Sunday 17 February 2013

Widely Used Diclofenac Associated With Increased Risk for Cardiovascular Events

The nonsteroidal anti-inflammatory drug (NSAID) diclofenac, a drug that is frequently used for the treatment of pain and inflammation caused by arthritis, is associated with a significantly increased risk of cardiovascular complications and should be removed from essential-medicines lists (EML), according to a newreview [1].

Diclofenac, which is listed on the EML of 74 countries, increased the risk of cardiovascular events between 38% and 63% in different studies. The increased risk with diclofenac was similar to the COX-2 inhibitor rofecoxib (Vioxx, Merck), a drug withdrawn from worldwide markets because of cardiovascular toxicity.

"We could find no-risk doses with some of the other drugs, like ibuprofen, naproxen, and celecoxib [Celebrex, Pfizer],"

Sunday 10 February 2013

Fitness Linked to Lower Dementia Risk

We need to do about  75  minutes of vigorous activity a week or 150 minutes of moderate activity.
Higher fitness levels in midlife are associated with a lower risk for dementia in later life, a new study suggests.
"We already know exercise has cardiovascular and many other benefits, but this may give people more incentive to get moving," lead author, Laura F. DeFina, MD,  "Dementia is the second most feared disease after cancer, and our research suggests you can lower your risk by keeping fit."
The study is published in the February 5 issue of the Annals of Internal Medicine.
The study included 19,458 individuals participating in the Cooper Clinic Longitudinal Study at the Cooper Institute, a preventive medicine clinic. All underwent standardized fitness testing in midlife (median age, 49.8 years) and were then followed for an average of 25 years. 
There were 1659 cases of all-cause dementia reported. After multivariable adjustment, participants with the highest fitness level  at midlife had a 36% reduction in risk of developing dementia from any cause during follow-up than those in the lowest fitness category 
Dr. DeFina also pointed out that the reduction in dementia was consistent in patients who had had a stroke and in those who hadn't, suggesting that the mechanism does not just involve vascular disease. "Exercise is known to reduce cardiovascular disease, which we would expect to be translated into benefit on stroke, but because we also saw a similar reduction in dementia with improved fitness in patients who hadn't had a stroke, this suggests that other mechanisms are also involved."
She added that animal studies have suggested that increased fitness and activity correlates with a reduction in brain atrophy and loss of cognition, and changes in amyloid have been seen with regular activity.
Although this was a study of fitness, rather than actual physical activity undertaken, Dr. DeFina said the results were consistent with US physical activity guidelines that recommend 150 minutes of moderate exercise or 75 minutes of vigorous activity per week for health benefits.

Tennis Elbow: No Long-Term Benefit From PT, Corticosteroids

What is  best practice for treatment of tennis elbow is a knotty issue. Studies continue to try to unravel this. A recent piece of research published showed little long term benefits of physio but it was stated that they:
 "... believe strongly in physical therapy for tennis elbow, both to help the patient through the acute phase of the injury and to provide the patient with exercises/knowledge to prevent reinjury down the line".  "In many cases, patients will benefit considerably just from knowledge gained in physical therapy. If they apply this knowledge consistently, they may achieve better long-term outcomes,"
Below is an abstract of this work:
A steroid injection and 2 months of physical therapy may not be the solution for lateral epicondylalgia, commonly known as tennis elbow, suggest research findings published in the February 5 issue of JAMA.
Brooke K. Coombes, PhD, from the University of Queensland, St. Lucia, Australia, and colleagues found that patients treated with a single corticosteroid injection had a 14% greater chance of poor outcome and a 77% increased risk for reinjury at 1 year relative to placebo.
Eight weeks of physical therapy appeared to have no long-term benefit with the exception of decreased analgesic use. However, the physical therapy did improve short-term pain and disability outcomes at 1 month, although those benefits were lost when steroid injection was added to the treatment.
JAMA. 2013;309:461-469. 

Sunday 3 February 2013

Skin, Joint, and Back Problems Prompt Most Physician Visits


Most patients without acute conditions see their physicians not because of diabetes, heart disease, or cancer but because of skin problems, joint disorders, and back pain, according to an article published in the January 2013 issue of Mayo Clinic Proceedings.

Jennifer L. St. Sauver, PhD, MPH, from the Division of Epidemiology, Mayo Clinic Center for the Science of Health Care Delivery, Rochester, Minnesota, and colleagues analyzed the medical records of residents of Olmstead County, Minnesota, as of April 1, 2009

They say, "Finding that skin and back problems are major drivers of health care utilization affirms the importance of moving beyond the commonly recognized health care priorities such as diabetes, heart disease, or cancer," the researchers conclude. "Our findings highlight opportunities to improve health care and decrease costs related to common non-acute conditions as we move forward through the changing health care landscape."

Using my Blackberry makes my thumbs hurt

Some of you might of experienced this but I thought is was worth passing on. We have all heard of RSI; well this an RSI of the the nerve that you find in the thumb. This information is being passed on by neuro orthopaedic institute or NOI. Have a read....NOI Notes Jan 2013 banner

I have self-diagnosed myself with ‘blackberry thumb’ (BT)! Bear with me and my personal minor health story. This is quite exciting as I have never owned a blackberry but I admit to being a recent convert to texting, perhaps tripling the amount of texting that I do in the last month. Blackberry thumb is basically pain in the thumb from excessive texting.  You imagine a bruised black thumb and you kind of want to lick it and I much prefer the label to others suggested such as ‘teen texting tendonitis’ ‘wii-tis’ and ‘playstation thumb’. I thought it was quite exotic until I read that 1 in 6 British teens complain of hand pain while texting. With iPhone sales alone around 120 million a year and even more androids, there will be more aches and pains. It is predicted that there will be 2 billion smartphones in use by 2015. Blackberrys were invented before iPhones otherwise it might have been called iPhone thumb which sounds weird. 

What is it?

If you read the various case studies in the literature, most refer to a thumb tendonitis or a joint arthritis. Maybe I am biased but my Blackberry thumb is a nerve irritation (an abnormal impulse generating site) in the dorsal nerve of the radial nerve (on the radial side). I think this is the first description of neurogenic blackberry thumb. I suspect (as in many other parts of the body) that peripheral neuropathic problems are often missed. Check out the image of my thumb in Figure 1.

The spotted part is where the thumb is slightly numb. I know numb is numb, but this area is slightly numbish. If I press the spot where the arrow is, the numbness increases and it can zing into the base of my nail – more of a thudding feeling than a pain. Of course I tried out an active radial nerve neurodynamic test – reaching down with an internally rotated shoulder and with my thumb flexed. This gives a real thudding feeling into the nail and I was wondering if it could neurogenically inflame the nail bed. However, it doesn’t do it always when I try and finds the thudding position again. This made me a bit frustrated at first and then I remembered that peripheral nerve problems often present with this unpredictability. The thumb looks exactly like the other thumb i.e. no swelling or colour changes.
spotty_thumb Figure 1

Did my fat thumbs cause it?

I think it is from texting with a firmly flexed thumb interphalangeal joint with ulnar deviation pressure. Because my thumbs are bigger and fatter than most, I flex, ulnar deviate and almost rotate the distal phalange to get a more angular edge of the thumb, ie near the nail to hit the right key. Check out my texting style in Figure 2.

I think it will take a while for our thumbs to evolve to handle texting and by then there will be sure to be a better way of communication. Such flexion will give quite a local stretch of the nerve and it is the repeated unusual tweaking of the nerve that I think has caused this. Older peripheral nerve entrapment books mention that compressive forces such as scissor use could cause a similar neuropathy, but this is more a repetitive traction injury which has not been mentioned before in regard to blackberry thumb.

iphone thumb injury pic Figure 2

Peeking inside

I would love to peek inside the thumb, take a look at the nerve and then peek inside the nerve. Tiny nerves, especially in the extremities are very mobile – they have to be so we can move so much. Look at the dorsal side (back) of your thumb. Flex it and imagine how much the nerves just under the skin have to glide and stretch. I think I overdid this a little and I may have stretched a bit of myelin, maybe peeled some of the Nodes of Ranvier in outerlying fibres apart, there must be a little bit of intraneural inflammation and perhaps a bit of ion channel upregulation.

So what?

The main issue here is that peripheral nerves and their injuries and problems are missed ‘out there’. The brain is now so trendy – peripheral nerve research or even clinical consideration, is rare these days. Many people still think a peripheral nerve is like the cord on the television set, i.e. if you cut it, it stops working. Yet peripheral nerves are reactive, adapting, mobile parts of our bodies which deserve to be included in a wider view of the neuromatrix.

Does my BT need treating?

Some of these minor problems can go onto chronic problems. I think as long as you know about it, and don’t panic that you have some rare neurological disease this should be OK. I have adapted my texting techniques, in particular to using my index fingers which are more designed for dextrous work. I am trying some active radial nerve mobilising techniques which include the thumb and I am expecting that it will slowly go away in a month or so. Or you could take on texting with a sausage – an adaptation that has spread throughout South Korea and Russia to stop frostbite in the winter time.

meat stylus pic

Light blackberry relief
Ronnie Corbett also has an issue with a Blackberry – check it out :)

Soldier Who Lost All Limbs Gets Two Arm Transplants

The things that are happening these days...! It will of course take months to years for recover
but peripheral nerves to regrow; 1mm a day. You are not going to transplant arms unless you know that there is a chance of success for the individual. The physical and physiological stresses are immense. Have a read about this pioneering work that is going on in Baltimore USA.

A retired U.S. Army sergeant who underwent a double arm transplant after losing both arms and both legs in Iraq was discharged from The Johns Hopkins Hospital, Baltimore USA saying he was anxious to get back to an active life.

Sgt. Brendan Marrocco, 26, of Staten Island, New York, had the successful bilateral arm transplant six weeks ago at the renowned Baltimore hospital.

"I feel like I'm getting a second chance to start over," Marrocco said at a news conference announcing his discharge. "I'm just looking forward to everything I would have wanted to do over the last four years."

A roadside bomb attack in Iraq in 2009 cost him all four limbs.

"I hated having no arms," Marrocco said. "I was alright with having no legs."

It will be a few years before Marrocco's nerves regenerate and he regains significant use of his arms but Marrocco wheeled himself into the news conference, during which he pushed his hair back several times with his left arm. He said his right arm and both hands have little or no feeling or movement.

Marrocco will spend up to six hours a day in physical therapy.

The rare surgery took 13 hours and involved 16 doctors who volunteered from plastic surgery, orthopedics and other disciplines, the hospital said.