Amy Rothman Schonfeld

PHILADELPHIA — Vertebral fractures are present in a significant percentage of children with rheumatic diseases, and these fractures appear prior to prolonged glucocorticoid exposure, according to Dr. Leanne M. Ward.

“Vertebral fractures are an underrecognized complication of steroid-treated rheumatic disorders,” said Dr. Ward, director of the Pediatric Bone Health Clinical and Research Programs at University of Ottawa. “But when do the fractures first occur—in the course of the disease or steroid treatment.”

Investigators from the Canadian STOPP (Steroid-Associated Osteoporosis in the Pediatric Population) Consortium evaluated the spine health of 134 children (89 girls, median age 10 years) with rheumatic conditions. Thirty children had juvenile dermatomyositis (JDM), 28 had juvenile idiopathic arthritis (JIA) excluding systemic JIA, and 76 were diagnosed with other rheumatic disorders (systemic lupus erythematosus, systemic vasculitides, systemic JIA, and others). The children underwent thoracolumbar spine x-rays and lumbar spine areal bone mineral density (LS aBMD) evaluation within 30 days of beginning glucocorticoid therapy.

Seven percent of the group (9 of 134) had vertebral fractures; in these 9 children, 6 patients had a single vertebral fracture, while 3 patients had between 2 and 5 fractures, for a total of 13 fractures. Three of the fractures (23%) were moderate, and the rest were deemed mild. Most fractures were located in the mid-thoracic and upper lumbar regions, said Dr. Ward, who presented the findings at the annual meeting of the American College of Rheumatology.

Although the mean LS aBMD scores for the group were lower compared with the norm (−0.6 plus or minus 1.22, P<.001), LS aBMD did not predict the development of vertebral fractures. The odds for fracture were increased 10-fold if the child reported back pain.

The STOPP Consortium was founded in 2003 as a Canadian national pediatric bone health working group of investigators from 12 tertiary children's hospitals. Its main focus is to track bone mineral accrual and incident spine fractures in glucocorticoid-treated children. The group plans to follow children for 6 years from the time treatment is initiated, allowing investigators to determine cumulative vertebral fracture rates and the potential for bone mass restitution and reshaping of fractured vertebral bodies.

Dr. Ward recommends children with rheumatic diseases undergo baseline spine radiographs at the time of diagnosis and then annually, or more frequently if they have new onset back pain. Children with vertebral fractures who are symptomatic (i.e., have back pain) may be candidates for bisphosphonate therapy, she said.

Dr. Ward reported having a business relationship with Novartis.

Fracture (L1), seen in a girl on chronic steroids for JDM.

Source Courtesy Dr. Leanne M. Ward

PHILADELPHIA — Vertebral fractures are present in a significant percentage of children with rheumatic diseases, and these fractures appear prior to prolonged glucocorticoid exposure, according to Dr. Leanne M. Ward.

“Vertebral fractures are an underrecognized complication of steroid-treated rheumatic disorders,” said Dr. Ward, director of the Pediatric Bone Health Clinical and Research Programs at University of Ottawa. “But when do the fractures first occur—in the course of the disease or steroid treatment.”

Investigators from the Canadian STOPP (Steroid-Associated Osteoporosis in the Pediatric Population) Consortium evaluated the spine health of 134 children (89 girls, median age 10 years) with rheumatic conditions. Thirty children had juvenile dermatomyositis (JDM), 28 had juvenile idiopathic arthritis (JIA) excluding systemic JIA, and 76 were diagnosed with other rheumatic disorders (systemic lupus erythematosus, systemic vasculitides, systemic JIA, and others). The children underwent thoracolumbar spine x-rays and lumbar spine areal bone mineral density (LS aBMD) evaluation within 30 days of beginning glucocorticoid therapy.

Seven percent of the group (9 of 134) had vertebral fractures; in these 9 children, 6 patients had a single vertebral fracture, while 3 patients had between 2 and 5 fractures, for a total of 13 fractures. Three of the fractures (23%) were moderate, and the rest were deemed mild. Most fractures were located in the mid-thoracic and upper lumbar regions, said Dr. Ward, who presented the findings at the annual meeting of the American College of Rheumatology.

Although the mean LS aBMD scores for the group were lower compared with the norm (−0.6 plus or minus 1.22, P<.001), LS aBMD did not predict the development of vertebral fractures. The odds for fracture were increased 10-fold if the child reported back pain.

The STOPP Consortium was founded in 2003 as a Canadian national pediatric bone health working group of investigators from 12 tertiary children's hospitals. Its main focus is to track bone mineral accrual and incident spine fractures in glucocorticoid-treated children. The group plans to follow children for 6 years from the time treatment is initiated, allowing investigators to determine cumulative vertebral fracture rates and the potential for bone mass restitution and reshaping of fractured vertebral bodies.

Dr. Ward recommends children with rheumatic diseases undergo baseline spine radiographs at the time of diagnosis and then annually, or more frequently if they have new onset back pain. Children with vertebral fractures who are symptomatic (i.e., have back pain) may be candidates for bisphosphonate therapy, she said.

Dr. Ward reported having a business relationship with Novartis.

Fracture (L1), seen in a girl on chronic steroids for JDM.

Source Courtesy Dr. Leanne M. Ward

PHILADELPHIA — Vertebral fractures are present in a significant percentage of children with rheumatic diseases, and these fractures appear prior to prolonged glucocorticoid exposure, according to Dr. Leanne M. Ward.

“Vertebral fractures are an underrecognized complication of steroid-treated rheumatic disorders,” said Dr. Ward, director of the Pediatric Bone Health Clinical and Research Programs at University of Ottawa. “But when do the fractures first occur—in the course of the disease or steroid treatment.”

Investigators from the Canadian STOPP (Steroid-Associated Osteoporosis in the Pediatric Population) Consortium evaluated the spine health of 134 children (89 girls, median age 10 years) with rheumatic conditions. Thirty children had juvenile dermatomyositis (JDM), 28 had juvenile idiopathic arthritis (JIA) excluding systemic JIA, and 76 were diagnosed with other rheumatic disorders (systemic lupus erythematosus, systemic vasculitides, systemic JIA, and others). The children underwent thoracolumbar spine x-rays and lumbar spine areal bone mineral density (LS aBMD) evaluation within 30 days of beginning glucocorticoid therapy.

Seven percent of the group (9 of 134) had vertebral fractures; in these 9 children, 6 patients had a single vertebral fracture, while 3 patients had between 2 and 5 fractures, for a total of 13 fractures. Three of the fractures (23%) were moderate, and the rest were deemed mild. Most fractures were located in the mid-thoracic and upper lumbar regions, said Dr. Ward, who presented the findings at the annual meeting of the American College of Rheumatology.

Although the mean LS aBMD scores for the group were lower compared with the norm (−0.6 plus or minus 1.22, P<.001), LS aBMD did not predict the development of vertebral fractures. The odds for fracture were increased 10-fold if the child reported back pain.

The STOPP Consortium was founded in 2003 as a Canadian national pediatric bone health working group of investigators from 12 tertiary children's hospitals. Its main focus is to track bone mineral accrual and incident spine fractures in glucocorticoid-treated children. The group plans to follow children for 6 years from the time treatment is initiated, allowing investigators to determine cumulative vertebral fracture rates and the potential for bone mass restitution and reshaping of fractured vertebral bodies.

Dr. Ward recommends children with rheumatic diseases undergo baseline spine radiographs at the time of diagnosis and then annually, or more frequently if they have new onset back pain. Children with vertebral fractures who are symptomatic (i.e., have back pain) may be candidates for bisphosphonate therapy, she said.

Dr. Ward reported having a business relationship with Novartis.

Fracture (L1), seen in a girl on chronic steroids for JDM.

Source Courtesy Dr. Leanne M. Ward

PHILADELPHIA — A new study confirms what rheumatologists already know: Some patients with gout fail to achieve adequate reductions in serum urate levels with recommended levels of allopurinol.

For these patients, increasing the dose of allopurinol above the recommended dose can lower serum urate to target levels, according to Dr. Lisa Stamp, who presented her results at the annual meeting of the American College of Rheumatology.

“The problem with the guidelines is that many patients fail to achieve target serum urate levels of less than 6 mg/dL, the critical level above which gout is more likely to occur. We are … commonly undertreating” the disease, said Dr. Stamp, a rheumatologist at the University of Otago, Dunedin, New Zealand.

Dr. Stamp and her colleagues enrolled 90 patients with gout who were on stable doses of allopurinol for at least 1 month (mean age, 58 years; 88% male). After the initial visit, 52 were found to have serum uric acid levels greater than 6 mg/dL. Of those, seven received lower-than-recommended allopurinol doses, as defined by the Hande criteria based on creatinine clearance.

Allopurinol dosage was increased above the recommended range for 45 patients in 50- to 100-mg increments per month until they reached target serum uric acid levels. Of 36 patients who completed the entire 12-month study period, 85% (31 patients) achieved serum uric acid levels less than or equal to 6 mg/dL at 12 months. No serious allopurinol-related adverse events were reported.

All dose increases of allopurinol above recommended guidelines significantly reduced serum uric acid. The percentage decrease in serum uric acid from baseline was 12.6% when 50 mg was added to the recommended dose, 20.8% when 100 mg was added, 25.9% with 150 mg 36.2% with 200 mg. 30% with 250 mg, and 35.6% with 300 mg. Some patients required dosage increases of up to 400 mg/day.

“My current recommendation is to first get the patient to the current recommended dose for at least 1 month before a dose increase. If that does not work, consider increasing the dose,” Dr. Stamp said.

Notably, five of the patients who were initially found to have serum uric acid levels greater than 6 mg/dL were actually found to have no detectable plasma oxypurinol, indicating noncompliance. “You have to keep reminding patients the disease will come back if they stop taking the allopurinol,” she added.

Dr. Stamp disclosed a relationship with Wyeth Pharmaceuticals.

PHILADELPHIA — A new study confirms what rheumatologists already know: Some patients with gout fail to achieve adequate reductions in serum urate levels with recommended levels of allopurinol.

For these patients, increasing the dose of allopurinol above the recommended dose can lower serum urate to target levels, according to Dr. Lisa Stamp, who presented her results at the annual meeting of the American College of Rheumatology.

“The problem with the guidelines is that many patients fail to achieve target serum urate levels of less than 6 mg/dL, the critical level above which gout is more likely to occur. We are … commonly undertreating” the disease, said Dr. Stamp, a rheumatologist at the University of Otago, Dunedin, New Zealand.

Dr. Stamp and her colleagues enrolled 90 patients with gout who were on stable doses of allopurinol for at least 1 month (mean age, 58 years; 88% male). After the initial visit, 52 were found to have serum uric acid levels greater than 6 mg/dL. Of those, seven received lower-than-recommended allopurinol doses, as defined by the Hande criteria based on creatinine clearance.

Allopurinol dosage was increased above the recommended range for 45 patients in 50- to 100-mg increments per month until they reached target serum uric acid levels. Of 36 patients who completed the entire 12-month study period, 85% (31 patients) achieved serum uric acid levels less than or equal to 6 mg/dL at 12 months. No serious allopurinol-related adverse events were reported.

All dose increases of allopurinol above recommended guidelines significantly reduced serum uric acid. The percentage decrease in serum uric acid from baseline was 12.6% when 50 mg was added to the recommended dose, 20.8% when 100 mg was added, 25.9% with 150 mg 36.2% with 200 mg. 30% with 250 mg, and 35.6% with 300 mg. Some patients required dosage increases of up to 400 mg/day.

“My current recommendation is to first get the patient to the current recommended dose for at least 1 month before a dose increase. If that does not work, consider increasing the dose,” Dr. Stamp said.

Notably, five of the patients who were initially found to have serum uric acid levels greater than 6 mg/dL were actually found to have no detectable plasma oxypurinol, indicating noncompliance. “You have to keep reminding patients the disease will come back if they stop taking the allopurinol,” she added.

Dr. Stamp disclosed a relationship with Wyeth Pharmaceuticals.

PHILADELPHIA — A new study confirms what rheumatologists already know: Some patients with gout fail to achieve adequate reductions in serum urate levels with recommended levels of allopurinol.

For these patients, increasing the dose of allopurinol above the recommended dose can lower serum urate to target levels, according to Dr. Lisa Stamp, who presented her results at the annual meeting of the American College of Rheumatology.

“The problem with the guidelines is that many patients fail to achieve target serum urate levels of less than 6 mg/dL, the critical level above which gout is more likely to occur. We are … commonly undertreating” the disease, said Dr. Stamp, a rheumatologist at the University of Otago, Dunedin, New Zealand.

Dr. Stamp and her colleagues enrolled 90 patients with gout who were on stable doses of allopurinol for at least 1 month (mean age, 58 years; 88% male). After the initial visit, 52 were found to have serum uric acid levels greater than 6 mg/dL. Of those, seven received lower-than-recommended allopurinol doses, as defined by the Hande criteria based on creatinine clearance.

Allopurinol dosage was increased above the recommended range for 45 patients in 50- to 100-mg increments per month until they reached target serum uric acid levels. Of 36 patients who completed the entire 12-month study period, 85% (31 patients) achieved serum uric acid levels less than or equal to 6 mg/dL at 12 months. No serious allopurinol-related adverse events were reported.

All dose increases of allopurinol above recommended guidelines significantly reduced serum uric acid. The percentage decrease in serum uric acid from baseline was 12.6% when 50 mg was added to the recommended dose, 20.8% when 100 mg was added, 25.9% with 150 mg 36.2% with 200 mg. 30% with 250 mg, and 35.6% with 300 mg. Some patients required dosage increases of up to 400 mg/day.

“My current recommendation is to first get the patient to the current recommended dose for at least 1 month before a dose increase. If that does not work, consider increasing the dose,” Dr. Stamp said.

Notably, five of the patients who were initially found to have serum uric acid levels greater than 6 mg/dL were actually found to have no detectable plasma oxypurinol, indicating noncompliance. “You have to keep reminding patients the disease will come back if they stop taking the allopurinol,” she added.

Dr. Stamp disclosed a relationship with Wyeth Pharmaceuticals.

PHILADELPHIA — Drinking water or skim milk can improve gout control, according to findings from two studies that highlight the important contribution of lifestyle factors on gout prevention and management.

“Our results show that drinking water is a simple, safe, and effective means of trying to reduce recurrent gout attacks,” Dr. Tuhina Neogi said at the annual meeting of the American College of Rheumatology.

The study included 535 people who had had a gout attack within the past year (78% male; mean age, 53 years) and who provided information via the Internet about food, drink, medications, physical activity, and other possible gout risk factors during periods preceding the attack and during attack-free periods. Through use of a case crossover study design, the participants acted as their own controls. Medical records were accessed to verify gout diagnosis, explained Dr. Neogi of Boston University.

The findings showed that increasing water intake was associated with decreased risk for recurrent gout attacks. Compared with those who drank no water or one 8-ounce glass of water per day, those who drank five to eight glasses had a 40% lower chance of a gout attack and those who drank more than eight glasses had a 46% lower chance.

“Our results were adjusted for total fluid intake. They were specific for water,” commented Dr. Neogi. “This suggests that dehydration, which can potentially affect uric acid in the blood and its solubility, may indeed be an important trigger for gout attacks.”

In the second study, researchers from New Zealand measured the acute effects of skim milk consumption on serum urate concentrations in 16 healthy male volunteers, in light of reports that skim milk was beneficial in gout prevention. The randomized, controlled, crossover study was designed to assess the effects of skim milk that was from the early season and the late season, as well as MCP85, a milk protein concentrate that contains 85% protein. The effects of soy milk consumption also were assessed, and it was considered the control.

“Late-season” skim milk, which is primarily available from countries where milking is seasonal and cows are grass fed, is high in orotic acid, a substance known to promote uric acid removal by the kidneys, explained Dr. Nicola Dalbeth, a senior lecturer in clinical medicine at the University of Auckland (New Zealand). MPC85 skim milk is ultrafiltered and contains very low concentrations of orotic acid, purines, and lactose.

Each participant received a single dose of each product in a random order, with each study visit separated by a week. The amount consumed was equal to about 3.5 8-ounce glasses of milk. Serum and urine were obtained immediately before ingestion and then hourly over the next 3 hours.

Drinking soy milk led to a 10% increase in serum urate. In contrast, all skim milks decreased serum urate by about 10% (P less than .0001). All products, including soy, led to an increase in the fractional excretion of uric acid (FEUA).

Interestingly, there were differences among the types of skim milk, which may shed light on the underlying mechanism. Late-season skim milk led to a greater increase in FEUA, compared with either ultrafiltered skim milk or early-season skim milk, suggesting that the acute urate-lowering effect of orotic acid may explain these effects.

“We cannot necessarily extrapolate these results from [healthy individuals] to those with gout,” Dr. Dalbeth acknowledged. “Furthermore, I am not saying drinking milk should replace allopurinol. But one of the key things we do is spend a lot of time telling people with gout what not to do, such as do not eat red meat. It is very useful to have some positive information.”

Dr. Neogi reported having no conflicts of interest. Dr. Dalbeth said that her study was funded in part by the Fonterra Dairy Cooperative, and that one of the study authors was an employee of Fonterra.

PHILADELPHIA — Drinking water or skim milk can improve gout control, according to findings from two studies that highlight the important contribution of lifestyle factors on gout prevention and management.

“Our results show that drinking water is a simple, safe, and effective means of trying to reduce recurrent gout attacks,” Dr. Tuhina Neogi said at the annual meeting of the American College of Rheumatology.

The study included 535 people who had had a gout attack within the past year (78% male; mean age, 53 years) and who provided information via the Internet about food, drink, medications, physical activity, and other possible gout risk factors during periods preceding the attack and during attack-free periods. Through use of a case crossover study design, the participants acted as their own controls. Medical records were accessed to verify gout diagnosis, explained Dr. Neogi of Boston University.

The findings showed that increasing water intake was associated with decreased risk for recurrent gout attacks. Compared with those who drank no water or one 8-ounce glass of water per day, those who drank five to eight glasses had a 40% lower chance of a gout attack and those who drank more than eight glasses had a 46% lower chance.

“Our results were adjusted for total fluid intake. They were specific for water,” commented Dr. Neogi. “This suggests that dehydration, which can potentially affect uric acid in the blood and its solubility, may indeed be an important trigger for gout attacks.”

In the second study, researchers from New Zealand measured the acute effects of skim milk consumption on serum urate concentrations in 16 healthy male volunteers, in light of reports that skim milk was beneficial in gout prevention. The randomized, controlled, crossover study was designed to assess the effects of skim milk that was from the early season and the late season, as well as MCP85, a milk protein concentrate that contains 85% protein. The effects of soy milk consumption also were assessed, and it was considered the control.

“Late-season” skim milk, which is primarily available from countries where milking is seasonal and cows are grass fed, is high in orotic acid, a substance known to promote uric acid removal by the kidneys, explained Dr. Nicola Dalbeth, a senior lecturer in clinical medicine at the University of Auckland (New Zealand). MPC85 skim milk is ultrafiltered and contains very low concentrations of orotic acid, purines, and lactose.

Each participant received a single dose of each product in a random order, with each study visit separated by a week. The amount consumed was equal to about 3.5 8-ounce glasses of milk. Serum and urine were obtained immediately before ingestion and then hourly over the next 3 hours.

Drinking soy milk led to a 10% increase in serum urate. In contrast, all skim milks decreased serum urate by about 10% (P less than .0001). All products, including soy, led to an increase in the fractional excretion of uric acid (FEUA).

Interestingly, there were differences among the types of skim milk, which may shed light on the underlying mechanism. Late-season skim milk led to a greater increase in FEUA, compared with either ultrafiltered skim milk or early-season skim milk, suggesting that the acute urate-lowering effect of orotic acid may explain these effects.

“We cannot necessarily extrapolate these results from [healthy individuals] to those with gout,” Dr. Dalbeth acknowledged. “Furthermore, I am not saying drinking milk should replace allopurinol. But one of the key things we do is spend a lot of time telling people with gout what not to do, such as do not eat red meat. It is very useful to have some positive information.”

Dr. Neogi reported having no conflicts of interest. Dr. Dalbeth said that her study was funded in part by the Fonterra Dairy Cooperative, and that one of the study authors was an employee of Fonterra.

PHILADELPHIA — Drinking water or skim milk can improve gout control, according to findings from two studies that highlight the important contribution of lifestyle factors on gout prevention and management.

“Our results show that drinking water is a simple, safe, and effective means of trying to reduce recurrent gout attacks,” Dr. Tuhina Neogi said at the annual meeting of the American College of Rheumatology.

The study included 535 people who had had a gout attack within the past year (78% male; mean age, 53 years) and who provided information via the Internet about food, drink, medications, physical activity, and other possible gout risk factors during periods preceding the attack and during attack-free periods. Through use of a case crossover study design, the participants acted as their own controls. Medical records were accessed to verify gout diagnosis, explained Dr. Neogi of Boston University.

The findings showed that increasing water intake was associated with decreased risk for recurrent gout attacks. Compared with those who drank no water or one 8-ounce glass of water per day, those who drank five to eight glasses had a 40% lower chance of a gout attack and those who drank more than eight glasses had a 46% lower chance.

“Our results were adjusted for total fluid intake. They were specific for water,” commented Dr. Neogi. “This suggests that dehydration, which can potentially affect uric acid in the blood and its solubility, may indeed be an important trigger for gout attacks.”

In the second study, researchers from New Zealand measured the acute effects of skim milk consumption on serum urate concentrations in 16 healthy male volunteers, in light of reports that skim milk was beneficial in gout prevention. The randomized, controlled, crossover study was designed to assess the effects of skim milk that was from the early season and the late season, as well as MCP85, a milk protein concentrate that contains 85% protein. The effects of soy milk consumption also were assessed, and it was considered the control.

“Late-season” skim milk, which is primarily available from countries where milking is seasonal and cows are grass fed, is high in orotic acid, a substance known to promote uric acid removal by the kidneys, explained Dr. Nicola Dalbeth, a senior lecturer in clinical medicine at the University of Auckland (New Zealand). MPC85 skim milk is ultrafiltered and contains very low concentrations of orotic acid, purines, and lactose.

Each participant received a single dose of each product in a random order, with each study visit separated by a week. The amount consumed was equal to about 3.5 8-ounce glasses of milk. Serum and urine were obtained immediately before ingestion and then hourly over the next 3 hours.

Drinking soy milk led to a 10% increase in serum urate. In contrast, all skim milks decreased serum urate by about 10% (P less than .0001). All products, including soy, led to an increase in the fractional excretion of uric acid (FEUA).

Interestingly, there were differences among the types of skim milk, which may shed light on the underlying mechanism. Late-season skim milk led to a greater increase in FEUA, compared with either ultrafiltered skim milk or early-season skim milk, suggesting that the acute urate-lowering effect of orotic acid may explain these effects.

“We cannot necessarily extrapolate these results from [healthy individuals] to those with gout,” Dr. Dalbeth acknowledged. “Furthermore, I am not saying drinking milk should replace allopurinol. But one of the key things we do is spend a lot of time telling people with gout what not to do, such as do not eat red meat. It is very useful to have some positive information.”

Dr. Neogi reported having no conflicts of interest. Dr. Dalbeth said that her study was funded in part by the Fonterra Dairy Cooperative, and that one of the study authors was an employee of Fonterra.

PHILADELPHIA — The rate of common joint operations in patients with rheumatoid arthritis, notably those aged 40-59 years, has decreased overall during the past 25 years, according to data from a population-based, cross-sectional study.

“Recent studies suggest long-term outcomes of rheumatoid arthritis have been improving. There have been notable decreases in disability as well as damage on x-rays,” said Dr. Grant H. Louie at the annual meeting of the American College of Rheumatology.

In their study of California residents 40 years of age or older with rheumatoid arthritis, Dr. Louie and his coinvestigator Dr. Michael Ward examined age-, sex-, and race-adjusted rates of four types of joint surgery per 100,000 rheumatoid arthritis patients from 1983 to 2007. Data were pooled into 5-year intervals.

The data showed that rates of joint surgery peaked in the 1990s, and since then have decreased.

For all patients aged 40 years or older, the total number of knee replacements fell by 2% between 1983 and 2007; this difference was not significant.

The rate of hip replacement in the overall population increased by 2%, a change that also was not significant, reported Dr. Louie of the National Institute of Arthritis and Musculoskeletal and Skin Diseases in Bethesda, Md.

However, when the data were stratified by age into older and younger groups, younger rheumatoid arthritis patients (aged 40-59 years) showed a 19% drop in the rate of total knee arthroplasty in 2003-2007, compared with 1983-1987 (adjusted rate ratio 0.81, 95% confidence interval 0.74-0.87, P less than .0001), while a 40% reduction was found for total hip arthroplasty (adjusted rate ratio 0.60; 95% CI 0.54-0.66, P less than .0001) over those same periods.

A 60% drop was noted for ankle surgery (total ankle arthroplasty or arthrodesis), while wrist surgery (total wrist anthroplasty or arthrodesis) fell by 57%.

For rheumatoid arthritis patients aged 60 years or older, the rates of total knee and hip replacement increased by 4% and 26%, respectively, while rates for ankle and wrist surgery significantly decreased.

“Although we can't know for sure the reasons for these declines in the rates, we speculate that one explanation may be improved treatment of rheumatoid arthritis in the last several decades, as well as better understanding of underlying mechanisms of disease,” he said.

Dr. Louie had no conflict of interest disclosures.

A related video is at www.youtube.com/InternalMedicineNews

“One explanation may be improved treatment of rheumatoid arthritis,” Dr. Grant H. Louie said.

Source Mitchel L. Zoler/Elsevier Global Medical News

PHILADELPHIA — The rate of common joint operations in patients with rheumatoid arthritis, notably those aged 40-59 years, has decreased overall during the past 25 years, according to data from a population-based, cross-sectional study.

“Recent studies suggest long-term outcomes of rheumatoid arthritis have been improving. There have been notable decreases in disability as well as damage on x-rays,” said Dr. Grant H. Louie at the annual meeting of the American College of Rheumatology.

In their study of California residents 40 years of age or older with rheumatoid arthritis, Dr. Louie and his coinvestigator Dr. Michael Ward examined age-, sex-, and race-adjusted rates of four types of joint surgery per 100,000 rheumatoid arthritis patients from 1983 to 2007. Data were pooled into 5-year intervals.

The data showed that rates of joint surgery peaked in the 1990s, and since then have decreased.

For all patients aged 40 years or older, the total number of knee replacements fell by 2% between 1983 and 2007; this difference was not significant.

The rate of hip replacement in the overall population increased by 2%, a change that also was not significant, reported Dr. Louie of the National Institute of Arthritis and Musculoskeletal and Skin Diseases in Bethesda, Md.

However, when the data were stratified by age into older and younger groups, younger rheumatoid arthritis patients (aged 40-59 years) showed a 19% drop in the rate of total knee arthroplasty in 2003-2007, compared with 1983-1987 (adjusted rate ratio 0.81, 95% confidence interval 0.74-0.87, P less than .0001), while a 40% reduction was found for total hip arthroplasty (adjusted rate ratio 0.60; 95% CI 0.54-0.66, P less than .0001) over those same periods.

A 60% drop was noted for ankle surgery (total ankle arthroplasty or arthrodesis), while wrist surgery (total wrist anthroplasty or arthrodesis) fell by 57%.

For rheumatoid arthritis patients aged 60 years or older, the rates of total knee and hip replacement increased by 4% and 26%, respectively, while rates for ankle and wrist surgery significantly decreased.

“Although we can't know for sure the reasons for these declines in the rates, we speculate that one explanation may be improved treatment of rheumatoid arthritis in the last several decades, as well as better understanding of underlying mechanisms of disease,” he said.

Dr. Louie had no conflict of interest disclosures.

A related video is at www.youtube.com/InternalMedicineNews

“One explanation may be improved treatment of rheumatoid arthritis,” Dr. Grant H. Louie said.

Source Mitchel L. Zoler/Elsevier Global Medical News

PHILADELPHIA — The rate of common joint operations in patients with rheumatoid arthritis, notably those aged 40-59 years, has decreased overall during the past 25 years, according to data from a population-based, cross-sectional study.

“Recent studies suggest long-term outcomes of rheumatoid arthritis have been improving. There have been notable decreases in disability as well as damage on x-rays,” said Dr. Grant H. Louie at the annual meeting of the American College of Rheumatology.

In their study of California residents 40 years of age or older with rheumatoid arthritis, Dr. Louie and his coinvestigator Dr. Michael Ward examined age-, sex-, and race-adjusted rates of four types of joint surgery per 100,000 rheumatoid arthritis patients from 1983 to 2007. Data were pooled into 5-year intervals.

The data showed that rates of joint surgery peaked in the 1990s, and since then have decreased.

For all patients aged 40 years or older, the total number of knee replacements fell by 2% between 1983 and 2007; this difference was not significant.

The rate of hip replacement in the overall population increased by 2%, a change that also was not significant, reported Dr. Louie of the National Institute of Arthritis and Musculoskeletal and Skin Diseases in Bethesda, Md.

However, when the data were stratified by age into older and younger groups, younger rheumatoid arthritis patients (aged 40-59 years) showed a 19% drop in the rate of total knee arthroplasty in 2003-2007, compared with 1983-1987 (adjusted rate ratio 0.81, 95% confidence interval 0.74-0.87, P less than .0001), while a 40% reduction was found for total hip arthroplasty (adjusted rate ratio 0.60; 95% CI 0.54-0.66, P less than .0001) over those same periods.

A 60% drop was noted for ankle surgery (total ankle arthroplasty or arthrodesis), while wrist surgery (total wrist anthroplasty or arthrodesis) fell by 57%.

For rheumatoid arthritis patients aged 60 years or older, the rates of total knee and hip replacement increased by 4% and 26%, respectively, while rates for ankle and wrist surgery significantly decreased.

“Although we can't know for sure the reasons for these declines in the rates, we speculate that one explanation may be improved treatment of rheumatoid arthritis in the last several decades, as well as better understanding of underlying mechanisms of disease,” he said.

Dr. Louie had no conflict of interest disclosures.

A related video is at www.youtube.com/InternalMedicineNews

“One explanation may be improved treatment of rheumatoid arthritis,” Dr. Grant H. Louie said.

Source Mitchel L. Zoler/Elsevier Global Medical News

PHILADELPHIA — Increasing the dose of allopurinol above the recommended dose can lower serum urate to target levels in gout patients who do not respond to recommended doses, said Dr. Lisa Stamp, who presented her results at the annual meeting of the American College of Rheumatology.

“My current recommendation is to first get the patient to the current recommended dose for at least 1 month before a dose increase. If that does not work, consider increasing the dose,” said Dr. Stamp, a rheumatologist at the University of Otago, Dunedin, New Zealand.

Dr. Stamp and her colleagues enrolled 90 patients with gout who were on stable doses of allopurinol for at least 1 month (mean age, 58 years; 88% male). After the initial visit, 52 were found to have serum uric acid levels greater than 6 mg/dL. Of those, seven received lower-than-recommended allopurinol doses, as defined by the Hande criteria based on creatinine clearance.

Allopurinol dosage was increased above the recommended range for 45 patients in 50- to 100-mg increments per month until they reached target serum uric acid levels. Of 36 patients who completed the entire 12-month study period, 85% (31 patients) achieved serum uric acid levels less than or equal to 6 mg/dL at the 12 month end point. In all, 6 of the 45 patients were lost to follow-up, and 3 discontinued because they developed a rash. No other serious allopurinol-related adverse events were reported, including no reports of hypersensitivity syndrome, renal stones, or impaired liver function.

Dr. Stamp disclosed a relationship with Wyeth Pharmaceuticals.

PHILADELPHIA — Increasing the dose of allopurinol above the recommended dose can lower serum urate to target levels in gout patients who do not respond to recommended doses, said Dr. Lisa Stamp, who presented her results at the annual meeting of the American College of Rheumatology.

“My current recommendation is to first get the patient to the current recommended dose for at least 1 month before a dose increase. If that does not work, consider increasing the dose,” said Dr. Stamp, a rheumatologist at the University of Otago, Dunedin, New Zealand.

Dr. Stamp and her colleagues enrolled 90 patients with gout who were on stable doses of allopurinol for at least 1 month (mean age, 58 years; 88% male). After the initial visit, 52 were found to have serum uric acid levels greater than 6 mg/dL. Of those, seven received lower-than-recommended allopurinol doses, as defined by the Hande criteria based on creatinine clearance.

Allopurinol dosage was increased above the recommended range for 45 patients in 50- to 100-mg increments per month until they reached target serum uric acid levels. Of 36 patients who completed the entire 12-month study period, 85% (31 patients) achieved serum uric acid levels less than or equal to 6 mg/dL at the 12 month end point. In all, 6 of the 45 patients were lost to follow-up, and 3 discontinued because they developed a rash. No other serious allopurinol-related adverse events were reported, including no reports of hypersensitivity syndrome, renal stones, or impaired liver function.

Dr. Stamp disclosed a relationship with Wyeth Pharmaceuticals.

PHILADELPHIA — Increasing the dose of allopurinol above the recommended dose can lower serum urate to target levels in gout patients who do not respond to recommended doses, said Dr. Lisa Stamp, who presented her results at the annual meeting of the American College of Rheumatology.

“My current recommendation is to first get the patient to the current recommended dose for at least 1 month before a dose increase. If that does not work, consider increasing the dose,” said Dr. Stamp, a rheumatologist at the University of Otago, Dunedin, New Zealand.

Dr. Stamp and her colleagues enrolled 90 patients with gout who were on stable doses of allopurinol for at least 1 month (mean age, 58 years; 88% male). After the initial visit, 52 were found to have serum uric acid levels greater than 6 mg/dL. Of those, seven received lower-than-recommended allopurinol doses, as defined by the Hande criteria based on creatinine clearance.

Allopurinol dosage was increased above the recommended range for 45 patients in 50- to 100-mg increments per month until they reached target serum uric acid levels. Of 36 patients who completed the entire 12-month study period, 85% (31 patients) achieved serum uric acid levels less than or equal to 6 mg/dL at the 12 month end point. In all, 6 of the 45 patients were lost to follow-up, and 3 discontinued because they developed a rash. No other serious allopurinol-related adverse events were reported, including no reports of hypersensitivity syndrome, renal stones, or impaired liver function.

Dr. Stamp disclosed a relationship with Wyeth Pharmaceuticals.

PHILADELPHIA — Drinking water or skim milk can improve gout control, according to findings from two studies that highlight the important contribution of lifestyle factors on gout prevention and management.

“Our results show that drinking water is a simple, safe, and effective means of trying to reduce recurrent gout attacks,” Dr. Tuhina Neogi said at the annual meeting of the American College of Rheumatology.

The study included 535 people who had had a gout attack within the past year (78% male; mean age, 53 years) and who provided information via the Internet about food, drink, medications, physical activity, and other possible gout risk factors during periods preceding the attack and during attack-free periods. By using a case-crossover study design, the participants acted as their own controls. Medical records were accessed to verify gout diagnosis, explained Dr. Neogi of Boston University.

The findings showed that increasing water intake was associated with decreased risk for recurrent gout attacks. Compared with those who drank no or one 8-ounce glass of water per day, those who drank five to eight glasses had a 40% lower chance of a gout attack and those who drank more than eight glasses had a 46% lower chance.

In the second study, researchers from New Zealand measured the acute effects of skim milk consumption on serum urate concentrations in 16 healthy male volunteers, in light of reports that skim milk was beneficial in gout prevention. The randomized controlled crossover study was designed to assess the effects of skim milk that was from the early season and the late season, as well as MPC85, a milk protein concentrate that contains 85% protein. The effects of soy milk consumption also were assessed, and it was considered the control.

“Late-season” skim milk, which is primarily available from countries where milking is seasonal and cows are grass fed, is high in orotic acid, a substance known to promote uric acid removal by the kidneys, explained Dr. Nicola Dalbeth, a senior lecturer in clinical medicine at the University of Auckland (New Zealand). MPC85 skim milk is ultrafiltered and contains very low concentrations of orotic acid, purines, and lactose.

Each participant received a single dose of each product in a random order, with each study visit separated by a week. The amount consumed was equal to about 3.5 8-ounce glasses of milk in one sitting (80 g of protein in 800 mL). Serum and urine were obtained immediately before ingestion and then hourly for the next 3 hours.

Drinking soy milk led to a 10% increase in serum urate. In contrast, all skim milks decreased serum urate by about 10% (P less than .0001). All products, including soy, led to an increase in the fractional excretion of uric acid (FEUA).

Interestingly, late-season skim milk led to a greater increase in FEUA, compared with either ultrafiltered skim milk or early-season skim milk, suggesting that the acute urate-lowering effect of orotic acid may explain these effects.

Dr. Neogi reported having no conflicts of interest. Dr. Dalbeth said that her study was funded in part by the Fonterra Dairy Cooperative, and that one of the study authors was an employee of Fonterra.

Drinking five to eight glasses of water a day reduced gout risk by 40%.

Source ©Igor Dutina/Fotolia.com

PHILADELPHIA — Drinking water or skim milk can improve gout control, according to findings from two studies that highlight the important contribution of lifestyle factors on gout prevention and management.

“Our results show that drinking water is a simple, safe, and effective means of trying to reduce recurrent gout attacks,” Dr. Tuhina Neogi said at the annual meeting of the American College of Rheumatology.

The study included 535 people who had had a gout attack within the past year (78% male; mean age, 53 years) and who provided information via the Internet about food, drink, medications, physical activity, and other possible gout risk factors during periods preceding the attack and during attack-free periods. By using a case-crossover study design, the participants acted as their own controls. Medical records were accessed to verify gout diagnosis, explained Dr. Neogi of Boston University.

The findings showed that increasing water intake was associated with decreased risk for recurrent gout attacks. Compared with those who drank no or one 8-ounce glass of water per day, those who drank five to eight glasses had a 40% lower chance of a gout attack and those who drank more than eight glasses had a 46% lower chance.

In the second study, researchers from New Zealand measured the acute effects of skim milk consumption on serum urate concentrations in 16 healthy male volunteers, in light of reports that skim milk was beneficial in gout prevention. The randomized controlled crossover study was designed to assess the effects of skim milk that was from the early season and the late season, as well as MPC85, a milk protein concentrate that contains 85% protein. The effects of soy milk consumption also were assessed, and it was considered the control.

“Late-season” skim milk, which is primarily available from countries where milking is seasonal and cows are grass fed, is high in orotic acid, a substance known to promote uric acid removal by the kidneys, explained Dr. Nicola Dalbeth, a senior lecturer in clinical medicine at the University of Auckland (New Zealand). MPC85 skim milk is ultrafiltered and contains very low concentrations of orotic acid, purines, and lactose.

Each participant received a single dose of each product in a random order, with each study visit separated by a week. The amount consumed was equal to about 3.5 8-ounce glasses of milk in one sitting (80 g of protein in 800 mL). Serum and urine were obtained immediately before ingestion and then hourly for the next 3 hours.

Drinking soy milk led to a 10% increase in serum urate. In contrast, all skim milks decreased serum urate by about 10% (P less than .0001). All products, including soy, led to an increase in the fractional excretion of uric acid (FEUA).

Interestingly, late-season skim milk led to a greater increase in FEUA, compared with either ultrafiltered skim milk or early-season skim milk, suggesting that the acute urate-lowering effect of orotic acid may explain these effects.

Dr. Neogi reported having no conflicts of interest. Dr. Dalbeth said that her study was funded in part by the Fonterra Dairy Cooperative, and that one of the study authors was an employee of Fonterra.

Drinking five to eight glasses of water a day reduced gout risk by 40%.

Source ©Igor Dutina/Fotolia.com

PHILADELPHIA — Drinking water or skim milk can improve gout control, according to findings from two studies that highlight the important contribution of lifestyle factors on gout prevention and management.

“Our results show that drinking water is a simple, safe, and effective means of trying to reduce recurrent gout attacks,” Dr. Tuhina Neogi said at the annual meeting of the American College of Rheumatology.

The study included 535 people who had had a gout attack within the past year (78% male; mean age, 53 years) and who provided information via the Internet about food, drink, medications, physical activity, and other possible gout risk factors during periods preceding the attack and during attack-free periods. By using a case-crossover study design, the participants acted as their own controls. Medical records were accessed to verify gout diagnosis, explained Dr. Neogi of Boston University.

The findings showed that increasing water intake was associated with decreased risk for recurrent gout attacks. Compared with those who drank no or one 8-ounce glass of water per day, those who drank five to eight glasses had a 40% lower chance of a gout attack and those who drank more than eight glasses had a 46% lower chance.

In the second study, researchers from New Zealand measured the acute effects of skim milk consumption on serum urate concentrations in 16 healthy male volunteers, in light of reports that skim milk was beneficial in gout prevention. The randomized controlled crossover study was designed to assess the effects of skim milk that was from the early season and the late season, as well as MPC85, a milk protein concentrate that contains 85% protein. The effects of soy milk consumption also were assessed, and it was considered the control.

“Late-season” skim milk, which is primarily available from countries where milking is seasonal and cows are grass fed, is high in orotic acid, a substance known to promote uric acid removal by the kidneys, explained Dr. Nicola Dalbeth, a senior lecturer in clinical medicine at the University of Auckland (New Zealand). MPC85 skim milk is ultrafiltered and contains very low concentrations of orotic acid, purines, and lactose.

Each participant received a single dose of each product in a random order, with each study visit separated by a week. The amount consumed was equal to about 3.5 8-ounce glasses of milk in one sitting (80 g of protein in 800 mL). Serum and urine were obtained immediately before ingestion and then hourly for the next 3 hours.

Drinking soy milk led to a 10% increase in serum urate. In contrast, all skim milks decreased serum urate by about 10% (P less than .0001). All products, including soy, led to an increase in the fractional excretion of uric acid (FEUA).

Interestingly, late-season skim milk led to a greater increase in FEUA, compared with either ultrafiltered skim milk or early-season skim milk, suggesting that the acute urate-lowering effect of orotic acid may explain these effects.

Dr. Neogi reported having no conflicts of interest. Dr. Dalbeth said that her study was funded in part by the Fonterra Dairy Cooperative, and that one of the study authors was an employee of Fonterra.

Drinking five to eight glasses of water a day reduced gout risk by 40%.

Source ©Igor Dutina/Fotolia.com

PHILADELPHIA — Women who personally used insecticides were more likely to develop autoimmune rheumatic diseases, and their risk increased with more frequent and longer use, according to findings from the Women's Health Initiative observational study presented by Christine G. Parks, Ph.D., at the annual meeting of the American College of Rheumatology. Similar results were found for those whose homes were treated with insecticides by others.

“Previous studies have suggested that rheumatoid arthritis and lupus might be associated with farm work and agricultural pesticide exposure, but these exposures are generally rare in the population. On the other hand, exposure to personal use of insecticides and other residential exposures are more common. Studies show about three-quarters of U.S. household reported using pesticides in the home or garden.

A recent survey in the National Health and Nutrition Examination Survey [NHANES] found that 20% of respondents applied insecticides in the past month, said Dr. Parks, an epidemiologist with the National Institute of Environmental Health Science in Research Triangle Park, N.C.

To examine whether there is an association with autoimmune rheumatic diseases and personal or residential insecticide use, investigators mined data from the WHI observational study, which included 76,861 postmenopausal women (aged 50-79 years) and looked at self-reports of lifetime personal or residential insecticide use.

The use of disease-modifying antirheumatic drugs after 3 years of follow-up was considered to be confirmation of the presence of an autoimmune rheumatic disease.

The investigators identified 213 new cases of autoimmune rheumatic diseases, of which 27 were systemic lupus erythematosus and 178 were rheumatoid arthritis. Eight of the women had both conditions.

Compared with the women who had never used insecticides, those who personally mixed or applied insecticides had greater risk of developing a rheumatic disease, with stronger associations among those who used insecticides more frequently.

For instance, the hazard ratio for those who either never used insecticides or used them for less than 1 year was 0.94, compared with 1.5 for those reporting 1-4 years of exposure, 1.2 for 5-19 years of exposure, and 1.9 for 20 or more years of exposure. The trend across time was statistically significant (P = .0034).

Similarly, the risk of developing a rheumatic disease was doubled in women who had used insecticides more frequently (six or more times per year), compared with those who personally had never used insecticides (HR 2.0). The trend with increased frequency of use also was statistically significant (P = .0036).

Hazard ratios and 95% confidence intervals were estimated by multivariate models. “Importantly, the associations we saw were not explained by other factors that we considered, including farm history; age; race; region; ethnicity; socioeconomic factors, such as education or occupation; smoking; or other risk factors for disease,” Dr. Parks said.

The investigators also confirmed the association between living or working on a farm, and the risk of autoimmune rheumatic diseases (HR 1.97; 95% CI 1.14-3.42 for 20 years). The highest risk was found in women who had lived on a farm and who also reported personal insecticide use.

Living in a house where insecticides had been used for 20 years or more also elevated the risk of autoimmune rheumatic diseases, regardless of farming history (HR 1.85; 95% CI 1.13-3.04 for 20 years).

No information was provided about specific types of pesticides used. Although the findings are not proof of a causal relationship between pesticide exposure and the development of rheumatic illnesses, the take-home message is that people should follow recommended practices to reduce their exposure to pesticides, Dr. Parks said.

PHILADELPHIA — Women who personally used insecticides were more likely to develop autoimmune rheumatic diseases, and their risk increased with more frequent and longer use, according to findings from the Women's Health Initiative observational study presented by Christine G. Parks, Ph.D., at the annual meeting of the American College of Rheumatology. Similar results were found for those whose homes were treated with insecticides by others.

“Previous studies have suggested that rheumatoid arthritis and lupus might be associated with farm work and agricultural pesticide exposure, but these exposures are generally rare in the population. On the other hand, exposure to personal use of insecticides and other residential exposures are more common. Studies show about three-quarters of U.S. household reported using pesticides in the home or garden.

A recent survey in the National Health and Nutrition Examination Survey [NHANES] found that 20% of respondents applied insecticides in the past month, said Dr. Parks, an epidemiologist with the National Institute of Environmental Health Science in Research Triangle Park, N.C.

To examine whether there is an association with autoimmune rheumatic diseases and personal or residential insecticide use, investigators mined data from the WHI observational study, which included 76,861 postmenopausal women (aged 50-79 years) and looked at self-reports of lifetime personal or residential insecticide use.

The use of disease-modifying antirheumatic drugs after 3 years of follow-up was considered to be confirmation of the presence of an autoimmune rheumatic disease.

The investigators identified 213 new cases of autoimmune rheumatic diseases, of which 27 were systemic lupus erythematosus and 178 were rheumatoid arthritis. Eight of the women had both conditions.

Compared with the women who had never used insecticides, those who personally mixed or applied insecticides had greater risk of developing a rheumatic disease, with stronger associations among those who used insecticides more frequently.

For instance, the hazard ratio for those who either never used insecticides or used them for less than 1 year was 0.94, compared with 1.5 for those reporting 1-4 years of exposure, 1.2 for 5-19 years of exposure, and 1.9 for 20 or more years of exposure. The trend across time was statistically significant (P = .0034).

Similarly, the risk of developing a rheumatic disease was doubled in women who had used insecticides more frequently (six or more times per year), compared with those who personally had never used insecticides (HR 2.0). The trend with increased frequency of use also was statistically significant (P = .0036).

Hazard ratios and 95% confidence intervals were estimated by multivariate models. “Importantly, the associations we saw were not explained by other factors that we considered, including farm history; age; race; region; ethnicity; socioeconomic factors, such as education or occupation; smoking; or other risk factors for disease,” Dr. Parks said.

The investigators also confirmed the association between living or working on a farm, and the risk of autoimmune rheumatic diseases (HR 1.97; 95% CI 1.14-3.42 for 20 years). The highest risk was found in women who had lived on a farm and who also reported personal insecticide use.

Living in a house where insecticides had been used for 20 years or more also elevated the risk of autoimmune rheumatic diseases, regardless of farming history (HR 1.85; 95% CI 1.13-3.04 for 20 years).

No information was provided about specific types of pesticides used. Although the findings are not proof of a causal relationship between pesticide exposure and the development of rheumatic illnesses, the take-home message is that people should follow recommended practices to reduce their exposure to pesticides, Dr. Parks said.

PHILADELPHIA — Women who personally used insecticides were more likely to develop autoimmune rheumatic diseases, and their risk increased with more frequent and longer use, according to findings from the Women's Health Initiative observational study presented by Christine G. Parks, Ph.D., at the annual meeting of the American College of Rheumatology. Similar results were found for those whose homes were treated with insecticides by others.

“Previous studies have suggested that rheumatoid arthritis and lupus might be associated with farm work and agricultural pesticide exposure, but these exposures are generally rare in the population. On the other hand, exposure to personal use of insecticides and other residential exposures are more common. Studies show about three-quarters of U.S. household reported using pesticides in the home or garden.

A recent survey in the National Health and Nutrition Examination Survey [NHANES] found that 20% of respondents applied insecticides in the past month, said Dr. Parks, an epidemiologist with the National Institute of Environmental Health Science in Research Triangle Park, N.C.

To examine whether there is an association with autoimmune rheumatic diseases and personal or residential insecticide use, investigators mined data from the WHI observational study, which included 76,861 postmenopausal women (aged 50-79 years) and looked at self-reports of lifetime personal or residential insecticide use.

The use of disease-modifying antirheumatic drugs after 3 years of follow-up was considered to be confirmation of the presence of an autoimmune rheumatic disease.

The investigators identified 213 new cases of autoimmune rheumatic diseases, of which 27 were systemic lupus erythematosus and 178 were rheumatoid arthritis. Eight of the women had both conditions.

Compared with the women who had never used insecticides, those who personally mixed or applied insecticides had greater risk of developing a rheumatic disease, with stronger associations among those who used insecticides more frequently.

For instance, the hazard ratio for those who either never used insecticides or used them for less than 1 year was 0.94, compared with 1.5 for those reporting 1-4 years of exposure, 1.2 for 5-19 years of exposure, and 1.9 for 20 or more years of exposure. The trend across time was statistically significant (P = .0034).

Similarly, the risk of developing a rheumatic disease was doubled in women who had used insecticides more frequently (six or more times per year), compared with those who personally had never used insecticides (HR 2.0). The trend with increased frequency of use also was statistically significant (P = .0036).

Hazard ratios and 95% confidence intervals were estimated by multivariate models. “Importantly, the associations we saw were not explained by other factors that we considered, including farm history; age; race; region; ethnicity; socioeconomic factors, such as education or occupation; smoking; or other risk factors for disease,” Dr. Parks said.

The investigators also confirmed the association between living or working on a farm, and the risk of autoimmune rheumatic diseases (HR 1.97; 95% CI 1.14-3.42 for 20 years). The highest risk was found in women who had lived on a farm and who also reported personal insecticide use.

Living in a house where insecticides had been used for 20 years or more also elevated the risk of autoimmune rheumatic diseases, regardless of farming history (HR 1.85; 95% CI 1.13-3.04 for 20 years).

No information was provided about specific types of pesticides used. Although the findings are not proof of a causal relationship between pesticide exposure and the development of rheumatic illnesses, the take-home message is that people should follow recommended practices to reduce their exposure to pesticides, Dr. Parks said.

BOCA RATON, FLA. — Patients with acute stroke who were successfully revascularized by having their clots removed with an endovascular mechanical device within 8 hours of symptom onset were less disabled and less likely to die than were those whose vessels remained closed, according to findings from a retrospective study.

Dr. Robert W. Tarr led a review of 157 “real-world” patients who had been treated with the Penumbra System, a mechanical device approved in Europe and in the United States in 2007 for use in patients with acute ischemic stroke secondary to intracranial large-vessel occlusive disease within 8 hours of symptom onset.

At baseline, the patients had a mean National Institutes of Health Stroke Scale (NIHSS) score of 16.3, and the average time from symptom onset to presentation was 2 hours.

About half of the patients were occluded in the middle cerebral arteries, whereas occlusions occurred in the internal carotid in about 25% and in the vertebrobasilar arteries in 25%, said Dr. Tarr, chief of neuroradiology at University Hospitals Case Medical Center, Cleveland.

After treatment, 87% of the treated vessels were revascularized to TIMI 2 or TIMI 3 levels. At discharge, those with open vessels were more likely to have an NIHSS score of 0 or 1 or an improvement of more than 10 points than were those whose vessels remained closed (40% vs. 10%, respectively), although this difference did not reach statistical significance. Three months after treatment, patients who were revascularized had lower modified Rankin scores than did patients with closed vessels, indicating that the revascularized patients had significantly lower rates of no to slight disability (45% vs. 13%) and a lower death rate (16% vs. 50%), Dr. Tarr reported at the annual meeting of the Society of NeuroInterventional Surgery.

Nine procedural serious adverse events were reported. Of the 157 patients, 10 (6%) experienced symptomatic intracranial hemorrhages. At the time of the presentation, the all-cause mortality rate was 20%. The device failure rate was about 2%, although Dr. Tarr said that he believes these failures did not promote or accelerate patient deterioration.

“Our postmarketing experience is consistent with the results of the pivotal trial with the Penumbra System with regards to revascularization, intracranial hemorrhage, and procedural complications.

“However, the current study demonstrated a lower mortality and a better functional outcome compared to the pivotal trial. This study also confirms that successful revascularization of intracranial vessels is associated with good outcomes, including less mortality,” said Dr. Tarr, who disclosed having competing interests with Cordis Neurovascular, Boston Scientific, and Philips.

Penumbra did not provide financial support for the study, but did help with data analysis.

BOCA RATON, FLA. — Patients with acute stroke who were successfully revascularized by having their clots removed with an endovascular mechanical device within 8 hours of symptom onset were less disabled and less likely to die than were those whose vessels remained closed, according to findings from a retrospective study.

Dr. Robert W. Tarr led a review of 157 “real-world” patients who had been treated with the Penumbra System, a mechanical device approved in Europe and in the United States in 2007 for use in patients with acute ischemic stroke secondary to intracranial large-vessel occlusive disease within 8 hours of symptom onset.

At baseline, the patients had a mean National Institutes of Health Stroke Scale (NIHSS) score of 16.3, and the average time from symptom onset to presentation was 2 hours.

About half of the patients were occluded in the middle cerebral arteries, whereas occlusions occurred in the internal carotid in about 25% and in the vertebrobasilar arteries in 25%, said Dr. Tarr, chief of neuroradiology at University Hospitals Case Medical Center, Cleveland.

After treatment, 87% of the treated vessels were revascularized to TIMI 2 or TIMI 3 levels. At discharge, those with open vessels were more likely to have an NIHSS score of 0 or 1 or an improvement of more than 10 points than were those whose vessels remained closed (40% vs. 10%, respectively), although this difference did not reach statistical significance. Three months after treatment, patients who were revascularized had lower modified Rankin scores than did patients with closed vessels, indicating that the revascularized patients had significantly lower rates of no to slight disability (45% vs. 13%) and a lower death rate (16% vs. 50%), Dr. Tarr reported at the annual meeting of the Society of NeuroInterventional Surgery.

Nine procedural serious adverse events were reported. Of the 157 patients, 10 (6%) experienced symptomatic intracranial hemorrhages. At the time of the presentation, the all-cause mortality rate was 20%. The device failure rate was about 2%, although Dr. Tarr said that he believes these failures did not promote or accelerate patient deterioration.

“Our postmarketing experience is consistent with the results of the pivotal trial with the Penumbra System with regards to revascularization, intracranial hemorrhage, and procedural complications.

“However, the current study demonstrated a lower mortality and a better functional outcome compared to the pivotal trial. This study also confirms that successful revascularization of intracranial vessels is associated with good outcomes, including less mortality,” said Dr. Tarr, who disclosed having competing interests with Cordis Neurovascular, Boston Scientific, and Philips.

Penumbra did not provide financial support for the study, but did help with data analysis.

BOCA RATON, FLA. — Patients with acute stroke who were successfully revascularized by having their clots removed with an endovascular mechanical device within 8 hours of symptom onset were less disabled and less likely to die than were those whose vessels remained closed, according to findings from a retrospective study.

Dr. Robert W. Tarr led a review of 157 “real-world” patients who had been treated with the Penumbra System, a mechanical device approved in Europe and in the United States in 2007 for use in patients with acute ischemic stroke secondary to intracranial large-vessel occlusive disease within 8 hours of symptom onset.

At baseline, the patients had a mean National Institutes of Health Stroke Scale (NIHSS) score of 16.3, and the average time from symptom onset to presentation was 2 hours.

About half of the patients were occluded in the middle cerebral arteries, whereas occlusions occurred in the internal carotid in about 25% and in the vertebrobasilar arteries in 25%, said Dr. Tarr, chief of neuroradiology at University Hospitals Case Medical Center, Cleveland.

After treatment, 87% of the treated vessels were revascularized to TIMI 2 or TIMI 3 levels. At discharge, those with open vessels were more likely to have an NIHSS score of 0 or 1 or an improvement of more than 10 points than were those whose vessels remained closed (40% vs. 10%, respectively), although this difference did not reach statistical significance. Three months after treatment, patients who were revascularized had lower modified Rankin scores than did patients with closed vessels, indicating that the revascularized patients had significantly lower rates of no to slight disability (45% vs. 13%) and a lower death rate (16% vs. 50%), Dr. Tarr reported at the annual meeting of the Society of NeuroInterventional Surgery.

Nine procedural serious adverse events were reported. Of the 157 patients, 10 (6%) experienced symptomatic intracranial hemorrhages. At the time of the presentation, the all-cause mortality rate was 20%. The device failure rate was about 2%, although Dr. Tarr said that he believes these failures did not promote or accelerate patient deterioration.

“Our postmarketing experience is consistent with the results of the pivotal trial with the Penumbra System with regards to revascularization, intracranial hemorrhage, and procedural complications.

“However, the current study demonstrated a lower mortality and a better functional outcome compared to the pivotal trial. This study also confirms that successful revascularization of intracranial vessels is associated with good outcomes, including less mortality,” said Dr. Tarr, who disclosed having competing interests with Cordis Neurovascular, Boston Scientific, and Philips.

Penumbra did not provide financial support for the study, but did help with data analysis.

BOCA RATON, FLA. – A group of researchers is looking at how patients who undergo endovascular coiling for aneurysmal subarachnoid hemorrhage fare psychologically in the years after the procedure.

The findings indicate that although the aneurysms were successfully repaired, some patients manifest clinical levels of anxiety and depression, as well as some deficits on a quality of life assessment scale, according to Dr. Antonio DeSimone, who presented his results at the annual meeting of the Society of Neurointerventional Surgery meeting.

“Our findings underline the need for focused interventions because of possible psychological morbidity even in good-outcome subjects,” says Dr. DeSimone, a neuroradiologist at the San Giovanni Bosco Hospital in Naples, Italy.

In one study, a group of 30 subjects was selected from a database of 248 subjects who had undergone coiling for intracranial aneurysms from June 2002 to February 2009. Patients had good outcomes with resumption of normal activities, had no evidence of aneurysm recurrence, and at least 1 year had elapsed since treatment.

On the Hospital Anxiety and Depression scale, seven patients (23%) showed anxiety in the clinical range while three other patients (10%) had borderline scores. Four patients (13%) had scores within the clinical range for depression, and an additional five patients (17%) had borderline symptoms.

The same group of subjects was asked to complete the validated Italian version of the Medical Outcome Study 36-item short form questionnaire (SF-36), a widely used tool for assessing quality of life. No difference was noted between the overall scores of the patients versus those of a reference population.

Patients who had undergone coiling did show significant deficits in some domains, such as social functioning (P less than .05), role limitations because of emotional problems (P less than .05), and mental health (P less than .01).

“After an aneurysm is secured either by coiling or clipping, a sympathetic physician must give patients a chance to share their subjective feelings. In most cases, this is enough.

But a competent physician/neurologist can also screen out the patients–according to our data, up to one-third even in those rated as 'good outcome'–who definitely need structured psychological support,” Dr. DeSimone said.

He points out that these patients and their families live in a disconcerting state of limbo and suggests that psychological support be made available to aneurysm patients.

BOCA RATON, FLA. – A group of researchers is looking at how patients who undergo endovascular coiling for aneurysmal subarachnoid hemorrhage fare psychologically in the years after the procedure.

The findings indicate that although the aneurysms were successfully repaired, some patients manifest clinical levels of anxiety and depression, as well as some deficits on a quality of life assessment scale, according to Dr. Antonio DeSimone, who presented his results at the annual meeting of the Society of Neurointerventional Surgery meeting.

“Our findings underline the need for focused interventions because of possible psychological morbidity even in good-outcome subjects,” says Dr. DeSimone, a neuroradiologist at the San Giovanni Bosco Hospital in Naples, Italy.

In one study, a group of 30 subjects was selected from a database of 248 subjects who had undergone coiling for intracranial aneurysms from June 2002 to February 2009. Patients had good outcomes with resumption of normal activities, had no evidence of aneurysm recurrence, and at least 1 year had elapsed since treatment.

On the Hospital Anxiety and Depression scale, seven patients (23%) showed anxiety in the clinical range while three other patients (10%) had borderline scores. Four patients (13%) had scores within the clinical range for depression, and an additional five patients (17%) had borderline symptoms.

The same group of subjects was asked to complete the validated Italian version of the Medical Outcome Study 36-item short form questionnaire (SF-36), a widely used tool for assessing quality of life. No difference was noted between the overall scores of the patients versus those of a reference population.

Patients who had undergone coiling did show significant deficits in some domains, such as social functioning (P less than .05), role limitations because of emotional problems (P less than .05), and mental health (P less than .01).

“After an aneurysm is secured either by coiling or clipping, a sympathetic physician must give patients a chance to share their subjective feelings. In most cases, this is enough.

But a competent physician/neurologist can also screen out the patients–according to our data, up to one-third even in those rated as 'good outcome'–who definitely need structured psychological support,” Dr. DeSimone said.

He points out that these patients and their families live in a disconcerting state of limbo and suggests that psychological support be made available to aneurysm patients.

BOCA RATON, FLA. – A group of researchers is looking at how patients who undergo endovascular coiling for aneurysmal subarachnoid hemorrhage fare psychologically in the years after the procedure.

The findings indicate that although the aneurysms were successfully repaired, some patients manifest clinical levels of anxiety and depression, as well as some deficits on a quality of life assessment scale, according to Dr. Antonio DeSimone, who presented his results at the annual meeting of the Society of Neurointerventional Surgery meeting.

“Our findings underline the need for focused interventions because of possible psychological morbidity even in good-outcome subjects,” says Dr. DeSimone, a neuroradiologist at the San Giovanni Bosco Hospital in Naples, Italy.

In one study, a group of 30 subjects was selected from a database of 248 subjects who had undergone coiling for intracranial aneurysms from June 2002 to February 2009. Patients had good outcomes with resumption of normal activities, had no evidence of aneurysm recurrence, and at least 1 year had elapsed since treatment.

On the Hospital Anxiety and Depression scale, seven patients (23%) showed anxiety in the clinical range while three other patients (10%) had borderline scores. Four patients (13%) had scores within the clinical range for depression, and an additional five patients (17%) had borderline symptoms.

The same group of subjects was asked to complete the validated Italian version of the Medical Outcome Study 36-item short form questionnaire (SF-36), a widely used tool for assessing quality of life. No difference was noted between the overall scores of the patients versus those of a reference population.

Patients who had undergone coiling did show significant deficits in some domains, such as social functioning (P less than .05), role limitations because of emotional problems (P less than .05), and mental health (P less than .01).

“After an aneurysm is secured either by coiling or clipping, a sympathetic physician must give patients a chance to share their subjective feelings. In most cases, this is enough.

But a competent physician/neurologist can also screen out the patients–according to our data, up to one-third even in those rated as 'good outcome'–who definitely need structured psychological support,” Dr. DeSimone said.

He points out that these patients and their families live in a disconcerting state of limbo and suggests that psychological support be made available to aneurysm patients.

OLYMPIC VALLEY, CALIF. — A new minimally invasive procedure dramatically reduced pain and disability for a small group of patients with lumbar spinal stenosis. No complications or adverse events were reported, and patients were discharged the same day or the next day.

The procedure is performed using the MILD (minimally invasive lumbar decompression) device that allows practitioners to perform a lumbar decompression to remove bone to access the area of stenosis under fluoroscopic guidance, and then widen and decompress the canal by thinning or sculpting the bone and enlarged ligaments that compress the nerve roots. Low back pain, leg fatigue and pain, and physical impairments are attributed to this compression, according to Dr. Joshua A. Hirsch.

“I view the MILD procedure as part of a broadening array of treatments that minimally invasive spine specialists can offer patients with lumbar spinal stenosis,” said Dr. Hirsch, director of interventional neuroradiology/endovascular neurosurgery and chief of minimally invasive spine surgery at Massachusetts General Hospital, Boston.

As of July 2008, 42 patients with severe spinal stenosis underwent the MILD procedure. Ten patients were followed under an institutional review board-approved protocol designed to assess improvement in pain using a Visual Analog Scale (VAS), and disability using the Oswestry Disability Index (ODI). Preoperatively, these patients had ODI scores of 60%–80%, indicating that they were crippled by their condition, and VAS pain scores of 6–10.

At 6 weeks post treatment, the mean disability score improved by 84% compared with baseline (ODI 0%–20%) and the mean pain score decreased by 90% (VAS scores at 1). All 10 patients had discontinued narcotics use for pain by 6 weeks post op and were discharged from the hospital on the same day or the day following the procedure. “These are phenomenal results,” said Dr. Hirsch, who noted that these initial promising results must be validated by further study.

No complications have been reported from the procedure. Other advantages of the procedure are that it requires only local sedation, allows patients to recover quickly, and offers the possibility of delaying or preventing more invasive surgery. The incisions are smaller than a dime, said Dr. Hirsch, who presented his findings at the annual meeting of the Society of Neurointerventional Surgery and received travel support from the device's manufacturer, Vertos Medical Inc., of San Jose, Calif.

During an interview, Dr. Allan L. Brook, director of interventional neuroradiology at Montefiore Medical Center, New York, said he has used the MILD device in three cases. Montefiore is 1 of 10 sites participating in the Vertos-sponsored MILD Preliminary Patient Evaluation Study, a multicenter, prospective clinical study to assess the clinical application and outcomes of minimally invasive lumbar decompression with the devices in patients who have symptomatic spinal stenosis.

“These patients have had dramatic pain relief. The majority of these patients have exhausted standard medical therapies, as well as numerous other less invasive injections. I believe many patients could benefit from this minimally invasive posterior lumbar decompression,” said Dr. Brook. He noted that there are no other percutaneous procedures that attempt to remove the soft tissue that impinges from behind the nerves; most aim to remove the disk or rely upon open surgical techniques, with their known risks.

Dr. Brooks reported that he has no financial relationship with Vertos Medical.

“Lumbar spinal stenosis is a huge problem which really impacts people's quality of life. Approximately 1.5 million people in the U.S. are diagnosed with it every year—about twice the number of those who have vertebral compression fractures,” said Dr. Hirsch. “The MILD device allows us to provide a minimally invasive alternative to traditional laminectomy/laminotomy.”

In the first step, the bone rongeur is utilized to remove posterior bone.

A bone-removing device accesses ligamentum flavum.

The soft tissue rongeur removes ligament posterior to epidural space. Photos courtesy Dr. Allan L. Brook

At 6 weeks post treatment, the mean disability score improved by 84% compared with baseline. DR. HIRSH

OLYMPIC VALLEY, CALIF. — A new minimally invasive procedure dramatically reduced pain and disability for a small group of patients with lumbar spinal stenosis. No complications or adverse events were reported, and patients were discharged the same day or the next day.

The procedure is performed using the MILD (minimally invasive lumbar decompression) device that allows practitioners to perform a lumbar decompression to remove bone to access the area of stenosis under fluoroscopic guidance, and then widen and decompress the canal by thinning or sculpting the bone and enlarged ligaments that compress the nerve roots. Low back pain, leg fatigue and pain, and physical impairments are attributed to this compression, according to Dr. Joshua A. Hirsch.

“I view the MILD procedure as part of a broadening array of treatments that minimally invasive spine specialists can offer patients with lumbar spinal stenosis,” said Dr. Hirsch, director of interventional neuroradiology/endovascular neurosurgery and chief of minimally invasive spine surgery at Massachusetts General Hospital, Boston.

As of July 2008, 42 patients with severe spinal stenosis underwent the MILD procedure. Ten patients were followed under an institutional review board-approved protocol designed to assess improvement in pain using a Visual Analog Scale (VAS), and disability using the Oswestry Disability Index (ODI). Preoperatively, these patients had ODI scores of 60%–80%, indicating that they were crippled by their condition, and VAS pain scores of 6–10.

At 6 weeks post treatment, the mean disability score improved by 84% compared with baseline (ODI 0%–20%) and the mean pain score decreased by 90% (VAS scores at 1). All 10 patients had discontinued narcotics use for pain by 6 weeks post op and were discharged from the hospital on the same day or the day following the procedure. “These are phenomenal results,” said Dr. Hirsch, who noted that these initial promising results must be validated by further study.

No complications have been reported from the procedure. Other advantages of the procedure are that it requires only local sedation, allows patients to recover quickly, and offers the possibility of delaying or preventing more invasive surgery. The incisions are smaller than a dime, said Dr. Hirsch, who presented his findings at the annual meeting of the Society of Neurointerventional Surgery and received travel support from the device's manufacturer, Vertos Medical Inc., of San Jose, Calif.

During an interview, Dr. Allan L. Brook, director of interventional neuroradiology at Montefiore Medical Center, New York, said he has used the MILD device in three cases. Montefiore is 1 of 10 sites participating in the Vertos-sponsored MILD Preliminary Patient Evaluation Study, a multicenter, prospective clinical study to assess the clinical application and outcomes of minimally invasive lumbar decompression with the devices in patients who have symptomatic spinal stenosis.

“These patients have had dramatic pain relief. The majority of these patients have exhausted standard medical therapies, as well as numerous other less invasive injections. I believe many patients could benefit from this minimally invasive posterior lumbar decompression,” said Dr. Brook. He noted that there are no other percutaneous procedures that attempt to remove the soft tissue that impinges from behind the nerves; most aim to remove the disk or rely upon open surgical techniques, with their known risks.

Dr. Brooks reported that he has no financial relationship with Vertos Medical.

“Lumbar spinal stenosis is a huge problem which really impacts people's quality of life. Approximately 1.5 million people in the U.S. are diagnosed with it every year—about twice the number of those who have vertebral compression fractures,” said Dr. Hirsch. “The MILD device allows us to provide a minimally invasive alternative to traditional laminectomy/laminotomy.”

In the first step, the bone rongeur is utilized to remove posterior bone.

A bone-removing device accesses ligamentum flavum.

The soft tissue rongeur removes ligament posterior to epidural space. Photos courtesy Dr. Allan L. Brook

At 6 weeks post treatment, the mean disability score improved by 84% compared with baseline. DR. HIRSH

OLYMPIC VALLEY, CALIF. — A new minimally invasive procedure dramatically reduced pain and disability for a small group of patients with lumbar spinal stenosis. No complications or adverse events were reported, and patients were discharged the same day or the next day.

The procedure is performed using the MILD (minimally invasive lumbar decompression) device that allows practitioners to perform a lumbar decompression to remove bone to access the area of stenosis under fluoroscopic guidance, and then widen and decompress the canal by thinning or sculpting the bone and enlarged ligaments that compress the nerve roots. Low back pain, leg fatigue and pain, and physical impairments are attributed to this compression, according to Dr. Joshua A. Hirsch.

“I view the MILD procedure as part of a broadening array of treatments that minimally invasive spine specialists can offer patients with lumbar spinal stenosis,” said Dr. Hirsch, director of interventional neuroradiology/endovascular neurosurgery and chief of minimally invasive spine surgery at Massachusetts General Hospital, Boston.

As of July 2008, 42 patients with severe spinal stenosis underwent the MILD procedure. Ten patients were followed under an institutional review board-approved protocol designed to assess improvement in pain using a Visual Analog Scale (VAS), and disability using the Oswestry Disability Index (ODI). Preoperatively, these patients had ODI scores of 60%–80%, indicating that they were crippled by their condition, and VAS pain scores of 6–10.

At 6 weeks post treatment, the mean disability score improved by 84% compared with baseline (ODI 0%–20%) and the mean pain score decreased by 90% (VAS scores at 1). All 10 patients had discontinued narcotics use for pain by 6 weeks post op and were discharged from the hospital on the same day or the day following the procedure. “These are phenomenal results,” said Dr. Hirsch, who noted that these initial promising results must be validated by further study.

No complications have been reported from the procedure. Other advantages of the procedure are that it requires only local sedation, allows patients to recover quickly, and offers the possibility of delaying or preventing more invasive surgery. The incisions are smaller than a dime, said Dr. Hirsch, who presented his findings at the annual meeting of the Society of Neurointerventional Surgery and received travel support from the device's manufacturer, Vertos Medical Inc., of San Jose, Calif.

During an interview, Dr. Allan L. Brook, director of interventional neuroradiology at Montefiore Medical Center, New York, said he has used the MILD device in three cases. Montefiore is 1 of 10 sites participating in the Vertos-sponsored MILD Preliminary Patient Evaluation Study, a multicenter, prospective clinical study to assess the clinical application and outcomes of minimally invasive lumbar decompression with the devices in patients who have symptomatic spinal stenosis.

“These patients have had dramatic pain relief. The majority of these patients have exhausted standard medical therapies, as well as numerous other less invasive injections. I believe many patients could benefit from this minimally invasive posterior lumbar decompression,” said Dr. Brook. He noted that there are no other percutaneous procedures that attempt to remove the soft tissue that impinges from behind the nerves; most aim to remove the disk or rely upon open surgical techniques, with their known risks.

Dr. Brooks reported that he has no financial relationship with Vertos Medical.

“Lumbar spinal stenosis is a huge problem which really impacts people's quality of life. Approximately 1.5 million people in the U.S. are diagnosed with it every year—about twice the number of those who have vertebral compression fractures,” said Dr. Hirsch. “The MILD device allows us to provide a minimally invasive alternative to traditional laminectomy/laminotomy.”

In the first step, the bone rongeur is utilized to remove posterior bone.

A bone-removing device accesses ligamentum flavum.

The soft tissue rongeur removes ligament posterior to epidural space. Photos courtesy Dr. Allan L. Brook

At 6 weeks post treatment, the mean disability score improved by 84% compared with baseline. DR. HIRSH