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Patients may ask about a study showing that older adults with spinal stenosis are more frequently undergoing complex (and more hazardous and expensive) surgery.

Writing in JAMA, researchers detail an investigation using Medicare claims data between 2002 and 2007. During that period, the overall number of lumbar stenosis operations declined slightly, while use of the most complex approach increased some 15-fold.

In examining 2007 data, the researchers found that more complex fusion operations had double the rate of major medical complications and double the 30-day mortality of decompression alone. The average hospital charge for the more complex procedure was some $80,000 — versus $24,000 for decompression.

An editorialist concludes that “conflicting economic incentives are clearly at work,” noting that a surgeon’s reimbursement for the more complex approach can be ten times that of simple decompression. Current financial incentives and market forces in medicine, he says, amount to “a formidable economic and social problem.”

 Archives of Internal Medicine article (Free)

Archives of Internal Medicine commentary (Subscription required)

American College of Physicians/American Pain Society guideline on managing low back pain (Free)

General practitioners rarely follow guidelines when managing new episodes of low back pain, reports the Archives of Internal Medicine. (The analysis was conducted in Australia, but the guidelines assessed match those in the U.S.)

 Researchers examined data on some 1700 visits to GPs for new low back pain from 2005 to 2008, after national guidelines for treating musculoskeletal pain were released. Among the findings:

 Although guidelines recommend acetaminophen as a first-line analgesic, it was prescribed for only 18% of patients. NSAIDs and opioids were prescribed for 37% and 20%, respectively.

• One fourth of patients were referred for imaging, despite guidelines advising against routine referral.
• Only one fifth of patients received advice and education as recommended.

 These findings were similar to those from the period before guideline publication.

 The authors conclude: “The results indicate that in most cases, usual care is not evidence-based care and so is not likely to provide the best outcomes.”

Listen to the world renowed thyroid expert and author of the book “Why do I still have thyroid symptoms, when my labs are normal?, Dr. Datis Kharrazian’s radio interview. There are 2 parts.

Audio 1

Audio 2

Effect of phototherapy on delayed onset muscle soreness.Douris P, Southard V, Ferrigi R, Grauer J, Katz D, Nascimento C, Podbielski P.
Department of Physical Therapy, School of Health Professions, Behavioral and Life Sciences, New York Institute of Technology, Old Westbury, New York 11568-8000, USA. pdouris@nyit.edu

OBJECTIVE: The purpose of this study was to investigate the effects of phototherapy on delayed onset muscle soreness (DOMS) as measured using the Visual Analog Scale (VAS), McGill Pain Questionnaire, Resting Angle (RANG), and girth measurements.
BACKGROUND DATA: Previous research has failed to prove the beneficial effects of phototherapy on DOMS.
METHODS: This was a randomized double-blind controlled study with 27 subjects (18-35 years) assigned to one of three groups. The experimental group received 8 J/cm2 of phototherapy each day for five consecutive days using super luminous diodes with wavelengths of 880 and visible diodes of 660 nm at three standardized sites over the musculotendinous junction of the bicep. The sham group received identical treatment from a dummy cluster. The controls did not receive treatment. The study was completed over five consecutive days: on day one baseline measurements of RANG and upper arm girths were recorded prior to DOMS induction. On days 2-5, RANG, girth, and pain were assessed using VAS and the McGill Pain Questionnaire.
RESULTS: The experimental group exhibited a significant decrease in pain associated with DOMS compared to the control (p=0.01) and sham groups (p=0.03) based upon the VAS at the 48-h period. The McGill Pain Questionnaire showed a significant difference in pain scores at the 48-h period between the experimental and the sham groups (p=0.01). There were no significant differences day to day and between the groups with respect to girth and RANG.
CONCLUSION: The results of this study provide scientific evidence that phototherapy as used in this study provides a beneficial effect to patients who may experience DOMS after a novel exercise session.

PMID: 16875447 [PubMed - indexed for MEDLINE]

Effect of 655-nm low-level laser therapy on exercise-induced skeletal muscle fatigue in humans.Leal Junior EC, Lopes-Martins RA, Dalan F, Ferrari M, Sbabo FM, Generosi RA, Baroni BM, Penna SC, Iversen VV, Bjordal JM.
Laboratory of Human Movement, University of Caxias do Sul, Caxias do Sul, RS, Brazil. ecplealj@ucs.br

OBJECTIVE: To investigate if development of skeletal muscle fatigue during repeated voluntary biceps contractions could be attenuated by low-level laser therapy (LLLT).
BACKGROUND DATA: Previous animal studies have indicated that LLLT can reduce oxidative stress and delay the onset of skeletal muscle fatigue.
MATERIALS AND METHODS: Twelve male professional volleyball players were entered into a randomized double-blind placebo-controlled trial, for two sessions (on day 1 and day at a 1-wk interval, with both groups performing as many voluntary biceps contractions as possible, with a load of 75% of the maximal voluntary contraction force (MVC). At the second session on day 8, the groups were either given LLLT (655 nm) of 5 J at an energy density of 500 J/cm2 administered at each of four points along the middle of the biceps muscle belly, or placebo LLLT in the same manner immediately before the exercise session. The number of muscle contractions with 75% of MVC was counted by a blinded observer and blood lactate concentration was measured.
RESULTS: Compared to the first session (on day 1), the mean number of repetitions increased significantly by 8.5 repetitions (+/- 1.9) in the active LLLT group at the second session (on day 8), while in the placebo LLLT group the increase was only 2.7 repetitions (+/- 2.9) (p = 0.0001). At the second session, blood lactate levels increased from a pre-exercise mean of 2.4 mmol/L (+/- 0.5 mmol/L), to 3.6 mmol/L (+/- 0.5 mmol/L) in the placebo group, and to 3.8 mmol/L (+/- 0.4 mmol/L) in the active LLLT group after exercise, but this difference between groups was not statistically significant.
CONCLUSION: We conclude that LLLT appears to delay the onset of muscle fatigue and exhaustion by a local mechanism in spite of increased blood lactate levels.

PMID: 18817474 [PubMed - indexed for MEDLINE]

Effects of low-level laser irradiation on rat skeletal muscle injury after eccentric exercise.Liu XG, Zhou YJ, Liu TC, Yuan JQ.
Britton Chance Center for Biomedical Photonics, Wuhan National Laboratory for Optoelectronics, Huazhong University of Science and Technology, Wuhan, China.

BACKGROUND AND OBJECTIVE: The effect of photobiomodulation on delayed onset muscle soreness remains unknown. This study represents the first investigation of this treatment using an animal model.
METHODS: Seventy-two Sprague-Dawley rats were randomly divided into five groups: sedentary control group, exercise control group and three exercise-plus-laser groups. Downhill running was used to induce muscle injury in the gastrocnemius muscle. He-Ne laser irradiations were administered to the injured muscles immediately and at 18 and 42 h after exercise in the three exercise-plus-laser groups at 12, 28, and 43 J/cm2, respectively. Histological examination and serum creatine kinase (CK), muscle superoxide dismutase (SOD) and malondialdehyde (MDA) analyses were done at 24 and 48 h after exercise.
RESULTS: The exercise control group exhibited a marked inflammation in the gastrocnemius muscle and significant elevations in serum CK activity and muscle MDA level after downhill running. He-Ne laser irradiation at 43 J/cm2 inhibited muscle inflammation, significantly enhanced muscle SOD activity and significantly reduced serum CK activity and muscle MDA level at both 24 and 48 h after exercise, whereas the irradiation at 12 or 28 J/cm2 slightly inhibited muscle inflammation and significantly reduced serum CK activity at 48 h after exercise only (P < 0.05).
CONCLUSIONS: Low-level He-Ne laser therapy could exert therapeutic effects on eccentric exercise-induced rat muscle injury through enhancing muscle anti-oxidative capacity and reducing the inflammatory reaction. The photobiomodulation was dose-dependent, and the 43 J/cm2 dose was the most efficient among the doses used.

PMID: 19697999 [PubMed - in process]

The FDA has approved liraglutide (Victoza) to help control blood sugar in adults with type 2 diabetes. The drug is not recommended as a first-line treatment.

Liraglutide is a glucagon-like peptide-1 (GLP-1) receptor agonist and will be available as a once-daily injection.

Results of clinical trials of liraglutide suggested an increased risk for pancreatitis, compared with other diabetes medications. The most frequent side effects included headache, nausea, and diarrhea. Animal studies showed an increased risk for tumors of the thyroid gland, but it is not clear whether the drug also causes thyroid problems in humans.

As part of the drug’s approval, the company must conduct additional studies on cardiovascular safety and other adverse effects.

FDA news release (Free)

FDA Q&A on liraglutide safety (Free)

The side effects are worse than the disease. Why not try a natural approach to control your blood sugar, which includes eating right (probably not what you’ve ever been told), proper supplements and exercise? Too hard? Easier to just take a pill or shot? Take control of your health today.

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BMJ article (Free)

Journal Watch General Medicine summary of 2005 study showing that vitamin D supplementation reduces risk for falls (Your Journal Watch registration required)

High doses of supplemental vitamin D may lower the risk for falls in older adults, reports a BMJ meta-analysis.Researchers examined data from eight randomized controlled trials of supplemental vitamin D (vitamin D2 or D3) in roughly 2400 adults aged 65 or older. Among the findings:

 Supplemental vitamin D at 700 to 1000 IU/day (but not lower doses) was associated with a significant, 19% reduction in falls relative to no supplementation.

• Serum vitamin D concentrations of 60 nmol/L or higher were associated with a 23% drop in falls (lower concentrations showed no significant association).

Researchers also looked at two trials of some 600 older adults and active vitamin D, a metabolite that may be more readily available for people with diminished kidney function. The reduction in falls was similar to that seen with supplemental vitamin D. However, patients taking the active form were more likely to experience hypercalcemia than controls.

 As a potential underlying mechanism, the authors note that vitamin D has direct effects on muscle strength.

FDA alert (Free)

FDA information for healthcare professionals (Free)

Journal Watch General Medicine 2007 summary on sitagliptin studies (Your Journal Watch registration required)

Physician’s First Watch coverage of Byetta and pancreatitis (Free)

The prescribing information for the type 2 diabetes drug sitagliptin (marketed alone as Januvia, and combined with metformin as Janumet) must be revised to note the incidence of acute pancreatitis in some patients using the drug, the FDA announced on Friday.

 Some 88 cases have been reported since sitagliptin was approved in 2006; two cases were necrotizing or hemorrhagic pancreatitis. Overall, 20% occurred within a month of drug initiation, and about half resolved after drug discontinuation.

 The FDA advises healthcare providers to monitor patients on sitagliptin for signs of pancreatitis (e.g., abdominal pain, nausea, vomiting), and to discontinue the drug if pancreatitis is suspected. Patients should also be educated about these symptoms.

 It is not known whether sitagliptin users with histories of pancreatitis are at increased risk for the condition, the FDA says.