Denise Napoli

Multiple sclerosis patients who smoke marijuana were more likely to have a history of a mental illness and also performed worse on a test of their mental processing speed and working memory, according to results of a community-based study.

The data “provide the first evidence of the injurious effect of inhaled cannabis on the mentation of patients with MS,” the authors wrote in Neurology.

Ascertaining the effect of cannabis use in MS patients is important because cannabis often is used as a therapeutic agent in the disease, and MS is “by itself a cause of neuropsychological impairment in 40%–65% of patients,” wrote Dr. Omar Ghaffar and his colleague, Dr. Anthony Feinstein, both of the Sunnybrook Health Sciences Centre, Toronto, and the University of Toronto.

The researchers looked at 140 consecutive, community-dwelling MS patients seen at an outpatient clinic in Toronto. Three-fourths were women. The disease was relapse-remitting in 82 patients, secondary progressive in 49 patients, and primary progressive in 9 patients (Neurology 2008 [Epub doi:10.1212/01.wnl.0000304046.23960.25]).

Overall, 10 subjects reported current cannabis use (use of inhaled marijuana purchased on the street in the past month). Users and nonusers differed significantly in age (users had a mean age of about 36 years, vs. nonusers, whose mean age was 44.5 years, P =.001). There were no other differences with respect to disease, duration, disability, education, or gender.

“Since age is a factor that could potentially affect cognition independent of cannabis use, the 10 current cannabis users were each age-matched to 4 subjects who did not use cannabis [total control sample n = 40],” wrote the authors. Subjects were then evaluated using the Structured Clinical Interview for DSM-IV Axis I Disorders; the Hospital Anxiety and Depression Scale; and several cognitive assessments.

Overall, the 10 cannabis users were not more likely to have a specific DSM-IV diagnosis (depression, anxiety disorders, alcohol use disorders, etc.), but they were more likely to have had one of those diagnoses in general (P = .04).

There were no differences on the four cognitive measures included in the Neuropsychological Battery for MS. However, on the Symbol Digit Modalities Test (SDMT), cannabis users displayed a significantly slower mean performance time (P = .006). “In the SDMT, nine different symbols, each associated with a number, were presented visually to the subject. Nine symbols at a time were shown to the subject in various orders and the subject had to respond by naming the number that corresponded to each symbol according to the original code,” wrote the authors.

“This test, an index of information processing speed and working memory, has emerged as one of the most sensitive markers of cognitive impairment in MS,” they wrote.

A small sample size was one important limitation to this study. The authors also noted that their reliance on self-reports of cannabis use was not confirmed by urinary toxicology. Finally, cannabis users and nonusers differed slightly in their treatment regimens: More nonusers took disease-modifying treatments while more cannabis users took antidepressants. However, neither of these differences was significant. Furthermore, wrote the authors, “the relation between disease-modifying treatments and cognition remains equivocal, and data [suggest] that patients with MS taking antidepressants are not more impaired on tests such as the SDMT.”

Multiple sclerosis patients who smoke marijuana were more likely to have a history of a mental illness and also performed worse on a test of their mental processing speed and working memory, according to results of a community-based study.

The data “provide the first evidence of the injurious effect of inhaled cannabis on the mentation of patients with MS,” the authors wrote in Neurology.

Ascertaining the effect of cannabis use in MS patients is important because cannabis often is used as a therapeutic agent in the disease, and MS is “by itself a cause of neuropsychological impairment in 40%–65% of patients,” wrote Dr. Omar Ghaffar and his colleague, Dr. Anthony Feinstein, both of the Sunnybrook Health Sciences Centre, Toronto, and the University of Toronto.

The researchers looked at 140 consecutive, community-dwelling MS patients seen at an outpatient clinic in Toronto. Three-fourths were women. The disease was relapse-remitting in 82 patients, secondary progressive in 49 patients, and primary progressive in 9 patients (Neurology 2008 [Epub doi:10.1212/01.wnl.0000304046.23960.25]).

Overall, 10 subjects reported current cannabis use (use of inhaled marijuana purchased on the street in the past month). Users and nonusers differed significantly in age (users had a mean age of about 36 years, vs. nonusers, whose mean age was 44.5 years, P =.001). There were no other differences with respect to disease, duration, disability, education, or gender.

“Since age is a factor that could potentially affect cognition independent of cannabis use, the 10 current cannabis users were each age-matched to 4 subjects who did not use cannabis [total control sample n = 40],” wrote the authors. Subjects were then evaluated using the Structured Clinical Interview for DSM-IV Axis I Disorders; the Hospital Anxiety and Depression Scale; and several cognitive assessments.

Overall, the 10 cannabis users were not more likely to have a specific DSM-IV diagnosis (depression, anxiety disorders, alcohol use disorders, etc.), but they were more likely to have had one of those diagnoses in general (P = .04).

There were no differences on the four cognitive measures included in the Neuropsychological Battery for MS. However, on the Symbol Digit Modalities Test (SDMT), cannabis users displayed a significantly slower mean performance time (P = .006). “In the SDMT, nine different symbols, each associated with a number, were presented visually to the subject. Nine symbols at a time were shown to the subject in various orders and the subject had to respond by naming the number that corresponded to each symbol according to the original code,” wrote the authors.

“This test, an index of information processing speed and working memory, has emerged as one of the most sensitive markers of cognitive impairment in MS,” they wrote.

A small sample size was one important limitation to this study. The authors also noted that their reliance on self-reports of cannabis use was not confirmed by urinary toxicology. Finally, cannabis users and nonusers differed slightly in their treatment regimens: More nonusers took disease-modifying treatments while more cannabis users took antidepressants. However, neither of these differences was significant. Furthermore, wrote the authors, “the relation between disease-modifying treatments and cognition remains equivocal, and data [suggest] that patients with MS taking antidepressants are not more impaired on tests such as the SDMT.”

Multiple sclerosis patients who smoke marijuana were more likely to have a history of a mental illness and also performed worse on a test of their mental processing speed and working memory, according to results of a community-based study.

The data “provide the first evidence of the injurious effect of inhaled cannabis on the mentation of patients with MS,” the authors wrote in Neurology.

Ascertaining the effect of cannabis use in MS patients is important because cannabis often is used as a therapeutic agent in the disease, and MS is “by itself a cause of neuropsychological impairment in 40%–65% of patients,” wrote Dr. Omar Ghaffar and his colleague, Dr. Anthony Feinstein, both of the Sunnybrook Health Sciences Centre, Toronto, and the University of Toronto.

The researchers looked at 140 consecutive, community-dwelling MS patients seen at an outpatient clinic in Toronto. Three-fourths were women. The disease was relapse-remitting in 82 patients, secondary progressive in 49 patients, and primary progressive in 9 patients (Neurology 2008 [Epub doi:10.1212/01.wnl.0000304046.23960.25]).

Overall, 10 subjects reported current cannabis use (use of inhaled marijuana purchased on the street in the past month). Users and nonusers differed significantly in age (users had a mean age of about 36 years, vs. nonusers, whose mean age was 44.5 years, P =.001). There were no other differences with respect to disease, duration, disability, education, or gender.

“Since age is a factor that could potentially affect cognition independent of cannabis use, the 10 current cannabis users were each age-matched to 4 subjects who did not use cannabis [total control sample n = 40],” wrote the authors. Subjects were then evaluated using the Structured Clinical Interview for DSM-IV Axis I Disorders; the Hospital Anxiety and Depression Scale; and several cognitive assessments.

Overall, the 10 cannabis users were not more likely to have a specific DSM-IV diagnosis (depression, anxiety disorders, alcohol use disorders, etc.), but they were more likely to have had one of those diagnoses in general (P = .04).

There were no differences on the four cognitive measures included in the Neuropsychological Battery for MS. However, on the Symbol Digit Modalities Test (SDMT), cannabis users displayed a significantly slower mean performance time (P = .006). “In the SDMT, nine different symbols, each associated with a number, were presented visually to the subject. Nine symbols at a time were shown to the subject in various orders and the subject had to respond by naming the number that corresponded to each symbol according to the original code,” wrote the authors.

“This test, an index of information processing speed and working memory, has emerged as one of the most sensitive markers of cognitive impairment in MS,” they wrote.

A small sample size was one important limitation to this study. The authors also noted that their reliance on self-reports of cannabis use was not confirmed by urinary toxicology. Finally, cannabis users and nonusers differed slightly in their treatment regimens: More nonusers took disease-modifying treatments while more cannabis users took antidepressants. However, neither of these differences was significant. Furthermore, wrote the authors, “the relation between disease-modifying treatments and cognition remains equivocal, and data [suggest] that patients with MS taking antidepressants are not more impaired on tests such as the SDMT.”

WASHINGTON – Migraines in midlife with accompanying visual aura predict later-life brain infarcts, according to a poster presentation at the annual meeting of the American Neurological Association.

Furthermore, the relationship between migraine with aura and late-life cortical and cerebellar infarcts “was not explained by measured cardiovascular risk factors,” wrote the authors.

In a longitudinal, population-based MRI study, A.I. Scher, Ph.D., of the National Institute on Aging, in Bethesda, Md., and associates looked at 1,843 subjects (812 men) from the Reykjavik (Iceland) Study, which began in 1967. All patients were born between 1907 and 1935, and had an average follow-up of 25 years. “Midlife” assessments took place at an average age of 49 (range of 34–59 years) and “late-life” assessments occurred at an average age of 75 (range of 66–90 years).

For patients who reported headache either once or more per month, data were gathered about associated nausea or vomiting, unilateral location, phototopia, visual disturbance during/just before headache, and any unilateral numbness before headache. Subjects also were assessed for cardiovascular risk factors, including blood pressure, total cholesterol, triglycerides, fasting glucose, hypertension, diabetes, and whether they smoked.

Participants underwent a Flair MRI in 2002 and subcortical, cortical, and cerebella infarcts were examined.

Overall, 80% of men and 60% of women experienced none of the associated headache symptoms. Some 14% of men and 22% of women experienced one to two symptoms; slightly less than 2% of men and nearly 7% of women experienced three or more symptoms. About 4% of men and 8% of women experienced headache with visual aura. Other symptoms were reported by a small minority of men and women.

The relative odds of late-life brain infarcts in those with headache plus visual aura versus those without headache symptoms (adjusted for age, gender, sampling stage, and duration of follow-up) was 2.35 in the cortical region (P less than .005). Those with headache and visual aura had an OR of 1.82 of having an infarct in the cerebellar region, compared with nonheadache subjects (P less than .05). The odds for migraineurs with aura having an infarct in the subcortical region were neither increased nor significant.

Those who reported other symptoms did not have significantly increased odds of brain infarcts in observed regions.

WASHINGTON – Migraines in midlife with accompanying visual aura predict later-life brain infarcts, according to a poster presentation at the annual meeting of the American Neurological Association.

Furthermore, the relationship between migraine with aura and late-life cortical and cerebellar infarcts “was not explained by measured cardiovascular risk factors,” wrote the authors.

In a longitudinal, population-based MRI study, A.I. Scher, Ph.D., of the National Institute on Aging, in Bethesda, Md., and associates looked at 1,843 subjects (812 men) from the Reykjavik (Iceland) Study, which began in 1967. All patients were born between 1907 and 1935, and had an average follow-up of 25 years. “Midlife” assessments took place at an average age of 49 (range of 34–59 years) and “late-life” assessments occurred at an average age of 75 (range of 66–90 years).

For patients who reported headache either once or more per month, data were gathered about associated nausea or vomiting, unilateral location, phototopia, visual disturbance during/just before headache, and any unilateral numbness before headache. Subjects also were assessed for cardiovascular risk factors, including blood pressure, total cholesterol, triglycerides, fasting glucose, hypertension, diabetes, and whether they smoked.

Participants underwent a Flair MRI in 2002 and subcortical, cortical, and cerebella infarcts were examined.

Overall, 80% of men and 60% of women experienced none of the associated headache symptoms. Some 14% of men and 22% of women experienced one to two symptoms; slightly less than 2% of men and nearly 7% of women experienced three or more symptoms. About 4% of men and 8% of women experienced headache with visual aura. Other symptoms were reported by a small minority of men and women.

The relative odds of late-life brain infarcts in those with headache plus visual aura versus those without headache symptoms (adjusted for age, gender, sampling stage, and duration of follow-up) was 2.35 in the cortical region (P less than .005). Those with headache and visual aura had an OR of 1.82 of having an infarct in the cerebellar region, compared with nonheadache subjects (P less than .05). The odds for migraineurs with aura having an infarct in the subcortical region were neither increased nor significant.

Those who reported other symptoms did not have significantly increased odds of brain infarcts in observed regions.

WASHINGTON – Migraines in midlife with accompanying visual aura predict later-life brain infarcts, according to a poster presentation at the annual meeting of the American Neurological Association.

Furthermore, the relationship between migraine with aura and late-life cortical and cerebellar infarcts “was not explained by measured cardiovascular risk factors,” wrote the authors.

In a longitudinal, population-based MRI study, A.I. Scher, Ph.D., of the National Institute on Aging, in Bethesda, Md., and associates looked at 1,843 subjects (812 men) from the Reykjavik (Iceland) Study, which began in 1967. All patients were born between 1907 and 1935, and had an average follow-up of 25 years. “Midlife” assessments took place at an average age of 49 (range of 34–59 years) and “late-life” assessments occurred at an average age of 75 (range of 66–90 years).

For patients who reported headache either once or more per month, data were gathered about associated nausea or vomiting, unilateral location, phototopia, visual disturbance during/just before headache, and any unilateral numbness before headache. Subjects also were assessed for cardiovascular risk factors, including blood pressure, total cholesterol, triglycerides, fasting glucose, hypertension, diabetes, and whether they smoked.

Participants underwent a Flair MRI in 2002 and subcortical, cortical, and cerebella infarcts were examined.

Overall, 80% of men and 60% of women experienced none of the associated headache symptoms. Some 14% of men and 22% of women experienced one to two symptoms; slightly less than 2% of men and nearly 7% of women experienced three or more symptoms. About 4% of men and 8% of women experienced headache with visual aura. Other symptoms were reported by a small minority of men and women.

The relative odds of late-life brain infarcts in those with headache plus visual aura versus those without headache symptoms (adjusted for age, gender, sampling stage, and duration of follow-up) was 2.35 in the cortical region (P less than .005). Those with headache and visual aura had an OR of 1.82 of having an infarct in the cerebellar region, compared with nonheadache subjects (P less than .05). The odds for migraineurs with aura having an infarct in the subcortical region were neither increased nor significant.

Those who reported other symptoms did not have significantly increased odds of brain infarcts in observed regions.

Cleanliness, Godliness, Psychosis

The Bureau of Indications' Nana Napoli recommends a cold shower and a clean colon before first dates and Sunday dinner, respectively. But an article in a recent issue of Medical Hypotheses proposed that these two low-cost practices could have even greater effects as treatments for psychosis. Cold showers send a “tremendous amount” of electrical impulses from the nerves to the brain, according to the investigator. “A cold shower … also can result in significant analgesia, possibly due to a several-fold increase in the blood level of β-endorphin.” As for the colon cleansing, the author writes that concentrated colon bacteria can cause a buildup of brain-altering, psychosis-promoting toxins. … Ah, yes, we can see it now: Lindsay Lohan and Britney Spears showing up to the Grammy Awards after-party not with red-rimmed eyes, but with raw skin from heavy showering and reeking of Herbal Essences. As for the colon cleansing, “If there is a concern about potential development of dependence on laxatives, in the author's experience, they could be replaced with massage and careful torso-bending exercises.” We'll stick with the lobotomy, thanks.

Tiptoe Through the Tulips

Retired Dutch gardeners who use electric lawn mowers and hedge trimmers regard wearing wooden shoes while operating the machines as being a particularly good method of ensuring safety, researchers concluded in a groundbreaking (pun intended) study. The researchers, whose data were published in the journal Safety Science, also found the gardeners had some trouble reading the warning symbols displayed on the devices. There was a picture of a book (meaning “read the instruction manual”), an exclamation point in a triangle (meaning “caution”) and a fluffy cloud with rain coming down, in a crossed-out “No Rain Cloud” circle, which participants took to mean either as a warning against using the device near a pool or a “don't mow upside down grass” symbol. One participant, whose “complicatedly shaped shrubs” made trimming very difficult, explained that the greatest danger was that the power cord might trip him up. Said the gardener/participant: “Ja, is het gevaarlijk. Maar de 6-metre giraf-vormige struik zal zich niet in orde maken.” (“Eet's dangerous, ja. But zat 20-foot giraffe-shape shrub will not trim eet-self.” English translation ours.) “Findings from this field study may provide leads for designers to improve the safety of powered gardening tools,” the authors concluded. Participants were thanked for their time with a gift certificate to a local gardening shop. Lawsuits filed by the two retirees who subsequently trimmed off their wooden shoes are pending.

We Still Love You, Angelina Jolie!

Tattooed women are perceived as being more promiscuous and heavier drinkers than their tattoo-naive counterparts, reported researchers in the journal Body Image. A highly sophisticated study used Microsoft Paint to create several simple female caricatures, each identical except for yellow or brown hair, with zero, one, two, or three tattoos drawn on the ankle, arm, and/or hip. “Only figures of women were used because no comparable stimulus set for men was available,” they wrote, referring to the well-known international doctrine that no drawings of male forms ever be created in Microsoft Paint. The images were then shown to 160 undergraduates, who guessed that the figure of a woman with zero tattoos would consume a mean of four alcohol units on a typical night, vs. eight units for a woman with three tattoos. They also guessed the woman with three tattoos was more promiscuous than the woman with none. “The repeated measures design of the present study … may have rendered the body art manipulation obvious to participants, thus potentially biasing the results,” the authors wrote. “Clearly, not all women who have tattoos are heavy drinkers, and some may even be teetotallers.” Like the twice-tattooed Lindsay Lohan, for instance. Errr …

Buzz Kill

In the interest of comprehensive, simplified medical news journalism, we would like to present a summary of the health effects of caffeine, as reported recently at various medical meetings and in several journals. First: Don't drink caffeine if you're pregnant, as a study in the American Journal of Obstetrics and Gynecology tied it to an increased risk of miscarriage. But do drink up if you want to become pregnant, as the journal Cancer reports that caffeine lowers the risk of ovarian cancer. On the other hand, too much can contribute to the development of osteoporosis, according to the University of Maryland Medical Center, Baltimore. But a report in Neuroscience says you should drink coffee to keep Alzheimer's away. Then again, Duke University, Durham, N.C., researchers have also said caffeine may promote the development of type 2 diabetes. But who cares about diabetes when caffeine also can help prevent skin cancer, according to a study in the National Academy of Sciences? Indeed, caffeine (and smoking) also protect against Parkinson's disease, according to research in the Archives of Neurology. But not too much: Excessive caffeine may worsen restless legs syndrome, says one physician at the University of Miami. Of course, it can also lower your gout risk, as explained in the journal Arthritis and Rheumatism. Now you should feel totally comfortable recommending a few daily cuppas to your patients… or not. Glad to be of help!

Cleanliness, Godliness, Psychosis

The Bureau of Indications' Nana Napoli recommends a cold shower and a clean colon before first dates and Sunday dinner, respectively. But an article in a recent issue of Medical Hypotheses proposed that these two low-cost practices could have even greater effects as treatments for psychosis. Cold showers send a “tremendous amount” of electrical impulses from the nerves to the brain, according to the investigator. “A cold shower … also can result in significant analgesia, possibly due to a several-fold increase in the blood level of β-endorphin.” As for the colon cleansing, the author writes that concentrated colon bacteria can cause a buildup of brain-altering, psychosis-promoting toxins. … Ah, yes, we can see it now: Lindsay Lohan and Britney Spears showing up to the Grammy Awards after-party not with red-rimmed eyes, but with raw skin from heavy showering and reeking of Herbal Essences. As for the colon cleansing, “If there is a concern about potential development of dependence on laxatives, in the author's experience, they could be replaced with massage and careful torso-bending exercises.” We'll stick with the lobotomy, thanks.

Tiptoe Through the Tulips

Retired Dutch gardeners who use electric lawn mowers and hedge trimmers regard wearing wooden shoes while operating the machines as being a particularly good method of ensuring safety, researchers concluded in a groundbreaking (pun intended) study. The researchers, whose data were published in the journal Safety Science, also found the gardeners had some trouble reading the warning symbols displayed on the devices. There was a picture of a book (meaning “read the instruction manual”), an exclamation point in a triangle (meaning “caution”) and a fluffy cloud with rain coming down, in a crossed-out “No Rain Cloud” circle, which participants took to mean either as a warning against using the device near a pool or a “don't mow upside down grass” symbol. One participant, whose “complicatedly shaped shrubs” made trimming very difficult, explained that the greatest danger was that the power cord might trip him up. Said the gardener/participant: “Ja, is het gevaarlijk. Maar de 6-metre giraf-vormige struik zal zich niet in orde maken.” (“Eet's dangerous, ja. But zat 20-foot giraffe-shape shrub will not trim eet-self.” English translation ours.) “Findings from this field study may provide leads for designers to improve the safety of powered gardening tools,” the authors concluded. Participants were thanked for their time with a gift certificate to a local gardening shop. Lawsuits filed by the two retirees who subsequently trimmed off their wooden shoes are pending.

We Still Love You, Angelina Jolie!

Tattooed women are perceived as being more promiscuous and heavier drinkers than their tattoo-naive counterparts, reported researchers in the journal Body Image. A highly sophisticated study used Microsoft Paint to create several simple female caricatures, each identical except for yellow or brown hair, with zero, one, two, or three tattoos drawn on the ankle, arm, and/or hip. “Only figures of women were used because no comparable stimulus set for men was available,” they wrote, referring to the well-known international doctrine that no drawings of male forms ever be created in Microsoft Paint. The images were then shown to 160 undergraduates, who guessed that the figure of a woman with zero tattoos would consume a mean of four alcohol units on a typical night, vs. eight units for a woman with three tattoos. They also guessed the woman with three tattoos was more promiscuous than the woman with none. “The repeated measures design of the present study … may have rendered the body art manipulation obvious to participants, thus potentially biasing the results,” the authors wrote. “Clearly, not all women who have tattoos are heavy drinkers, and some may even be teetotallers.” Like the twice-tattooed Lindsay Lohan, for instance. Errr …

Buzz Kill

In the interest of comprehensive, simplified medical news journalism, we would like to present a summary of the health effects of caffeine, as reported recently at various medical meetings and in several journals. First: Don't drink caffeine if you're pregnant, as a study in the American Journal of Obstetrics and Gynecology tied it to an increased risk of miscarriage. But do drink up if you want to become pregnant, as the journal Cancer reports that caffeine lowers the risk of ovarian cancer. On the other hand, too much can contribute to the development of osteoporosis, according to the University of Maryland Medical Center, Baltimore. But a report in Neuroscience says you should drink coffee to keep Alzheimer's away. Then again, Duke University, Durham, N.C., researchers have also said caffeine may promote the development of type 2 diabetes. But who cares about diabetes when caffeine also can help prevent skin cancer, according to a study in the National Academy of Sciences? Indeed, caffeine (and smoking) also protect against Parkinson's disease, according to research in the Archives of Neurology. But not too much: Excessive caffeine may worsen restless legs syndrome, says one physician at the University of Miami. Of course, it can also lower your gout risk, as explained in the journal Arthritis and Rheumatism. Now you should feel totally comfortable recommending a few daily cuppas to your patients… or not. Glad to be of help!

Cleanliness, Godliness, Psychosis

The Bureau of Indications' Nana Napoli recommends a cold shower and a clean colon before first dates and Sunday dinner, respectively. But an article in a recent issue of Medical Hypotheses proposed that these two low-cost practices could have even greater effects as treatments for psychosis. Cold showers send a “tremendous amount” of electrical impulses from the nerves to the brain, according to the investigator. “A cold shower … also can result in significant analgesia, possibly due to a several-fold increase in the blood level of β-endorphin.” As for the colon cleansing, the author writes that concentrated colon bacteria can cause a buildup of brain-altering, psychosis-promoting toxins. … Ah, yes, we can see it now: Lindsay Lohan and Britney Spears showing up to the Grammy Awards after-party not with red-rimmed eyes, but with raw skin from heavy showering and reeking of Herbal Essences. As for the colon cleansing, “If there is a concern about potential development of dependence on laxatives, in the author's experience, they could be replaced with massage and careful torso-bending exercises.” We'll stick with the lobotomy, thanks.

Tiptoe Through the Tulips

Retired Dutch gardeners who use electric lawn mowers and hedge trimmers regard wearing wooden shoes while operating the machines as being a particularly good method of ensuring safety, researchers concluded in a groundbreaking (pun intended) study. The researchers, whose data were published in the journal Safety Science, also found the gardeners had some trouble reading the warning symbols displayed on the devices. There was a picture of a book (meaning “read the instruction manual”), an exclamation point in a triangle (meaning “caution”) and a fluffy cloud with rain coming down, in a crossed-out “No Rain Cloud” circle, which participants took to mean either as a warning against using the device near a pool or a “don't mow upside down grass” symbol. One participant, whose “complicatedly shaped shrubs” made trimming very difficult, explained that the greatest danger was that the power cord might trip him up. Said the gardener/participant: “Ja, is het gevaarlijk. Maar de 6-metre giraf-vormige struik zal zich niet in orde maken.” (“Eet's dangerous, ja. But zat 20-foot giraffe-shape shrub will not trim eet-self.” English translation ours.) “Findings from this field study may provide leads for designers to improve the safety of powered gardening tools,” the authors concluded. Participants were thanked for their time with a gift certificate to a local gardening shop. Lawsuits filed by the two retirees who subsequently trimmed off their wooden shoes are pending.

We Still Love You, Angelina Jolie!

Tattooed women are perceived as being more promiscuous and heavier drinkers than their tattoo-naive counterparts, reported researchers in the journal Body Image. A highly sophisticated study used Microsoft Paint to create several simple female caricatures, each identical except for yellow or brown hair, with zero, one, two, or three tattoos drawn on the ankle, arm, and/or hip. “Only figures of women were used because no comparable stimulus set for men was available,” they wrote, referring to the well-known international doctrine that no drawings of male forms ever be created in Microsoft Paint. The images were then shown to 160 undergraduates, who guessed that the figure of a woman with zero tattoos would consume a mean of four alcohol units on a typical night, vs. eight units for a woman with three tattoos. They also guessed the woman with three tattoos was more promiscuous than the woman with none. “The repeated measures design of the present study … may have rendered the body art manipulation obvious to participants, thus potentially biasing the results,” the authors wrote. “Clearly, not all women who have tattoos are heavy drinkers, and some may even be teetotallers.” Like the twice-tattooed Lindsay Lohan, for instance. Errr …

Buzz Kill

In the interest of comprehensive, simplified medical news journalism, we would like to present a summary of the health effects of caffeine, as reported recently at various medical meetings and in several journals. First: Don't drink caffeine if you're pregnant, as a study in the American Journal of Obstetrics and Gynecology tied it to an increased risk of miscarriage. But do drink up if you want to become pregnant, as the journal Cancer reports that caffeine lowers the risk of ovarian cancer. On the other hand, too much can contribute to the development of osteoporosis, according to the University of Maryland Medical Center, Baltimore. But a report in Neuroscience says you should drink coffee to keep Alzheimer's away. Then again, Duke University, Durham, N.C., researchers have also said caffeine may promote the development of type 2 diabetes. But who cares about diabetes when caffeine also can help prevent skin cancer, according to a study in the National Academy of Sciences? Indeed, caffeine (and smoking) also protect against Parkinson's disease, according to research in the Archives of Neurology. But not too much: Excessive caffeine may worsen restless legs syndrome, says one physician at the University of Miami. Of course, it can also lower your gout risk, as explained in the journal Arthritis and Rheumatism. Now you should feel totally comfortable recommending a few daily cuppas to your patients… or not. Glad to be of help!

Methotrexate's adverse event profile in psoriatic arthritis was different from that in rheumatoid arthritis in a study of more than 1,000 “everyday” patients treated in 30 rheumatology clinics across 13 countries.

“We have suspected for some time that there is differential toxicity, but the studies have not been based in 'everyday practice,' so these data help,” said lead investigator Dr. Philip Helliwell of the University of Leeds (England) in an interview.

In a study that sought to characterize both drug use patterns and side effect profiles in psoriatic arthritis (PsA) and rheumatoid arthritis (RA) patients, Dr. Helliwell and his colleague, Dr. William J. Taylor, of the University of Otago, Wellington (New Zealand), looked at enrollees in the Classification Criteria for Psoriatic Arthritis (CASPAR) study, including 588 consecutive clinic attendees with PsA and 536 controls, who were also clinic attendees with some form of inflammatory arthritis, most often RA.

Details about drug therapy were unavailable for 12% of PsA and 2% of RA patients. However, in the cases where treatment was known, methotrexate (MTX) was the most often prescribed first-line therapy in both diseases, given as the initial therapy to 39% of patients with PsA and 29% of RA patients. The second most often prescribed first-line therapy was sulfasalazine in PsA and corticosteroids in RA (J. Rheum 2008 Jan. 15 [Epub before print]).

Of the 404 patients with psoriatic arthritis who were still taking pharmacotherapy at the study's conclusion, 23% were treated with combination therapy. The most frequent combinations were “MTX/sulfasalazine (33 cases), MTX/steroids (22 cases), and MTX/anti-TNF (16 cases),” wrote the researchers. Triple drug therapy was used in nine PsA patients.

Combination therapy was used in 45% of the 315 RA patients still taking drugs at the study's end, with the most often prescribed regimens being MTX/corticosteroids (74 cases), MTX/antimalarials (33 cases), MTX/sulfasalazine (22 cases), and MTX/anti-TNF (13 cases). Triple drug therapy was used in 26 cases.

Methotrexate monotherapy was used through the study's completion by “a majority … over 50%,” said Dr. Helliwell.

According to Dr. Helliwell, methotrexate's popularity is despite the fact that it is prescribed “off-label” for both PsA and RA in the United Kingdom. “The people who make methotrexate have no incentive to seek regulatory approval because everybody is using it anyway, and [getting approval] is an expensive process,” he said.

In the United States, methotrexate has Food and Drug Administration approval for the treatment of psoriasis and rheumatoid arthritis, including Polyarticular-Course Juvenile Rheumatoid Arthritis, and neoplastic diseases, according to a representative of the Center for Drug Evaluation for Research at the FDA.

As for the second goal of the study—to ascertain the adverse event profile in each drug—the researchers found that while some events were common to both diseases, like renal problems with cyclosporine and gold salts, and skin problems with antimalarials and gold salts, “pulmonary toxicity seen with MTX was confined to the patients with RA,” affecting 4% of RA patients vs. 1% of PsA cases. Also, “although MTX is infrequently discontinued for reasons of inefficacy in both diseases, it was more often discontinued in PsA compared to RA, primarily for reasons of toxicity.”

Hepatic adverse events occurred in 7% of PsA cases vs. 4% of RA cases. “The problem of hepatotoxicity and methotrexate is of particular concern with psoriasis. Dermatologists seem to see much more hepatotoxicity than we as rheumatologists,” said Dr. Helliwell.

“Treatment trials are constrained in ways that may detract from the use of the drug in everyday practice—patients entered into trials are often a very select group with little comorbidity, which confounds extrapolation of drug use to a wide spectrum of patients,” wrote the authors.

Dr. Helliwell reported no conflicts of interest in relation to this study.

Methotrexate's adverse event profile in psoriatic arthritis was different from that in rheumatoid arthritis in a study of more than 1,000 “everyday” patients treated in 30 rheumatology clinics across 13 countries.

“We have suspected for some time that there is differential toxicity, but the studies have not been based in 'everyday practice,' so these data help,” said lead investigator Dr. Philip Helliwell of the University of Leeds (England) in an interview.

In a study that sought to characterize both drug use patterns and side effect profiles in psoriatic arthritis (PsA) and rheumatoid arthritis (RA) patients, Dr. Helliwell and his colleague, Dr. William J. Taylor, of the University of Otago, Wellington (New Zealand), looked at enrollees in the Classification Criteria for Psoriatic Arthritis (CASPAR) study, including 588 consecutive clinic attendees with PsA and 536 controls, who were also clinic attendees with some form of inflammatory arthritis, most often RA.

Details about drug therapy were unavailable for 12% of PsA and 2% of RA patients. However, in the cases where treatment was known, methotrexate (MTX) was the most often prescribed first-line therapy in both diseases, given as the initial therapy to 39% of patients with PsA and 29% of RA patients. The second most often prescribed first-line therapy was sulfasalazine in PsA and corticosteroids in RA (J. Rheum 2008 Jan. 15 [Epub before print]).

Of the 404 patients with psoriatic arthritis who were still taking pharmacotherapy at the study's conclusion, 23% were treated with combination therapy. The most frequent combinations were “MTX/sulfasalazine (33 cases), MTX/steroids (22 cases), and MTX/anti-TNF (16 cases),” wrote the researchers. Triple drug therapy was used in nine PsA patients.

Combination therapy was used in 45% of the 315 RA patients still taking drugs at the study's end, with the most often prescribed regimens being MTX/corticosteroids (74 cases), MTX/antimalarials (33 cases), MTX/sulfasalazine (22 cases), and MTX/anti-TNF (13 cases). Triple drug therapy was used in 26 cases.

Methotrexate monotherapy was used through the study's completion by “a majority … over 50%,” said Dr. Helliwell.

According to Dr. Helliwell, methotrexate's popularity is despite the fact that it is prescribed “off-label” for both PsA and RA in the United Kingdom. “The people who make methotrexate have no incentive to seek regulatory approval because everybody is using it anyway, and [getting approval] is an expensive process,” he said.

In the United States, methotrexate has Food and Drug Administration approval for the treatment of psoriasis and rheumatoid arthritis, including Polyarticular-Course Juvenile Rheumatoid Arthritis, and neoplastic diseases, according to a representative of the Center for Drug Evaluation for Research at the FDA.

As for the second goal of the study—to ascertain the adverse event profile in each drug—the researchers found that while some events were common to both diseases, like renal problems with cyclosporine and gold salts, and skin problems with antimalarials and gold salts, “pulmonary toxicity seen with MTX was confined to the patients with RA,” affecting 4% of RA patients vs. 1% of PsA cases. Also, “although MTX is infrequently discontinued for reasons of inefficacy in both diseases, it was more often discontinued in PsA compared to RA, primarily for reasons of toxicity.”

Hepatic adverse events occurred in 7% of PsA cases vs. 4% of RA cases. “The problem of hepatotoxicity and methotrexate is of particular concern with psoriasis. Dermatologists seem to see much more hepatotoxicity than we as rheumatologists,” said Dr. Helliwell.

“Treatment trials are constrained in ways that may detract from the use of the drug in everyday practice—patients entered into trials are often a very select group with little comorbidity, which confounds extrapolation of drug use to a wide spectrum of patients,” wrote the authors.

Dr. Helliwell reported no conflicts of interest in relation to this study.

Methotrexate's adverse event profile in psoriatic arthritis was different from that in rheumatoid arthritis in a study of more than 1,000 “everyday” patients treated in 30 rheumatology clinics across 13 countries.

“We have suspected for some time that there is differential toxicity, but the studies have not been based in 'everyday practice,' so these data help,” said lead investigator Dr. Philip Helliwell of the University of Leeds (England) in an interview.

In a study that sought to characterize both drug use patterns and side effect profiles in psoriatic arthritis (PsA) and rheumatoid arthritis (RA) patients, Dr. Helliwell and his colleague, Dr. William J. Taylor, of the University of Otago, Wellington (New Zealand), looked at enrollees in the Classification Criteria for Psoriatic Arthritis (CASPAR) study, including 588 consecutive clinic attendees with PsA and 536 controls, who were also clinic attendees with some form of inflammatory arthritis, most often RA.

Details about drug therapy were unavailable for 12% of PsA and 2% of RA patients. However, in the cases where treatment was known, methotrexate (MTX) was the most often prescribed first-line therapy in both diseases, given as the initial therapy to 39% of patients with PsA and 29% of RA patients. The second most often prescribed first-line therapy was sulfasalazine in PsA and corticosteroids in RA (J. Rheum 2008 Jan. 15 [Epub before print]).

Of the 404 patients with psoriatic arthritis who were still taking pharmacotherapy at the study's conclusion, 23% were treated with combination therapy. The most frequent combinations were “MTX/sulfasalazine (33 cases), MTX/steroids (22 cases), and MTX/anti-TNF (16 cases),” wrote the researchers. Triple drug therapy was used in nine PsA patients.

Combination therapy was used in 45% of the 315 RA patients still taking drugs at the study's end, with the most often prescribed regimens being MTX/corticosteroids (74 cases), MTX/antimalarials (33 cases), MTX/sulfasalazine (22 cases), and MTX/anti-TNF (13 cases). Triple drug therapy was used in 26 cases.

Methotrexate monotherapy was used through the study's completion by “a majority … over 50%,” said Dr. Helliwell.

According to Dr. Helliwell, methotrexate's popularity is despite the fact that it is prescribed “off-label” for both PsA and RA in the United Kingdom. “The people who make methotrexate have no incentive to seek regulatory approval because everybody is using it anyway, and [getting approval] is an expensive process,” he said.

In the United States, methotrexate has Food and Drug Administration approval for the treatment of psoriasis and rheumatoid arthritis, including Polyarticular-Course Juvenile Rheumatoid Arthritis, and neoplastic diseases, according to a representative of the Center for Drug Evaluation for Research at the FDA.

As for the second goal of the study—to ascertain the adverse event profile in each drug—the researchers found that while some events were common to both diseases, like renal problems with cyclosporine and gold salts, and skin problems with antimalarials and gold salts, “pulmonary toxicity seen with MTX was confined to the patients with RA,” affecting 4% of RA patients vs. 1% of PsA cases. Also, “although MTX is infrequently discontinued for reasons of inefficacy in both diseases, it was more often discontinued in PsA compared to RA, primarily for reasons of toxicity.”

Hepatic adverse events occurred in 7% of PsA cases vs. 4% of RA cases. “The problem of hepatotoxicity and methotrexate is of particular concern with psoriasis. Dermatologists seem to see much more hepatotoxicity than we as rheumatologists,” said Dr. Helliwell.

“Treatment trials are constrained in ways that may detract from the use of the drug in everyday practice—patients entered into trials are often a very select group with little comorbidity, which confounds extrapolation of drug use to a wide spectrum of patients,” wrote the authors.

Dr. Helliwell reported no conflicts of interest in relation to this study.

Ultrasonography is a noninvasive, inexpensive technique for evaluating the salivary glands in patients with suspected Sjögren's syndrome, according to a recent study.

Other methods of assessing salivary gland involvement—sialography, for one, or scintigraphy of the salivary glands– are invasive and have low specificity, respectively, wrote the researchers.

Dr. Dirk Wernicke of the Clinic for Rheumatology Berlin-Buch, Berlin, and colleagues looked at 316 consecutive patients with rheumatic diseases. Overall, 57 had primary Sjögren's syndrome (SS); 33 had secondary SS due to the presence of other inflammatory diseases; 78 had sicca syndrome involving symptoms of dry mouth and eyes in the absence of other evidence of SS; and 148 were asymptomatic controls who had other inflammatory conditions, including rheumatoid arthritis, lupus, or undifferentiated connective tissue disease. In all groups, the majority was female, and the mean ages were 51, 53, 48, and 45, respectively (J. Rheumatol. 2008 Jan. 15 [Epub ahead of print]).

“In comparison with asymptomatic controls, the mean volume of the submandibular glands in the women with primary and secondary SS was reduced by 33% and 40%, respectively” on ultrasound, wrote the authors, from 4.8 mL in the controls to 3.2 mL and 2.9 mL in primary and secondary SS patients, respectively. There was also a significant difference in men with primary SS—the mean volume was reduced by 28%, compared with controls—but, likely due to the small number of men in the cohort, no significance was seen between controls and secondary SS.

The researchers also looked at parenchymal inhomogenicity. In this study, a diagnosis of SS was made when “at least two major salivary glands showed evident grade II parenchymal inhomogenicity,” wrote the researchers. In an interview, Dr. Wernicke said grade II parenchymal inhomogenicity refers to “diffuse hypoechoic areolae larger than 2 mm.” (Grade 0 is normal homogenous parenchyma, and grade I mild parenchymal inhomogenicity is seen on ultrasound as diffuse hypoechoic areolae smaller than 2 mm.) This yielded a specificity of 96.1% in sicca symptom patients and 100% in the asymptomatic controls. “SS was diagnosed in our cohort with a sensitivity of 63%” (in both primary and secondary groups), they added.

“The use of imaging techniques is very different in [various] countries,” said Dr. Wernicke. In the U.S., he said, it is “so far, not widely used by rheumatologists. The experience is good in Germany and Italy, less in the U.K. and in North America.” He believes ultrasound should be included in the diagnostic criteria of the disease.

Dr. Wernicke and his associates disclosed no conflicts of interest.

Ultrasonography is a noninvasive, inexpensive technique for evaluating the salivary glands in patients with suspected Sjögren's syndrome, according to a recent study.

Other methods of assessing salivary gland involvement—sialography, for one, or scintigraphy of the salivary glands– are invasive and have low specificity, respectively, wrote the researchers.

Dr. Dirk Wernicke of the Clinic for Rheumatology Berlin-Buch, Berlin, and colleagues looked at 316 consecutive patients with rheumatic diseases. Overall, 57 had primary Sjögren's syndrome (SS); 33 had secondary SS due to the presence of other inflammatory diseases; 78 had sicca syndrome involving symptoms of dry mouth and eyes in the absence of other evidence of SS; and 148 were asymptomatic controls who had other inflammatory conditions, including rheumatoid arthritis, lupus, or undifferentiated connective tissue disease. In all groups, the majority was female, and the mean ages were 51, 53, 48, and 45, respectively (J. Rheumatol. 2008 Jan. 15 [Epub ahead of print]).

“In comparison with asymptomatic controls, the mean volume of the submandibular glands in the women with primary and secondary SS was reduced by 33% and 40%, respectively” on ultrasound, wrote the authors, from 4.8 mL in the controls to 3.2 mL and 2.9 mL in primary and secondary SS patients, respectively. There was also a significant difference in men with primary SS—the mean volume was reduced by 28%, compared with controls—but, likely due to the small number of men in the cohort, no significance was seen between controls and secondary SS.

The researchers also looked at parenchymal inhomogenicity. In this study, a diagnosis of SS was made when “at least two major salivary glands showed evident grade II parenchymal inhomogenicity,” wrote the researchers. In an interview, Dr. Wernicke said grade II parenchymal inhomogenicity refers to “diffuse hypoechoic areolae larger than 2 mm.” (Grade 0 is normal homogenous parenchyma, and grade I mild parenchymal inhomogenicity is seen on ultrasound as diffuse hypoechoic areolae smaller than 2 mm.) This yielded a specificity of 96.1% in sicca symptom patients and 100% in the asymptomatic controls. “SS was diagnosed in our cohort with a sensitivity of 63%” (in both primary and secondary groups), they added.

“The use of imaging techniques is very different in [various] countries,” said Dr. Wernicke. In the U.S., he said, it is “so far, not widely used by rheumatologists. The experience is good in Germany and Italy, less in the U.K. and in North America.” He believes ultrasound should be included in the diagnostic criteria of the disease.

Dr. Wernicke and his associates disclosed no conflicts of interest.

Ultrasonography is a noninvasive, inexpensive technique for evaluating the salivary glands in patients with suspected Sjögren's syndrome, according to a recent study.

Other methods of assessing salivary gland involvement—sialography, for one, or scintigraphy of the salivary glands– are invasive and have low specificity, respectively, wrote the researchers.

Dr. Dirk Wernicke of the Clinic for Rheumatology Berlin-Buch, Berlin, and colleagues looked at 316 consecutive patients with rheumatic diseases. Overall, 57 had primary Sjögren's syndrome (SS); 33 had secondary SS due to the presence of other inflammatory diseases; 78 had sicca syndrome involving symptoms of dry mouth and eyes in the absence of other evidence of SS; and 148 were asymptomatic controls who had other inflammatory conditions, including rheumatoid arthritis, lupus, or undifferentiated connective tissue disease. In all groups, the majority was female, and the mean ages were 51, 53, 48, and 45, respectively (J. Rheumatol. 2008 Jan. 15 [Epub ahead of print]).

“In comparison with asymptomatic controls, the mean volume of the submandibular glands in the women with primary and secondary SS was reduced by 33% and 40%, respectively” on ultrasound, wrote the authors, from 4.8 mL in the controls to 3.2 mL and 2.9 mL in primary and secondary SS patients, respectively. There was also a significant difference in men with primary SS—the mean volume was reduced by 28%, compared with controls—but, likely due to the small number of men in the cohort, no significance was seen between controls and secondary SS.

The researchers also looked at parenchymal inhomogenicity. In this study, a diagnosis of SS was made when “at least two major salivary glands showed evident grade II parenchymal inhomogenicity,” wrote the researchers. In an interview, Dr. Wernicke said grade II parenchymal inhomogenicity refers to “diffuse hypoechoic areolae larger than 2 mm.” (Grade 0 is normal homogenous parenchyma, and grade I mild parenchymal inhomogenicity is seen on ultrasound as diffuse hypoechoic areolae smaller than 2 mm.) This yielded a specificity of 96.1% in sicca symptom patients and 100% in the asymptomatic controls. “SS was diagnosed in our cohort with a sensitivity of 63%” (in both primary and secondary groups), they added.

“The use of imaging techniques is very different in [various] countries,” said Dr. Wernicke. In the U.S., he said, it is “so far, not widely used by rheumatologists. The experience is good in Germany and Italy, less in the U.K. and in North America.” He believes ultrasound should be included in the diagnostic criteria of the disease.

Dr. Wernicke and his associates disclosed no conflicts of interest.

Trends in drug prescribing for osteoporosis following a hip fracture have changed dramatically over the last decade: The proportion of patients treated post fracture has increased, but fewer than one-third are ever prescribed drugs at all, according to a population-based study of nearly 16,000 fracture patients.

In an interview, lead author Suzanne M. Cadarette, Ph.D., said, “Many patients, following hip fracture, still do not receive adequate pharmacotherapy. While there have been some successful quality improvement interventions to address this gap in care, health systems must sit up and recognize that there is a problem.”

A total of 15,685 hip fracture patients, all enrollees from the Pennsylvania Pharmaceutical Assistance Contract for the Elderly (PACE), met inclusion criteria. (PACE is a state-run program that provides unrestricted drug coverage for patients aged 65 or older whose income is too high for Medicaid, but below $20,000. Dr. Cadarette conceded that the relatively low income status of this cohort, and the fact that the majority was white, means that “extrapolating the exact level of care to the rest of the U.S. population may be difficult, but I expect that the general trend of undertreatment holds nationwide.”) Although Dr. Cadarette did not confirm the presence of osteoporosis in this cohort, she pointed to a recent Canadian trial that found that 21% of hip fracture patients aged 50 years or older had normal bone mass, but 45% had osteoporosis and were thus clear candidates for pharmacotherapy (Arch. Intern. Med. 2007;167:2110-5). “Our population was much older than the [randomized clinical trial] referenced here, and thus I expect that fewer hip fracture patients in our study would have normal bones and rather the majority had osteoporosis.”

In 1995, 7% of patients received pharmacotherapy to treat osteoporosis within 6 months of fracture; this figure increased to 31% in 2002, and then remained stable through 2004, the study's cutoff date.

The study also found that the type of therapy patients receive varies according to what sort of physician treats them. The specialty of the prescribing physician was identified in 94% (3,038) of the total 3,231 treated cases. Rheumatologists and endocrinologists prescribed bisphosphonates in 59.5% of cases, calcitonin in 32.5%, hormone therapy in 3.5%, raloxifene in 3%, and teriparatide or a combination of drugs very rarely, in 1% or fewer of cases. Obstetricians and gynecologists most often prescribed hormone therapy, in 63.3% of patients, followed by bisphosphonates in 22.4%, calcitonin in 8.2%, raloxifene in 4%, and teriparatide or combination therapy hardly ever. Geriatricians prescribed calcitonin about half the time and for about the other half prescribed bisphosphonates.

Dr. Cadarette, of the Brigham and Women's Hospital, Boston, urged caution in interpreting this seemingly alarming finding. “Patients seeing specialists may have other chronic health conditions contraindicating bisphosphonate therapy, or may be more frail, making the complex bisphosphonate dosing difficult.” She also said her findings did not reflect the time periods in which the different therapies were prescribed. For example, fracture patients seen by obstetricians and gynecologists were largely treated in 1995, before the 2002 Women's Health Initiative results showed the potential harm associated with hormone therapy.

Also significant was the finding that, over time, family physicians and general practitioners have become the prescribing physicians in a greater proportion of these cases. In 1995, general practitioners were the prescribers in about 71% of treated fracture patients, and in 2004, they were responsible for 80% of these cases. Rheumatologists and endocrinologists, on the other hand, dropped from being the treating physician in 15% of cases in 1995 to only 3.5% in 2004. A similar decline was seen among obstetrics/gynecology physicians and orthopedic surgeons.

Responding to this finding, Dr. Steven Petak, chancellor of the American College of Endocrinology, said in an interview, “There are a limited number of endocrinologists and rheumatologists in proportion to the number of patients with or at risk for osteoporosis.”

Poorly responsive patients who have bone mineral density loss on DXA, continued fractures, intolerance of oral therapies, or secondary osteoporosis should have consultations with specialist, he said.

Dr. Cadarette reported no disclosures for herself or any of her fellow researchers in relation to this study.

Trends in drug prescribing for osteoporosis following a hip fracture have changed dramatically over the last decade: The proportion of patients treated post fracture has increased, but fewer than one-third are ever prescribed drugs at all, according to a population-based study of nearly 16,000 fracture patients.

In an interview, lead author Suzanne M. Cadarette, Ph.D., said, “Many patients, following hip fracture, still do not receive adequate pharmacotherapy. While there have been some successful quality improvement interventions to address this gap in care, health systems must sit up and recognize that there is a problem.”

A total of 15,685 hip fracture patients, all enrollees from the Pennsylvania Pharmaceutical Assistance Contract for the Elderly (PACE), met inclusion criteria. (PACE is a state-run program that provides unrestricted drug coverage for patients aged 65 or older whose income is too high for Medicaid, but below $20,000. Dr. Cadarette conceded that the relatively low income status of this cohort, and the fact that the majority was white, means that “extrapolating the exact level of care to the rest of the U.S. population may be difficult, but I expect that the general trend of undertreatment holds nationwide.”) Although Dr. Cadarette did not confirm the presence of osteoporosis in this cohort, she pointed to a recent Canadian trial that found that 21% of hip fracture patients aged 50 years or older had normal bone mass, but 45% had osteoporosis and were thus clear candidates for pharmacotherapy (Arch. Intern. Med. 2007;167:2110-5). “Our population was much older than the [randomized clinical trial] referenced here, and thus I expect that fewer hip fracture patients in our study would have normal bones and rather the majority had osteoporosis.”

In 1995, 7% of patients received pharmacotherapy to treat osteoporosis within 6 months of fracture; this figure increased to 31% in 2002, and then remained stable through 2004, the study's cutoff date.

The study also found that the type of therapy patients receive varies according to what sort of physician treats them. The specialty of the prescribing physician was identified in 94% (3,038) of the total 3,231 treated cases. Rheumatologists and endocrinologists prescribed bisphosphonates in 59.5% of cases, calcitonin in 32.5%, hormone therapy in 3.5%, raloxifene in 3%, and teriparatide or a combination of drugs very rarely, in 1% or fewer of cases. Obstetricians and gynecologists most often prescribed hormone therapy, in 63.3% of patients, followed by bisphosphonates in 22.4%, calcitonin in 8.2%, raloxifene in 4%, and teriparatide or combination therapy hardly ever. Geriatricians prescribed calcitonin about half the time and for about the other half prescribed bisphosphonates.

Dr. Cadarette, of the Brigham and Women's Hospital, Boston, urged caution in interpreting this seemingly alarming finding. “Patients seeing specialists may have other chronic health conditions contraindicating bisphosphonate therapy, or may be more frail, making the complex bisphosphonate dosing difficult.” She also said her findings did not reflect the time periods in which the different therapies were prescribed. For example, fracture patients seen by obstetricians and gynecologists were largely treated in 1995, before the 2002 Women's Health Initiative results showed the potential harm associated with hormone therapy.

Also significant was the finding that, over time, family physicians and general practitioners have become the prescribing physicians in a greater proportion of these cases. In 1995, general practitioners were the prescribers in about 71% of treated fracture patients, and in 2004, they were responsible for 80% of these cases. Rheumatologists and endocrinologists, on the other hand, dropped from being the treating physician in 15% of cases in 1995 to only 3.5% in 2004. A similar decline was seen among obstetrics/gynecology physicians and orthopedic surgeons.

Responding to this finding, Dr. Steven Petak, chancellor of the American College of Endocrinology, said in an interview, “There are a limited number of endocrinologists and rheumatologists in proportion to the number of patients with or at risk for osteoporosis.”

Poorly responsive patients who have bone mineral density loss on DXA, continued fractures, intolerance of oral therapies, or secondary osteoporosis should have consultations with specialist, he said.

Dr. Cadarette reported no disclosures for herself or any of her fellow researchers in relation to this study.

Trends in drug prescribing for osteoporosis following a hip fracture have changed dramatically over the last decade: The proportion of patients treated post fracture has increased, but fewer than one-third are ever prescribed drugs at all, according to a population-based study of nearly 16,000 fracture patients.

In an interview, lead author Suzanne M. Cadarette, Ph.D., said, “Many patients, following hip fracture, still do not receive adequate pharmacotherapy. While there have been some successful quality improvement interventions to address this gap in care, health systems must sit up and recognize that there is a problem.”

A total of 15,685 hip fracture patients, all enrollees from the Pennsylvania Pharmaceutical Assistance Contract for the Elderly (PACE), met inclusion criteria. (PACE is a state-run program that provides unrestricted drug coverage for patients aged 65 or older whose income is too high for Medicaid, but below $20,000. Dr. Cadarette conceded that the relatively low income status of this cohort, and the fact that the majority was white, means that “extrapolating the exact level of care to the rest of the U.S. population may be difficult, but I expect that the general trend of undertreatment holds nationwide.”) Although Dr. Cadarette did not confirm the presence of osteoporosis in this cohort, she pointed to a recent Canadian trial that found that 21% of hip fracture patients aged 50 years or older had normal bone mass, but 45% had osteoporosis and were thus clear candidates for pharmacotherapy (Arch. Intern. Med. 2007;167:2110-5). “Our population was much older than the [randomized clinical trial] referenced here, and thus I expect that fewer hip fracture patients in our study would have normal bones and rather the majority had osteoporosis.”

In 1995, 7% of patients received pharmacotherapy to treat osteoporosis within 6 months of fracture; this figure increased to 31% in 2002, and then remained stable through 2004, the study's cutoff date.

The study also found that the type of therapy patients receive varies according to what sort of physician treats them. The specialty of the prescribing physician was identified in 94% (3,038) of the total 3,231 treated cases. Rheumatologists and endocrinologists prescribed bisphosphonates in 59.5% of cases, calcitonin in 32.5%, hormone therapy in 3.5%, raloxifene in 3%, and teriparatide or a combination of drugs very rarely, in 1% or fewer of cases. Obstetricians and gynecologists most often prescribed hormone therapy, in 63.3% of patients, followed by bisphosphonates in 22.4%, calcitonin in 8.2%, raloxifene in 4%, and teriparatide or combination therapy hardly ever. Geriatricians prescribed calcitonin about half the time and for about the other half prescribed bisphosphonates.

Dr. Cadarette, of the Brigham and Women's Hospital, Boston, urged caution in interpreting this seemingly alarming finding. “Patients seeing specialists may have other chronic health conditions contraindicating bisphosphonate therapy, or may be more frail, making the complex bisphosphonate dosing difficult.” She also said her findings did not reflect the time periods in which the different therapies were prescribed. For example, fracture patients seen by obstetricians and gynecologists were largely treated in 1995, before the 2002 Women's Health Initiative results showed the potential harm associated with hormone therapy.

Also significant was the finding that, over time, family physicians and general practitioners have become the prescribing physicians in a greater proportion of these cases. In 1995, general practitioners were the prescribers in about 71% of treated fracture patients, and in 2004, they were responsible for 80% of these cases. Rheumatologists and endocrinologists, on the other hand, dropped from being the treating physician in 15% of cases in 1995 to only 3.5% in 2004. A similar decline was seen among obstetrics/gynecology physicians and orthopedic surgeons.

Responding to this finding, Dr. Steven Petak, chancellor of the American College of Endocrinology, said in an interview, “There are a limited number of endocrinologists and rheumatologists in proportion to the number of patients with or at risk for osteoporosis.”

Poorly responsive patients who have bone mineral density loss on DXA, continued fractures, intolerance of oral therapies, or secondary osteoporosis should have consultations with specialist, he said.

Dr. Cadarette reported no disclosures for herself or any of her fellow researchers in relation to this study.

The risk of a stroke within 7 days of a transient ischemic attack was lowest when patients were treated by specialist stroke services on an emergency basis, according to a systematic review and meta-analysis that included 10,126 TIA patients.

The review looked at 18 cohorts in 17 studies of different design in multiple countries, all assessing the risk of stroke following TIA within 7 days. The investigators searched Ovid Medline from 1950 to June 2007 and Embase between 1980 and June 2007, as well as books of abstracts from recent conferences for studies not yet published as full papers. Studies of patients with underlying pathologies were excluded.

The mean age of patients in the cohorts ranged from 61 to 73 years. The proportion of men ranged from 39% to 62% (Lancet Neurol. 2007;6:1063–72).

The pooled stroke risk across all cohorts for which 2-day data were available (a total of 15 cohorts, with 9,433 patients) was 3.1%. In the 17 cohorts for which data at 7 days were available (7,830 patients), the risk was 5.2%. However, significant heterogeneity among study design led to a large range of risk, from 0% to 12.8%.

The researchers classified the studies into the following categories, and calculated the risk for each category:

▸ Population-based studies over multiple emergency departments (EDs), with face-to-face follow-up. The three studies in this category had an overall 6.7% risk of stroke at 2 days and 10.4% risk at 7 days.

▸ Population-based studies at multiple EDs that relied on administrative follow-up (notes and diagnostic coding review) and that had important exclusions. Such exclusions included patients who were admitted to the hospital, patients with persistent symptoms at discharge from the ED, and strokes on the same day as the TIA. Three studies in this category had an overall stroke risk of 1.6% within 2 days and 3.0% within 7 days.

▸ Population-based studies at multiple EDs that used administrative follow-up but had no exclusions. Three studies in this group had an overall 2-day risk of 4.8% and a 7-day risk of 6.5%.

▸ Studies that ascertained consecutive patients attending a single ED with face-to-face or telephone follow-up. Three studies in this category showed an overall stroke risk after 2 days of 3.1% and risk at 7 days of 5.8%.

▸ Routine outpatient studies that used administrative follow-up. There was a 2-day stroke risk of 1.7% and a 7-day risk of 3.3% in the two studies in this group.

▸ Studies conducted at sites using specialist stroke services. The four studies in this group had the lowest incidence both of 2-day stroke risk, 0.6%, and 7-day risk, at 0.9%.

This analysis is not direct evidence for specialized centers, “but it is certainly supportive of specialist units,” lead investigator Dr. Matthew F. Giles, of the Oxford (England) University department of clinical neurology, said in an interview.

Rather than specialized stroke centers, “This study is supportive of specialist 'TIA units,' which should offer urgent access, rapid investigation, and immediate preventive treatment,” he explained. Four studies included in the meta-analysis involved that type of urgent access treatment.

The risk of publication bias was not totally overcome in his analysis, Dr. Giles admitted. However, he doubted this bias had any significant effect on his analysis. “Producing data on the outcome of TIA is a very labor-intensive exercise, and once a study has been completed, I very much doubt that it would go unpublished,” he said.

The researchers reported no conflicts of interest.

The risk of a stroke within 7 days of a transient ischemic attack was lowest when patients were treated by specialist stroke services on an emergency basis, according to a systematic review and meta-analysis that included 10,126 TIA patients.

The review looked at 18 cohorts in 17 studies of different design in multiple countries, all assessing the risk of stroke following TIA within 7 days. The investigators searched Ovid Medline from 1950 to June 2007 and Embase between 1980 and June 2007, as well as books of abstracts from recent conferences for studies not yet published as full papers. Studies of patients with underlying pathologies were excluded.

The mean age of patients in the cohorts ranged from 61 to 73 years. The proportion of men ranged from 39% to 62% (Lancet Neurol. 2007;6:1063–72).

The pooled stroke risk across all cohorts for which 2-day data were available (a total of 15 cohorts, with 9,433 patients) was 3.1%. In the 17 cohorts for which data at 7 days were available (7,830 patients), the risk was 5.2%. However, significant heterogeneity among study design led to a large range of risk, from 0% to 12.8%.

The researchers classified the studies into the following categories, and calculated the risk for each category:

▸ Population-based studies over multiple emergency departments (EDs), with face-to-face follow-up. The three studies in this category had an overall 6.7% risk of stroke at 2 days and 10.4% risk at 7 days.

▸ Population-based studies at multiple EDs that relied on administrative follow-up (notes and diagnostic coding review) and that had important exclusions. Such exclusions included patients who were admitted to the hospital, patients with persistent symptoms at discharge from the ED, and strokes on the same day as the TIA. Three studies in this category had an overall stroke risk of 1.6% within 2 days and 3.0% within 7 days.

▸ Population-based studies at multiple EDs that used administrative follow-up but had no exclusions. Three studies in this group had an overall 2-day risk of 4.8% and a 7-day risk of 6.5%.

▸ Studies that ascertained consecutive patients attending a single ED with face-to-face or telephone follow-up. Three studies in this category showed an overall stroke risk after 2 days of 3.1% and risk at 7 days of 5.8%.

▸ Routine outpatient studies that used administrative follow-up. There was a 2-day stroke risk of 1.7% and a 7-day risk of 3.3% in the two studies in this group.

▸ Studies conducted at sites using specialist stroke services. The four studies in this group had the lowest incidence both of 2-day stroke risk, 0.6%, and 7-day risk, at 0.9%.

This analysis is not direct evidence for specialized centers, “but it is certainly supportive of specialist units,” lead investigator Dr. Matthew F. Giles, of the Oxford (England) University department of clinical neurology, said in an interview.

Rather than specialized stroke centers, “This study is supportive of specialist 'TIA units,' which should offer urgent access, rapid investigation, and immediate preventive treatment,” he explained. Four studies included in the meta-analysis involved that type of urgent access treatment.

The risk of publication bias was not totally overcome in his analysis, Dr. Giles admitted. However, he doubted this bias had any significant effect on his analysis. “Producing data on the outcome of TIA is a very labor-intensive exercise, and once a study has been completed, I very much doubt that it would go unpublished,” he said.

The researchers reported no conflicts of interest.

The risk of a stroke within 7 days of a transient ischemic attack was lowest when patients were treated by specialist stroke services on an emergency basis, according to a systematic review and meta-analysis that included 10,126 TIA patients.

The review looked at 18 cohorts in 17 studies of different design in multiple countries, all assessing the risk of stroke following TIA within 7 days. The investigators searched Ovid Medline from 1950 to June 2007 and Embase between 1980 and June 2007, as well as books of abstracts from recent conferences for studies not yet published as full papers. Studies of patients with underlying pathologies were excluded.

The mean age of patients in the cohorts ranged from 61 to 73 years. The proportion of men ranged from 39% to 62% (Lancet Neurol. 2007;6:1063–72).

The pooled stroke risk across all cohorts for which 2-day data were available (a total of 15 cohorts, with 9,433 patients) was 3.1%. In the 17 cohorts for which data at 7 days were available (7,830 patients), the risk was 5.2%. However, significant heterogeneity among study design led to a large range of risk, from 0% to 12.8%.

The researchers classified the studies into the following categories, and calculated the risk for each category:

▸ Population-based studies over multiple emergency departments (EDs), with face-to-face follow-up. The three studies in this category had an overall 6.7% risk of stroke at 2 days and 10.4% risk at 7 days.

▸ Population-based studies at multiple EDs that relied on administrative follow-up (notes and diagnostic coding review) and that had important exclusions. Such exclusions included patients who were admitted to the hospital, patients with persistent symptoms at discharge from the ED, and strokes on the same day as the TIA. Three studies in this category had an overall stroke risk of 1.6% within 2 days and 3.0% within 7 days.

▸ Population-based studies at multiple EDs that used administrative follow-up but had no exclusions. Three studies in this group had an overall 2-day risk of 4.8% and a 7-day risk of 6.5%.

▸ Studies that ascertained consecutive patients attending a single ED with face-to-face or telephone follow-up. Three studies in this category showed an overall stroke risk after 2 days of 3.1% and risk at 7 days of 5.8%.

▸ Routine outpatient studies that used administrative follow-up. There was a 2-day stroke risk of 1.7% and a 7-day risk of 3.3% in the two studies in this group.

▸ Studies conducted at sites using specialist stroke services. The four studies in this group had the lowest incidence both of 2-day stroke risk, 0.6%, and 7-day risk, at 0.9%.

This analysis is not direct evidence for specialized centers, “but it is certainly supportive of specialist units,” lead investigator Dr. Matthew F. Giles, of the Oxford (England) University department of clinical neurology, said in an interview.

Rather than specialized stroke centers, “This study is supportive of specialist 'TIA units,' which should offer urgent access, rapid investigation, and immediate preventive treatment,” he explained. Four studies included in the meta-analysis involved that type of urgent access treatment.

The risk of publication bias was not totally overcome in his analysis, Dr. Giles admitted. However, he doubted this bias had any significant effect on his analysis. “Producing data on the outcome of TIA is a very labor-intensive exercise, and once a study has been completed, I very much doubt that it would go unpublished,” he said.

The researchers reported no conflicts of interest.

Rheumatoid arthritis patients have not experienced a decline in mortality, despite dramatically increased life expectancy in the general population and newer, more aggressive arthritis treatments.

This stagnation is contributing to a widening mortality gap between patients with rheumatoid arthritis (RA) and their unaffected counterparts in the general population, whose mortality has significantly decreased since the 1950s.

In a population-based incidence cohort study, Dr. Hilal Maradit Kremers and colleagues at the Mayo Clinic, Rochester, Minn., looked at a total of 822 RA patients—all of whom were adult residents of Rochester in whom RA was first diagnosed between 1955 and 1995 and all adult residents of Olmsted County in whom RA was diagnosed between 1995 and 2000.

The patients were followed up through medical records until their death or Jan. 1, 2007. The mean age at incidence at 58 years, and nearly three-quarters of the patients were women. The median length of follow-up was 11.7 years (Arthritis Rheum. 2007;56:3583–7).

RA patients' mortality was unchanged in each of the five periods looked at in the study: from 1955 to 1964, 1965 to 1974, 1975 to 1984, 1985 to 1994, and 1995 to 2000. Female mortality hovered around 2.4 per 100 person-years for each period, and the male mortality was constant at about 2.5 per 100 person-years.

In sharp contrast, mortality in women in the Minnesota general population declined from 1.0 per 100 person-years in 1965 to 0.2 per 100 person-years in 2000.

For men, the rate went from 1.2 to 0.3 per 100 person-years over the same time period.

Dr. Kremers reported no conflicts of interest in relation to this study.

Rheumatoid arthritis patients have not experienced a decline in mortality, despite dramatically increased life expectancy in the general population and newer, more aggressive arthritis treatments.

This stagnation is contributing to a widening mortality gap between patients with rheumatoid arthritis (RA) and their unaffected counterparts in the general population, whose mortality has significantly decreased since the 1950s.

In a population-based incidence cohort study, Dr. Hilal Maradit Kremers and colleagues at the Mayo Clinic, Rochester, Minn., looked at a total of 822 RA patients—all of whom were adult residents of Rochester in whom RA was first diagnosed between 1955 and 1995 and all adult residents of Olmsted County in whom RA was diagnosed between 1995 and 2000.

The patients were followed up through medical records until their death or Jan. 1, 2007. The mean age at incidence at 58 years, and nearly three-quarters of the patients were women. The median length of follow-up was 11.7 years (Arthritis Rheum. 2007;56:3583–7).

RA patients' mortality was unchanged in each of the five periods looked at in the study: from 1955 to 1964, 1965 to 1974, 1975 to 1984, 1985 to 1994, and 1995 to 2000. Female mortality hovered around 2.4 per 100 person-years for each period, and the male mortality was constant at about 2.5 per 100 person-years.

In sharp contrast, mortality in women in the Minnesota general population declined from 1.0 per 100 person-years in 1965 to 0.2 per 100 person-years in 2000.

For men, the rate went from 1.2 to 0.3 per 100 person-years over the same time period.

Dr. Kremers reported no conflicts of interest in relation to this study.

Rheumatoid arthritis patients have not experienced a decline in mortality, despite dramatically increased life expectancy in the general population and newer, more aggressive arthritis treatments.

This stagnation is contributing to a widening mortality gap between patients with rheumatoid arthritis (RA) and their unaffected counterparts in the general population, whose mortality has significantly decreased since the 1950s.

In a population-based incidence cohort study, Dr. Hilal Maradit Kremers and colleagues at the Mayo Clinic, Rochester, Minn., looked at a total of 822 RA patients—all of whom were adult residents of Rochester in whom RA was first diagnosed between 1955 and 1995 and all adult residents of Olmsted County in whom RA was diagnosed between 1995 and 2000.

The patients were followed up through medical records until their death or Jan. 1, 2007. The mean age at incidence at 58 years, and nearly three-quarters of the patients were women. The median length of follow-up was 11.7 years (Arthritis Rheum. 2007;56:3583–7).

RA patients' mortality was unchanged in each of the five periods looked at in the study: from 1955 to 1964, 1965 to 1974, 1975 to 1984, 1985 to 1994, and 1995 to 2000. Female mortality hovered around 2.4 per 100 person-years for each period, and the male mortality was constant at about 2.5 per 100 person-years.

In sharp contrast, mortality in women in the Minnesota general population declined from 1.0 per 100 person-years in 1965 to 0.2 per 100 person-years in 2000.

For men, the rate went from 1.2 to 0.3 per 100 person-years over the same time period.

Dr. Kremers reported no conflicts of interest in relation to this study.

Gold therapy seems to be a safe treatment option for severe rheumatoid arthritis in both pregnant women and women who are trying to conceive who must discontinue or forgo other teratogenic therapies, according to findings from a small chart review.

The study looked at 14 women with severe rheumatoid arthritis (RA) who became pregnant while taking gold between January 1992 and January 2006. One woman had stopped taking gold therapy 4 weeks prior to conception; four women stayed on gold throughout the pregnancy.

The 14 women reported 20 pregnancies, according to Dr. Mohammed Almarzouqi, a rheumatologist at the University of British Columbia, Vancouver, and his fellow researchers.

Rheumatoid arthritis was considered controlled if there were fewer than four swollen or tender joints in an assessment by a clinic rheumatologist, and if no new prescription of prednisone or nonsteroidal anti-inflammatory drugs was required.

The mean age at pregnancy was 35 years (range 24–41) and the mean disease duration was 8.5 years. Rheumatoid factor was positive in 9 of 14 women.

The amount of time taking gold prior to conception was less than 1 year in seven pregnancies, 1–2 years in four pregnancies, 25–34 months in two pregnancies, and 2–8 years in seven pregnancies. Six of the patients had 11 pregnancies prior to gold therapy.

Ten patients had never taken methotrexate (MTX) prior to conception, while the other four women had discontinued MTX 8–16 months before conception. Thirteen pregnancies had a mean dose of gold while planning pregnancy and prior to conception of 25–50 mg/week. At the high end of the dosage spectrum, two pregnancies followed a dose of 50 mg/every 2 weeks, and in one pregnancy it was 60 mg/week.

At the low end, two pregnancies had a mean dose of 5–10 mg/week, and two other pregnancies had a mean dose of 10 mg every 2 weeks (J. Rheumatol. 2007;34:1827-31).

“In our small series of women taking gold for RA while planning pregnancy, 5 of 20 pregnancies ended in spontaneous abortion,” wrote the investigators.

However, they pointed out that the mean age of women in their study was 35 years, and that the rate of fetal loss in women over 40 and women near that age is higher than for younger women.

Additionally, two of the reported spontaneous abortions occurred in a woman with a “known chromosomal defect.” Two of the women who lost a fetus also reported birth of one healthy baby while taking gold.

The remaining children, including one set of twins, were healthy at birth.

Rheumatoid arthritis flared during just 3 of the 15 full-term pregnancies, and it was controlled in the rest.

Although this study was small, the authors concluded that, in light of the fact that there are so few available disease-modifying antirheumatic drugs that are recommended for pregnant women or women attempting pregnancy, gold is a safe and efficacious rheumatoid arthritis treatment during pregnancy.

The investigators disclosed no conflicts of interest related to this study.

Gold therapy seems to be a safe treatment option for severe rheumatoid arthritis in both pregnant women and women who are trying to conceive who must discontinue or forgo other teratogenic therapies, according to findings from a small chart review.

The study looked at 14 women with severe rheumatoid arthritis (RA) who became pregnant while taking gold between January 1992 and January 2006. One woman had stopped taking gold therapy 4 weeks prior to conception; four women stayed on gold throughout the pregnancy.

The 14 women reported 20 pregnancies, according to Dr. Mohammed Almarzouqi, a rheumatologist at the University of British Columbia, Vancouver, and his fellow researchers.

Rheumatoid arthritis was considered controlled if there were fewer than four swollen or tender joints in an assessment by a clinic rheumatologist, and if no new prescription of prednisone or nonsteroidal anti-inflammatory drugs was required.

The mean age at pregnancy was 35 years (range 24–41) and the mean disease duration was 8.5 years. Rheumatoid factor was positive in 9 of 14 women.

The amount of time taking gold prior to conception was less than 1 year in seven pregnancies, 1–2 years in four pregnancies, 25–34 months in two pregnancies, and 2–8 years in seven pregnancies. Six of the patients had 11 pregnancies prior to gold therapy.

Ten patients had never taken methotrexate (MTX) prior to conception, while the other four women had discontinued MTX 8–16 months before conception. Thirteen pregnancies had a mean dose of gold while planning pregnancy and prior to conception of 25–50 mg/week. At the high end of the dosage spectrum, two pregnancies followed a dose of 50 mg/every 2 weeks, and in one pregnancy it was 60 mg/week.

At the low end, two pregnancies had a mean dose of 5–10 mg/week, and two other pregnancies had a mean dose of 10 mg every 2 weeks (J. Rheumatol. 2007;34:1827-31).

“In our small series of women taking gold for RA while planning pregnancy, 5 of 20 pregnancies ended in spontaneous abortion,” wrote the investigators.

However, they pointed out that the mean age of women in their study was 35 years, and that the rate of fetal loss in women over 40 and women near that age is higher than for younger women.

Additionally, two of the reported spontaneous abortions occurred in a woman with a “known chromosomal defect.” Two of the women who lost a fetus also reported birth of one healthy baby while taking gold.

The remaining children, including one set of twins, were healthy at birth.

Rheumatoid arthritis flared during just 3 of the 15 full-term pregnancies, and it was controlled in the rest.

Although this study was small, the authors concluded that, in light of the fact that there are so few available disease-modifying antirheumatic drugs that are recommended for pregnant women or women attempting pregnancy, gold is a safe and efficacious rheumatoid arthritis treatment during pregnancy.

The investigators disclosed no conflicts of interest related to this study.

Gold therapy seems to be a safe treatment option for severe rheumatoid arthritis in both pregnant women and women who are trying to conceive who must discontinue or forgo other teratogenic therapies, according to findings from a small chart review.

The study looked at 14 women with severe rheumatoid arthritis (RA) who became pregnant while taking gold between January 1992 and January 2006. One woman had stopped taking gold therapy 4 weeks prior to conception; four women stayed on gold throughout the pregnancy.

The 14 women reported 20 pregnancies, according to Dr. Mohammed Almarzouqi, a rheumatologist at the University of British Columbia, Vancouver, and his fellow researchers.

Rheumatoid arthritis was considered controlled if there were fewer than four swollen or tender joints in an assessment by a clinic rheumatologist, and if no new prescription of prednisone or nonsteroidal anti-inflammatory drugs was required.

The mean age at pregnancy was 35 years (range 24–41) and the mean disease duration was 8.5 years. Rheumatoid factor was positive in 9 of 14 women.

The amount of time taking gold prior to conception was less than 1 year in seven pregnancies, 1–2 years in four pregnancies, 25–34 months in two pregnancies, and 2–8 years in seven pregnancies. Six of the patients had 11 pregnancies prior to gold therapy.

Ten patients had never taken methotrexate (MTX) prior to conception, while the other four women had discontinued MTX 8–16 months before conception. Thirteen pregnancies had a mean dose of gold while planning pregnancy and prior to conception of 25–50 mg/week. At the high end of the dosage spectrum, two pregnancies followed a dose of 50 mg/every 2 weeks, and in one pregnancy it was 60 mg/week.

At the low end, two pregnancies had a mean dose of 5–10 mg/week, and two other pregnancies had a mean dose of 10 mg every 2 weeks (J. Rheumatol. 2007;34:1827-31).

“In our small series of women taking gold for RA while planning pregnancy, 5 of 20 pregnancies ended in spontaneous abortion,” wrote the investigators.

However, they pointed out that the mean age of women in their study was 35 years, and that the rate of fetal loss in women over 40 and women near that age is higher than for younger women.

Additionally, two of the reported spontaneous abortions occurred in a woman with a “known chromosomal defect.” Two of the women who lost a fetus also reported birth of one healthy baby while taking gold.

The remaining children, including one set of twins, were healthy at birth.

Rheumatoid arthritis flared during just 3 of the 15 full-term pregnancies, and it was controlled in the rest.

Although this study was small, the authors concluded that, in light of the fact that there are so few available disease-modifying antirheumatic drugs that are recommended for pregnant women or women attempting pregnancy, gold is a safe and efficacious rheumatoid arthritis treatment during pregnancy.

The investigators disclosed no conflicts of interest related to this study.

Diacerein is safe and effective for reducing osteoarthritis-associated pain, and its effects persisted for at least 3 months after treatment was stopped in a randomized, double-blind, placebo-controlled, multi-center study.

The anthraquinone derivative is approved for use in several European countries but not in the United States.

An intent-to-treat analysis was carried out on 165 patients randomized to receive 50-mg diacerein capsules (82 patients) or placebo twice daily for 3 months. Most patients had bilateral knee OA, and most were taking nonsteroidal anti-inflammatory drugs. The majority were female and the mean duration of OA was 6.5 years (Arthritis Rheum. 2007;56:4055-64).

The two primary end points were the percentage change in baseline pain as recorded on a 100-mm visual analog scale (VAS) in section A of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and change in score on the total WOMAC from baseline to the fifth month.

“Diacerein showed statistically significant superiority over placebo (P less than .0001) for the primary efficacy criterion,” wrote Dr. Karel Pavelka, of Charles University, Prague, and his associates. Changes in pain on a 100-mm normalized scale were “already significantly different in favor of diacerein at month 2” and the level of pain “decreased further in the diacerein group by the end of treatment (month 3) (P = .0006) and persisted at this level not only at months 4 and 5 … but also at month 6.”

The absolute change in pain at month 3 for the treatment group was 21.6 mm, versus 9.4 mm in the placebo group. At month 5, the treatment group change persisted, at 23.3 mm, versus 9.5 mm in the placebo group.

The other primary end point—change on the total WOMAC—“was also significantly different (P less than .0001) compared with placebo at month 5,” wrote the investigators. The total WOMAC score at baseline was 1,251 and 1,183 in the diacerein and placebo groups, respectively. The diacerein group's score dropped to 834 at month 3 versus 982 in the placebo group, and diacerein patients had a total score of 733 at month 6 versus 1,011 for placebo patients (P = .0045 at month 3 and P less than .0001 at month 6).

A former consultant for Negma, a French company that marketed the drug, Dr. Roy Altman said in an interview that the drug was put before the Food and Drug Administration several times in the last decade. But the “shifting sands” of the agency's clinical trial data requirements prevented the drug from ever gaining approval. (A representative from the FDA's Center for Drug Evaluation and Research would not comment on drugs that had not been approved.)

The Osteoarthritis Research Society International's new therapeutic guidelines are likely to give “approval for diacerein for OA, but not a high recommendation,” according to Dr. Altman, a visiting professor in the division of rheumatology of the University of California, Los Angeles.

The study was supported by a joint grant from TRB Chemedica International SA and Glynn Brothers Chemicals AG, two Switzerland-based companies.

Unpublished international guidelines likely will approve the use of diacerein for OA pain. DR. ALTMAN

Diacerein is safe and effective for reducing osteoarthritis-associated pain, and its effects persisted for at least 3 months after treatment was stopped in a randomized, double-blind, placebo-controlled, multi-center study.

The anthraquinone derivative is approved for use in several European countries but not in the United States.

An intent-to-treat analysis was carried out on 165 patients randomized to receive 50-mg diacerein capsules (82 patients) or placebo twice daily for 3 months. Most patients had bilateral knee OA, and most were taking nonsteroidal anti-inflammatory drugs. The majority were female and the mean duration of OA was 6.5 years (Arthritis Rheum. 2007;56:4055-64).

The two primary end points were the percentage change in baseline pain as recorded on a 100-mm visual analog scale (VAS) in section A of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and change in score on the total WOMAC from baseline to the fifth month.

“Diacerein showed statistically significant superiority over placebo (P less than .0001) for the primary efficacy criterion,” wrote Dr. Karel Pavelka, of Charles University, Prague, and his associates. Changes in pain on a 100-mm normalized scale were “already significantly different in favor of diacerein at month 2” and the level of pain “decreased further in the diacerein group by the end of treatment (month 3) (P = .0006) and persisted at this level not only at months 4 and 5 … but also at month 6.”

The absolute change in pain at month 3 for the treatment group was 21.6 mm, versus 9.4 mm in the placebo group. At month 5, the treatment group change persisted, at 23.3 mm, versus 9.5 mm in the placebo group.

The other primary end point—change on the total WOMAC—“was also significantly different (P less than .0001) compared with placebo at month 5,” wrote the investigators. The total WOMAC score at baseline was 1,251 and 1,183 in the diacerein and placebo groups, respectively. The diacerein group's score dropped to 834 at month 3 versus 982 in the placebo group, and diacerein patients had a total score of 733 at month 6 versus 1,011 for placebo patients (P = .0045 at month 3 and P less than .0001 at month 6).

A former consultant for Negma, a French company that marketed the drug, Dr. Roy Altman said in an interview that the drug was put before the Food and Drug Administration several times in the last decade. But the “shifting sands” of the agency's clinical trial data requirements prevented the drug from ever gaining approval. (A representative from the FDA's Center for Drug Evaluation and Research would not comment on drugs that had not been approved.)

The Osteoarthritis Research Society International's new therapeutic guidelines are likely to give “approval for diacerein for OA, but not a high recommendation,” according to Dr. Altman, a visiting professor in the division of rheumatology of the University of California, Los Angeles.

The study was supported by a joint grant from TRB Chemedica International SA and Glynn Brothers Chemicals AG, two Switzerland-based companies.

Unpublished international guidelines likely will approve the use of diacerein for OA pain. DR. ALTMAN

Diacerein is safe and effective for reducing osteoarthritis-associated pain, and its effects persisted for at least 3 months after treatment was stopped in a randomized, double-blind, placebo-controlled, multi-center study.

The anthraquinone derivative is approved for use in several European countries but not in the United States.

An intent-to-treat analysis was carried out on 165 patients randomized to receive 50-mg diacerein capsules (82 patients) or placebo twice daily for 3 months. Most patients had bilateral knee OA, and most were taking nonsteroidal anti-inflammatory drugs. The majority were female and the mean duration of OA was 6.5 years (Arthritis Rheum. 2007;56:4055-64).

The two primary end points were the percentage change in baseline pain as recorded on a 100-mm visual analog scale (VAS) in section A of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and change in score on the total WOMAC from baseline to the fifth month.

“Diacerein showed statistically significant superiority over placebo (P less than .0001) for the primary efficacy criterion,” wrote Dr. Karel Pavelka, of Charles University, Prague, and his associates. Changes in pain on a 100-mm normalized scale were “already significantly different in favor of diacerein at month 2” and the level of pain “decreased further in the diacerein group by the end of treatment (month 3) (P = .0006) and persisted at this level not only at months 4 and 5 … but also at month 6.”

The absolute change in pain at month 3 for the treatment group was 21.6 mm, versus 9.4 mm in the placebo group. At month 5, the treatment group change persisted, at 23.3 mm, versus 9.5 mm in the placebo group.

The other primary end point—change on the total WOMAC—“was also significantly different (P less than .0001) compared with placebo at month 5,” wrote the investigators. The total WOMAC score at baseline was 1,251 and 1,183 in the diacerein and placebo groups, respectively. The diacerein group's score dropped to 834 at month 3 versus 982 in the placebo group, and diacerein patients had a total score of 733 at month 6 versus 1,011 for placebo patients (P = .0045 at month 3 and P less than .0001 at month 6).

A former consultant for Negma, a French company that marketed the drug, Dr. Roy Altman said in an interview that the drug was put before the Food and Drug Administration several times in the last decade. But the “shifting sands” of the agency's clinical trial data requirements prevented the drug from ever gaining approval. (A representative from the FDA's Center for Drug Evaluation and Research would not comment on drugs that had not been approved.)

The Osteoarthritis Research Society International's new therapeutic guidelines are likely to give “approval for diacerein for OA, but not a high recommendation,” according to Dr. Altman, a visiting professor in the division of rheumatology of the University of California, Los Angeles.

The study was supported by a joint grant from TRB Chemedica International SA and Glynn Brothers Chemicals AG, two Switzerland-based companies.

Unpublished international guidelines likely will approve the use of diacerein for OA pain. DR. ALTMAN