Monthly Archives: November 2017

Workplace Bullying, Violence Tied to T2D Risk

Related depression and anxiety might contribute to diabetes risk

by Jeff Minerd Jeff Minerd, Contributing Writer, MedPage Today November 13, 2017

Action Points

  • Bullying and violence in the workplace were linked with an increased risk for type 2 diabetes.
  • The study suggests that research is warranted on bullying and violence prevention policies with workplaces as the target to determine whether these policies could be effective means of reducing the incidence of type 2 diabetes.

Bullying and violence in the workplace were linked with an increased risk for type 2 diabetes in a large Scandinavian cohort study.

Over approximately 12 years of follow-up, being bullied at work was associated with a 46% increase in risk for developing type 2 diabetes (hazard ratio 1.46, 95% CI 1.23-1.74), after adjusting for factors including age, sex, education level, and marital status, reported Tianwei Xu, a PhD fellow at the University of Copenhagen in Denmark, and colleagues.

Similarly, exposure to workplace violence or threats of violence was linked with a 26% rise in type 2 diabetes risk (HR 1.26, 95% CI 1.02-1.56), the authors wrote online in Diabetologia.

“Recent meta-analyses have suggested that psychosocial work characteristics, such as job insecurity and long working hours, are associated with a moderately higher risk of diabetes, while the health effects of highly adverse social work stressors, such as bullying and violence at work, are far less well documented,” Xu’s group said. “To the best of our knowledge, no previous longitudinal studies have addressed the relationships between workplace bullying and workplace violence and type 2 diabetes.

“In this large multinational, multi-cohort study, approximately one in ten employees reported being exposed to bullying or violence/threats of violence at work,” they noted. “Both men and women who were exposed to these severe social stressors were at a higher risk of developing type 2 diabetes. The higher risk was consistent across cohorts and independent of follow-up length or the method of case ascertainment.”

The study included 45,905 men and women, ages 40-65 ,who did not have diabetes at baseline. The study population was derived from four Scandinavian cohort studies: the Swedish Work Environment Survey (SWES), the Swedish Longitudinal Occupational Survey of Health (SLOSH), the Finnish Public Sector Study (FPS), and the Danish Work Environment Cohort Study (DWECS).

The investigators used questionnaires to assess exposure to workplace bullying, defined as unkind or negative behavior from colleagues, and workplace violence, defined as having been the target of violent actions, or threats of violence, in the previous 12 months. They obtained information on new diabetes diagnoses through national medical records.

Approximately 9% of participants reported bullying at work, and 12% said they had experienced workplace violence. The exposure to violence varied greatly among different occupations. The highest prevalence of violence or threats of violence were found among occupations with frequent client contact, including social workers (46%), personal and protective service workers (29%), healthcare professionals (25%), and teachers (16%).

Bullying and type 2 diabetes risk were significantly associated for both men (HR 1.61, 95% CI 1.24-2.09) and women (HR 1.36, 95% CI 1.06-1.74). There were no differences between men and women for exposure to workplace violence and diabetes risk, the authors reported.

When they adjusted for BMI, the results were attenuated but still significant for bullying (HR 1.37, 95% CI 1.11-1.69) and borderline significant for violence (HR 1.27, 95% CI 0.96-1.70). Xu’s group suggested that obese employees may be more frequent targets of workplace bullying or violence, or that the stress of these conditions might lead to negative emotions and comfort eating behavior.

The depression and anxiety resulting from workplace bullying or violence might contribute to diabetes risk by chronic activation of the hypothalamic-pituitary-adrenal axis and sympathetic nervous system, the authors said, adding that impaired sleep might also increase diabetes risk indirectly.

“Furthermore, stress-related coping strategies, such as comfort eating behavior with an increased preference for energy and nutrient dense foods, may result in weight gain or an increase in waist circumference, which are both pivotal risk factors for diabetes,” they said.

Study limitations included its reliance on self-reporting. It also only measured workplace bullying and violence at baseline and did not assess the effects of these conditions over time, the authors stated.

“Both bullying and violence or threats of violence are common in the workplace. Research on bullying and violence prevention policies with workplaces as the target are warranted to determine whether these policies could be effective means of reducing the incidence of type 2 diabetes,” they said.

The study was funded by NordForsk, the Nordic Research Program on Health and Welfare, the Project on Psychosocial Work Environment and Healthy Ageing, and Danish Working Environment Foundation.

Xu and co-authors disclosed relevant relationships with industry.

  • Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner
  • Primary Source

 

Diabetologia

Source Reference: Xu T, et al “Workplace bullying and violence as risk factors for type 2 diabetes: a multi-cohort study and meta-analysis” Diabetologia 2017; DOI:10.1007/s00125-017-4480-3.

Heart Attack Fells AHA President During Annual Meeting

The AHA reports that he received a stent and is doing well

by Larry Husten, CardioBrief November 13, 2017

ANAHEIM — The president of the American Heart Association, John Warner, MD, 52, had a “mild heart attack” on Monday morning, according to the AHA. Warner received a stent at an undisclosed hospital. The AHA said he is “doing well.”

The attack occurred during the AHA’s annual scientific sessions meeting here. The first indication of problems occurred early today when the AHA announced that Warner would not be available to moderate a press briefing on new hypertension guidelines.

Warner, an interventional cardiologist, has been the CEO of UT Southwestern Hospital in Dallas since 2012. Warner has an MD from Vanderbilt University and a MBA from the University of Tennessee. He completed his residency training in internal medicine at UT Southwestern and his cardiology fellowship at Duke University.

AHA: 130/80 mm Hg Is New National BP Target

Multisociety guidelines released accounting for SPRINT data

by Crystal Phend Crystal Phend, Senior Associate Editor, MedPage Today November 13, 2017

This article is a collaboration between MedPage Today® and: American College of Cardiology

ANAHEIM — After years of contention among professional societies over raising blood pressure targets, national guidelines have reduced the goal from 140/90 mm Hg to 130/80 mm Hg for the general population, including community-dwelling seniors.

The American Heart Association and American College of Cardiology, which took over from the NHLBI’s Joint National Commission in 2013, released the 2017 guideline with endorsement from nine other groups with key changes to the threshold and treatment algorithm.

BP Classifications

Normal blood pressure remains below 120 mm Hg, but hypertension has been split into stage 1 (130/80 to 139/89 mm Hg) and stage 2 (140/90 mm Hg and higher) with different implications for treatment.

With the new target, the overall prevalence of hypertension among U.S. adults will jump to 45.6% compared with 31.9% based on the JNC7’s 140/90 mm Hg threshold. That represents an additional 31.1 million people — based on National Health and Nutrition Examination Survey data through 2014 — for a total prevalence of 103.3 million, a simultaneously published study in Circulation indicated.

The targets were the same for older and younger adults, with the caveat that treatment decisions should be individualized for seniors with a high comorbidity burden and limited life expectancy.

The change was largely based on the SPRINT trial’s finding that a target below 120 mm Hg reduced heart attack, stroke, or death in higher-risk older adults, with clear benefit and no evidence of increased risk of falls or orthostatic hypertension in elderly individuals in the trial.

But the SPRINT researchers have cautioned that the blood pressure measurements were taken with a careful automated process and in a clinical trial setting with a motivated population that differs from most clinical settings, such that their findings should not be directly applied to usual practice.

The guideline writing committee selected 130/80 mm Hg as an intermediate target balancing the risk tradeoffs for the general population, Bob Carey, MD, vice-chair of the writing committee explained at a press conference.

“It’s much less evidenced-based than JNC8, but it’s important to give advice. You can’t study everything. There will never be another SPRINT,” commented Suzanne Oparil, MD, who was a reviewer for the new guideline but had co-chaired the JNC8 effort that resulted in unofficial recommendations after being disbanded by the NHLBI.

That controversial guideline had recommended looser thresholds for most hypertensive individuals 60 or older, starting pharmacologic treatment when the systolic pressure is 150 mm Hg or higher or the diastolic pressure is 90 mm Hg or higher.

“You can’t get a direct conversion,” agreed ACC immediate-past president Richard Chazal, MD, “but it’s about as ‘science-y’ as one can get.”

BP Treatment

The blood pressure target for treatment also shifted to less than 130/80 mm Hg. However, there were key differences in recommended treatment by hypertension category.

  • Stage 1 hypertension in the 130/80 to 139/89 mm Hg range was recommended for nonpharmacologic (predominantly lifestyle) therapy only unless the patient has clinical cardiovascular disease or at least a 10% 10-year risk of it based on the ACC/AHA atherosclerotic cardiovascular disease risk calculator already in use for cholesterol treatment decisions
  • Stage 2 hypertension is recommended for blood pressure medication regardless of 10-year risk or cardiovascular disease status
  • Elevated blood pressure in the 120-129 mm Hg systolic range was recommended for non-pharmacologic attention to lifestyle therapy

Lifestyle measures are weight loss, the DASH diet, reducing sodium, increasing potassium through diet, physical activity, and moderate alcohol consumption (limit one drink per day for women, two for men).

Lifestyle change is challenging, acknowledged Paul Whelton, chair of the guidelines writing committee, also speaking at the press conference. However, “we have to come to grips with it, whether we can achieve it or not.”

Carey suggested “this guideline may be a can opener” to force change and a re-commitment to lifestyle improvements.

Donald Lloyd-Jones, MD, of Northwestern University in Chicago, predicted it will be a paradigm shift in how blood pressure is treated in the U.S.

Adoption

The guideline itself was published in Hypertension, as a rambling, 192-page document that might be too much for many physicians to comb through, commented William Cushman, MD, a key SPRINT investigator.

Still, “I generally think it is a very good guideline. I agree with most of recommendations,” he told MedPage Today. “I do think more emphasis could be made that the <130/80 mm Hg goal is reasonable, but SBP <120 mm Hg may be more appropriate if BP is taken properly with an automated manometer (not with how BPs are often measured in practice).

“Realize the diastolic BP goal is based on expert opinion, not evidence. We need to continue to emphasize how BP is measured in most settings should change. You can’t use a conversion factor since the difference in a sloppy BP reading and a correct technique is unpredictable in the individual patient. I think the goals are very feasible — they are already being achieved in a high percentage in some practice settings, e.g., Kaiser. ”

“It’s long because it’s comprehensive,” Whelton said.

Endorsing organizations were the American Academy of Physician Assistants, American College of Preventive Medicine, American Geriatrics Society, American Pharmacists Association, American Society of Hypertension, American Society of Preventive Cardiology, Association of Black Cardiologists, National Medical Association, and the Preventive Cardiovascular Nurses Association.

While the American Medical Association wasn’t a party to the guidelines, it is a “close” partner and will help disseminate them along with a public service advertising campaign, Whelton said.

Conflict Ahead?

Notably, primary care and diabetes care organizations that have clashed with cardiologists over blood pressure guidelines did not sign on to the ACC/AHA 2017 guideline. The American College of Physicians and American College of Family Physicians, for instance, released guidelines earlier this year loosening thresholds to 150 mm Hg systolic for people 60 and older.

While the AHA/ACC have embraced their role as setting the national guideline from the government’s perspective, “I think it would be naïve for us to say we are the only guideline. We are the people that NHLBI asked to do this, so here we are. But the others exist,” Chazal told MedPage Today.

Oparil cautioned that it may be hard for physicians to shift practice quickly. “There’s not enough emphasis placed on hypertension. People will settle on any old number you get any old way, and that’s not appropriate.”

In order for this to really take hold it’s going to have to be established as a standard for payment, she suggested.

What the timeline might be for adopting these guidelines into the performance standards of the Centers for Medicare and Medicaid Services, insurers, and even the AHA/ACC’s own programs is unclear, Chazal said.

  • Primary Source

 

Hypertension

Source Reference: Whelton PK, et al “2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults” Hypertension 2017. DOI: 2017;HYP.0000000000000065

  • Secondary Source

 

Circulation

Source Reference: Muntner P, et al “Potential U.S. population impact of the 2017 American College of Cardiology/American Heart Association high blood pressure guideline” Circulation 2017. DOI: 10.1161/CIRCULATIONAHA.117.032582

Do Acne Treatments Promote Antibiotic Resistance?

Few studies to confirm risk, but guidelines discourage monotherapy with antimicrobials
by John Jesitus, Dermatology Times November 12, 2017

The most striking finding from a recent review of the impact of acne-related antibiotic use on microbial resistance is a lack of high-quality studies upon which to base recommendations. However, authors conclude, the few studies available sound sufficient alarm to renew major dermatologic societies’ calls to limit antibiotic use wherever possible.
The issue of antibiotic resistance is pertinent not only to dermatologists, but also to general, medical and family practitioners who treat acne, said co-author Brandon L. Adler, MD, a second-year dermatology resident (PGY-3) at the University of Southern California Keck School of Medicine.
“Studies can be meaningful in 2 directions: positive findings, or an absence of findings. The latter is more relevant to what we found.” Dating back to 1987, researchers examined five clinical trials (none randomized) that reported patient-level data.
“Essentially, we don’t know as much as we should about problems relating to antibiotic resistance in acne because of a lack of good, high-quality studies. The little that we do know is troubling enough” that possible changes to prescribing habits must continue to be discussed.
AAD AND EADV RECOMMENDATIONS
Both the American Academy of Dermatology (AAD) and the European Academy of Dermatology and Venereology (EADV) discourage topical or oral antibiotic monotherapy. “The official stance of major Academies of dermatology in the United States and Europe is that monotherapy with either topical or oral antibiotics is strongly discouraged because the available evidence shows that there’s a trend toward resistance among Propionibacterium acnes and possibly off-target effects” such as increased antibiotic resistance among Staphylococcus aureus associated with topical antibiotics, said Adler.
“Often,” he said, “our solution for avoiding monotherapy is having patients use over-the-counter products like benzoyl peroxide (BP) – which they’re not always purchasing. This can lead to a kind of functional monotherapy. So even though we may be recommending the use of benzoyl peroxide, that’s not always being adhered to on the patient end. That’s why patient education becomes such a major focus.”
As dermatology residents, “We’ve been very well exposed to the idea of combination therapy for acne. There are excellent combination products available that incorporate a topical antibiotic with benzoyl peroxide. This makes it much easier for both the practitioner and patient” to use more than one topical agent simultaneously.
Dermatologists typically have very busy clinics, he said, “And it can be tough sitting down with patients to try and educate them as fully as possible. But we need to explain to them that not only will their acne get better, but on a personal and population level as well, using multiple therapeutic modalities is geared toward stemming the tide of rising antimicrobial resistance, which carries possible serious implications going forward.”
While the AAD and EADV agree that dermatologists should limit courses of oral antibiotics to 3 to 4 months wherever possible, the academies differ regarding the specific role of BP in combination therapies. For mild-to-moderate acne, the AAD recommends BP, topical retinoids or combination therapy, which may include a topical antibiotic and any of the foregoing medications, as first-line treatment. Conversely, EADV guidelines for mild-to-moderate acne allow fixed-dose antibiotic/retinoid combinations without BP.
For first-line treatment of moderate-to-severe acne, the AAD recommends oral antibiotics (specifically doxycycline and minocycline, which have antimicrobial and anti-inflammatory effects) combined with BP and a topical retinoid. Topical antibiotics are also permissible, provided practitioners prescribe BP concomitantly. To facilitate limiting oral antibiotic courses to 3 or 4 months, patients should continue BP and topical retinoids as maintenance therapy after stopping oral antibiotics.
The EADV recommends combining oral antibiotics with topical retinoids, fixed-dose topical retinoid/BP or azelaic acid for moderate-to-severe acne. But while the strength of evidence for these combinations is medium, says the EADV, it assigns only a low strength of recommendation to the combination of oral antibiotics plus BP.
“The differences highlight the fact that the data are limited. All the guidelines are based as much as possible on available evidence,” Adler said. “The AAD recommends using benzoyl peroxide topically whenever oral antibiotics are being used for acne. The EADV still recommends that, but they make a point of saying that the evidence to support it is low. That makes sense because if someone’s taking an oral antibiotic – getting systemic distribution of the drug throughout the body – there’s not great evidence that using benzoyl peroxide topically on the face, chest or back will appreciably alter the resistance load among their bacteria.”
Both groups’ recommendations for BP are reasonable based on available evidence, he said. “Adding benzoyl peroxide is a low-cost intervention with very minimal opportunity for harm – and a potentially fair to very good opportunity for limiting resistance,” depending on the antibiotic and acne location. Regarding research gaps, Adler and colleagues call for additional studies to help quantify reductions in bacterial resistance achieved by combining BP with both oral and fixed-dose topical formulations.

This article originally appeared on our partner’s website Dermatology Times, which is a part of UBM Medica. (Free registration is required.)

Ambulatory Patient Safety Hinges on Addressing Clinician Stress

More needs to be done to improve outpatient safety, ACP says
by Debra Shute,, HealthLeaders Media November 12, 2017

The American College of Physicians (ACP) has called for healthcare organizations and other stakeholders to address physician burnout and stress, among other measures, as a means to improve patient safety in ambulatory settings.
“Burnout and stress may affect patient safety in various ways,” wrote the authors of the ACP’s new policy paper, Patient Safety in the Office-Based Practice Setting.
“Emotional exhaustion, which is linked to standardized mortality ratios among intensive care units, may affect cognitive and physical ability to perform tasks and diminish memory and attention, lessening ability to attend to details and process highly technical information; mental detachment and deficiencies in personal accomplishment may cause individuals to neglect duties or complete seemingly minor but crucial patient safety activities,” the authors continued.
The paper went on to support the National Patient Safety Foundation’s recommendations that organizations should strive to improve working conditions and staff resiliency, and that programs should include fatigue management systems, and communication, apology, and resolution skills.
Other safety principles outlined by the paper include the following:
• Physicians and healthcare organizations have a responsibility to promote a culture of patient safety within their practices and among colleagues with whom they collaborate
• Patient and family education, engagement, and health literacy efforts are needed to educate the public about asking the right questions and providing the necessary information to their physician or other healthcare professional
• ACP supports the continued research into and development of a comprehensive collection of standardized patient safety metrics and strategies, with particular attention to primary care and other ambulatory settings
• Team-based care models, such as the patient-centered medical home, should be encouraged and optimized to improve patient safety and facilitate communication, cooperation, and information sharing among team members
• Health information technology systems should be tailored to emphasize patient safety improvement
• ACP supports the establishment of a national effort to prevent patient harm across the healthcare sector
“In recent years, much attention has been focused on improving patient safety in hospitals,” said Jack Ende, MD, MACP, ACP president. “We now must extend that focus to include the ambulatory setting. Medical errors that happen outside of the hospital are just as important to prevent.”

This report is brought to you by HealthLeaders Media.

Breathing Bad Air May Boost Bone Fracture Risk

Two large studies link air pollution exposure to osteoporosis
by Salynn Boyles, Contributing Writer November 11, 2017

Action Points
• Poor air quality may be a modifiable risk factor for osteoporosis and bone fractures, especially among people living in low-income communities.
• Note that the studies are just the latest in a growing body of research linking air pollution exposure to osteoporosis.
Poor air quality may be a modifiable risk factor for osteoporosis and bone fractures, especially among people living in low-income communities, according to a newly published analysis of data from two independent studies.
In one study researchers documented higher rates of hospital admissions for bone fractures in communities exposed to elevated levels of ambient particulate matter (PM2.5) air pollution in an analysis of data on more than nine million Medicare enrollees.
In another 8-year follow-up of approximately 700 middle-age, low-income adults participating in a bone health study, participants living in areas with relatively high levels of PM2.5 and black carbon vehicle emissions had lower levels of a key calcium and bone-related hormone and greater decreases in bone mineral density than participants exposed to lower levels of these air pollutants.
All associations were linear and observed — at least for part of the PM2.5 distribution — at PM2.5 concentrations below the annual average limits set by the U.S. Environmental Protection Agency (12 μg/m3) and most other industrialized nations.
“Reducing emissions as a result of innovation in technologies or policy changes in emission standards of this modifiable risk factor might reduce the impact of air pollution on bone fracture and osteoporosis,” wrote Andrea Baccarelli, MD, PhD, chair of the Environmental Health Sciences Department and director of the Laboratory of Precision Environmental Biosciences at Columbia University’s Mailman School of Public Health in New York City, and colleagues, in Lancet Planetary Health.
In the hospital admission study, the team examined the association of long-term exposure to PM2.5 and hospital admissions for osteoporosis-related bone fractures among 9.2 million Medicare enrollees residing in the northeast, mid-Atlantic between January 2003 and December 2010.
In the second study, the researchers examined the association of long-term black carbon and PM2·5 concentrations with serum calcium homoeostasis biomarkers (parathyroid hormone, calcium, and 25-hydroxyvitamin [25(OH)D]) and annualized bone mineral density over 8 years (baseline, November 2002 — July 2005; follow-up, June 2010 — October 2012) of 692 middle-aged (46·7 years [SD12·3]), low-income men from the Boston Area Community Health/Bone Survey (BACH/Bone study) cohort.
PM2·5 concentrations were estimated using spatiotemporal hybrid modeling, including Aerosol Optical Depth data, spatial smoothing, and local predictors. Black carbon concentrations were estimated using spatiotemporal land-use regression models.
Among the main findings:
• In the Medicare analysis, risk of bone fracture admissions at osteoporosis-related sites was greater in areas with higher PM2·5 concentrations (risk ratio [RR] 1·041, 95% CI, 1·030 to 1·051; this risk was particularly high within low-income communities [RR 1·076, 95% CI, 1·052 to 1·100])
• In the longitudinal BACH/Bone study, baseline black carbon and PM2·5 concentrations were associated with lower serum parathyroid hormone (β=–1·16, 95% CI, –1·93 to –0·38, P=0·004, for 1 IQR increase [0·106 μg/m³] in the 1-year average of black carbon concentrations; β=–7·39, 95% CI, –14·17 to –0·61, P=0·03, for 1 IQR increase [2·18 μg/m³] in the 1-year average of PM2·5 concentrations)
• Black carbon concentration was associated with higher bone mineral density loss over time at multiple anatomical sites, including the femoral neck (–0·08% per year for 1 IQR increase, 95% CI, –0·14 to –0·02) and ultradistal radius (–0·06% per year for 1 IQR increase, –0·12 to –0·01)
• Black carbon and PM2·5 concentrations were not associated with serum calcium or serum 25(OH)D concentrations
The researchers acknowledged multiple limitations in both studies, which limit the ability to establish causality.
But in an editorial published with the studies, Tuan Nguyen, PhD, of the Garvan Institute of Medical Research in New South Wales, Australia, wrote that the studies are just the latest in a growing body of research linking air pollution exposure to osteoporosis: “Osteoporosis and its consequence of fragility fracture represent one of the most important public health problems worldwide because fracture is associated with increased mortality.”
He said it is now clear that genetic factors account for a modest proportion of fracture cases and bone density variance, suggesting that an environmental profile in the form of cumulative lifetime environmental exposures, known as exposome, is likely the main driver of disease.
“Conceptually, an individual’s risk of fracture is grounded by the individual’s genome and modified by the individual’s exposome. The delineation of the interaction between genome and exposome has the potential to transform our thinking about the etiology of osteoporosis.”

Funding for this research was provided by the National Institutes of Health, Institute on Aging, National Institute of Environmental Health Sciences, and the U.S. Environmental Protection Agency.
The researchers reported no relevant relationships with industry related to the study.
• Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner
last updated 11.10.2017
• Primary Source
Lancet Planetary Health
Source Reference: Prada D, et al “Association of air particulate pollution with bone loss over time and bone fracture risk: analysis of data from two independent studies” Lancet Planetary Health 2017; DOI 10.1016/S2542-5196(17)30136-5.

Gout Worsens Its Comorbidities

New study evaluates how disease and its treatments affect other common conditions
by Gregory M. Weiss MD, Rheumatology Network November 11, 2017

Gout and the medications used for its treatment worsen the comorbidities as well as patients’ perceptions of their quality of life.
Gout leads many patients to report feeling a sense of “body failure” and to have a negative effect on social roles. Also, a loss of identity-associated performance is progressive in patients with gout.
The most common inflammatory arthritis, gout has been linked to obesity and the metabolic syndrome as well as to associated comorbidities, such as heart disease, hypertension, diabetes, sleep apnea, and heart failure.
Writing in Arthritis Research & Therapy, Jasvinder Singh, MD, of the University of Alabama at Birmingham, pointed out that little is known about how gout affects the known comorbidities and their outcomes and that published qualitative research has focused on gout’s effect on quality of life, and there is also an under-representation of women in studies to date.
He sought to shed light using a trajectory model developed by Corbin and Strauss to form a qualitative description of the effect gout has on comorbidities.
The Study
A nominal group study was conducted by looking at 45 patients with gout in nine nominal groups. The trajectory model assessed body (organ system and function), biographical time (explicit narrative that gives meaning and purpose to a person’s life), and conceptions of self (role identity, social identity). The three components were reported as answers to the question, “How does gout or its treatment affect your other conditions and their treatment?”
The Results
The study showed that the effects of gout or gout treatment on comorbidities and their management included the following:
• Three groups rated the interaction of gout medications with medications for other medical conditions as a top concern
• Seven groups rated gout’s effect in worsening medical comorbidities, including hospitalizations, as a high concern
• Three groups cited worsening anxiety and depression as a top concern
• Three groups considered changes in diet as a primary concern
• Three groups cited new disease diagnosis on top of gout as a concern
• Two groups named irreversible joint damage as a top concern
• Four groups listed weight gain and inability to exercise as a problem
• Three groups cited misdiagnosis of their gout as another problem
In addition, the effects of gout or its treatment on daily life included the following:
• Six groups cited the negative effect of gout on daily life and activities, including the ability to work and social activities, as a concern
• All nine groups cited medication adverse effects as a problem
• One group cited weight loss as a negative effect on quality of life
• Three groups cited high cost as a concern
There were no observable differences between men and women on the impact of gout on their lives.
Implications for Physicians
Singh noted the following as the major clinical implications:
• Complaints with regard to loss of self, loss of role identity, and lower quality of life dominate within the gout population
• Although treatment of gout and its symptoms is important, physicians should not discount patients’ perceptions and the effect of gout on their comorbid conditions
• Physicians should, as a routine, ask patients how gout affects their lives and validate the concerns
• How physicians can change these comorbid interactions is unclear

This article originally appeared on our partner’s website Rheumatology Network, which is a part of UBM Medica. (Free registration is required.)
• Primary Source
Arthritis Research & Therapy
Source Reference: Singh JA “Gout and comorbidity: a nominal group study of people with gout” Arthritis Res Ther 2017; DOI: 10.1186/s13075-017-1416-1418.

Technology Helps Keep Arthritis Patients on Track

Juvenile and adult patients benefit from digital tools
by John Gever, Managing Editor, MedPage Today  November 10, 2017

SAN DIEGO — Two studies presented here at the American College of Rheumatology’s annual meeting showed that online technologies were able to improve self-management in patients with juvenile idiopathic arthritis (JIA) and rheumatoid arthritis.
For JIA, teens randomized to an Internet-based program providing disease information and social support over 3 months showed significantly better health-related quality of life as well as trends toward improved outcomes by other measures, as compared with a control group receiving education only.
Separately, adult RA patients participating in a digital and telephone-based health coaching program developed by a private company showed improvements from baseline in a variety of health behaviors, including sleep, alcohol and tobacco use, and physical activity.
Speaking at an ACR press briefing, the researchers said these techniques hold significant promise for helping patients cope with their disease without extensive (and expensive) in-person visits with physicians.
JIA Intervention
Teens with chronic diseases such as JIA are an especially challenging population, said Jennifer Stinson, RN-EC, PhD, of Toronto’s Hospital for Sick Children. As adolescents they expect, and are expected by others, to begin taking an active part in their disease management, yet typically aren’t fully able to process informational materials and self-management methods developed for adults.
Stinson noted, for example, that one study had shown that typical parent-directed handouts for JIA were written at a New York Times level of sophistication.
And when the disease verges on rare, as is the case with JIA, most teens don’t know anyone else with the disease and thus have little peer support.
In recognition of these problems, Stinson and colleagues have spent about a decade developing self-management techniques and materials geared specifically toward adolescents. In a presentation here, she reported results of a randomized trial testing what they have come up with so far, an interactive online program called “Teens Taking Charge” (TTC).
That intervention consists of teen-centric educational information about JIA, skills for mitigating symptoms and compensating for disabilities, and a social support platform connecting patients to adult professionals and to each other. (Stinson’s group has posted a YouTube video illustrating the program.)
In the trial, 169 JIA patients age 12-18 were assigned to participate in the TTC program, which also included monthly “coach” calls, goal-setting sessions, and parent modules as well as skills and disease-education components. Another 164 were enrolled in a control program that included only the monthly coach calls, parent modules, and static web-based disease education.
Stinson didn’t report quantitative results, but said the TTC program was associated with statistically significant improvement in health-related quality of life related to treatment problems and in pain interference with enjoyment of daily life. There was also a non-significant trend toward improved self-efficacy.
Improvements in pain coping, disease knowledge, and overall health-related quality of life were seen equally in both groups, Stinson said. There was no important change in either group in treatment adherence, anxiety, or depression, but that was because treatment adherence was relatively high to begin with and because psychiatric complaints were uncommon, she said.
One of the major benefits reported by TTC participants in post-study interviews was simply learning that they were not alone and that one could cope successfully with JIA. The digital social support platform, however, did not work as well as the researchers had hoped; participants said it was too unlike the social media platforms they were accustomed to using and found it boring.
The TTC program is now being integrated into a separate peer support program developed at the Hospital for Sick Children. A U.S. version of TTC, funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases is scheduled to launch in January 2018, she said.
Health Coaching in Adult RA
Teens aren’t the only group that may need more help in self-management than can be delivered effectively during clinic visits, said Uma Srivastava, MS, of Pack Health, a private firm in Birmingham, Alabama. Pack Health has developed some 20 online programs for a range of chronic illnesses including type 2 diabetes, cardiovascular conditions, cancer, pulmonary diseases, and rheumatological disorders including rheumatoid arthritis.
At the ACR meeting, Srivastava presented results of an open-label study of 155 patients participating in a 12-week RA program. Like the others, it adapts to the individual patient’s needs and wants, she explained. Patients lay out their goals and the Pack Health program provides a “game plan” for achieving them through lifestyle changes, all conducted online.
Like the RA program, it also included pairing each patient with a trained layperson serving as a “health coach” who spoke with the patient weekly by telephone. During those conversations, the patient-coach pair discussed goals, progress, and barriers. The coach also helped the patient in coordinating care and services.
Patients completed surveys based on the PROMIS Global-10 instrument for assessing physical and mental health. PROMIS scores are normalized such that 50 represents the average for the general U.S. population. In the current study, patients were scored before and after completing the 12-week program. Disease flares and medication adherence were also evaluated.
Mean numerical results were as follows:
• Physical health: 33.6 at baseline versus 40.6 at completion (P<0.001)
• Mental health: 41.4 at baseline versus 47.6 at completion (P<0.001)
• Flares in previous month: 6.6 at baseline versus 3.3 at completion (P<0.001)
• Drug doses missed per week: 0.4 at baseline versus 0.2 at completion (P=0.01)
Participants also lost a mean 0.55 BMI points during the program (P<0.001), Srivastava reported.
Pack Health’s programs cost $30 per month plus $99 at signup, although the company says that employers and insurers may pay some or all of the costs.
Limitations to the study included its open-label design with voluntary participation — the sample may have represented patients already motivated to improve their health behaviors — and it couldn’t be determined whether certain aspects of the program contributed more than others to the results.

The adult health coaching study was supported by Pack Health, a for-profit developer of similar programs for a range of conditions, and several investigators were Pack Health employees. The JIA study had no commercial funding and investigators declared they had no relevant financial interests.
• Primary Source
American College of Rheumatology
Source Reference: Stinson J, et al “A Randomized Controlled Trial (RCT) of an Internet-Based Self-Management Program for Adolescents with Juvenile Idiopathic Arthritis (JIA)” ACR 2017; Abstract 2952.
• Secondary Source
American College of Rheumatology
Source Reference: Burton BS, et al “Assessing the Impact of a Digital Health Coaching Program for Patients with Rheumatoid Arthritis” ACR 2017; Abstract 2257.

Start with OTC Pain Killers to Curb Opioid Abuse? (Tech Times)

ER study has broad implications
by MedPage Today Staff November 08, 2017

A combination of nonprescription pain relievers worked as well as opioids for controlling pain in the emergency department, Tech Times reported.
Patients who received ibuprofen and acetaminophen rated their pain relief as at least as good as that of patients who received one of three different opioid analgesics. As reported in JAMA, the 400-patient clinical study included patients who had varying degrees of pain associated with a different types of injuries and conditions, including fractures, strains, and sprains.
The findings have implications for countering the growing problem of opioid dependence and abuse, said principal investigator Andrew Chang, MD, of Albany Medical College in New York. “Although this study focused on treatment while in the emergency department, if we can successfully treat acute extremity pain with a non-opioid combination painkiller in there, then we might be able to send these patients home without an opioid prescription.”

Lifestyle Changes, Meds May Prevent Diabetes in Those at Risk

But effects decline with time
by Kristen Monaco, Staff Writer, MedPage Today November 08, 2017

Action Points
• Diabetes may be effectively prevented by lifestyle modification (LSM) and medication interventions in patients at risk for the disease.
• Note that the LSM interventions were sustained for several years although their effects declined with time, suggesting that interventions to preserve effects are needed.

Diabetes may be effectively prevented by lifestyle modification (LSM) and medication interventions in patients at risk for the disease, researchers reported.
In a meta-analysis, active lifestyle modification — ranging from 6 months to 6 years — was associated with a pooled relative risk reduction of 39% (risk reduction 0.61, 95% CI 0.54-0.68) for the development of diabetes, according to J. Sonya Haw, MD, of Emory University in Atlanta, and colleagues.
Lifestyle modification was also tied to a significantly lower risk difference of diabetes incidence compared with controls (7.4 cases per 100 person-years versus 11.4 cases, 95% CI 1.8-6.3), they wrote in JAMA Internal Medicine.
Similarly, medication intervention — active use ranging from 1 year up to 6.3 years — was tied to a 36% relative risk reduction for diabetes (0.64, 95% CI 0.54-0.76), with a significant risk difference for the development of diabetes compared with controls (5.4 cases per 100 person-years versus 9.4 cases, 95% CI 2.3-5.7).
But “medication effects were short lived. The LSM interventions were sustained for several years; however, their effects declined with time, suggesting that interventions to preserve effects are needed,” the authors wrote.
Haw’s group determined 25 individuals would have to be treated with either lifestyle modification or medication intervention to prevent one case of diabetes.
“Diabetes affects one in 11 adults worldwide and though there is evidence that lifestyle modification (eating healthier diets and exercising) and certain medications can prevent or delay diabetes onset, it is not clear which of these strategies offers long-term benefits,” Haw and co-author Karla I. Galaviz, PhD, also of Emory University, explained to MedPage Today.
“To answer this question, we compiled all available randomized controlled trials of lifestyle programs and medications to prevent diabetes, and analyzed the data to see if the diabetes prevention effects persisted in the long-term. We specifically compared studies where the lifestyle or drug interventions were discontinued to see if the effect persisted or diminished when the intervention was stopped,” they noted.
Their group gathered trials for their systematic review from MEDLINE, EMBASE, Cochrane Library, and Web of Science databases. The trials included adults with prediabetes, defined by the American Diabetes Association or the World Health Organization’s diagnostic criteria of impaired glucose tolerance and/or impaired fasting glucose. Trial exclusion criteria included studies that assessed prevention therapies other than lifestyle modification or pharmacological interventions, such as bariatric surgery, as well as trials that included those with metabolic syndrome, type 1, type 2, or gestational diabetes.
The meta-analysis included 43 trials (n=49,029 total), 19 of which assessed medications for at least 6 months, 19 tested lifestyle modification, while five measured both interventions.
Lifestyle interventions that combined both diet and physical activity were most effective at diabetes prevention, achieving a risk reduction of 41% (0.59, 95%CI 0.51-0.69).
In terms of medications, weight loss drugs, including orlistat or combination phentermine-topiramate, had the largest impact of a 63% diabetes risk reduction (0.37, 95% CI 0.22-0.62). Insulin sensitizers also showed a 53% reduction in diabetes risk, which included metformin, rosiglitazone, and pioglitazone (0.47, 95% CI 0.32-0.68).
Other medication types, such as lipid lowering, RAS blockade, insulin secretagogues, insulin, hormone therapy of estrogen/progestin, and alpha-glucosidase inhibitors, all showed a relative risk reduction for diabetes during active treatment.
However, following the end of an intervention washout period, lasting around 17 weeks, medication use did not have a significantly sustained reduction in diabetes risk (0.95, 95% CI 0.79-1.14). However, lifestyle modification carried a 28% sustained risk reduction (0.72, 95% CI 0.60-0.86) following an average washout period of 7.2 years.
“We were surprised that the effect of medications ended once the study drug was discontinued, as this implies that the physiologic changes exerted by medications to prevent or prolong diabetes onset is short-lived, and temporally dependent on the use of the medication.” Haw and Galaviz explained.
Although the analysis included a large number of comprehensive studies, the researchers noted that there was a “high level of heterogeneity in treatment effects,” which they highlighted may suggest that “there are other factors affecting treatment efficacy that were not accounted for.”
Future research should be a focus on finding both cost-effective and efficacious maintenance interventions in order to best prevent diabetes, Haw and Galaviz stated.
“Additionally, it is not clear that these benefits are shared equally by all people at high risk of diabetes, and there needs to be more studies exploring if and how these interventions work in people with different high-risk profiles (for example, those with impaired fasting glucose alone, impaired glucose tolerance alone, and those with both impaired fasting glucose and glucose tolerance). This may help us individualize prevention approaches. More data regarding costs, cost-effectiveness, and approaches to implement lifestyle programs in different settings worldwide are also needed,” they said.

The study was funded by a Disease Control Priorities Network grant to the Institute for Health Metrics and Evaluation from the Bill & Melinda Gates Foundation. Three co-authors disclosed support from the Georgia Center for Diabetes Translation Research.
Haw and Galaviz disclosed no relevant relationships with industry. One co-authors disclosed a relevant relationships with Novo Nordisk.
• Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner
• Primary Source
JAMA Internal Medicine
Source Reference: Haw S et al “Long-term sustainability of diabetes prevention approaches” JAMA Intern Med 2017; DOI:10.1001/jamainternmed.2017.6040.