Psoriatic Arthritis List NEWSLETTER

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News & Views Newletter
edited by Jack Nicholas, cornishpro@aol.com

PSORIATIC ARTHRITIS NEWS AND VIEWS
VOL. 3 ISSUE 23 December 30, 2003
PSORIATIC ARTHRITIS MEDICAL NEWS

DO YOU REALLY KNOW YOUR HEALTH RISK? ODDS ARE YOU DON'T--AND NEITHER MAY YOUR DOCTOR by Daniel DeNoon - WebMD Medical News Reviewed By Michael Smith, MD

Your life depends on knowing your health risks. Yet a new study shows few people -- and surprisingly few doctors -- really understand risk.

It's not that the math is too hard. The problem is that the way doctors talk about risk clouds people's minds, says Gerd Gigerenzer, PhD, director of the Center for Adaptive Behavior and Cognition at the Max Planck Institute for Human Development, Berlin.

"Risk is often expressed in ways that cloud patients' minds," Gigerenzer tells WebMD. "It clouds the mind so that patients don't even notice they don't understand their true risks."

Gigerenzer is one of several scientists whose reports on health-risk communication appear in the Sept. 27 issue of The British Medical Journal. Their consensus: Doctors aren't doing a very good job of explaining health risks to patients.

True, lots of people are mathematically illiterate -- innumerate, as Gigerenzer puts it. But that's no excuse, he says. Just being bad at math doesn't mean you can't understand risk.

"It is not a problem with people's minds," Gigerenzer says. "The key problem is with how information is presented. The problem is in the form, not the content."

What's My Health Risk?
Let's say taking a certain pill will cut your risk of X disease by 50%. Half the risk! That sounds great. Give me that pill!

But what if only two out of every million people get disease X? Halving your risk to one in a million doesn't sound nearly as good. And if the pill has side effects, it might do more harm than good. So should you take the pill? You might, depending on how scared you are of disease X -- and how you feel about risking side effects. Your choice -- even having a choice -- depends on all this information, not just on the "cuts risk by 50%" figure.

Most doctors wouldn't be fooled by this example. But here's one that few doctors get right. The scenario looks like this: Suppose the risk of colon cancer is 0.3% A test detects colon cancer in 50% of people who have the disease 3% of the time, the test says a person has colon cancer when he doesn't

What is the chance that someone who tests positive actually has colon cancer?

Doctors are supposed to know this stuff. But more than half of them were way off, guessing 50%. The correct answer is about 5%. Answers ranged from 1% to 90%.

"Doctors don't get the right training for communicating health risk," Gigerenzer says. "Many young people interested in science study medicine because they want to avoid statistics and psychology. And even if they get statistical training, they get it in a form they do not truly understand or easily forget."

That's true, says John Paling, PhD, research director at Risk Communication Institute, Gainesville, Fla.

"Risks in every other profession are recognized as so difficult to communicate that they use specially trained people to explain them," Paling tells WebMD. "Every doctor has to do health-risk communication and none are trained."

That's scary. It means most of us base important life decisions on our gut feelings. Once upon a time, that may not have been a bad idea. But in today's technology-driven world, feelings dangerously deceive.

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GALLUP: CANCER, INFECTIONS CAUSE WORRY Cancer, Heart Disease Most Worrisome Health Problems- By Jeanie Lerche Davis WebMD Medical News Reviewed By Brunilda Nazario, MD

Cancer, heart disease, and heart attack are health problems that worry many more Americans than AIDS, a new Gallup poll says.

The telephone survey of 1,000 American adults -- conducted early last month -- gives a snapshot of the nation's health worries. It shows:
2 in 3 Americans are not worried at all about getting AIDS. Their greatest concerns are cancer, heart disease, and heart attack. Fewer than half of those surveyed replied that that they were concerned about SARS-like infections and terrorist-spread viruses. There is great concern about the health risks associated with smoking or obesity.

AIDS Feared Least; Cancer Most In the survey, each adult was asked to rate their level of concern about personally experiencing each of 14 different diseases or health problems.

The majority (63%) was "very" or "somewhat concerned" about cancer; 55% worry about heart disease or heart attack. Arthritis, stroke, high blood pressure, vision loss, and diabetes were just a few points lower, with at least 4 in 10 people saying they were "somewhat" or "very" concerned.

Fear of Alzheimer's disease was a bit lower, with 37% of Americans expressing worry. Hearing loss topped the list for 35% adults; 34% were most concerned about influenza. Just 16% of those polled worry about AIDS and 18% are concerned about Lyme disease, Parkinson's disease, and emphysema.

Deadly infections were also a big concern: getting a SARS-like virus concerns 45% of adults; infectious disease such as smallpox, which could be spread by terrorists, worries 46% of adults.

Older Americans' Concerns
Adults over age 50 showed concern for several age-related health problems:
42% fear Alzheimer's disease
48% are concerned about stroke

Whereas younger Americans under the age of 50 worried about getting these health related problems:
44% worry about diabetes compared with 32% of those over the age of 50, and 26% of those over the age of 65.
46% worry about high blood pressure compared with 34% of those over the age of 50.
Worry about AIDS decreased with age: 28% of under-30 adults were concerned; that slipped to 7% in the over-50 group.

Cancer worried older Americans less, especially those age 65 and older, the poll also showed.

Smokers, Overweight Americans Realize Risks
Smoking and obesity are linked to a number of deadly health problems -- and many people in the poll who were most at risk appear to worry most about that.

Among Americans who describe themselves as overweight, 62% are substantially more concerned about heart disease; 47% are very concerned about high blood pressure; 45% are concerned about diabetes.

However, smokers are more inclined to worry about their health problems especially cancer: 66% showed concern about cancer, while 61% of nonsmokers did;

62% of smokers compared with 52% of nonsmokers worried about heart disease. Smokers do worry more about emphysema -- five times more than nonsmokers, the poll showed.

SOURCE: Gallup News Service.

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GET A NEW HIP, WALK HOME THAT DAY

New Technique Turns Hip Replacement Surgery Into Outpatient Procedure By Sid Kirchheimer WebMD Medical News

Hip replacement surgery has allowed millions of Americans crippled with arthritis to once again walk pain-free -- but traditionally, only after weeks or

months of recovery. But a new technique is helping to transform this popular surgery into an outpatient procedure -- and allowing most patients to recover fully much sooner.

With this technique, first performed in February 2001, nearly 90% of patients leave the hospital the day of or day after their hip replacement surgery, instead of the traditional weeklong stay. The technique is also proving to be virtually pain-free in many patients and results in less surgery blood loss and less chance of post-operation blood clots. It also reduces or eliminates months of grueling rehabilitation therapy and is proving to drastically cut the risk of later chance of limping.

Go Home the Same Day
"Virtually all of my patients now go home the same day of their surgery," says Chicago orthopedic surgeon Richard A. Berger, MD, who pioneered the procedure and has since performed it on more than 200 patients. "Most are walking with no support at all within a week of surgery, rather than the several months it takes with traditional surgery. For them, it's proven to be better and safer than the traditional method."

The reason: The Zimmer Minimally Invasive Solutions 2-Incision technique allows surgeons to install the same artificial hip joint through two small incisions -- each no more than 2 inches long -- rather than the traditional single incision between 4 and 12 inches long.

By doing this with new smaller surgical instruments designed by Berger, an MIT-trained mechanical engineer-turned-surgeon, those who perform hip replacement surgery can now operate between muscles, tendons, and ligaments rather than cutting through these soft tissues.

About 90% of pain resulting from hip replacement surgery -- done on some 250,000 Americans a year -- results from cutting through this tissue, Berger tells WebMD.

He and three other pioneers of the procedure -- named after Zimmer Inc., the company that manufactures the smaller surgical instruments -- document outcomes in 375 patients who have had this new procedure since Berger first performed it nearly three years ago at Rush Presbyterian-St. Luke's Medical Center in Chicago. Their findings appear in the November issue of the Journal of Bone and Joint Surgery.

At least 80% of those patients getting the Zimmer procedure left the hospital within 24 hours of their hip replacement surgery. In order to be discharged, patients must demonstrate an ability to walk and climb stairs by themselves or with crutches or a cane, and require less potent oral pain medication.

A second study, not yet published, on other patients studied since that first group indicates the outpatient rate is now approaching 90% or better, says Berger.

None of the patients studied in the published research had any complications or needed to be readmitted for additional surgery, meaning their artificial joint remained fully attached. With the traditional surgery, a small number of patients have these postoperative problems.

Berger says many of his patients require no medication for postoperative pain. And since their scars are smaller, they heal faster and lose less blood in surgery.

Two Incisions, Smaller Instruments
With traditional hip replacement surgery, a large incision cutting into tissue is needed for surgeons to see and maneuver the artificial hip joint into place. But with the new technique, the two small incisions allow the surgeon to view the bone area from two different angles, and the smaller instruments allow for maneuverability in the smaller space.

The new procedure also doesn't require surgeons to twist the leg as was traditionally done, so veins aren't "kinked" -- raising risk of a post-op blood clot, says Berger. "So far, not a single patient I operated on has developed a blood clot," he tells WebMD. "By comparison, 3 to 5 percent of those getting traditional hip replacement do."

Others are equally impressed with the Zimmer procedure, which is also being developed for knee replacement surgery.

"With the smaller instruments in the hands of specially trained surgeons, this offers numerous benefits to everyone," says Dana C. Mears, MD, PhD, of the University of Pittsburgh Medical Center. He also contributed to the newly published report and first conceived the concept of a two-incision surgical technique for hip replacement procedures about 10 years ago.

"The patient has a faster recovery and less pain, if any," Mears tells WebMD. "The hospital can release patients sooner. And since months of the rehabilitation process can cost $20,000 or more per patient, and many getting hip replacement surgery are on Medicare, by reducing that rehabilitation to days or eliminating it altogether, the health-care system can save billions of dollars a year."

Another first with the Zimmer procedure: X-rays are used during, rather than following, hip replacement surgery to ensure the artificial joint is properly aligned and installed.

While Berger and Mears are among the first surgeons to do the Zimmer procedure, it's now performed by some 300 orthopaedic surgeons in the U.S., who receive special training by Zimmer Inc. and must be specially licensed to use the smaller instruments.

Not for Everyone
"This procedure is technically more demanding for the surgeon, but patients have less pain and can get back to their normal functions and everyday activities much sooner," says surgeon Donald M. Kastenbaum, MD, assistant chairman of orthopaedic surgery at Beth Israel Medical Center in New York City. "I don't want to call it better than traditional hip replacement surgery, but it's certainly a better procedure for certain patients. Anytime a patient can return to work or their regular activities sooner, it's a good thing."

Generally, the procedure is not recommended for severely overweight or overly muscular patients, says Kastenbaum, who has performed the Zimmer hip replacement surgery technique since August but was not involved in the published study.

"I did my first Zimmer procedure two weeks ago and I'm thrilled with it," says Michael C. Racklewicz, MD, an orthopaedic surgeon in Wilkes-Barre, Pa. "For me, the biggest advantage is not only that there's less pain involved for the patient, but there is less tissue trauma. My patient was able to walk with a cane immediately following the surgery, and with no limp at all.

"It will be years before we really know the long-term outcomes," Racklewicz tells WebMD. "But from what I know and have personally seen so far, this new method is really something."

SOURCES: Berger, R. The Journal of Bone and Joint Surgery, November 1, 2003; vol 85: pp 2235-2246.
Richard A. Berger, MD, assistant professor of orthopaedic surgery, Rush Presbyterian-St. Luke's Medical Center, Chicago.
Dana C. Mears, MD, PhD, attending orthopaedic surgeon, University of Pittsburgh Medical Center/Shadyside Hospital, Pittsburgh.
Donald M. Kastenbaum, MD, assistant chairman of orthopaedic surgery, Beth Israel Medical Center, New York City.
Michael C. Racklewicz, MD, Orthopedic Consultants of Wyoming Valley, Wilkes-Barre, Pa. © 2003 WebMD Inc.

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HITTING THE GREENS CAN HURT YOUR HIPS
Shoulders, elbows and wrists not only vulnerable joints in golfers (HealthDayNews)

Golfers usually consider their shoulders, elbows and wrists their most vulnerable joints.

Well, they can add hips to that list, says a University of Pittsburgh Medical Center (UPMC) study.

Hip injuries in golfers often involve injury to the labrum cartilage, a condition that's often diagnosed as arthritis or muscle strain.

"The ability to detect labral injuries using magnetic resonance imaging (MRI) has increased significantly in the last 10 years. At the same time, arthroscopic interventions have been developed to treat these injuries without subjecting the patient to major surgery," study author Dr. Derek R. Armfield, an assistant professor in UPMC's division of musculoskeletal radiology, says in a prepared statement.

He and his colleagues used MRI to examine eight professional golfers with hip pain. Along with the MRI, the golfers had a physical exam and subsequent arthroscopy.

The MRI detected injuries to each golfer's labrum, which is the ligament-like cartilage that contains nerves and lines the socket of the hip. The injuries included labral tears and detachments.

It's believed tears in the labrum can damage adjacent cartilage and may lead to arthritis. All the golfers in the study were successfully treated with arthroscopic surgery.

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SHOCK THERAPY FOR ROTATOR CUFF INJURY
Treatment Dissolves Calcifications, Could Replace Surgery in Some Patients By Jeanie Lerche Davis WebMD Medical News

A new treatment for chronic shoulder pain is showing promise. A new study shows that an ultrasound treatment called "extracorporeal shock wave therapy" can be effective in helping a painful rotator cuff.

The study appears in this week's issue of The Journal of the American Medical Association.

Extracorporeal shock wave therapy involves either applying high-energy or low-energy shock waves to the painful area -- in this case, the rotator cuff.

Specifically, the researchers were testing the ability of the ultrasound treatment to treat calcific tendonitis of the rotator cuff, a common cause of shoulder pain. In this condition, calcium deposits build up on the tendons that connect rotator cuff muscles to the nearby bones.

The shock wave treatment has been shown in other studies to help destroy other types of calcified deposits and could be an alternative to surgery, writes lead researcher Ludger Gerdesmeyer, MD, with Orthopedic Surgery and Sportstraumology at Technical University Munich in Germany.

In their study, researchers treated patients with either high-energy or low-energy shock waves. For comparison, some patients received a placebo treatment during which the same procedure was performed but no shock waves were delivered. All 134 patients had shoulder pain caused by calcific tendonitis of the rotator cuff. The participants received two treatments, each two weeks apart.

Three, six, and 12 months later, the high-energy and low-energy patients all had significant rotator cuff improvement in various areas -- pain reduction, activities of daily living, range of motion, and power -- compared with the placebo group.

Those receiving the placebo treatment also showed improvement, but they required more medication and were more likely to need surgery than patients that received either dose of the shock wave therapy.

The group getting high-energy therapy to the rotator cuff got significantly better results than the low-energy group.

The researchers suggest that if further studies duplicate the beneficial results seen in this study, treatment with shock wave therapy could one day replace surgery in some patients.

SOURCE: Gerdesmeyer, L. The Journal of the American Medical Association

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PRESCRIPTION DRUG PRICE COMPARISONS - U.S. AND CANADA
The Associated Press checked the prices of 10 of the most popular prescription drugs on Web sites maintained by U.S. and Canadian companies.

CanadaRx, a Toronto-based company, mails drugs to U.S. residents. The American Web sites belong to CVS Corp. and Walgreen Co. Fosamax, for osteoporosis, cost $46 for 30 10-milligram tablets at CanadaRx and $69 at Walgreens.com. Lipitor, to reduce cholesterol, cost $132 for 90 10-milligram tablets at CanadaRx and $208 at CVS.com. Neurontin, an anti-seizure medication, was $36.68 for 100 100-milligram capsules at CanadaRx and $58 at Walgreens.com. Nexium, for heartburn and ulcers, cost $51.37 for 28 20-milligram capsules at CanadaRx and $120 for 30 capsules at Walgreens.com. Paxil, an anti-depressant, cost $40.80 for 30 10-milligram tablets at CanadaRx and $81 at Walgreens.com. Prevacid, for heartburn, cost $53.18 for 30 15-milligram capsules at CanadaRx and $126 at Walgreens.com. Risperdal, an anti-psychotic, cost $39.16 for 60 half-milligram tablets at CanadaRx and $199 at CVS.com. Vioxx, an arthritis drug, cost $36.17 for 30 12.5-milligram tablets at CanadaRx and $86 at Walgreens.com. Zocor, a cholesterol-lowering drug, cost $46.65 for 30 10-milligram tablets at CanadaRx and $66 at Walgreens.com. Zyprexa, an anti-psychotic, cost $176.91 for 60 5-milligram tablets at CanadaRx and $380 at CVS.com.

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MEDICAL JOURNAL QUESTIONS HERBAL REMEDIES CHICAGO (Reuters)

The editor of a leading U.S. medical journal called on Tuesday for tighter regulation of herbal remedies because of "potentially misleading" health claims made by distributors of the products.

"Because many dietary supplements have or promote biological activity, they must be considered active drugs and regulated as such," wrote Dr. Catherine DeAngelis, editor of the Journal of the American Medical Association.

Classified since 1994 by federal regulators as untested dietary supplements, U.S. sales of such popular herbal remedies such as ginkgo biloba, St. John's wort, echinacea, ginseng, garlic, saw palmetto and kava have risen nearly fivefold in the past decade to $18 billion in 2001, a study appearing in the same journal said.

Researchers Charles Morris and Jerry Avorn of Boston's Brigham and Women's Hospital analyzed hundreds of Web sites pertaining to health-related uses of herbal products. After linking to vendors' sites, they found four out of five made one or more health claims and half of those omitted the standard Food and Drug Administration disclaimer the product "is not intended to diagnose, treat, cure, or prevent any disease."

"The study ... provides evidence for the easily accessible and widespread potentially misleading claims made by vendors of herbal products on the Internet," DeAngelis wrote in her editorial.

Another study in the journal found that St. John's wort, taken to treat depression, sped up the elimination from the body of a common class of pharmaceutical drugs.

"These findings underscore the potential inherent problems associated with the widespread practice of using herbal products (at the same time) with conventional medications," wrote John Markowitz from the Medical University of South Carolina, in Charleston.

Herbal remedies have also come under scrutiny recently because of deaths linked to high-profile athletes' use of the herbal stimulant ephedra.

The editorial said the solution was greater regulation, although that would increase the FDA's workload. "The U.S. public deserves to have the funding and resources allocated for their protection," DeAngelis wrote. Copyright © 2003 Reuters Limited.

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TOP 10 ARTHRITIS ADVANCES OF 2003
Better Testing and Treatments Improve Outlook for People With Arthritis By Jennifer Warner - WebMD Medical News Reviewed By Brunilda Nazario, MD

Routine genetic testing may soon not only identify people at risk for potentially debilitating diseases like rheumatoid arthritis, but it might also predict the severity of the disease and help guide treatment.

Researchers say advances in the detection and treatment of some of the most common and devastating forms of arthritis are among the highlights of the past year, according to the Arthritis Foundation's Top 10 Research Advances of 2003.

It's the first time the group has compiled a year-end list to highlight the most significant advances in arthritis research, and experts say the list should offer hope to the millions of people with the disease.

"We're living in a time in which the time between when research advances are made and when people actually benefit from those advances is becoming much, much shorter," says John H. Klippel, MD, president and CEO of the Arthritis Foundation, in a teleconference today. "All of these represent major advances and all should substantially improve the health care for people with arthritis."

Klippel says the top 10 arthritis advances of 2003 offer a glimpse into the future of arthritis testing and treatment. In no particular order, those advances are as follows:
Protein found to be marker of rheumatoid arthritis years before symptoms appear. Researchers found that levels of antibodies known, as "anti-CCP" are higher in people with RA than healthy people. Blood tests that screen for these antibodies can diagnose people with rheumatoid arthritis years before symptoms emerge, which could prevent future joint damage. Klippel likens the discovery of this marker for RA to the PSA marker used in screening for prostate cancer. "It appears this antibody shows up in blood tests years before symptoms and joint damage occur," says Klippel. Synthetic hormones prevent bone loss without raising risk of cancer. The hunt for alternatives to menopausal hormone therapy for the treatment of osteoporosis intensified after concerns emerged in 2002 about Premarin's link to breast cancer. In 2003, researchers found that the synthetic hormone estren can prevent bone loss like conventional menopausal hormone therapy without the additional cancer risks. Researchers also believe that an entire class of synthetic chemical compounds called ANGELS (activators of non-genomic estrogen-like signaling), under which estren falls, may have potential bone benefits without the cancer-causing side effects of their natural counterparts. Many people with arthritis also develop osteoporosis, and some treatments for arthritis, such as corticosteroids, increase the risk of the bone-thinning disease. Sturdier joint replacements challenge long-held belief of surgery as a last resort treatment. Doctors have traditionally been hesitant to recommend joint replacement surgery to younger patients because the artificial joints wear out over time and require repeat surgeries. But last year, researchers demonstrated the durability of new wear-resistant joint replacement materials, such as prepared polyethylenes and newly FDA-approved metal and ceramic surfaces. These improvements may allow many more people, especially baby boomers, to benefit from joint replacement surgery. Lupus gene patterns activated by interferon identified in adults and children.

In 2003, researchers found evidence that a virus-fighting protein called interferon plays a key role in lupus. This may open the door to new treatments that target interferon as well as allow doctors to more accurately diagnose the disease at earlier stages. First FDA-approved oral scleroderma drug reverses life-threatening complications. Scleroderma is one of the most serious autoimmune disorders and affects about 250,000 Americans. In scleroderma, the skin gradually tightens and thickens or hardens. Tiny blood vessels throughout the body also may be affected, causing widespread damage to the internal organs. A common cause of death among people with scleroderma is lung failure caused by a lung disorder called pulmonary arterial hypertension (PAH). In the past, researchers thought that blood vessel complications caused by scleroderma were irreversible. But recently they discovered that these changes may be reversed with drug treatment. In July 2003,

results of a long-term study using the first FDA-approved oral treatment for PAH, Tracleer, showed that the drug can help people with scleroderma live longer, fuller lives. Clarification of how a genetic defect may lead to childhood arthritis. In 2003, scientists helped to explain how certain gene mutations result in uncontrolled inflammation. This finding shed new light on the role that genetics may play in the development of arthritis in children. It also raises the possibility that mutations in other genes that control inflammation might be important in the development of select childhood rheumatic diseases. Klippel says this discovery may also have broad implications in helping to explain the role of inflammation in other inflammatory diseases and arthritis. Prevention of heart disease complications in rheumatoid arthritis. People with RA have a shorter life span than others, and in 2003 researchers discovered that a major reason is that women with RA are twice as likely to have heart attacks compared with women without RA. At the same time, studies showed treatment with common statin drugs cannot only help reduce the joint inflammation associated with rheumatoid arthritis, but it also helps lower cholesterol levels and prevent heart complications.

MRI allows earlier detection of osteoarthritis and prevention of painful symptoms. Advances in different types of magnetic resonance imaging (MRI) techniques now offer a way to measure subtle changes in the quantity of cartilage in people with osteoarthritis. In 2003, researchers showed MRIs can accurately assess the changes in cartilage volume, as well as detect osteoarthritis before symptoms emerge, which may lead to better treatment for the disease. Individually tailored physical activity programs in people with arthritis. Klippel says that as little as a decade ago exercise was discouraged among people with arthritis. Now, researchers know that the right kind of exercise not only helps prevent arthritis but also improves symptoms in people with existing disease. In 2003, the first international conference determined exercise guidelines for arthritis patients to help overcome barriers to physical activity.

Disparities in joint replacement surgery revealed. Recent research found that African Americans and Hispanics are recommended for and receive joint replacement surgery at about two-thirds the frequency of whites. This disparity was not explained by differences in geographic characteristics, health status, or economic access.

The list was compiled by the Arthritis Foundation with input from arthritis researchers and clinicians from a variety of disciplines, as well as from the American College of Rheumatology, the American Academy of Orthopaedic Surgeons, the CDC, and the National Institutes of Health.

My wish for each and every one of us is a healthier New Year, with the hope that our skin will be better, the joints won't be as swollen, the pain will be less, and our bodies allow us a day or two of just being normal again.

Good Health to All and Happy New Year

Jack Nicholas
Newsletter Editor
Cornishpro@aol.com
Issue 2003 12/30/03-23