Alice Goodman | Disclosures

PARIS — For patients with fibromyalgia, treatment should be individualized and include nonpharmacologic approaches, which are often more effective than drugs, according to an expert in the field.

“There is no magic drug against fibromyalgia and, in my opinion, there will never be. Psychotherapists don’t work miracles, but psychotherapy can help and, in a few cases, turn people with fibromyalgia into nonpatients. Drugs may help, but patients don’t like them,” said investigator Winfried Häuser, MD, from Technische Universität München in Germany, who has published widely on fibromyalgia.

“Aerobic exercise is the most effective weapon we have; healthy people profit from continuous physical exercise, and so do patients with fibromyalgia,” he explained.

Dr. Häuser presented an overview of research on fibromyalgia treatment here at the European League Against Rheumatism Congress 2014.

A Meta-Analysis 

Pharmacologic therapies for fibromyalgia include GABA analogues, serotonin–norepinephrine reuptake inhibitors (SNRIs), tricyclic antidepressants, and serotonin-specific reuptake inhibitor (SSRIs). Nonpharmacologic therapies include aerobic exercise, acupuncture, and psychotherapy.

Few head-to-head comparisons of pharmacologic and nonpharmacologic approaches have been published, making the question of which treatments are more effective difficult to answer, said Dr. Häuser.

He and his colleagues recently published a network meta-analysis that was an indirect comparison of all available therapies (Ann Rheum Dis. 2013;72:955-962). They found no significant differences in effectiveness between drug and nondrug therapies.

“Studies may show an effect of drugs, but the effects of drugs are lost once the patient is not taking them,” he explained.

“In contrast, we see sustained but declining effects of aerobic exercise and multicomponent therapy [e.g. psychotherapy and exercise] in fibromyalgia at 1 or 2 years. Cognitive behavioral therapies do have some effect on pain and disability, but these may be small,” he reported.

Treat the Individual, Not the Average 

“Results of trials are averages and not representative of individual patient experiences,” said Dr. Häuser. “Some patients obtain little or no relief and others obtain very good relief of pain; the average represents only a tiny minority of patients. The same is true for psychological therapies.”

Treatment decisions should take tolerability, safety, cost, and the patient’s willingness to continue therapy into account, he explained. And treatment should provide substantial pain relief.

“If we really want to know what works in clinical practice, we have to go beyond randomized controlled trials that exclude a lot of patients seen in real-world clinical practice. We need to look at databanks and consumer reports,” he said.

For example, the National Data Bank on Rheumatic Disease contains data on 3123 adults with fibromyalgia who were followed for 11 years. Overall, no improvement was seen for fatigue or functional status, and the improvement for pain was small (0.2 on a 10-point scale).

And a cross-sectional survey Dr. Häuser was involved in revealed some important findings on the most beneficial therapies for fibromyalgia (Clin Exp Rheumatol. 2013;31[6 Suppl 79]:S34-S40).

When patients were asked to list the top 10 most beneficial therapies for fibromyalgia, no drugs were mentioned, Dr. Häuser reported. When they were asked to list what they considered to be the 10 most harmful therapies, they named only approved drugs.

A Graduated Approach 

Dr. Häuser advocates a graduated approach to treating fibromyalgia. Mild forms of fibromyalgia can be managed with reassurance from the doctor and encouragement to engage in regular physical and mental activities. Moderate fibromyalgia should be managed with aerobic exercise and the temporary limited use of drugs. For severe fibromyalgia, he recommends aerobic exercise, drugs, and the psychological and/or psychopharmalogic treatment of mental comorbidities.

There are currently 2 streams of thought about treating fibromyalgia: pharmacologic and nonpharmacologic, said Mary-Ann Fitzcharles, MD, a rheumatologist at McGill University in Montreal who treats fibromyalgia patients.

“Nonpharmacologic therapies are probably the most important for fibromyalgia patients. Every patient should be managed with the following nonpharmacologic approaches: exercise, promotion of an internal locus of control, and education,” she said.

It is important not to overdo exercise or to avoid it, she added. “Activity pacing is the key.”

“I agree with the patient-tailored approach Dr. Häuser presented. We should be cautious about overmedicating patients and keeping them on continued medications. We worry about the side effects. Nonpharmacologic therapies have no risks,” Dr. Fitzcharles explained.

Dr. Häuser and Dr. Fitzcharles have disclosed no relevant financial relationships. 

European League Against Rheumatism (EULAR) Congress 2013: Abstract SP0061. Presented June 13, 2014.

Shelley Wood | Disclosures

ATHENS, GREECE — New data from the Longitudinal Aging Study Amsterdam (LASA) offer a boost to calls for physicians to consider “biological” age over chronological age when managing blood pressure in the elderly[1]. In a LASA analysis presented here at HYPERTENSION 2014 , a joint conference of the European Society of Hypertension (ESH) and the International Society of Hypertension (ISH), Dr Majon Muller (Leiden University Medical Center, the Netherlands) showed that both high and low diastolic blood pressure (DBP) are associated with increased cardiovascular risk, depending on the relative fitness or frailty of the subject.

“It’s important when you treat an older patient with hypertension not to look only at the chronological age, which is what clinicians tend to do—one 85-year-old could be totally different from another 85-year-old, in terms of function and biological age,” she told heartwire . “There is a group of older people who are really fit, and they should probably be treated the same as younger patients, and there is a group of older people who are really frail, and then you probably have to be careful treating too aggressively, or [consider whether you should] even be treating at all.”

Muller and colleagues tracked all-cause mortality over 15 years of follow-up in 1466 older men and women participating in LASA, with all participants stratified at baseline according to their “biological” age. This was derived from a scoring system that took into account their fitness—arbitrarily defined by gait speed during the 6-m-walk test—and cognitive function by Mini Mental State Examination (MMSE) score.

Young at Heart?

Mean chronological age in the study was 76 at baseline, but 59% of patients were categorized as frail by the biological age score, while the remaining 41% were deemed fit.

Over a median of 11 years, 1008 participants died. In the population as a whole, systolic blood pressure (SBP) had no relationship with mortality risk. By contrast, both high and low DBP were linked to increased mortality.

When the mortality risk according to diastolic blood pressure was analyzed by biological age, a striking pattern emerged, Muller said.

For fit elderly patients, a high DBP (>90 mm Hg) was associated with a 50% increase in mortality; however, no significantly increased risk was seen for a low DBP (70 mm Hg) in these patients.

By contrast, for frail elderly patients, a low DBP was associated with a 50% increased risk of dying during the follow-up period, while no such risk was seen among frail elderly with DBPs higher than 90 mm Hg.

“Future research should focus on whether we can use biological age to identify those older people who might benefit or not from antihypertensive treatment and maybe whether less stringent targets could be used in the frail, older subjects,” Muller concluded. “The ultimate goal is personalized treatment so that we can avoid overtreatment of the frail and undertreatment of the fit.”

The ultimate goal is personalized treatment so that we can avoid overtreatment of the frail, and undertreatment of the fit.

Commenting on the study, Dr Michael Weber (State University of New York, Brooklyn), one of the session moderators, called the study “provocative” but noted that it was at odds with the Framingham study in which both low systolic and low diastolic BP appeared to track with risk in older subjects.

In response, Muller acknowledged she, too, was surprised to see no link with low SBP but noted that patients in this LASA analysis were “a little older” than the Framingham subjects. Moreover, the range in SBP values for fit and frail subjects was not large, potentially limiting the ability of researchers to see a difference.

A Simple Score vs Gut Instinct

The “Biological Age Combination Score” used by Muller and colleagues awarded a 0 to subjects with a gait speed of 0.8 m/s, a 1 for a gait speed <0.8 m/s, and a 2 for subjects who did not complete the test. A 0 was also given to subjects who scored >28 points on the MMSE, a 1 if they scored 27 to 28 points, and a 2 if they scored 26 points. Fit was then defined as score of 0-1 and frail by a score of 2-4.

To heartwire , Muller clarified that the score has not been validated, but it offers a simple tool physicians can use to try to gauge biological age. Many physicians, however, are already comfortable trusting their gut feeling as to whether a patient is physically or mentally frail.

“I think many physicians do this instinctively, and maybe the gut feeling of the physician is enough,” she said. In fact, she continued, it may not matter what tool is used to estimate biological age, as long as physicians are aware of its importance. “This score may help especially for less experienced physicians to have a tool to quantify the fitness of the person. If you are experienced, maybe that gut feeling is enough, but if not, you could apply these tests, just to make sure that you can quantify it.”

Muller had no conflicts of interest.

References

(CNN) — Do you tend to forget things when you’re stressed? Like when you’re late for a meeting and can’t remember where you left your car keys? Or when you have to give a big presentation and suddenly forget all your talking points seconds before you start?

There’s nothing like stress to make your memory go a little spotty. A 2010 study found that chronic stress reduces spatial memory: the memory that helps you recall locations and relate objects.

Hence, your missing car keys.

University of Iowa researchers also found a connection between the stress hormone cortisol and short-term memory loss in older adults. Their findings, published in the Journal of Neuroscience this week, found that cortisol reduced synapses — connections that help store and recall information — in the pre-frontal cortex.

But there’s a difference between how your brain processes long-term job stress, for example, and the stress of getting into a car accident. Research suggests low levels of anxiety can affect your ability to recall memories; acute or high-anxiety situations, on the other hand, can actually reinforce the learning process.

Trust your memory? Maybe you shouldn’t

How addiction changes your brain

We may soon be able to upload memories

Generation stressed: teens boiling over

Acute stress increases your brain’s ability to encode and recall traumatic events, according to studies. These memories get stored in the part of the brain responsible for survival, and serve as a warning and defense mechanism against future trauma.

If the stress you’re experiencing is ongoing, however, there can be devastating effects.

Neuroscientists from the University of California, Berkeley, found that chronic stress can create long-term changes in the brain. Stress increases the development of white matter, which helps send messages across the brain, but decreases the number of neurons that assist with information processing.

The neuroscientists say the resulting imbalance can affect your brain’s ability to communicate with itself, and make you more vulnerable to developing a mental illness.

Defects in white matter have been associated with schizophrenia, chronic depression, bipolar disorder, obsessive-compulsive disorder and post-traumatic stress disorder. Research on post-traumatic stress disorder further shows that it can reduce the amount of gray matter in the brain.

The Berkeley researchers believe their findings could explain why young people who are exposed to chronic stress early in life are prone to learning difficulties, anxiety and other mood disorders.

To reduce the effects of stress, the Mayo Clinic recommends identifying and reducing stress triggers. Eating a healthy diet, exercising, getting enough sleep and participating in a stress-reduction activity such as deep breathing, massage or yoga, can also help.

Stress may harm the brain, but it recovers

Lisa Nainggolan | Disclosures

SAN FRANCISCO — Improving the quality of food consumed was associated with a significant 10% reduction in risk for type 2 diabetes among healthy adults, while a worsening diet had the opposite effect, boosting the chance of developing diabetes by about 20%, new observational research shows.

“Improving diet quality could be helpful in diabetes prevention — changing your diet matters,” lead author Sylvia H Ley, PhD, of the department of nutrition at the Harvard School of Public Health, Boston, Massachusetts, told a press conference here at the American Diabetes Association (ADA) 2014 Scientific Sessions.

Dr. Ley presented her findings during an oral session today, and while she acknowledged the outcomes were perhaps not rocket science, she ventured: “Healthy eating is still somewhat abstract, and people have difficulty understanding what better-quality eating means. Whole grains, fruits and vegetables, and nuts and seeds are all healthful, and these were not huge changes [to make].”

Moderator of the press briefing, diabetes educator Melinda Maryniuk, RD, from the Joslin Diabetes Center, Boston, Massachusetts, said: “This is known, but isn’t it great to have more science to prove what we know makes sense?

“An improved quality of diet really does matter, [as does] getting that message — what we mean by quality nutrition — out to people.”

Dr. Ley said they also found that diet was associated with diabetes “independent of weight loss and increased physical activity,” indicating that “improving diet quality alone has significant benefits.”

Ms. Maryniuk added to Medscape Medical News: “It’s exciting that we don’t have to put as much focus on weight loss, which can feel so frustrating to patients because so often it’s not successful. Whereas making small changes and improving the quality — whether it’s whole grains or more fruit and vegetables, or less saturated fat — really can make a significant difference in reducing the risk for getting type 2 diabetes.”

For Better, for Worse: Both Changes Have an Impact

Dr. Ley explained that while randomized controlled trials have shown that lifestyle changes can prevent or delay type 2 diabetes in individuals at high risk, it has not been clear that improving diet quality would be associated with a reduced risk for diabetes among healthy adults.

So she and her colleagues looked at those who changed the quality of the food they ate, for better or worse, during a 4-year period and examined the impact of these changes on subsequent 4-year type 2 diabetes risk among 3 observational cohorts of men and women: the Nurses’ Health Study (NHS) I (1986–2010), NHS II (1991–2011), and the Health Professionals Follow-up Study (1986–2010).

The Alternative Health Eating Index 2010 score was used to assess diet quality and comprised 11 variables, Dr. Ley explained, including consumption of red meat; nuts; sugar-sweetened beverages; vegetables; fruits; polyunsaturated fats; trans fats; omega-3 fats (fish); alcohol; whole grains; and sodium.

They documented just over 9000 incident cases of type 2 diabetes during almost 2,500,000 person-year follow-up.

A greater than 10% decrease in diet quality score over 4 years was associated with an almost 20% higher subsequent diabetes risk (pooled hazard ratio [HR], 1.18 with multiple adjustment).

Conversely, an improvement of 10% in dietary score was associated with a lower risk for type 2 diabetes (pooled HR, 0.91).

“So the message is, there is impact on both ends,” Dr. Ley observed.

And Where You Start Doesn’t Matter

She and her colleagues also looked at starting points and whether being on a poor-, medium-, or high-quality diet to begin with had a bearing on the results.

“We learned that at all these different starting points, people who improved their intake had an improvement in their diabetes incidence. This shows that regardless of where you start, improving your diet quality is helpful to diabetes prevention,” she observed.

And, she noted, most people were eating a very poor-quality diet to begin with; “this is what people were doing naturally.”

Dr. Ley and Ms. Maryniuk have reported no relevant financial relationships.

American Diabetes Association 2014 Scientific Sessions; June 14, 2014. Abstract 74-OR 

Alice Goodman | Disclosures

PARIS — The presence of 3 specific micro (mi)RNAs in the blood appears to predict the eventual development of severe osteoarthritis, new research shows.

“Ours is the first study to identify these biomarkers in a large population-based cohort,” said investigator Christian Beyer, MD, from the University of Erlangen-Nuremberg in Germany.

“Results suggest that, for the first time, we will be able to predict the risk of severe osteoarthritis before the disease starts to take a toll on patients’ lives. This will enable us to take preventive action early on to decrease the impact on patients’ lives and the socioeconomic burden,” he explained.

Currently, miRNAs are being used as biomarkers in many fields, including cancer, diabetes, and cardiovascular disease. “They can persist, remain stable at different temperatures and conditions, and are assessable in the blood,” said Dr. Beyer.

He presented the study results here at the European League Against Rheumatism (EULAR) Congress 2014.

The investigators evaluated existing serum samples from patients with osteoarthritis who were part of the Bruneck cohort that was followed from 1995 to 2010. The primary outcome measure was the need for joint replacement surgery of the hip or knee.

During the follow-up period, 67 of the 816 patients underwent at least 1 joint replacement surgery for severe osteoarthritis of the knee or hip. These patients were significantly older than those who did not undergo surgery (P = .053), and they had higher body mass indexes (P = .002).

The existing blood samples were tested for miRNA expression at baseline.

The investigators identified 12 of about 374 miRNAs as candidate biomarkers. On Cox regression analysis, they found that 3 of these miRNAs were associated with the need for hip or knee replacement: miR-454, miR-885-5p, and let-7e.

“The most promising single miRNA was let-7e,” Dr. Beyer reported. “The lower the levels of let-7e, the higher the likelihood of needing surgery for osteoarthritis of the knee or hip.”

“The study opens many new questions,” Dr. Beyer said. “Where do these miRNAs arise? In the diseased joint? Can they affect disease activity? Should we validate these in other cohorts?”

He pointed out that the study cohort consisted of heterogeneous group of people from a small hospital, and noted that these findings need to be confirmed in a larger study.

Currently, several ongoing studies are underway to determine if these biomarkers can be used in clinical practice.

Use in Clinical Practice

One expert thinks that might happen soon.

These biomarkers could come to clinical practice sooner rather than later, said Ulf Müller-Ladner, MD, chair of the Department of Rheumatology at the University of Giessen in Germany and chair of the EULAR scientific program.

“Small miRNA are easily measured. If you pick the right ones, you can predict or diagnose disease,” he said. Once these findings are validated in a larger study, they can be used clinically. “Right now, miRNAs are being used in other diseases. They are easily measured and are not affected by temperature,” Dr. Müller-Ladner said.

If a patient has a mother in a wheelchair because of osteoarthritis, “you will be able to discuss the predicted course of the disease. If patients appear to have biomarkers for severe disease, you can encourage them to lose weight and exercise and treat them more aggressively,” he explained.

Dr. Beyer and Dr. Müller-Ladner have disclosed no relevant financial relationships.

European League Against Rheumatism (EULAR) Congress 2014: Abstract OP0003. Presented June 11, 2014.

5 studies you may have missed
http://thechart.blogs.cnn.com/2014/06/05/hope-for-parkinsons-patients-5-studies-you-may-have-missed/

DALLAS ― A yoga program designed specifically for patients with multiple sclerosis (MS) improves walking ability, balance, fatigue, and general health status, and might even help control inflammation, a new pilot study suggests.

The results add weight to the importance of physical activity in MS patients, said lead study author Evan T. Cohen, PhD, a physical therapist and associate professor, Rutgers School of Health Related Professions, the State University of New Jersey, Stratford.

“Neurologists should be recommending exercise to their MS patients, and if a patient chooses yoga, that’s a viable option, depending on that person’s needs.”

However, it’s not possible from this study to say definitively that yoga is better than other modes of physical activity. Dr. Cohen pointed out that the study was “exploratory” and involved researchers “casting a very wide net.” Larger studies, now being planned, will likely bring in more conclusive information, he said.

Dr. Cohen presented the current study results at the 6th Cooperative Meeting of the Consortium of Multiple Sclerosis Centers (CMSC) and the Americas Committee for Treatment and Research in Multiple Sclerosis (ACTRIMS).

Expert Panel

The study enrolled 15 women, with a mean age of 53.5 years, who had been living with MS for about 14 years. They participated in specially designed yoga classes that were held at a nearby center. In a way, the size of the study was limited by the number of individuals who could fit into the yoga studio, commented Dr. Cohen.

The yoga program was developed by a panel of experts that included yoga instructors, researchers, patients who teach or practice yoga, healthcare providers, and scientists. Led by 2 trained teachers and an assistant, the classes were a “hybridized” version of various yoga styles, said Dr. Cohen. They included elements of breathing, meditation, yoga philosophy, relaxation, and yoga postures.

The program was specifically designed for MS patients with moderate disability, said Dr. Cohen. “It’s probably too easy for people in an early stage of the disease, but probably not appropriate for people in later stages.”

However, moderate disability can encompass varying levels of mobility. The study included patients with almost full function, as well as 2 patients whose primary mode of mobility was a wheelchair, even though they met the study’s inclusion criteria of being able to walk a certain distance, said Dr. Cohen.

The yoga program consisted of 2 90-minute sessions per week for 8 weeks.

Participants were encouraged to also practice yoga at home.

The classes were very well tolerated, with a participation rate of 89%. Fourteen of the 15 enrollees finished the program; 1 participant dropped out early. After complaining of chest pain while completing the 6-minute walk test, it was discovered that she had heart disease and needed surgery.

Researchers collected data at baseline (before the intervention), immediately after the intervention (at week 9), and again after an 8-week period (week 16).

They found significant improvements (P ˂ .05) at week 9 in the Timed 25 Walk Test (T25FW), the Nine-Hole Peg Test–Dominant Hand (NHPT-D), the 5-Times Sit-to-Stand (5STS) test, the Multidirectional Reach Test–Backward (MDRT-B), the 12-Item Multiple Sclerosis Walking Scale, the Modified Fatigue Impact Scale, the Mental Health Inventory (MHI), and several subscales of the 36- item Short Form Health Status Survey (SF-36). Significant improvements persisted to week 16 in performance of the T25FW, NHPT-D, 5STS, MDRT-B, and MHI.

One area of improvement was balance, noted Dr. Cohen. “In yoga, there is a lot of balancing on a stable platform ― you’re standing on your feet rather than moving around a lot like with Tai Chi exercises,” said Dr. Cohen.

Practice Element

How does yoga improve such deficits in MS? “I think that there’s an element of task-specific practice,” said Dr. Cohen. “In the posturing and the breathing, there may be an element of physical practice that might explain some of the changes in physical performance measures.”

As for improvements in quality-of-life measures, “an element of camaraderie and purpose” may be involved, said Dr. Cohen.

What sets this study apart from others is that the researchers took blood samples and are now analyzing the impact of yoga on various parameters. So far, said Dr. Cohen, preliminary analysis has shown changes to C-reactive protein and interleukin-6, -7, and -8, which, although interesting, is not conclusive.

But although changes in physical performance and quality-of-life measures may to some degree be attributable to a placebo effect, that cannot be the case for inflammatory markers. “You can’t lie about blood work,” said Dr Cohen, adding that these changes “certainly raise the question of what’s happening.”

Dr. Cohen cautioned, though, that the sample size was small.

The meditation element of yoga may have contributed in some way to improvements in quality of life, and perhaps even changes in blood work, said Dr. Cohen. “There’s evidence that shows that mindfulness and meditation have a physiological effect.”

The researchers now plan to do a larger study ― with as many as 60 participants to control for heterogeneity. That study would include some kind of control, possibly a “wait list” group, said Dr. Cohen.

Practicing yoga is common among MS patients. Surveys shows that between 12% and 31% of these patients have participated in yoga and that 60% to 80% found it helpful. However, although there is plenty of anecdotal evidence of yoga’s benefits, there has been little research to substantiate this, said Dr. Cohen.

Approached for a comment, Lily Jung-Henson, MD, a neurologist at Swedish Neuroscience Institute, Seattle, Washington, said the results “look great.”

“Although the sample size is small, there are essentially no negatives here regardless of whether the benefits we see are due to yoga itself or the socialization which it provides participants.”

Most neurologists and physiatrists already recommend yoga to their MS patients, said Dr. Jung-Henson. “This just gives us more incentive.”

Dr. Cohen reports no relevant financial relationships.

6th Cooperative Meeting of the Consortium of Multiple Sclerosis Centers (CMSC) and the Americas Committee for Treatment and Research in Multiple Sclerosis (ACTRIMS). Abstract SX02. Presented May 30, 2014.

People working at physically inactive jobs who do not do physical exercise outside of work were more likely to develop chronic neck pain than workers who did some physical activity during their leisure time.

The CDC has called on physicians and other health providers to encourage adults with disabilities to get regular aerobic activity for their physical and mental health.