip or delay at least some vaccinations ("nonconformers").

In an online survey, Brunson asked the parents to list the people and other sources -- such as websites and books -- they had gone to for vaccine advice.

She found that nearly all parents had sought advice from other people -- usually several people, including their doctor, spouse, family members and friends. And parents' ultimate decisions generally fell in line with that advice.

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Designated Drivers Often Drink Themselves, Study Finds

While most abstained, 35 percent had alcohol in bloodstreams and some were legally drunk

By Randy Dotinga

HealthDay Reporter

MONDAY, June 10 (HealthDay News) -- Having a designated driver sounds like a great idea, but a new study found that more than one-third of those who were supposed to drive their pals home safely had been boozing it up themselves.

And some were legally drunk.

The study has limitations that prevent it from being definitive, and researchers aren't sure how much danger lurks in designated drivers who have a drink or two. But the message is clear, said study author Adam Barry, an assistant professor at the University of Florida: Some designated drivers are drinking when they should be abstaining.

"While more of the designated drivers didn't drink than did drink, which is a good thing, you have people being selected because they're the least drunk, or the least intoxicated or they've driven drunk before," Barry said. "The only real safe option is to completely abstain."

The researchers, all from the University of Florida, Gainesville, went to an unidentified college-area town and talked to almost 1,100 bar patrons, mostly white, male and college-aged. They then gave blood alcohol tests to 165 people who said they were serving as designated drivers -- those who are expected to take care of driving their friends home so the others can drink.

Sixty-five percent, or 108, of the designated drivers had zero alcohol in their systems. Another 17 percent, or 28, had a blood alcohol level of between 0.02 and 0.049 (grams of alcohol per 210 liters of breath). And 18 percent, or 29, were at 0.05 or more; the legal limit is 0.08 or higher.

It's not clear how many of the designated drivers actually drove after taking the blood alcohol tests, nor do researchers know if they were able to sober up before driving.

The researchers also didn't examine how many of the designated drivers were legally drunk at 0.08 or higher. Barry said the researchers chose to look at those above 0.05 because experts think drivers are significantly impaired at that level; some public health advocates want to lower the legal level for driving to 0.05.

People can be arrested for driving while intoxicated at levels under 0.08, but they must show signs that they're impaired.

Why does it matter if designated drivers have had only a bit of alcohol? Barry said they may have more trouble handling the task of driving with boozed-up passengers: "You've got roughhousing, unruly passengers, music -- so many competing factors on top of your ability to process information and brake and steer effectively," he explained.

Is it realistic to expect designated drivers to not drink at all? James Lange, an alcohol researcher and coordinator of Alcohol and Other Drug Initiatives at San Diego State University, said it is.

Because people's alcohol tolerance varies, "it would be difficult for me to make a blanket statement that a certain amount is OK," Lange said. "The easiest recommendation is that they don't drink at all."

E. Scott Geller, a professor who studies alcohol use at Virginia Tech, suggested that "we should not trust a designated driver to be sober." Instead, he said, there should be ways to guarantee that they don't drink, such as providing rewards at a party or bar if blood alcohol tests shows they've abstained.

The study appears in the July issue of the Journal of Studies on Alcohol and Drugs.

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Autism, ADHD Often Occur Together, Research Shows

Study finds nearly one-third of kids with autism also have problems with attention and hyperactivity

By Brenda Goodman

HealthDay Reporter

THURSDAY, June 6 (HealthDay News) -- Almost 30 percent of young children with autism also show signs of attention-deficit/hyperactivity disorder (ADHD), a rate that's three times higher than it is in the general population, a new study shows.

"We don't know the cause for ADHD in most cases. We don't know the cause of autism in most cases. It's not surprising that something that's going to affect the brain and cause one developmental outcome may also cause a second developmental outcome," said Dr. Andrew Adesman, chief of developmental and behavioral pediatrics at Steven and Alexandra Cohen Children's Medical Center in Lake Success, N.Y. He was not involved in the study.

Kids in the study who had both problems together also tended to have more difficulty learning and socializing than children who had autism alone.

The researchers noted that the treatment of ADHD may benefit children with autism if they aren't making progress with autism treatment programs, which often require sustained focus on specific skills.

"In a child [with autism] who has great difficulties with attention, or hyperactivity or both, you really have to layer in another level of intervention strategies for them," said study author Rebecca Landa, director of the Center for Autism and Related Disorders at the Kennedy Krieger Institute in Baltimore.

For the study, which is published in the June 5 online issue of the journal Autism, researchers asked parents of kids enrolled in a community-based study of child development about symptoms of attention and hyperactivity -- whether or not children could wait their turn, interrupted others who were speaking, fiddled with things during meals or could not slow down, for example. All the children in the study were between the ages of 4 and 8.

Out of 62 children diagnosed with autism, 18 (29 percent) also showed signs of ADHD.

A previous study of slightly older children found that 31 percent of children had the two disorders together.

"It's not surprising," said Dr. Patty Manning-Courtney, director of the Kelly O'Leary Center for Autism Spectrum Disorders at Cincinnati Children's Hospital Medical Center.

"What's good about this study is that they went to the trouble to look at who met diagnostic criteria and what was different about those children," said Manning-Courtney, who was not involved in the research.

All the children who had both problems together were boys. Boys have higher rates of autism and ADHD than girls, research shows.

One limitation of the study was that researchers had to rely on questionnaires that are meant to spot ADHD in typical children. There really aren't good tests for attention and hyperactivity developed for kids with autism, and their problems may look different than those seen in typical school-aged children.

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Ready-to-Eat Foods for Toddlers Often Too Salty: Study

Parents urged to balance convenience with healthier meals, snacks

By Kathleen Doheny

HealthDay Reporter

THURSDAY, March 21 (HealthDay News) -- Those convenient, prepackaged meals and snacks for toddlers may contain worrisome levels of salt, U.S. researchers report.

More than three quarters of 90 toddler meals evaluated by the U.S. Centers for Disease Control and Prevention were high in sodium, according to a new study.

Ready-to-eat foods for babies were less alarming, found the experts, who reported on the sodium content of 1,115 products for babies and toddlers using per-serving data from major and private-label brands.

"The products we assessed for babies and infants were relatively low in sodium," said Joyce Maalouf, a fellow at the CDC division for heart disease and stroke prevention.

"Unfortunately, the toddler food products -- meals and snacks -- have higher amounts of sodium," she said. Those products are aimed for kids 1 to 3 years old.

She is scheduled to present the findings Thursday at a American Heart Association meeting in New Orleans.

Eating too much sodium, the main component of salt, can lead to high blood pressure, which is a risk factor for heart disease and stroke.

Moreover, studies have suggested that children's taste for salt may be reduced if they consume less sodium at a young age, Maalouf said. "Children are not born with a taste for salt," she noted.

The researchers defined a product as high in sodium if it exceeded 210 milligrams (mg) per serving. The American Heart Association recommends limiting sodium intake to less than 1,500 mg a day, but some toddler meals contained as much as 630 mg per serving -- 40 percent of the recommended daily total.

"The toddler meals ranged from 100 milligrams per serving up to 630 milligrams per serving," Maalouf said. The average was 369 mg, with 71 percent of the meals high in sodium.

The researchers evaluated four toddler savory snacks, such as cheese and crackers, and found they ranged from 70 mg to 310 mg per serving.

Cereal bars for toddlers ranged from zero to 85 mg of sodium per serving. Fruit snacks for toddlers ranged from zero to 60 mg per serving.

Maalouf declined to name products by brand. "The main purpose of the study was to look at food categories, not compare brands," she said. "Even within the same brand, we had a wide variation of sodium."

Still, prepackaged macaroni and cheese, cheese and crackers, pasta and chicken, pepperoni pizza and chicken noodle soup typically have high sodium levels, Maalouf added.

The message for parents, Maalouf said, is to read nutrition labels and choose lower-sodium items.

The findings are no surprise to Julia Zumpano, a registered dietitian at the Cleveland Clinic's department of preventive cardiology. Foods prepackaged for infants tend to be lower in sodium, as they contain just one or two ingredients, often vegetable- or fruit-based, and servings are smaller than those for toddlers.

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Spine MRIs Often Show Harmless 'Defects,' Study Finds

After treatment, many people have visible evidence of a herniated disc without any symptoms

By Serena Gordon

HealthDay Reporter

WEDNESDAY, March 13 (HealthDay News) -- Even though expensive MRIs produce very detailed images for assessing back pain, they may not be very good at evaluating results after treatment, research suggests.

Many physicians order an MRI before and after treatment of patients with lumbar-disk herniation and persistent sciatica. But some experts say spine imaging is overused and not necessarily accurate in certain cases.

This new study used MRI scans from a study initially designed to compare surgery to conservative care for sciatica, which is pain or weakness that radiates from the back down the leg. The researchers compared a person's first MRI to their follow-up MRI taken a year later. They couldn't tell from the follow-up MRIs who had good results and who didn't.

"The discriminative power of MRI is much less than expected in patients who had sciatica before or who have had persistent complaints for more than one year," said the study's senior author, Dr. Wilco Peul, professor and chairman of neurosurgery at Leiden University Medical Center in the Netherlands.

Peul said that the decision to have a second surgery shouldn't be based on MRI findings alone.

Even if it appears from a follow-up MRI that surgery is necessary, he said people should be advised that their continued pain may be caused by inflammation rather than nerve compression, and in that case, it's unlikely that surgery would relieve their symptoms.

Results of the study are published in the March 14 issue of the New England Journal of Medicine.

Sciatica is a common problem, affecting as many as 40 percent of adults at some time in their lives. Sciatica is commonly caused by a herniated disc in the back as it presses down on the sciatic nerve, according to background information in the study. These discs are located between each of the vertebra, or bones, in the spine.

For most people, sciatica is a short-lived problem. Within eight weeks, most people no longer have sciatic pain, according to the study. For some people, however, sciatic pain can be long-lasting.

When sciatic pain doesn't go away, doctors often recommend imaging tests, such as MRIs, to rule out serious causes of the pain, such as a tumor, said Dr. Devon Klein, chief of musculoskeletal radiology at Lenox Hill Hospital in New York City.

The problem is that many people have herniated discs, often without any symptoms. Previous research has found that between 20 percent and 76 percent of people who don't have symptoms will show signs of disk herniation on an MRI, the study found.

Klein confirmed this. "If you take all comers and give them an MRI, you will see disc disease in most of them," he said. "Everyone hurts their back at some point."

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Low-Income Patients Often Have Trouble Reaching Doctor Via Email

Title: Low-Income Patients Often Have Trouble Reaching Doctor Via Email
Category: Health News
Created: 3/1/2013 2:36:00 PM
Last Editorial Review: 3/4/2013 12:00:00 AM

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'Worried Well' Often Ignore Negative Test Results: Study

Title: 'Worried Well' Often Ignore Negative Test Results: Study
Category: Health News
Created: 2/26/2013 10:35:00 AM
Last Editorial Review: 2/26/2013 12:00:00 AM

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Shift to Hospice Care Often Comes Too Late, Study Finds

By Serena Gordon

HealthDay Reporter

TUESDAY, Feb. 5 (HealthDay News) -- Although most people would prefer to die peacefully in a comfortable setting, a new study shows that almost one in three spend some time in the intensive-care unit of a hospital in their last month of life while a similar number only get hospice care a few days before dying.

And 40 percent of those late hospice care referrals come right after an ICU stay, the researchers noted.

"People end up with these very short stays in hospice [care]," said study author Dr. Joan Teno, a professor of health services, policy and practice at Brown University's Warren Alpert Medical School, in Providence, R.I. "Those short stays are difficult on the patients and the families. They don't benefit from hospice's psychosocial support for patients and their families."

Another expert put it this way: "I think what has happened is that we're using hospice [care] as a last resort. It's something we do when people have gotten so bad that they can't respond to any possible intervention," said Dr. Mary Tinetti, chief of geriatrics and professor of internal medicine and public health at the Yale University School of Medicine and Yale New Haven Hospital.

"Hospice [care] should be used as a treatment for those who are focused on quality of life," said Tinetti, who is also the co-author of an editorial accompanying the study. "Some people are going to want to access to palliative care earlier in the process."

The findings were published in the Feb. 6 issue of the Journal of the American Medical Association.

The study reviewed a random sample of 20 percent of fee-for-service Medicare beneficiaries who died in 2000, 2005 and 2009. Each year, fewer people died in the hospital, according to the study. In 2000, 32.6 percent died in the hospital. In 2005, 26.9 percent died under hospital care, and 24.6 percent did so in 2009.

At the same time, however, the use of the intensive-care unit in the last month of life increased for each time period. In 2000, 24.3 percent of people were in the ICU in their last month. By 2005, that number was 26.3 percent, and in 2009 it had risen to 29.2 percent.

During that same period, the use of hospice care also increased significantly. In 2000, 21.6 percent of people received hospice care at the time of their death. That number was 32.3 percent in 2005 and 42.2 percent in 2009.

In 2009, however, 28.4 percent of hospice care was for three days or less, according to the study. And 40 percent of those short hospice stays came on the heels of an ICU stay.

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Pap Tests Often Given When Not Needed

Dec. 3, 2012 -- Against clinical guidelines, many women are still getting Pap smears (a test that’s meant to find cancer of the cervix) even after they've had a total hysterectomy, which removes the uterus and cervix, according to a new government report.

The cervix is the “neck-like” lower part of the uterus. A Pap test uses cells scraped from the cervix to check for early changes that may indicate cervical cancer or precancer. The new report, from the CDC, looked at trends in Pap testing in U.S. women from 2000 to 2010.

In telephone surveys of thousands of women, about 60% of those over age 30 who said they’d had a hysterectomy also reported having a recent Pap smear in 2010.

Even though that number was down about 15 percentage points since 2000, researchers said it was still too high.

“Some of these women would need continued screening, for various reasons, but that’s a small percentage,” says researcher Meg Watson, MPH, an epidemiologist with the CDC’s Division of Cancer Prevention and Control. “We wouldn’t think it would be 60%.”

A hysterectomy is an operation that removes all or part of the uterus. The most common kind of hysterectomy is a total hysterectomy, or an operation that removes both uterus and cervix.

Even after the cervix has been removed, doctors can scrape cells from an area called the vaginal cuff. And in the past, Watson says, many doctors continued to perform the test even after a total hysterectomy to check for signs of vaginal cancers.

“But vaginal cancer rates are quite low,” Watson says, and subsequent studies have shown that using Pap smears to find vaginal cancers isn’t an effective strategy.

Experts who were not involved in the research agree.

“It doesn’t really make a lot of sense,” says Virginia Moyer, MD, MPH, a pediatrician and chair of the U.S. Preventive Services Task Force, a panel of expert advisors that makes recommendations about tests and treatments that are meant to prevent disease.

Last year, the panel said most healthy women only need Pap smears every three years, and it advised women who’d had total hysterectomies for reasons other than cancer to skip the test altogether.

The American College of Obstetricians and Gynecologists and the American Cancer Society also recommended against routine Pap smears after a total hysterectomy.

“The only thing I can sort of speculate is that people get in the habit of doing them and just keep doing them without really thinking about it, which is regrettable,” Moyer says.

The Pap test is one of the great success stories in medicine. Before it was introduced, in the 1950s, cervical cancer was a leading cause of cancer death in women. The test is credited with helping cut the rates of cervical cancer deaths by 60% between 1955 and 1992.

But like many cancer screening tests, Pap tests can be harmful as well as helpful.  

Watson says studies have shown that for every 100 abnormal Pap tests, only one woman will actually turn out to have cervical cancer. But all 100 women would need additional testing and sometimes invasive procedures to rule out cancer. That can cause significant anxiety and stress.

In cases where a woman has her cervix or uterus removed after cervical cancer, she would need to continue to get a regular Pap smear to check for cancer recurrence, Watson says.

But about 90% of hysterectomies are performed for non-cancerous conditions, like uterine fibroids.

“Obviously the large majority of that group would be people who had an unnecessary Pap smear,” Moyer says.

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