<?xml version="1.0" encoding="utf-8"?>
<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_443"
                     title="Evidence-Based Treatment Improves Older Stroke Victims&apos; Chances (CME/CE)"
                     score="0.014"
                     href="http://www.medpagetoday.com/Cardiology/Strokes/tb/18360?impressionId=1265808146452"
                     
      &lt;p&gt;Older stroke patients remain at higher risk for adverse outcomes than younger ones, but the gap has narrowed with wider implementation of evidence-based guidelines, researchers say.&lt;/p&gt;
&lt;p&gt;More than 10% of stroke patients over 80 died in the hospital, compared with 3% of those under age 50, Gregg C. Fonarow, MD, of the University of California Los Angeles, and colleagues reported online in &lt;em&gt;Circulation&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;But overall use of guideline-recommended therapies improved substantially in older patients from 2003 to 2009, particularly for patients over 90, they said.&lt;/p&gt;
&lt;p&gt;During that time, several hospitals and stroke centers have adopted &quot;Get with the Guidelines,&quot; an intervention to apply evidence-based guidelines to care. Adopters have seen &quot;substantial improvements ... in performance measures for ischemic stroke patients, including pharmacological and nonpharmacological management in each age group,&quot; the researchers wrote.&lt;/p&gt;
&lt;p&gt;Before launching the initiative in 2003, studies generally showed lower use of guideline-recommended therapy and worse outcomes in older stroke patients.&lt;/p&gt;
&lt;p&gt;To assess changes since initiative started, the researchers analyzed more than 502,036 ischemic stroke admissions to 1,256 hospitals participating in the guidelines program between 2003 and 2009. Mean patient age was 71, and 52.5% were women.&lt;/p&gt;
&lt;p&gt;They found that performance on most evidence-based measures was lower in older patients  --  those ages 80 and up  --  compared with younger patients.&lt;/p&gt;
&lt;p&gt;The largest differences were seen in the proportion of eligible patients who received intravenous tissue plasminogen activator (tPA) treatments (51.1% for older patients versus 61.6% for those under 50, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001).&lt;/p&gt;
&lt;p&gt;Providers were also less likely to treat older stroke patients with lipid-lowering therapies than younger patients (54.2% versus 71.7%, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001).&lt;/p&gt;
&lt;p&gt;The smallest differences involved antithrombotic therapy within 48 hours of admission and at discharge.&lt;/p&gt;
&lt;p&gt;In terms of outcomes, older patients had a significantly higher inhospital mortality rate (10.3% versus 3%), and they were less likely to be discharged home. Rather, they were more likely to be discharged to a skilled nursing facility (42.1% versus 5.3%, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001) or hospice (12% versus 0.5%, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001).&lt;/p&gt;
&lt;p&gt;With each 10-year age increase, patients with ischemic stroke were 31% less likely to be discharged home and 27% more likely to die in the hospital.&lt;/p&gt;
&lt;p&gt;But the researchers said that, generally, the use of guideline-recommended therapies improved substantially in older patients from 2003 to 2009.&lt;/p&gt;
&lt;p&gt;In those ages 90 and older, use of intravenous tPA increased threefold, from 20.4% in 2003 to 62.4% in 2009. And use of lipid lowering therapy increased from 15.6% in 2003 to 71.7%.&lt;/p&gt;
&lt;p&gt;The researchers wrote that by 2009, &quot;many of the age-related differences in care had narrowed or were eliminated.&quot;&lt;/p&gt;
&lt;p&gt;They cautioned, however, that there could be residual confounding by unmeasured factors. For example, physicians may be uncertain about risks versus benefits in treating older patients who are under-represented in RCTs.&lt;/p&gt;
&lt;p&gt;The authors noted that their study was limited by its reliance on the accuracy and completeness of medical records.&lt;/p&gt;
&lt;p&gt;Also, they noted, the &quot;Get with the Guidelines&quot; program tends to attract larger teaching hospitals, which already have a &quot;strong interest in stroke care and quality improvement,&quot; and thus the findings may not be generalizable.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The &quot;Get with the Guidelines&quot; program is supported by the American Heart Association and the American Stroke Association, as well as grants from Pfizer and the Merck-Schering Plough Partnership.&lt;/p&gt;&lt;p&gt;Fonarow reported relationships with Pfizer, Merck/Schering Plough, BMS/Sanofi.&lt;/p&gt;&lt;p&gt;Co-authors reported relationships with Boehringer Ingelheim, Ferrer, CoAxia, Talecris, Concentric Medical, and Cygnis.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_361"
                     title="Hidden Dangers of Herbal Meds Reviewed"
                     score="0.011"
                     href="http://www.medpagetoday.com/PrimaryCare/AlternativeMedicine/tb/18244?impressionId=1265808146452"
                     
      Herbal medicines are not always the harmless nostrums that many patients and even some physicians think, but may actually contribute to cardiovascular morbidity and mortality, researchers warned in a review covering 44 years of research into the subject.&lt;br&gt;
&lt;br&gt;Many such products, including aloe vera, ginkgo biloba, ginseng, and green tea, can interact with conventional cardiovascular drugs and lead to serious adverse reactions, according to Arshad Jahangir, MD, of the Mayo Clinic in Scottsdale, Ariz., and two other Mayo physicians.&lt;br&gt;
&lt;br&gt;&quot;There is a clear need for better public and physician understanding of herbal products through health education, early detection and management of herbal toxicities, scientific scrutiny of their use, and research on their safety and effectiveness,&quot; they wrote in the Feb. 9 &lt;em&gt;Journal of the American College of Cardiology&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Jahangir and colleagues also called for increased regulation of such products, at least requiring manufacturers of herbal medicines to register with the FDA and provide evidence of good manufacturing practices.&lt;/p&gt;
&lt;p&gt;&quot;Some of these adverse drug reactions are preventable,&quot; Jahangir told &lt;em&gt;MedPage Today&lt;/em&gt; in a telephone interview. &quot;Simple things like taking a good history or giving that history and discussing these issues, probably we can avoid [such reactions].&quot;&lt;/p&gt;
&lt;p&gt;Other physicians contacted by &lt;em&gt;MedPage Today&lt;/em&gt; and ABC News agreed that the growth in popularity of herbal medicines poses problems for physicians and patients.&lt;/p&gt;
&lt;p&gt;&quot;Because these remedies are &apos;natural,&apos; their potential dangers are not considered the same way they would be if they were medication,&quot; commented Suzanne Steinbaum, MD, a cardiologist at Lenox Hill Hospital in New York City, in an e-mail.&lt;/p&gt;
&lt;p&gt;&quot;For many reasons, patients tend not to disclose to their doctors if they are taking herbal remedies, including fear that their doctors won&apos;t approve or they will be told to stop them,&quot; Steinbaum added. &quot;This lack of knowledge and full-disclosure, for some, might be a fatal omission.&quot;&lt;/p&gt;
&lt;p&gt;Jahangir and colleagues reviewed nearly 90 publications that have addressed herbal or complementary therapies and cardiovascular effects since 1966.&lt;/p&gt;
&lt;p&gt;Their &lt;em&gt;JACC&lt;/em&gt; article listed 15 common herbal medicines known to interact adversely with conventional cardiovascular drugs.&lt;/p&gt;
&lt;p&gt;In many cases, the herbal products compete with the regular medicines for the same drug-metabolizing cytochrome P450 enzymes, potentiating the latter&apos;s effects. In other cases, the herbal products have their own cardiovascular effects.&lt;/p&gt;
&lt;p&gt;Many physicians already know that grapefruit juice occupies the CYP3A4 enzyme, leading to slower-than-expected metabolism and, therefore, higher blood levels of a host of pharmaceuticals.&lt;/p&gt;
&lt;p&gt;These include the statins, calcium channel antagonists, several common anti-arrhythmic drugs, and the angiotensin receptor blocker irbesartan (Avapro), Jahangir and colleagues noted.&lt;/p&gt;
&lt;p&gt;Garlic is one of several common herbal remedies with specific cardiovascular effects in its own right (others include ginkgo biloba, ginseng, and saw palmetto). Garlic inhibits platelet aggregation and thus can lead to increased bleeding risks when combined with aspirin, clopidogrel (Plavix), or warfarin (Coumadin), the researchers noted.&lt;/p&gt;
&lt;p&gt;The Mayo group identified 10 herbal products that increase bleeding risks with anticoagulant and antiplatelet drugs, as well as 14 that can induce arrhythmias.&lt;/p&gt;
&lt;p&gt;In all, Jahangir and colleagues listed 27 herbal products that patients with cardiovascular diseases would do well to avoid. These include such common and harmless-seeming products as green tea, capsicum pepper, licorice, and kelp, as well as grapefruit juice and garlic.&lt;/p&gt;
&lt;p&gt;&quot;We need to check with our patients what type of products they are using, to identify these potential interactions,&quot; Jahangir told &lt;em&gt;MedPage Today&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;He cited the previously reported figure of 100,000 deaths annually from drug interactions, adding, &quot;We don&apos;t even know how many of these are due to use of compounds that we are not aware that our patients are taking.&quot;&lt;/p&gt;
&lt;p&gt;Jahangir said he was surprised, in preparing the review, at the scale of hebal medicine use in the U.S.&lt;/p&gt;
&lt;p&gt;He and his colleagues found data from the 1990s suggesting that more patients consult complementary and alternative medicine providers than regular physicians.&lt;/p&gt;
&lt;p&gt;The total annual out-of-pocket expenditure on complementary and alternative medicine services and products also was greater than for conventional physician services.&lt;/p&gt;
&lt;p&gt;&quot;The surprise for me was . . . how much people are willing to spend on a type of therapy which has not shown, in any scientific way, to be effective or safe,&quot; Jahangir said.&lt;/p&gt;
&lt;p&gt;He added that the trend may reflect shortcomings of the conventional medical system.&lt;/p&gt;
&lt;p&gt;&quot;What is the reason people are going there? Is it because there is some unmet type of need that we are not recognizing as practitioners of conventional medicine?&quot;&lt;/p&gt;
&lt;p&gt;Jahangir said it may be that physicians aren&apos;t spending enough time with patients to understand their true needs. He said it appears that, &quot;despite the advancement in our technology and new medicines, there is a demand for alternative therapies that is increasing.&quot;&lt;/p&gt;
&lt;p&gt;He recommended that, in addition to asking patients in detail about herbal and other alternative therapies they may be using, physicians should educate themselves on what these therapies purport to do and what is known about their real biological effects.&lt;/p&gt;
&lt;p&gt;The &lt;a href=&quot;http://nccam.nih.gov&quot; mce_href=&quot;http://nccam.nih.gov&quot; target=&quot;_blank&quot;&gt;National Center for Complementary and Alternative Medicine&lt;/a&gt; at the National Institutes of Health is a good starting point for such information, both for physicians and for patients, Jahangir said.&lt;/p&gt;
&lt;p&gt;Lenox Hill&apos;s Steinbaum said it was important that conventional physicians &quot;become more open-minded and accepting&quot; of alternative medicine, if only because so many of their patients are already practicing it.&lt;/p&gt;
&lt;p&gt;David Meyerson, MD, JD, a Johns Hopkins University cardiologist, told &lt;em&gt;MedPage Today&lt;/em&gt; and ABC News in an e-mail that he advises patients to limit their use of &quot;unstudied and unproven and FDA-unregulated herbal medications.&quot;&lt;/p&gt;
&lt;p&gt;&quot;It&apos;s unfortunately very big business, and potential drug interactions and potential harmful effects abound,&quot; he wrote.&lt;/p&gt;
&lt;p&gt;But another physician criticized the Mayo physicians&apos; emphasis on adverse effects in their review.&lt;/p&gt;
&lt;p&gt;&quot;For many of products listed, evidence for side effects seems to be minimal,&quot; Scott Grundy, MD, of the University of Texas Southwestern Medical Center in Dallas, argued in an e-mail.&lt;/p&gt;
&lt;p&gt;He agreed that the efficacy and safety of such drugs remains largely unproven, but added, &quot;It is mainly for these reasons that they cannot be recommended for use.&quot;&lt;/p&gt;
&lt;p&gt;Creating alarm about side effects &quot;may not be the appropriate way to discourage their use,&quot; Grundy said.&lt;/p&gt;
&lt;p&gt;&lt;em&gt;This article was developed in collaboration with ABC News. &lt;/em&gt;&lt;img src=&quot;http://www.medpagetoday.com/upload/2009/10/1/14357_1.jpg&quot; mce_src=&quot;http://www.medpagetoday.com/upload/2009/10/1/14357_1.jpg&quot; alt=&quot;&quot;&gt;&lt;/p&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_315"
                     title="A Few Extra Pounds May Benefit Older People (CME/CE)"
                     score="0.007"
                     href="http://www.medpagetoday.com/Geriatrics/GeneralGeriatrics/tb/18183?impressionId=1265808146452"
                     
      &lt;p&gt;A little excess weight after age 70 could do the body some good, according to results of a study involving 9,000 older patients.&lt;/p&gt;
&lt;p&gt;Overweight participants in the cohort study had the lowest 10-year mortality. Normal-weight and obese participants ages 70 to 75 had a similar and slightly higher risk of death, Leon Flicker, PhD, of the Western Australian Center for Health and Aging in Perth, and colleagues found.&lt;/p&gt;
&lt;p&gt;The findings add to evidence suggesting that being overweight in older age is not such a bad thing and might even be beneficial.&lt;/p&gt;
&lt;p&gt;&quot;These results lend further credence to claims that the body mass index [BMI] thresholds for overweight and obese are overly restrictive for older people,&quot; the researchers concluded in an article in the &lt;em&gt;Journal of the American Geriatrics Society&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;The authors also found that a sedentary lifestyle doubled the mortality risk for older women but did not affect survival of older men.&lt;/p&gt;
&lt;p&gt;The World Health Organization has established four BMI thresholds to characterize body weight: &lt;ul&gt; &lt;li&gt;&amp;lt;18.5 kg/m&lt;sup&gt;2&lt;/sup&gt;, underweight&lt;/li&gt; &lt;li&gt;18.5 to 24.9 kg/m&lt;sup&gt;2&lt;/sup&gt;, normal weight&lt;/li&gt; &lt;li&gt;25 to 29.9 kg/m&lt;sup&gt;2&lt;/sup&gt;, overweight&lt;/li&gt; &lt;li&gt;&amp;#8805;30 kg/m&lt;sup&gt;2&lt;/sup&gt;, obese&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;The authors noted that the thresholds were derived primarily from studies of younger and middle-age adults. Whether the cut points for overweight and obese are appropriate for older individuals has remained unclear.&lt;/p&gt;
&lt;p&gt;Two systematic reviews and a meta-analysis showed no increased mortality risk associated with a BMI in the overweight range for older people (&lt;em&gt;Arch Intern Med&lt;/em&gt; 2001; 161: 1194-1203, &lt;em&gt;Obesity Rev&lt;/em&gt; 2007; 8: 41-59). However, methodologic differences complicated the comparison of different studies, Flicker and colleagues wrote.&lt;/p&gt;
&lt;p&gt;So they sought to address some of the uncertainty by analyzing data from two large Australian cohort studies involving more than 9,000 individuals ages 70 to 75 (4,677 men, 4,563 women).&lt;/p&gt;
&lt;p&gt;The principal objectives were to determine the BMI threshold associated with the lowest mortality in older people and to determine whether the relationship between BMI and mortality differed between men and women.&lt;/p&gt;
&lt;p&gt;Data for the analysis came from self-reported measures of height and weight, which the authors used to calculate BMI for the study participants. Participants also provided demographic, lifestyle, and health information.&lt;/p&gt;
&lt;p&gt;Using the WHO criteria for BMI, the authors found that 1.3% of men and 3.1% of women were underweight; 43.5% of men and 50.3% of women were normal weight; 44.3% of men and 33.5% of women were overweight; and 11% of men and 13.1% of women were obese.&lt;/p&gt;
&lt;p&gt;During 10 years of follow-up, overweight study participants had a 13% lower risk of death compared with normal-weight participants (HR 0.87, 95% CI 0.78 to 0.94). Obese participants had a mortality risk similar to that of normal-weight participants (HR 0.98, 95% CI 0.85 to 1.11).&lt;/p&gt;
&lt;p&gt;Self-reported sedentary lifestyle doubled the mortality risk for women across all BMI categories (HR 2.08, 95% CI 1.79 to 2.41). In contrast, sedentary lifestyle increased the mortality risk for men by 28% (HR 1.28, 95% CI 1.14 to 1.44).&lt;/p&gt;
&lt;p&gt;Separate analyses involving common causes of death, such as cardiovascular disease and cancer, showed similar relationships between BMI and mortality risk.&lt;/p&gt;
&lt;p&gt;&quot;Even after removing the effects of early mortality, those who were overweight were still at lowest risk, a finding consistent with the observation that weight loss in older age groups is associated with greater mortality,&quot; the authors wrote.&lt;/p&gt;
&lt;p&gt;&quot;Overweight older people are not at greater mortality risk, and there is little evidence that dieting in this age group confers any benefit,&quot; they added.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The authors had no relevant disclosures&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_323"
                     title="Peptide Predicts Heart Failure in Older Patients (CME/CE)"
                     score="0.007"
                     href="http://www.medpagetoday.com/Cardiology/CHF/tb/18193?impressionId=1265808146452"
                     
      &lt;p&gt;Serial measurement of a natriuretic peptide predicted the risk of heart failure and cardiovascular death in older patients who were initially free of heart failure, data from a longitudinal cohort study showed.&lt;/p&gt;
&lt;p&gt;An increase of more than 25% in levels of N-terminal pro-B type natriuretic peptide (NT-proBNP) doubled the risk of heart failure and cardiovascular death. In contrast, a more than 25% decrease in NT-proBNP was associated with a greater than 40% reduction in the risk of both end points.&lt;/p&gt;
&lt;p&gt;&quot;NT-proBNP levels frequently change over time, and these fluctuations reflect dynamic changes in cardiovascular risk,&quot; Christopher R. deFilippi, MD, of the University of Maryland in Baltimore, and co-authors concluded in an article in the Feb. 2 issue of the &lt;em&gt;Journal of the American College of Cardiology&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;&quot;This change in [NT-proBNP] level reflects a significant change in patient risk independent of cardiovascular risk factors, ejection fraction, or medication use,&quot; they added. &quot;Ultimately, NT-proBNP levels may guide further diagnostic testing or potential preventive measures to reduce the risk of developing heart failure or dying of cardiovascular disease.&quot;&lt;/p&gt;
&lt;p&gt;About 80% of cardiovascular deaths occur in older adults. Assessing cardiovascular risk in older patients is challenging because traditional cardiovascular risk factors are less predictive in older versus middle-age populations, the authors wrote.&lt;/p&gt;
&lt;p&gt;Subclinical cardiovascular disease is common among older adults and increases the risk of cardiovascular events, including heart failure. Repeated measures of traditional markers of cardiovascular disease in patients with subclinical disease are associated with increased risk compared with patients who remain free of identifiable disease, the authors continued.&lt;/p&gt;
&lt;p&gt;Levels of BNP and NT-proBNP are associated with long-term cardiovascular outcomes in the general population. However, the peptides&apos; ability to provide additional prognostic information beyond that of traditional risk factors remained controversial.&lt;/p&gt;
&lt;p&gt;To examine the prognostic value of NT-proBNP in an older population, deFilippi and colleagues analyzed data on 3,000 participants in the Cardiovascular Health Study. The authors hypothesized that NT-proBNP levels in an ambulatory population of older patients would independently predict new-onset heart failure and cardiovascular death.&lt;/p&gt;
&lt;p&gt;&quot;Furthermore, we anticipated that serial measurements of NT-proBNP, as a possible surrogate for change in subclinical disease status, identify a dynamic change in long-term risk of incident heart failure and cardiovascular mortality,&quot; the authors wrote.&lt;/p&gt;
&lt;p&gt;Stored serum samples obtained at enrollment and two to three years later were used to measure NT-proBNP levels. Median follow-up for the cohort was 11.9 years.&lt;/p&gt;
&lt;p&gt;After separating the study group into quintiles of NT-proBNP levels, investigators found that patients with the highest baseline levels of the peptide (&amp;gt;267.7 pg/mL) had a threefold greater risk of new-onset heart failure (HR 3.05, 95% CI 2.46 to 3.78) and cardiovascular death (HR 3.02, 95% CI 2.36 to 3.86) compared with patients in the lowest NT-proBNP quintile (&amp;lt;47.5 pg/mL).&lt;/p&gt;
&lt;p&gt;The researchers identified 190 pg/mL as the NT-proBNP threshold for increased risk. Among study participants with baseline levels less than 190 pg/mL, an increase greater than 25% to a level above 190 pg/mL had a twofold increased risk of heart failure (HR 2.13, 95% CI 1.68 to 2.71) and cardiovascular death (HR 1.91, 95% CI 1.43 to 2.53) compared with participants whose NT-proBNP levels remained below 190 pg/mL.&lt;/p&gt;
&lt;p&gt;Among study participants with elevated baseline NT-proBNP levels, an increase greater than 25% also doubled the risk of heart failure (HR 2.06, 95% CI 1.56 to 2.72) and cardiovascular disease (HR 1.88, 95% CI 1.37 to 2.57).&lt;/p&gt;
&lt;p&gt;A decrease greater than 25% from baseline significantly reduced the risk of heart failure (HR 0.58, 95% CI 0.36 to 0.93) and cardiovascular death (HR 0.57, 95% CI 0.32 to 1.01) compared with participants whose baseline levels remained elevated.&lt;/p&gt;
&lt;p&gt;The investigators noted limitations of the study including the fact that a quarter of the participants did not have a follow-up blood sample and those who did were younger and had fewer cardiac risk factors.&lt;/p&gt;
&lt;p&gt;In addition, the length of follow-up could not account for differences in treatment over time, and the accuracy of NT-proBNP levels in samples as much as 20 years old cannot be assured.&lt;/p&gt;
&lt;p&gt;The study is noteworthy for highlighting the concept of dynamic risk assessment based on serial measurement of NT-proBNP, Richard W. Troughton, MB ChB, PhD, Matthew G. Daly, MB ChB, and Christopher M. Frampton, PhD, of the University of Otago in Christchurch, New Zealand, wrote in an editorial.&lt;/p&gt;
&lt;p&gt;&quot;The findings confirm a modest improvement in risk stratification by including a single measurement of NT-proBNP levels,&quot; they wrote &quot;The investigators take this a step further by showing that serial NT-proBNP measurement at a later time provides a further modest improvement in risk stratification.&quot;&lt;/p&gt;
&lt;p&gt;&quot;Whether the improvement in risk stratification achieved by performing serial NT-proBNP testing crosses a threshold of definite clinical value needs further evaluation, with particular consideration of the cost-effectiveness of such a strategy,&quot; they added.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was supported by the National Institutes of Health, University of Pittsburgh, and Roche Diagnostics.&lt;/p&gt;&lt;p&gt;DeFilippi disclosed relationships with Siemens, Roche Diagnostics, BG Medicine, and Critical Diagnostics. Co-author Robert H. Christenson disclosed relationships with Roche Diagnostics, Siemens Healthcare Diagnostics, and Response Biomedical. Co-author Stephen L. Seliger disclosed a relationship with Roche.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_268"
                     title="No Meds Needed for Two Effective OA Regimens (CME/CE)"
                     score="0.003"
                     href="http://www.medpagetoday.com/Rheumatology/GeneralRheumatology/tb/18119?impressionId=1265808146452"
                     
      &lt;p&gt;Middle-aged patients with early knee osteoarthritis can benefit from either a self-managment program or strength training, but a combination of the two did not provide additional gains, a study found.&lt;/p&gt;
&lt;p&gt;During a two-year trial, roughly two-thirds of participants randomized to one of three groups achieved clinically meaningful improvements in functioning, defined as a 26% change from baseline, according to a new report in the Jan. 15 &lt;em&gt;Arthritis Care &amp;amp; Research&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Patients also achieved clinically meaningful improvements in pain -- defined as a 40% change from baseline -- regardless of treatment group, wrote Patrick E. McKnight, PhD, of George Mason University in Fairfax, Va., and colleagues.&lt;/p&gt;
&lt;p&gt;The functional improvements were 70% for patients in the strength training group, 64% for those in the self-management group, and a 66% improvement in the combined treatment group. For pain, the breakdown was as follows: &lt;ul&gt; &lt;li&gt;Strength training, 65%&lt;/li&gt; &lt;li&gt;Self-management, 56%&lt;/li&gt; &lt;li&gt;Combined treatment, 65%&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;McKnight and colleagues wrote that studies in older patients have reported positive changes for both strength training and self-management.&lt;/p&gt;
&lt;p&gt;To see if these modalities also could benefit younger patients with milder disease, and whether combining the two would lead to additional benefits, the investigators recruited 273 subjects ages 35 to 64 years.&lt;/p&gt;
&lt;p&gt;Participants all had pain on most days in at least one knee, had symptoms for less than five years, had radiographic evidence of osteoarthritis, and had self-reported disability.&lt;/p&gt;
&lt;p&gt;The strength training program consisted of two phases, the first being nine months focused on stretching and balance, range of motion and flexibility, and isotonic muscle strengthening in three sessions each week.&lt;/p&gt;
&lt;p&gt;Phase two involved the development of self-directed long-term exercising habits, following the guidance and advice of trainers.&lt;/p&gt;
&lt;p&gt;The self-management program also included two phases. During the first nine-month phase, participants attended 12 weekly 90-minute classroom sessions addressing coping and self-efficacy skills, promoting active adaptive strategies and increasing perception of control for physical function and pain management.&lt;/p&gt;
&lt;p&gt;Phase two consisted of telephone calls from instructors and problem-solving discussions.&lt;/p&gt;
&lt;p&gt;The combined treatment group concurrently participated in both strength training and self-management programs, adjusted to maintain equivalent contact time with the other two groups.&lt;/p&gt;
&lt;p&gt;Overall compliance was modest, with 55.8% of those in the strength training group completing the study, along with 69.1% and 59.6% of the self-management and combined groups, respectively.&lt;/p&gt;
&lt;p&gt;Objective measures of physical functioning consisted of five physical performance tests measured at baseline and at months nine and 24. Pain and disability were self-reported.&lt;/p&gt;
&lt;p&gt;All of these outcomes showed significant changes over time in all three treatment groups, with effect sizes computed using the standard Cohen&apos;s d units: &lt;ul&gt; &lt;li&gt;Leg press, d=0.85&lt;/li&gt; &lt;li&gt;Range of motion, d=1.00&lt;/li&gt; &lt;li&gt;Work capacity, d=0.60&lt;/li&gt; &lt;li&gt;Balance, d=0.59&lt;/li&gt; &lt;li&gt;Stair climbing, d=0.59&lt;/li&gt; &lt;li&gt;Pain, d= &amp;#8722;0.51&lt;/li&gt; &lt;li&gt;Disability, d= &amp;#8722;0.55&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Both men and women improved, although benefits were greater among men, who gained more large muscle mass strength. Study-related adverse effects included accident, injury, or increased pain with strength training.&lt;/p&gt;
&lt;p&gt;Within-group and between-group effect sizes were also computed. All within-group effect sizes differed significantly from zero, with the exception of the pain outcome in the strength training group, but none of the between-group effects were significant.&lt;/p&gt;
&lt;p&gt;&quot;The logic behind the combined treatment was that the different factors addressed in physical and psychological treatments might produce an additive effect if administered together. These results suggest otherwise,&quot; the investigators conceded.&lt;/p&gt;
&lt;p&gt;As to why there were no differences between the three treatment arms, the length of the study and the relative youth of the participants may have contributed.&lt;/p&gt;
&lt;p&gt;The sample was younger than are included in typical osteoarthritis studies and were higher functioning at baseline, which could mean that there was less opportunity to produce a significant effect, the investigators suggested.&lt;/p&gt;
&lt;p&gt;Also, the increased burden of the combined treatment may have diluted the effects of the two programs.&lt;/p&gt;
&lt;p&gt;Despite the fact that combined treatment in this study had negligible benefits beyond that seen with strength training and self-management, other long-term outcomes such as physical activity level might show a greater response. This remains speculative, but deserves further study, according to the investigators.&lt;/p&gt;
&lt;p&gt;Limitations of the study include the fact that the researchers did not assess effects of the treatment on articular cartilage or inflammation, and they did not include a no-treatment arm.&lt;/p&gt;
&lt;p&gt;Also, there may have been differences in self-medication practices between the groups.&lt;/p&gt;
&lt;p&gt;Nonetheless, the study findings suggest that the two nonpharmacologic approaches can produce gains in middle-age patients with osteoarthritis, and both can be recommended.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases.&lt;/p&gt;&lt;p&gt;One co-author is an employee of Bristol-Myers Squibb and holds stock and/or stock options in the company.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
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