Key clinical point: In Brazil, the COVID-19 pandemic changed how specialists managed early breast cancer, especially HR-positive tumors.

Major finding: Nearly 70% of breast cancer specialists reported changing their management of early breast cancer. For more proliferative HR-positive tumors (Ki-67 >30%), 34% recommended neoadjuvant endocrine therapy (NET) for postmenopausal patients, while 10.9% recommended NET for premenopausal patients.

Study details: Survey of 503 breast cancer specialists in Brazil.

Disclosures: The study was not funded. The researchers reported having no conflicts.

Citation: Cavalcante FP et al. Breast Cancer Res Treat. 2020 Aug 16. doi: 10.1007/s10549-020-05877-y

Key clinical point: In Brazil, the COVID-19 pandemic changed how specialists managed early breast cancer, especially HR-positive tumors.

Major finding: Nearly 70% of breast cancer specialists reported changing their management of early breast cancer. For more proliferative HR-positive tumors (Ki-67 >30%), 34% recommended neoadjuvant endocrine therapy (NET) for postmenopausal patients, while 10.9% recommended NET for premenopausal patients.

Study details: Survey of 503 breast cancer specialists in Brazil.

Disclosures: The study was not funded. The researchers reported having no conflicts.

Citation: Cavalcante FP et al. Breast Cancer Res Treat. 2020 Aug 16. doi: 10.1007/s10549-020-05877-y

Key clinical point: In Brazil, the COVID-19 pandemic changed how specialists managed early breast cancer, especially HR-positive tumors.

Major finding: Nearly 70% of breast cancer specialists reported changing their management of early breast cancer. For more proliferative HR-positive tumors (Ki-67 >30%), 34% recommended neoadjuvant endocrine therapy (NET) for postmenopausal patients, while 10.9% recommended NET for premenopausal patients.

Study details: Survey of 503 breast cancer specialists in Brazil.

Disclosures: The study was not funded. The researchers reported having no conflicts.

Citation: Cavalcante FP et al. Breast Cancer Res Treat. 2020 Aug 16. doi: 10.1007/s10549-020-05877-y

Key clinical point: For patients with early breast cancer, ≤ 6 months of adjuvant trastuzumab was noninferior to a 1-year course and appeared to be less cardiotoxic.

Major finding: 5-year DFS rates were 85.4% vs. 87.1%, respectively. Rates of congestive heart failure were 3.9% vs. 6.9%, respectively.

Study details: Meta-analysis of 5 randomized trials (11,376 patients).

Disclosures: Funding sources were not reported. Two coinvestigators disclosed ties to Roche, Eisai, Novartis, Sanofi, Kendle India, and several other pharmaceutical companies.

Citation: Gulia S et al. 2020 Aug 24. JAMA Netw Open. doi: 10.1001/jamanetworkopen.2020.11777

Key clinical point: For patients with early breast cancer, ≤ 6 months of adjuvant trastuzumab was noninferior to a 1-year course and appeared to be less cardiotoxic.

Major finding: 5-year DFS rates were 85.4% vs. 87.1%, respectively. Rates of congestive heart failure were 3.9% vs. 6.9%, respectively.

Study details: Meta-analysis of 5 randomized trials (11,376 patients).

Disclosures: Funding sources were not reported. Two coinvestigators disclosed ties to Roche, Eisai, Novartis, Sanofi, Kendle India, and several other pharmaceutical companies.

Citation: Gulia S et al. 2020 Aug 24. JAMA Netw Open. doi: 10.1001/jamanetworkopen.2020.11777

Key clinical point: For patients with early breast cancer, ≤ 6 months of adjuvant trastuzumab was noninferior to a 1-year course and appeared to be less cardiotoxic.

Major finding: 5-year DFS rates were 85.4% vs. 87.1%, respectively. Rates of congestive heart failure were 3.9% vs. 6.9%, respectively.

Study details: Meta-analysis of 5 randomized trials (11,376 patients).

Disclosures: Funding sources were not reported. Two coinvestigators disclosed ties to Roche, Eisai, Novartis, Sanofi, Kendle India, and several other pharmaceutical companies.

Citation: Gulia S et al. 2020 Aug 24. JAMA Netw Open. doi: 10.1001/jamanetworkopen.2020.11777

Key clinical point: Despite showing efficacy in specific subgroups, immune checkpoint inhibitors (ICIs) are unlikely to benefit most women with metastatic breast cancer.

Major finding: Objective response rates were 19% overall, 27% in PD-L1 positive patients, 18% in PD-L1 negative patients, 28% in HER2-positive breast cancer, 23% in triple-negative breast cancer, 35% when used in the first line, 26% when combined with systemic therapy, and 9% when used as monotherapy.

Study details: Meta-analysis of 27 studies of metastatic breast cancer (1,746 patients).

Disclosures: The study was funded by the National Natural Science Foundation of China. The investigators reported having no conflicts.

Citation: Zou Y et al. Ther Adv Med Oncol. 2020 Aug 17. doi: 10.1177/1758835920940928

Key clinical point: Despite showing efficacy in specific subgroups, immune checkpoint inhibitors (ICIs) are unlikely to benefit most women with metastatic breast cancer.

Major finding: Objective response rates were 19% overall, 27% in PD-L1 positive patients, 18% in PD-L1 negative patients, 28% in HER2-positive breast cancer, 23% in triple-negative breast cancer, 35% when used in the first line, 26% when combined with systemic therapy, and 9% when used as monotherapy.

Study details: Meta-analysis of 27 studies of metastatic breast cancer (1,746 patients).

Disclosures: The study was funded by the National Natural Science Foundation of China. The investigators reported having no conflicts.

Citation: Zou Y et al. Ther Adv Med Oncol. 2020 Aug 17. doi: 10.1177/1758835920940928

Key clinical point: Despite showing efficacy in specific subgroups, immune checkpoint inhibitors (ICIs) are unlikely to benefit most women with metastatic breast cancer.

Major finding: Objective response rates were 19% overall, 27% in PD-L1 positive patients, 18% in PD-L1 negative patients, 28% in HER2-positive breast cancer, 23% in triple-negative breast cancer, 35% when used in the first line, 26% when combined with systemic therapy, and 9% when used as monotherapy.

Study details: Meta-analysis of 27 studies of metastatic breast cancer (1,746 patients).

Disclosures: The study was funded by the National Natural Science Foundation of China. The investigators reported having no conflicts.

Citation: Zou Y et al. Ther Adv Med Oncol. 2020 Aug 17. doi: 10.1177/1758835920940928

Key clinical point: Later uptake and less extensive use of screening mammography might explain a relatively high rate of deaths from breast cancer among older women in Germany.

Major finding: Women aged ≥ 70 years in Germany had a 19% lower incidence but a 45% higher rate of mortality from breast cancer compared with their peers in the United States.

Study details: Population-based study of the Surveillance, Epidemiology, and End Results (SEER) 9 registry in the United States, and the Saarland Cancer Registry and the German Centre for Cancer Registry Data in Germany. 

Disclosures: German Cancer Aid funded the study. The investigators reported having no conflicts.

Citation: Jansen L et al. Cancers (Basel). 2020 Aug 26. doi: 10.3390/cancers12092419

Key clinical point: Later uptake and less extensive use of screening mammography might explain a relatively high rate of deaths from breast cancer among older women in Germany.

Major finding: Women aged ≥ 70 years in Germany had a 19% lower incidence but a 45% higher rate of mortality from breast cancer compared with their peers in the United States.

Study details: Population-based study of the Surveillance, Epidemiology, and End Results (SEER) 9 registry in the United States, and the Saarland Cancer Registry and the German Centre for Cancer Registry Data in Germany. 

Disclosures: German Cancer Aid funded the study. The investigators reported having no conflicts.

Citation: Jansen L et al. Cancers (Basel). 2020 Aug 26. doi: 10.3390/cancers12092419

Key clinical point: Later uptake and less extensive use of screening mammography might explain a relatively high rate of deaths from breast cancer among older women in Germany.

Major finding: Women aged ≥ 70 years in Germany had a 19% lower incidence but a 45% higher rate of mortality from breast cancer compared with their peers in the United States.

Study details: Population-based study of the Surveillance, Epidemiology, and End Results (SEER) 9 registry in the United States, and the Saarland Cancer Registry and the German Centre for Cancer Registry Data in Germany. 

Disclosures: German Cancer Aid funded the study. The investigators reported having no conflicts.

Citation: Jansen L et al. Cancers (Basel). 2020 Aug 26. doi: 10.3390/cancers12092419

Key clinical point: Prior use of conjugated equine estrogen in women who had a hysterectomy was associated with lower breast cancer incidence and mortality.

Major finding: Conjugated equine estrogen alone was associated with lower mortality (30 deaths, annualized mortality rate 0.031%), compared with placebo (46 deaths, annualized mortality rate 0.046%); HR 0.60; 95% CI, 0.37-0.97; P = .04.

Study details: This was a long-term follow-up study of two Women’s Health Initiative clinical trials of postmenopausal women with no prior breast cancer.

Disclosures: The Women’s Health Initiative is supported by the National Heart, Lung, and Blood Institute, the National Institutes of Health, and the Department of Health and Human Services. The authors reported numerous potential conflicts of interest, including receiving personal fees and grants from various government organizations, foundations, and pharmaceutical companies.

Citation: Chlebowski RT et al. JAMA. 2020 Jul 28. doi: 10.1001/jama.2020.9482.

Key clinical point: Prior use of conjugated equine estrogen in women who had a hysterectomy was associated with lower breast cancer incidence and mortality.

Major finding: Conjugated equine estrogen alone was associated with lower mortality (30 deaths, annualized mortality rate 0.031%), compared with placebo (46 deaths, annualized mortality rate 0.046%); HR 0.60; 95% CI, 0.37-0.97; P = .04.

Study details: This was a long-term follow-up study of two Women’s Health Initiative clinical trials of postmenopausal women with no prior breast cancer.

Disclosures: The Women’s Health Initiative is supported by the National Heart, Lung, and Blood Institute, the National Institutes of Health, and the Department of Health and Human Services. The authors reported numerous potential conflicts of interest, including receiving personal fees and grants from various government organizations, foundations, and pharmaceutical companies.

Citation: Chlebowski RT et al. JAMA. 2020 Jul 28. doi: 10.1001/jama.2020.9482.

Key clinical point: Prior use of conjugated equine estrogen in women who had a hysterectomy was associated with lower breast cancer incidence and mortality.

Major finding: Conjugated equine estrogen alone was associated with lower mortality (30 deaths, annualized mortality rate 0.031%), compared with placebo (46 deaths, annualized mortality rate 0.046%); HR 0.60; 95% CI, 0.37-0.97; P = .04.

Study details: This was a long-term follow-up study of two Women’s Health Initiative clinical trials of postmenopausal women with no prior breast cancer.

Disclosures: The Women’s Health Initiative is supported by the National Heart, Lung, and Blood Institute, the National Institutes of Health, and the Department of Health and Human Services. The authors reported numerous potential conflicts of interest, including receiving personal fees and grants from various government organizations, foundations, and pharmaceutical companies.

Citation: Chlebowski RT et al. JAMA. 2020 Jul 28. doi: 10.1001/jama.2020.9482.

Key clinical point: An automated image cytometry system called CytoPAN provides rapid cancer profiling and requires “scant” cellular specimens, according to researchers.

Major finding: In preclinical experiments, CytoPAN detected cancer in 1 hour using as few as 50 cells. In a patient cohort, CytoPAN detected breast cancer with 100% accuracy.

Study details: Preclinical research and a prospective study of 68 breast cancer patients.

Disclosures: The authors received funding from the National Institutes of Health, the MGH Scholar Fund, and Robert Wood Johnson Foundation. Some authors disclosed relationships with Akili, Accure Health, ModeRNA, Tarveda, Lumicell, and Noul.

Citation: Min J et al. Sci Transl Med. 2020 Aug 5. doi: 10.1126/scitranslmed.aaz9746.

Key clinical point: An automated image cytometry system called CytoPAN provides rapid cancer profiling and requires “scant” cellular specimens, according to researchers.

Major finding: In preclinical experiments, CytoPAN detected cancer in 1 hour using as few as 50 cells. In a patient cohort, CytoPAN detected breast cancer with 100% accuracy.

Study details: Preclinical research and a prospective study of 68 breast cancer patients.

Disclosures: The authors received funding from the National Institutes of Health, the MGH Scholar Fund, and Robert Wood Johnson Foundation. Some authors disclosed relationships with Akili, Accure Health, ModeRNA, Tarveda, Lumicell, and Noul.

Citation: Min J et al. Sci Transl Med. 2020 Aug 5. doi: 10.1126/scitranslmed.aaz9746.

Key clinical point: An automated image cytometry system called CytoPAN provides rapid cancer profiling and requires “scant” cellular specimens, according to researchers.

Major finding: In preclinical experiments, CytoPAN detected cancer in 1 hour using as few as 50 cells. In a patient cohort, CytoPAN detected breast cancer with 100% accuracy.

Study details: Preclinical research and a prospective study of 68 breast cancer patients.

Disclosures: The authors received funding from the National Institutes of Health, the MGH Scholar Fund, and Robert Wood Johnson Foundation. Some authors disclosed relationships with Akili, Accure Health, ModeRNA, Tarveda, Lumicell, and Noul.

Citation: Min J et al. Sci Transl Med. 2020 Aug 5. doi: 10.1126/scitranslmed.aaz9746.

The American College of Physicians and the American Academy of Family Physicians recently authored a guideline regarding the treatment of acute, non–low back, musculoskeletal injuries in adults in the outpatient setting. While their recommendations mirror what most clinicians currently do in their medical practices, they don’t address the multiple components of pain that include sensory, emotional, cognitive, and behavioral processes in addition to the physical discomfort.

According to the authors, musculoskeletal injuries result in more than 65 million medical visits a year with an annual estimated cost of $176.1 billion in 2010.

In summary, the guideline, which was published in the Annals of Internal Medicine, is based on a review of the best available evidence. The research reviewed by the guideline authors showed favorable results with topical NSAIDs, oral NSAIDs, oral acetaminophen, acupressure, and transcutaneous electrical nerve stimulation in reducing pain and/or improving function. The guideline authors “recommend that clinicians treat patients with acute pain from non–low back, musculoskeletal injuries with topical [NSAIDs] with or without gel as first-line therapy to reduce or relieve symptoms, including pain; improve physical function; and improve the patient’s treatment satisfaction (Grade: strong recommendation; moderate-certainty evidence).” Additionally, the guideline recommends against treating acute pain from non–low back, musculoskeletal injuries with opioids, including tramadol (Grade: conditional recommendation; low-certainty evidence).

The guideline also mentions improving function in relation to decreasing pain, which can be multifactorial.

Treating pain requires a multipronged approach. Many patients require more than one therapy to treat their pain, such as NSAIDs plus physical therapy. The ACP and AAFP did not make any recommendations for combination therapies in this guideline.

When physical therapy is needed

Nonopioid pain medications can do a great job of reducing a patient’s physical discomfort, which the evidence for these guideline demonstrates. However, much of the dysfunction caused by musculoskeletal injuries will not improve by reducing the pain alone. Physical therapy, exercise, and mobilization did not show a significant benefit in reducing symptoms in the systematic review and meta-analysis of randomized trials that appeared alongside the guideline. The type of pain, however, was not evaluated in relation to the effectiveness of these treatments. A fractured bone, for example, may heal just fine with casting and pain management, without the need for additional therapies. However, the muscles surrounding that bone can atrophy and become weak from not being used. Physical therapy may be needed to restrengthen those muscles. Therefore, a multifaceted approach is often needed, even for uncomplicated conditions.

Mental pain often comes with physical pain, and this is an aspect of care that is often neglected. It can be quite devastating for patients to not be able to do the things they were previously able to do. While this is easily recognized in professional athletes when they can no longer play, it is not so readily apparent with a mother who is just trying to take care of her kids. As doctors, especially those of us in family medicine, we should be addressing more than just physical pain.

Patients can also do activities that exacerbate their pain. As doctors, we need to be asking questions that help us determine whether a patient’s pain is caused by a particular action. Maybe that increase in shoulder pain is due to nothing more than lifting something heavy rather than a failure in a prescribed medication. Pain diaries are helpful, and clinicians don’t use them often enough.
 

How pain affects mental health

Acute injuries can also lead to disability. Many patients become quite distressed about being unable to work. They often need Famiy & Medical Leave Act forms filled out, and this task usually falls to the primary care doctor. In addition to assessing the pain, we need to be evaluating, at each visit, a patient’s level of functioning and their ability to do their job.

Every patient responds to pain differently, and it is important to evaluate patients’ mindsets regarding theirs. A patient may be in severe pain and may try to ignore it for a variety of reasons. A patient may “catastrophize” their pain, believing only the worst outcome will happen to them. Helping patients set appropriate expectations and having a positive mindset can help.

Overall, the new recommendations are a great tool as a guideline, but they are not complete enough to be the only ones used in managing acute, non–low back, musculoskeletal pain in adults.

They are very important for clinicians who may be prescribing opioid medications for patients with this type of pain. Amid an opioid crisis, it is the responsibility of every doctor to prescribe these medications appropriately. The evidence clearly shows they provide little benefit and place patients at risk of addiction.

We should all be following these recommendations as the baseline of care for acute pain. However, we need to delve deeper and manage all the components involved. We would be ignoring very real suffering in our patients if we limited our focus to only the physical discomfort.
 

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Rutgers RWJ Medical School.

SOURCE: Ann Intern Med. 2020 Aug 18. doi: 10.7326/M19-3602.

The American College of Physicians and the American Academy of Family Physicians recently authored a guideline regarding the treatment of acute, non–low back, musculoskeletal injuries in adults in the outpatient setting. While their recommendations mirror what most clinicians currently do in their medical practices, they don’t address the multiple components of pain that include sensory, emotional, cognitive, and behavioral processes in addition to the physical discomfort.

According to the authors, musculoskeletal injuries result in more than 65 million medical visits a year with an annual estimated cost of $176.1 billion in 2010.

In summary, the guideline, which was published in the Annals of Internal Medicine, is based on a review of the best available evidence. The research reviewed by the guideline authors showed favorable results with topical NSAIDs, oral NSAIDs, oral acetaminophen, acupressure, and transcutaneous electrical nerve stimulation in reducing pain and/or improving function. The guideline authors “recommend that clinicians treat patients with acute pain from non–low back, musculoskeletal injuries with topical [NSAIDs] with or without gel as first-line therapy to reduce or relieve symptoms, including pain; improve physical function; and improve the patient’s treatment satisfaction (Grade: strong recommendation; moderate-certainty evidence).” Additionally, the guideline recommends against treating acute pain from non–low back, musculoskeletal injuries with opioids, including tramadol (Grade: conditional recommendation; low-certainty evidence).

The guideline also mentions improving function in relation to decreasing pain, which can be multifactorial.

Treating pain requires a multipronged approach. Many patients require more than one therapy to treat their pain, such as NSAIDs plus physical therapy. The ACP and AAFP did not make any recommendations for combination therapies in this guideline.

When physical therapy is needed

Nonopioid pain medications can do a great job of reducing a patient’s physical discomfort, which the evidence for these guideline demonstrates. However, much of the dysfunction caused by musculoskeletal injuries will not improve by reducing the pain alone. Physical therapy, exercise, and mobilization did not show a significant benefit in reducing symptoms in the systematic review and meta-analysis of randomized trials that appeared alongside the guideline. The type of pain, however, was not evaluated in relation to the effectiveness of these treatments. A fractured bone, for example, may heal just fine with casting and pain management, without the need for additional therapies. However, the muscles surrounding that bone can atrophy and become weak from not being used. Physical therapy may be needed to restrengthen those muscles. Therefore, a multifaceted approach is often needed, even for uncomplicated conditions.

Mental pain often comes with physical pain, and this is an aspect of care that is often neglected. It can be quite devastating for patients to not be able to do the things they were previously able to do. While this is easily recognized in professional athletes when they can no longer play, it is not so readily apparent with a mother who is just trying to take care of her kids. As doctors, especially those of us in family medicine, we should be addressing more than just physical pain.

Patients can also do activities that exacerbate their pain. As doctors, we need to be asking questions that help us determine whether a patient’s pain is caused by a particular action. Maybe that increase in shoulder pain is due to nothing more than lifting something heavy rather than a failure in a prescribed medication. Pain diaries are helpful, and clinicians don’t use them often enough.
 

How pain affects mental health

Acute injuries can also lead to disability. Many patients become quite distressed about being unable to work. They often need Famiy & Medical Leave Act forms filled out, and this task usually falls to the primary care doctor. In addition to assessing the pain, we need to be evaluating, at each visit, a patient’s level of functioning and their ability to do their job.

Every patient responds to pain differently, and it is important to evaluate patients’ mindsets regarding theirs. A patient may be in severe pain and may try to ignore it for a variety of reasons. A patient may “catastrophize” their pain, believing only the worst outcome will happen to them. Helping patients set appropriate expectations and having a positive mindset can help.

Overall, the new recommendations are a great tool as a guideline, but they are not complete enough to be the only ones used in managing acute, non–low back, musculoskeletal pain in adults.

They are very important for clinicians who may be prescribing opioid medications for patients with this type of pain. Amid an opioid crisis, it is the responsibility of every doctor to prescribe these medications appropriately. The evidence clearly shows they provide little benefit and place patients at risk of addiction.

We should all be following these recommendations as the baseline of care for acute pain. However, we need to delve deeper and manage all the components involved. We would be ignoring very real suffering in our patients if we limited our focus to only the physical discomfort.
 

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Rutgers RWJ Medical School.

SOURCE: Ann Intern Med. 2020 Aug 18. doi: 10.7326/M19-3602.

The American College of Physicians and the American Academy of Family Physicians recently authored a guideline regarding the treatment of acute, non–low back, musculoskeletal injuries in adults in the outpatient setting. While their recommendations mirror what most clinicians currently do in their medical practices, they don’t address the multiple components of pain that include sensory, emotional, cognitive, and behavioral processes in addition to the physical discomfort.

According to the authors, musculoskeletal injuries result in more than 65 million medical visits a year with an annual estimated cost of $176.1 billion in 2010.

In summary, the guideline, which was published in the Annals of Internal Medicine, is based on a review of the best available evidence. The research reviewed by the guideline authors showed favorable results with topical NSAIDs, oral NSAIDs, oral acetaminophen, acupressure, and transcutaneous electrical nerve stimulation in reducing pain and/or improving function. The guideline authors “recommend that clinicians treat patients with acute pain from non–low back, musculoskeletal injuries with topical [NSAIDs] with or without gel as first-line therapy to reduce or relieve symptoms, including pain; improve physical function; and improve the patient’s treatment satisfaction (Grade: strong recommendation; moderate-certainty evidence).” Additionally, the guideline recommends against treating acute pain from non–low back, musculoskeletal injuries with opioids, including tramadol (Grade: conditional recommendation; low-certainty evidence).

The guideline also mentions improving function in relation to decreasing pain, which can be multifactorial.

Treating pain requires a multipronged approach. Many patients require more than one therapy to treat their pain, such as NSAIDs plus physical therapy. The ACP and AAFP did not make any recommendations for combination therapies in this guideline.

When physical therapy is needed

Nonopioid pain medications can do a great job of reducing a patient’s physical discomfort, which the evidence for these guideline demonstrates. However, much of the dysfunction caused by musculoskeletal injuries will not improve by reducing the pain alone. Physical therapy, exercise, and mobilization did not show a significant benefit in reducing symptoms in the systematic review and meta-analysis of randomized trials that appeared alongside the guideline. The type of pain, however, was not evaluated in relation to the effectiveness of these treatments. A fractured bone, for example, may heal just fine with casting and pain management, without the need for additional therapies. However, the muscles surrounding that bone can atrophy and become weak from not being used. Physical therapy may be needed to restrengthen those muscles. Therefore, a multifaceted approach is often needed, even for uncomplicated conditions.

Mental pain often comes with physical pain, and this is an aspect of care that is often neglected. It can be quite devastating for patients to not be able to do the things they were previously able to do. While this is easily recognized in professional athletes when they can no longer play, it is not so readily apparent with a mother who is just trying to take care of her kids. As doctors, especially those of us in family medicine, we should be addressing more than just physical pain.

Patients can also do activities that exacerbate their pain. As doctors, we need to be asking questions that help us determine whether a patient’s pain is caused by a particular action. Maybe that increase in shoulder pain is due to nothing more than lifting something heavy rather than a failure in a prescribed medication. Pain diaries are helpful, and clinicians don’t use them often enough.
 

How pain affects mental health

Acute injuries can also lead to disability. Many patients become quite distressed about being unable to work. They often need Famiy & Medical Leave Act forms filled out, and this task usually falls to the primary care doctor. In addition to assessing the pain, we need to be evaluating, at each visit, a patient’s level of functioning and their ability to do their job.

Every patient responds to pain differently, and it is important to evaluate patients’ mindsets regarding theirs. A patient may be in severe pain and may try to ignore it for a variety of reasons. A patient may “catastrophize” their pain, believing only the worst outcome will happen to them. Helping patients set appropriate expectations and having a positive mindset can help.

Overall, the new recommendations are a great tool as a guideline, but they are not complete enough to be the only ones used in managing acute, non–low back, musculoskeletal pain in adults.

They are very important for clinicians who may be prescribing opioid medications for patients with this type of pain. Amid an opioid crisis, it is the responsibility of every doctor to prescribe these medications appropriately. The evidence clearly shows they provide little benefit and place patients at risk of addiction.

We should all be following these recommendations as the baseline of care for acute pain. However, we need to delve deeper and manage all the components involved. We would be ignoring very real suffering in our patients if we limited our focus to only the physical discomfort.
 

Dr. Girgis practices family medicine in South River, N.J., and is a clinical assistant professor of family medicine at Rutgers RWJ Medical School.

SOURCE: Ann Intern Med. 2020 Aug 18. doi: 10.7326/M19-3602.

The more patients with type 2 diabetes exercise, the greater their drop in A1c, according to a new post hoc analysis of data collected during 6 months of supervised exercise.

This “dose-response” relationship between exercise and reductions in A1c held firm for those who did aerobic training or a mixture of aerobic and resistance exercises (combined), but not for those who did only resistance exercises, say Ronald J. Sigal, MD, and colleagues in their article published in the September issue of Medicine & Science in Sports & Exercise.

The findings “suggest that an increased volume of aerobic or combined aerobic and resistance exercise is associated with greater improvement in glycemic control,” say Dr. Sigal, a professor in the division of endocrinology and metabolism at the University of Calgary (Alta.) and colleagues.

In addition, the results “support aerobic and combined exercise prescriptions outlined in clinical practice guidelines … such as those published by the American Diabetes Association (Diabetes Care. 2016;39:2065-79),” they note.

Dr. Sigal was also a coauthor of the ADA position statement on exercise, physical activity, and diabetes.
 

Those who exercised the most saw biggest drop in A1c

In the new report, Dr. Sigal and coauthors note they are “unaware of previous studies exploring the relationship between adherence to prescribed exercise and change in glycemic control in patients with type 2 diabetes.”

The analysis used data collected from the DARE (Diabetes Aerobic and Resistance Exercise) trial, which randomized 251 patients with type 2 diabetes to a 6-month supervised exercise program or their usual habits (the latter were used as sedentary controls). The original DARE results showed that each of the three tested modes of supervised exercise – exclusively aerobic, exclusively resistance training, or a combination of both – resulted in a significant drop in average A1c level, compared with controls (Ann Int Med. 2007;147:357-69).  

This original study did not subdivide patients in the intervention groups by level of adherence to their exercise prescription.

The new analysis focused on the 185 patients randomized to one of the three exercise arms and tracked adherence by both self-recorded logs from patients and reports from the trainers who ran the exercise sessions.

The patients were an average of 54 years old, and slightly more than a third were women. Median A1c at baseline was about 7.7%. Median overall adherence to their exercise regimen was about 86% and was roughly similar in the three exercise subgroups.

The exercise prescription consisted of a 60-minute session (including warm-up and cool-down) three times weekly.

Those who did the most exercise saw the biggest improvements in A1c: a 20% increase in adherence (which correlated with an additional two sessions per month) was associated with a 0.15% decrease in A1c (P = .021)

When analyzed by type of exercise, both the subgroup that performed aerobic exercise only and the subgroup that did both aerobic and resistance exercise showed significant correlations with reductions in A1c. There was no significant association with A1c for the patients who did only resistance training.

Further subgroup analyses showed that significant relationships between exercise adherence and reduced glycemia were seen in only patients younger than 55 years old, men, and those with a baseline A1c ≥ 7.5%.

The researchers caution that the low number of patients in their analysis limits the statistical power and thereby interpretation of the findings, as does the post-hoc nature of the analysis.

DARE received no commercial funding. The authors have reported no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

The more patients with type 2 diabetes exercise, the greater their drop in A1c, according to a new post hoc analysis of data collected during 6 months of supervised exercise.

This “dose-response” relationship between exercise and reductions in A1c held firm for those who did aerobic training or a mixture of aerobic and resistance exercises (combined), but not for those who did only resistance exercises, say Ronald J. Sigal, MD, and colleagues in their article published in the September issue of Medicine & Science in Sports & Exercise.

The findings “suggest that an increased volume of aerobic or combined aerobic and resistance exercise is associated with greater improvement in glycemic control,” say Dr. Sigal, a professor in the division of endocrinology and metabolism at the University of Calgary (Alta.) and colleagues.

In addition, the results “support aerobic and combined exercise prescriptions outlined in clinical practice guidelines … such as those published by the American Diabetes Association (Diabetes Care. 2016;39:2065-79),” they note.

Dr. Sigal was also a coauthor of the ADA position statement on exercise, physical activity, and diabetes.
 

Those who exercised the most saw biggest drop in A1c

In the new report, Dr. Sigal and coauthors note they are “unaware of previous studies exploring the relationship between adherence to prescribed exercise and change in glycemic control in patients with type 2 diabetes.”

The analysis used data collected from the DARE (Diabetes Aerobic and Resistance Exercise) trial, which randomized 251 patients with type 2 diabetes to a 6-month supervised exercise program or their usual habits (the latter were used as sedentary controls). The original DARE results showed that each of the three tested modes of supervised exercise – exclusively aerobic, exclusively resistance training, or a combination of both – resulted in a significant drop in average A1c level, compared with controls (Ann Int Med. 2007;147:357-69).  

This original study did not subdivide patients in the intervention groups by level of adherence to their exercise prescription.

The new analysis focused on the 185 patients randomized to one of the three exercise arms and tracked adherence by both self-recorded logs from patients and reports from the trainers who ran the exercise sessions.

The patients were an average of 54 years old, and slightly more than a third were women. Median A1c at baseline was about 7.7%. Median overall adherence to their exercise regimen was about 86% and was roughly similar in the three exercise subgroups.

The exercise prescription consisted of a 60-minute session (including warm-up and cool-down) three times weekly.

Those who did the most exercise saw the biggest improvements in A1c: a 20% increase in adherence (which correlated with an additional two sessions per month) was associated with a 0.15% decrease in A1c (P = .021)

When analyzed by type of exercise, both the subgroup that performed aerobic exercise only and the subgroup that did both aerobic and resistance exercise showed significant correlations with reductions in A1c. There was no significant association with A1c for the patients who did only resistance training.

Further subgroup analyses showed that significant relationships between exercise adherence and reduced glycemia were seen in only patients younger than 55 years old, men, and those with a baseline A1c ≥ 7.5%.

The researchers caution that the low number of patients in their analysis limits the statistical power and thereby interpretation of the findings, as does the post-hoc nature of the analysis.

DARE received no commercial funding. The authors have reported no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

The more patients with type 2 diabetes exercise, the greater their drop in A1c, according to a new post hoc analysis of data collected during 6 months of supervised exercise.

This “dose-response” relationship between exercise and reductions in A1c held firm for those who did aerobic training or a mixture of aerobic and resistance exercises (combined), but not for those who did only resistance exercises, say Ronald J. Sigal, MD, and colleagues in their article published in the September issue of Medicine & Science in Sports & Exercise.

The findings “suggest that an increased volume of aerobic or combined aerobic and resistance exercise is associated with greater improvement in glycemic control,” say Dr. Sigal, a professor in the division of endocrinology and metabolism at the University of Calgary (Alta.) and colleagues.

In addition, the results “support aerobic and combined exercise prescriptions outlined in clinical practice guidelines … such as those published by the American Diabetes Association (Diabetes Care. 2016;39:2065-79),” they note.

Dr. Sigal was also a coauthor of the ADA position statement on exercise, physical activity, and diabetes.
 

Those who exercised the most saw biggest drop in A1c

In the new report, Dr. Sigal and coauthors note they are “unaware of previous studies exploring the relationship between adherence to prescribed exercise and change in glycemic control in patients with type 2 diabetes.”

The analysis used data collected from the DARE (Diabetes Aerobic and Resistance Exercise) trial, which randomized 251 patients with type 2 diabetes to a 6-month supervised exercise program or their usual habits (the latter were used as sedentary controls). The original DARE results showed that each of the three tested modes of supervised exercise – exclusively aerobic, exclusively resistance training, or a combination of both – resulted in a significant drop in average A1c level, compared with controls (Ann Int Med. 2007;147:357-69).  

This original study did not subdivide patients in the intervention groups by level of adherence to their exercise prescription.

The new analysis focused on the 185 patients randomized to one of the three exercise arms and tracked adherence by both self-recorded logs from patients and reports from the trainers who ran the exercise sessions.

The patients were an average of 54 years old, and slightly more than a third were women. Median A1c at baseline was about 7.7%. Median overall adherence to their exercise regimen was about 86% and was roughly similar in the three exercise subgroups.

The exercise prescription consisted of a 60-minute session (including warm-up and cool-down) three times weekly.

Those who did the most exercise saw the biggest improvements in A1c: a 20% increase in adherence (which correlated with an additional two sessions per month) was associated with a 0.15% decrease in A1c (P = .021)

When analyzed by type of exercise, both the subgroup that performed aerobic exercise only and the subgroup that did both aerobic and resistance exercise showed significant correlations with reductions in A1c. There was no significant association with A1c for the patients who did only resistance training.

Further subgroup analyses showed that significant relationships between exercise adherence and reduced glycemia were seen in only patients younger than 55 years old, men, and those with a baseline A1c ≥ 7.5%.

The researchers caution that the low number of patients in their analysis limits the statistical power and thereby interpretation of the findings, as does the post-hoc nature of the analysis.

DARE received no commercial funding. The authors have reported no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

Key clinical point: Early and continuous ocrelizumab treatment can provide sustained benefit on clinical and magnetic resonance imaging measures for disease progression in patients with relapsing multiple sclerosis (MS).

Major finding: At 5 years, the cumulative proportion of patients with 24-week confirmed disability progression was lower among those who continued ocrelizumab vs those who switched from interferon (IFN) β-1a to ocrelizumab (16.1% vs 21.3%; P = .014). Similarly, brain atrophy was significantly lower among those who continued ocrelizumab than in those who switched to ocrelizumab (P less than .01).

Study details: The OPERA open label extension study evaluated long-term efficacy and safety (5 years follow-up) of ocrelizumab (600 mg) in adults with relapsing MS. Patients previously assigned to INF β-1a  (n = 829) and ocrelizumab (n = 827) entered the open-label extension phase in this study, of which 623 switched to ocrelizumab and 702 continued ocrelizumab, respectively

Disclosures: This study was supported by F. Hoffmann-La Roche Ltd, Basel, Switzerland. The lead author reporting receiving travel reimbursement and writing assistance from F. Hoffmann-La Roche Ltd for CD20-related meetings and presentations. Some of his coinvestigators reported owning stock in, being an employee of, receiving support from, and/or serving on scientific advisory board for F. Hoffmann-La Roche Ltd.

Citation: Hauser SL et al. Neurology. 2020 Jul 20. doi: 10.1212/WNL.0000000000010376.

Key clinical point: Early and continuous ocrelizumab treatment can provide sustained benefit on clinical and magnetic resonance imaging measures for disease progression in patients with relapsing multiple sclerosis (MS).

Major finding: At 5 years, the cumulative proportion of patients with 24-week confirmed disability progression was lower among those who continued ocrelizumab vs those who switched from interferon (IFN) β-1a to ocrelizumab (16.1% vs 21.3%; P = .014). Similarly, brain atrophy was significantly lower among those who continued ocrelizumab than in those who switched to ocrelizumab (P less than .01).

Study details: The OPERA open label extension study evaluated long-term efficacy and safety (5 years follow-up) of ocrelizumab (600 mg) in adults with relapsing MS. Patients previously assigned to INF β-1a  (n = 829) and ocrelizumab (n = 827) entered the open-label extension phase in this study, of which 623 switched to ocrelizumab and 702 continued ocrelizumab, respectively

Disclosures: This study was supported by F. Hoffmann-La Roche Ltd, Basel, Switzerland. The lead author reporting receiving travel reimbursement and writing assistance from F. Hoffmann-La Roche Ltd for CD20-related meetings and presentations. Some of his coinvestigators reported owning stock in, being an employee of, receiving support from, and/or serving on scientific advisory board for F. Hoffmann-La Roche Ltd.

Citation: Hauser SL et al. Neurology. 2020 Jul 20. doi: 10.1212/WNL.0000000000010376.

Key clinical point: Early and continuous ocrelizumab treatment can provide sustained benefit on clinical and magnetic resonance imaging measures for disease progression in patients with relapsing multiple sclerosis (MS).

Major finding: At 5 years, the cumulative proportion of patients with 24-week confirmed disability progression was lower among those who continued ocrelizumab vs those who switched from interferon (IFN) β-1a to ocrelizumab (16.1% vs 21.3%; P = .014). Similarly, brain atrophy was significantly lower among those who continued ocrelizumab than in those who switched to ocrelizumab (P less than .01).

Study details: The OPERA open label extension study evaluated long-term efficacy and safety (5 years follow-up) of ocrelizumab (600 mg) in adults with relapsing MS. Patients previously assigned to INF β-1a  (n = 829) and ocrelizumab (n = 827) entered the open-label extension phase in this study, of which 623 switched to ocrelizumab and 702 continued ocrelizumab, respectively

Disclosures: This study was supported by F. Hoffmann-La Roche Ltd, Basel, Switzerland. The lead author reporting receiving travel reimbursement and writing assistance from F. Hoffmann-La Roche Ltd for CD20-related meetings and presentations. Some of his coinvestigators reported owning stock in, being an employee of, receiving support from, and/or serving on scientific advisory board for F. Hoffmann-La Roche Ltd.

Citation: Hauser SL et al. Neurology. 2020 Jul 20. doi: 10.1212/WNL.0000000000010376.

Key clinical point: Increased high-density lipoprotein cholesterol (HDL-C) is associated with decreased gray matter and cortical atrophy in patients with multiple sclerosis (MS) after adjusting for baseline serum neurofilaments (sNfL).

Major finding: Gray matter volume and cortical volume had significant associations with percent change in HDL-C (P = .0024 and P less than .001, respectively) after adjusting for sNfL as a predictor.

Study details: This prospective longitudinal study assessed patients with relapsing-remitting MS (n = 75) and progressive multiple sclerosis (n = 37) over a 5-year follow-up period.

Disclosures: The study was funded by the National Center for Advancing Translational Sciences of the National Institutes of Health. B Weinstock-Guttman, J Kuhle, R Zivadinov and M Ramanathan reported ties with multiple pharmaceutical companies. The remaining authors declared no conflicts of interest.

Citation: McComb M et al. Mult Scler Relat Disord. 2020 Jul 11. doi: 10.1016/j.msard.2020.102389.

Key clinical point: Increased high-density lipoprotein cholesterol (HDL-C) is associated with decreased gray matter and cortical atrophy in patients with multiple sclerosis (MS) after adjusting for baseline serum neurofilaments (sNfL).

Major finding: Gray matter volume and cortical volume had significant associations with percent change in HDL-C (P = .0024 and P less than .001, respectively) after adjusting for sNfL as a predictor.

Study details: This prospective longitudinal study assessed patients with relapsing-remitting MS (n = 75) and progressive multiple sclerosis (n = 37) over a 5-year follow-up period.

Disclosures: The study was funded by the National Center for Advancing Translational Sciences of the National Institutes of Health. B Weinstock-Guttman, J Kuhle, R Zivadinov and M Ramanathan reported ties with multiple pharmaceutical companies. The remaining authors declared no conflicts of interest.

Citation: McComb M et al. Mult Scler Relat Disord. 2020 Jul 11. doi: 10.1016/j.msard.2020.102389.

Key clinical point: Increased high-density lipoprotein cholesterol (HDL-C) is associated with decreased gray matter and cortical atrophy in patients with multiple sclerosis (MS) after adjusting for baseline serum neurofilaments (sNfL).

Major finding: Gray matter volume and cortical volume had significant associations with percent change in HDL-C (P = .0024 and P less than .001, respectively) after adjusting for sNfL as a predictor.

Study details: This prospective longitudinal study assessed patients with relapsing-remitting MS (n = 75) and progressive multiple sclerosis (n = 37) over a 5-year follow-up period.

Disclosures: The study was funded by the National Center for Advancing Translational Sciences of the National Institutes of Health. B Weinstock-Guttman, J Kuhle, R Zivadinov and M Ramanathan reported ties with multiple pharmaceutical companies. The remaining authors declared no conflicts of interest.

Citation: McComb M et al. Mult Scler Relat Disord. 2020 Jul 11. doi: 10.1016/j.msard.2020.102389.