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Reducing the Pain of Fibromyalgia

Reducing the Pain of Fibromyalgia

The chronic pain syndrome of fibromyalgia afflicts nearly 2% of women and a smaller proportion of men, and is both enigmatic and controversial. Many patients with fibromyalgia are misinformed and told that they are imagining or exaggerating their pain. Others with fibromyalgia learn that they have a medical disease that is chronic and unremitting—in other words, that they’re doomed to suffer from this pain syndrome for the rest of their lives. The unfortunate part of these messages is that they aren’t completely true. Research indicates that the pain and suffering associated with fibromyalgia are real, as illustrated by functional MRI studies and the fact that there are no significant pathological processes occurring at the peripheral sites of pain. Rather, there are overly sensitized central nervous system pathways that initiate and maintain pain, and most patients with fibromyalgia have associated syndromes such as headaches, fatigue, IBS, pelvic pain, interstitial cystitis, and/or temporomandibular joint syndrome, suggesting the presence of an overarching central sensitization dysfunction. Linking Stress to Fibromyalgia There is substantial literature documenting the links between stressful life events, how patients manage strong negative emotions, and fibromyalgia. Patients with fibromyalgia are much more likely than controls to have had significant adverse events in childhood and adulthood. More than half of patients with fibromyalgia have PTSD or substantial PTSD symptoms. People with fibromyalgia are also more likely to suppress emotions and report an “inability to express” themselves. “There is substantial literature documenting the links between stressful life events, how patients manage strong negative emotions, and fibromyalgia.” My colleagues and I published a small randomized, controlled trial of a mind-body approach to fibromyalgia...

Antiretroviral Therapy in HIV Infection: A Guideline Update

Successful antiretroviral therapy (ART) has been linked to dramatic decreases in HIV- and AIDS-defining conditions and their associated mortality. In 2008, the International AIDS Society–USA released guidelines on the timing of therapy, optimal regimen choices, and monitoring in patients with HIV. Since that time, treatment options have expanded, and knowledge on the initiation and long-term management of ART in adults with HIV infection has evolved. “Recent research has shed light on the role of ART in reducing the rates of serious non-AIDS events associated with uncontrolled HIV replication,” explains Melanie A. Thompson, MD. “Clinicians have also gained a better understanding of the efficacy, toxicity, and potential uses of newer drugs. As such, an expert panel was convened to update the International AIDS Society–USA guidelines for the use of ART in adults with HIV infection.” The updated guidelines were presented at the AIDS 2010: XVIII International AIDS Conference and published in the July 21, 2010 JAMA. The Need for Early Initiation of ART Clinical studies have shown that progressive damage occurs during asymptomatic HIV infection. “This underscores the potential benefit of ART, even when the risk of traditional AIDS-defining diseases is relatively low,” says Dr. Thompson, who chaired the International AIDS Society–USA antiretroviral therapy guidelines consensus panel. Dr. Thompson notes that non-AIDS events are now a major contributor to morbidity and mortality in persons with HIV infection. “Uncontrolled HIV replication is associated with immune activation and inflammation, and these are associated with non-AIDS illnesses,” she says. “This suggests that viral suppression with ART might improve survival and quality of life for patients. Multiple studies have now shown this to be...

Conference Highlights: The 2010 Veith Symposium

The 37th annual Veith Symposium was held from November 17 to 21 in New York City. The features below highlight some of the news emerging from the meeting. Analyzing Different Stenting Approaches for Restenosis The Particulars: Few studies have compared the use of drug-eluting stents after angioplasty with balloon angioplasty and bare-metal stenting in the treatment of restenosis. The Zilver PTX (Cook Medical, Inc.) is the first drug-eluting stent approved for the superficial femoral artery and is currently under investigation in the United States for use in restenosis. Researchers conducted a study comparing the Zilver PTX drug-eluting stent after angioplasty with balloon angioplasty and bare-metal stenting. Data Breakdown: The study enrolled 479 patients at 56 institutions in the United States, Japan, and Germany, with 241 patients randomized to the Zilver PTX group and 238 to the bare-metal stenting group. Demographics and lesion characteristics were similar for the groups. Approximately, half of the bare-metal stenting group experienced acute failure and underwent secondary randomization in which 59 and 61 patients were assigned to provisional stenting with Zilver bare-metal stents and Zilver PTX, respectively. Study results met the 12-month primary endpoint goals showing non-inferiority and superior patency for the Zilver PTX as compared with a bare-metal stenting group. Endpoints included event-free survival, stent integrity by radiographic core laboratory analysis, and primary patency by Duplex ultrasound core laboratory analysis. There was also significant clinical improvement with the Zilver PTX. Take Home Pearl: The Zilver PTX drug-eluting peripheral stent appears to be safe and effective for the treatment of restenosis when compared with bare-metal stenting. Ultrasound-Accelerated CDT Beneficial in PE Treatment The Particulars: Pulmonary...

Pediatric Surgery: Analyzing Informed Consent

When performing surgery in adults, the processes preceding the operation are often routine for surgeons and patients, but surgery is anything but routine for parents of pediatric patients undergoing surgery. Parents and guardians typically lack the experience and expertise of surgeons. As such, trust must be developed between surgeons and parents and/or guardians. To ensure that this trust is attained,...

Conference Highlights: American Heart Association’s 2010 Scientific Sessions

The American Heart Association held its 2010 Scientific Sessions from November 13 to 17 in Chicago. The features below highlight some of the news emerging from the meeting. » Benefits Observed With Experimental Cholesterol Drug » A New Approach for Difficult Hypertension Cases » PTSD Linked to Death, Atherosclerosis » Smoking Rates Decline, But Cessation Efforts Still Warranted » Scanning Matters When Managing Diabetics With Heart Disease » Combination Therapy Effective in Heart Failure Benefits Observed With Experimental Cholesterol Drug The Particulars:  Elevated LDL and low HDL cholesterol levels are risk factors for cardiovascular disease (CVD). Statins have been shown to reduce LDL and lessen CVD risk. Despite statin therapy, many patients still have a high risk of CVD. Anacetrapib is an experimental cholesteryl ester transfer protein (CETP) inhibitor. It is intended to block the ability of the CETP enzyme to transfer cholesterol particles from HDL to LDL cholesterol. Data Breakdown: The DEFINE study (Determining the Efficacy and Tolerability of CETP Inhibition with Anacetrapib) was a randomized, double-blind trial of 1,623 patients who took either 100 mg anacetrapib or a placebo for 18 months. Patients were already being treated with a statin and/or other lipid-lowering medicine. Anacetrapib reduced LDL by 40%—from 81 mg/dL to 49 mg/dL. It also more than doubled the level of HDL cholesterol—from 40 mg/dL to 101 mg/dL—without raising blood pressure. Take Home Pearls: Anacetrapib appears to more than double the level of HDL cholesterol and reduce LDL cholesterol without the blood pressure increase that has been linked to other CETP inhibitors. The full efficacy and safety of anacetrapib must be evaluated in a larger, phase...

Balancing Life With a Career in Surgery

Graduate surgical education has changed significantly during the past 20 years. Several events have changed the landscape considerably, including the elimination of the pyramidal training system in 1983, the institution of the Accreditation Council for Graduate Medical Education core competencies in 1999, and the 80-hour work week mandate in 2003. As a result, there have been many new fast-track residencies and a rapid increase in the number of specialty fellowships, especially in minimally invasive surgery. These changes reflect a growing interest in tailoring traditional general surgery to the desire of residents who want to obtain specialty training. This has created a generation gap between current trainees and experienced surgeons in practice. In addition, specialization has emerged as a growing trend that might jeopardize the future of general surgery. According to published research, many factors play a role, including the changing demographics of medical schools and surgery residency programs, residency types, and early exposure through research that is performed during residency. “Gender-related studies on specialty training have historically focused on increasing the female surgeon pool,” says Julie Ann Sosa, MD, MA. “These studies highlight issues surrounding maternity leave, child care, female faculty role models, and shorter training programs. Unfortunately, there’s a paucity of research addressing the influence of external support systems, such as family, on surgical trainees’ plans to specialize during or after their residencies.” New Survey Highlights In the May 2010 Archives of Surgery, Dr. Sosa and colleagues conducted a nationwide survey of all categorical general surgery residents in the United States to identify factors that motivate residents to specialize. “More specifically, we examined the influences of marriage, family,...

Electronic Health Records Present Potential Malpractice Threat

One of the highly touted benefits of electronic health records (EHRs) is reducing malpractice incidents and medical errors by providing improved documentation, an automatic safeguard against medication errors and drug interactions, and a system to track test results and follow up with patients. However, physicians who aren’t careful when implementing and using an EHR can increase their malpractice liability. According to a November article published in the New England Journal of Medicine, physicians should be aware of malpractice pitfalls of EHR use. Some of these include the following: The initial transition from paper to electronic records may create documentation gaps. Failure of clinicians to use EHRs consistently may lead to gaps in documentation and communication. E-mail advice multiplies the number of clinical encounters that could give rise to claims and may heighten the risk of claims if advice is offered without thorough investigation and examination of the patient. More extensive documentation of clinical decisions and activity creates more discoverable evidence for plaintiffs, including metadata. Temptation to copy and paste patient histories instead of taking new histories risks missing new information and perpetuates previous mistakes. Failure to reply to patient e-mails in a timely fashion could constitute negligence and raise patient ire. Better access to clinical information through EHRs could create legal duties to act on the information. While the benefits of EHRs far exceed the drawbacks, awareness of potential consequences is critical to ensure patient safety as well as the integrity of a...

New Insights in Treating SFA & Popliteal Arteries

There is still considerable uncertainty about the best endovascular treatment strategies for patients with stenosis or occlusion of the superficial femoral artery (SFA) or popliteal artery. Percutaneous transluminal angioplasty (PTA) has been performed for over 30 years now, but there is an evolving body of literature that has documented suboptimal outcomes with PTA for all but only the most focal (<4 cm) femoropopliteal lesions. While there is considerable enthusiasm for atherectomy in some centers, there is a paucity of comparative data demonstrating superiority of any of the atherectomy devices over PTA. Over the years, there has also been controversy about the role of stents in the SFA. Clinicians currently do not have enough data demonstrating the superiority of stenting over PTA, but more research is accumulating in this field. Two randomized trials comparing stenting with PTA in the SFA and proximal popliteal artery have recently been published. Schillinger et al randomized patients with SFA disease to balloon angioplasty with provisional/bailout stent implantation versus primary nitinol stent implantation. At 12 months, there was a significantly lower rate of restenosis in the primary stent group compared with the angioplasty group (37% vs 63%). Krankenberg et al randomized 244 patients with shorter SFA lesions to balloon angioplasty versus implantation of a single nitinol stent. At 12 months, there was no significant difference in restenosis between the treatment groups (31.7% vs 38.6%). The disparate results from these trials can likely be explained by the significant differences in lesion length as well as differences between the two stent designs. The RESILIENT Trial The RESILIENT trial (A Randomized Study Comparing the Edwards Self-Expanding LifeStent vs...

Conference Highlights: ACR 2010 Annual Scientific Sessions

The 2010 Scientific Sessions of the American College of Rheumatology, or ACR, was held from November 7 to 11 in Atlanta. The features below highlight just some of the studies that emerged from the meeting. » Promising Results for Experimental RA Drug » Comparing Therapies for ANCA-Positive Vasculitis » Abatacept Well-Tolerated in Patients With RA Promising Results for Experimental RA Drug The Particulars: Tasocitinib is an investigational oral JAK inhibitor that may be beneficial for patients suffering from rheumatoid arthritis (RA). It is thought to block cytokine production. A phase III trial involving 611 patients with RA was conducted to assess the effect of tasocitinib on reducing symptoms, disability, and remission. Data Breakdown: In the study, responses at the ACR20 symptom level after 3 months were seen in 65.7% of patients receiving tasocitinib at 10 mg twice daily and in 59.8% of those taking a 5 mg dose, compared with 26.7% of those taking placebo. ACR50 and ACR70 symptom responses were seen in 36.8% and 20.3%, respectively, of the 10-mg tasocitinib patients at 3 months, compared with 12.5% and 5.8% of the placebo group. Similar results were seen in responses assessed with the Health Assessment Questionnaire-Disability Index. An analysis of remission (according to the Disease Activity Scale-28) at 3 months found that tasocitinib did not offer a significant advantage at either dosage relative to placebo. However, remission was seen in 6.0% of the 5-mg group (relative to placebo). Take Home Pearl: Tasocitinib appears to offer some benefits for RA patients, but more studies are needed to assess efficacy and safety. Comparing Therapies for ANCA-Positive Vasculitis [back to top] The...

Strategies to Prevent Clostridium difficile Infection

Clostridium difficile infection (CDI) is one of the most common causes of infectious healthcare-associated diarrhea in hospitals, with as many as 25% of cases caused by the organism. The increasing incidence and severity of CDI has led to greater efforts to prevent healthcare-associated CDI. The infection has been associated with increased length of hospital stay and inflicts a significant financial burden on healthcare institutions, with an estimated cost of $1.1 billion per year in the United States. “There have been several recent studies analyzing the prevalence of C difficile,” says Jennifer L. Hsu, MD. “One recent investigation showed about 13.1 patients per 1,000 in U.S. hospitals acquired CDI, and about 73% of those were healthcare-associated. In addition, studies have found acquisition rates of CDI in 1% to 13% of patients hospitalized for less than 1 week. This figure increases to 50% for patients hospitalized for more than 4 weeks.” Key Recommendations Researchers from the University of Wisconsin School of Medicine and Public Health conducted a systematic review of interventions to reduce healthcare-associated CDI. Searching multiple computerized databases and relevant articles, the study team sought to identify interventions that were deemed effective in preventing CDI. Although more research is needed on many established and novel prevention measures, the review revealed that antimicrobial stewardship, glove use, and disposable thermometers can be recommended for the prevention of CDI (Table). “Traditional hand hygiene with soap and water has clearly been shown to reduce the rates of CDI,” says Dr. Hsu, who was the lead author of the review. “Two studies examined the effects of alcohol-based hand rub products on the rates CDI. One found a slight...

Conference Highlights: IDSA 2010 Annual Meeting

The Infectious Diseases Society of America, or IDSA, held its 2010 annual meeting from October 21 to 24 in Vancouver. The features below highlight some of the news emerging from the meeting. » Comparing Treatments for Nosocomial Pneumonia » Earlier Treatment for HIV-Infected Patients Lagging » Analyzing Treatment Approaches for Cholera » Veterans Less Likely to Be Tested for HIV » The Link Between Smoking & Flu Risk in Children  Comparing Treatments for Nosocomial Pneumonia The Particulars: An estimated 1.7 million healthcare-associated infections are reported in American hospitals annually, and about 16% of those are associated with pathogens that are resistant to the antimicrobials traditionally used to treat them, including MRSA. Nosocomial pneumonia continues to be a significant cause of illness. When these infections are due to MRSA, treatment options are limited because there are few antibiotics that are effective against this resistant organism. Data Breakdown: A phase 4 study trial compared the efficacy and safety of linezolid with vancomycin in the treatment of nosocomial pneumonia proven to be caused by MRSA. Patients were randomized to receive linezolid IV 600 mg every 12 hours or vancomycin 15 mg/kg every 12 hours over the course of 7 to 14 days; vancomycin doses could be titrated at the investigator’s discretion based on creatinine clearance and vancomycin trough levels. Clinical success rates at the end of study were 57.6% for patients treated with linezolid compared with 46.6% for patients treated with vancomycin in the per-protocol group, the primary endpoint. Treatment-related adverse events, serious adverse events and deaths were comparable for linezolid and vancomycin. Take Home Pearl: Linezolid appears to achieve a statistically significantly higher clinical...

A Toolkit on Supervised Exercise for PAD

Clinical practice guidelines for treatment of lower extremity peripheral artery disease (PAD) include a Class I recommendation for supervised exercise training for patients with intermittent claudication (IC). Prospective studies and meta-analyses have consistently shown that supervised exercise for patients with IC can increase their walking distances, quality of life, and function. Unfortunately, these programs are not available in all communities, and instructions from physicians to “get out and walk” are clearly not as effective as a supervised exercise program. To help correct this treatment gap, the Vascular Disease Foundation and the American Association of Cardiovascular and Pulmonary Rehabilitation partnered to develop a PAD Exercise Training Toolkit. This toolkit is available in a free, downloadable format at www.vdf.org or www.aacvpr.org. It includes evidence-based and practical information for healthcare professionals to use to develop exercise programs specifically designed for patients with PAD. Differences in Exercise for PAD Patients Patients with lower extremity PAD often develop IC due to inadequate oxygenation of exercising muscles. These patients often self-regulate their activity level to avoid discomfort, which can lead to a downward spiral of worsened disability. Multiple studies have shown that supervised treadmill walking to the point of moderate claudication pain, interspersed with brief rest periods, with exercise sessions lasting 30 minutes or longer and occurring at least three times per week can double maximum walking distance and significantly reduce symptoms. “Instructions from physicians to ‘get out and walk’ are clearly not as effective as a supervised exercise program.” The mechanisms leading to improved symptoms and function have not been fully elucidated but include changes in the exercising muscle. This includes improved oxygen extraction...
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