Keeping you up-to-date

LRC members keep up to date in a variety of ways, such as reading journals and attending meetings.  Here we summarise some of the more important aspects of our work, and some facts we have come across that may also be of interest to you and your health.


PHYSICAL ACTIVITY & HEALTH

Regular physical exercise: the ‘miracle cure’ to ageing
- Regular exercise can make you feel ten years younger.
- Fitness loss increases the risk of needing social care.
- You need to be able to get to the lavatory in time.
- Provision for exercise needs to be prioritised.
BMJ 2017;359:j4609

Too old to exercise
When the US researchers took 1635 free-living adults aged 70-89 and compared an exercise programme with health education over two years, there was no difference in progression to frailty, as defined by standardised criteria. To be sure, this was not an ideally designed trial, and the intervention did help people stand up more easily. But if you decide to stay on the sofa sipping your cocoa while channel-hopping or watching an old episode of Morse, the difference will be small and the comfort will be great.
Ann Intern Med doi:10.7326/M16-2011

Get your free Active 10 app to encourage more exercise
- More than four in ten adults in England aged 40-60 are not even managing ten minutes of continuous brisk walking a month, according to Public Health England (PHE).
- PHE’s evidence summary concludes that ten minutes of walking at a brisk intensity each day can help prevent cancer, heart disease, and poor mental health.
- The report estimates that physical activity in adults contributes to one in six deaths in the UK. What’s more, it also costs the NHS over £0.9bn a year.
- Why not try it? Free Active 10 app available as part of a new campaign to encourage people to build ten minutes of continuous brisk walking into their day.
BMJ 2017;358:j4017

Yoga matches physical therapy for back pain
A weekly yoga class designed for patients with chronic low back pain over 12 weeks was as effective as 15 physical therapy sessions for reducing pain, improving function, and lowering the use of pain medicine, a trial found in the Annals of Internal Medicine.
BMJ 2017;357:j2968

Physical activity, cognitive decline, and risk of dementia
This study sought to answer the question of whether there is an association between physical activity and dementia. Data from 10,308 participants who took part in a variety of exercise modalities. Unfortunately there was no association between physical activity and risk of dementia over an average 27 year follow up. The suggestion is that a decrease in physical activity could be part of the cascade of changes occurring in the preclinical phase of dementia. Oh well, we can all give up exercise now.
BMJ 2017;356:j2709

Exercise deficiency disorder
Evidence to support a link between lack of exercise and obesity and type 2 diabetes comes thick and fast. A cross-sectional study of adults in Toronto shows an association between neighbourhood “walkability” and metabolic risk factors. Those in least walkable areas had higher blood pressure, body mass index, low density lipoprotein cholesterol, and glycated haemoglobin. Message: each extra increment of exercise was associated with lower body mass index and glycated haemoglobin. People need to heed the title of Sir Muir Gray’s latest book, Sod Sitting Get Moving!
BMJ Open doi: 10.1136/bmjopen-2016-013889

Exercise boosts brain power in over 50s
A combination of aerobic and resistance exercises (such as weights) can significantly boost brain power in people over 50 regardless of cognitive status, a review of 39 studies in the British Journal of Sports Medicine found. The evidence is strong enough to recommend prescribing both types of exercise to improve brain health in over 50s said the researchers.
BMJ 2017;357:j2018

Addiction to exercise
Exercise has numerous health benefits and is generally viewed as a positive behaviour, so patients and clinicians may overlook the dangers of exercise and addiction.
What you need to know:
- Addiction to exercise might form part of a broader eating disorder or may occur in isolation.
- Inability to stop or reduce exercising, for example in response to an injury, may indicate addiction.
- Treatment broadly follows the principles of treating other addictions, for example cognitive behavioural therapy and exercise reprogramming.
BMJ 2017;357:j1745

Exercising only at weekends is still beneficial
Although guidelines recommend spreading exercise throughout the week, “weekend warriors” who compress the recommended amount into the weekend still experience substantial benefits, research published in Jama Internal Medicine showed. The risks of death from all causes, cardiovascular disease, and cancer, were 30%, 40%, and 18% lower, respectively, in weekend warriors than among inactive adults.
BMJ 2016; doi 10.1136/bmj.j126

Gotta catch ‘em all! Pokémon GO and physical activity in young adults
- In young adults using iPhones, in the USA, Pokémon GO was associated with a moderate increase in daily number of steps.
- This increase was not, however, sustained: the number of steps reverted to pre-installation levels by the sixth week.
- The impact of Pokémon GO on physical activity was limited in the study population of young adults in the US.
BMJ 2016;355:i6270

An hour’s exercise offsets impact of sitting all day
Doing at least an hour a day of moderate physical activity, such as brisk walking or cycling, seems to eliminate the increased risk of death associated with sitting for more than eight hours a day, a study published in the Lancet has shown.
BMJ 2016;354:i4166

Physical activity and risk of breast cancer, colon cancer, diabetes, ischaemic heart disease and ischaemic stroke events
Exercise results in decrease in the risk of these diseases as level of activity increases.  Most health gains occur with relatively low levels of activity, with diminishing returns at high levels of activity.
BMJ;2016;354:i3857

Hip replacements fail to make patients more active
Researchers from the Physiotherapy Department at the University of East Anglia have reported in the Journal of Clinical Rehabilitation that hip replacement surgery is failing to improve the physical activity levels of patients.  Following a study of more than 1000 patients, investigating a number of physical activity modalities e.g. walking distance and speed, they found that there was no clear evidence of a change in physical activity following surgery.  Patients need to be encouraged to be more physically active.
Daily Telegraph: 24/10/16

Exercise therapy versus surgery for knee arthritis
- Exercise therapy and knee arthroscopy were similarly effective for pain relief and other patient reported outcomes in a younger, more active population with a lower body mass index than previously studied.
- Exercise therapy resulted in better thigh muscle strength than surgery.
- Supervised exercise therapy should be considered as a treatment option for patients with pain and degenerative meniscal tears verified by magnetic resonance imaging (MRI), and without radiographic signs of osteoarthritis. 
BMJ 2016;354:i3740

Tai chi reduces the pain of knee arthritis
Tai chi produces beneficial effects similar to a standard course of physical therapy when treating knee osteoarthritis. In addition, tai chi practitioners showed significantly greater improvements in depression and the physical component of quality of life.
BMJ 2016:doi:10.1136/bmj.i2726

Exercise
Older people are bombarded with advice to keep active.  A cross-sectional survey of 3499 Irish people aged 65 years and over, revealed that nearly 70% of responders managed at least 30 minutes/day of moderate intensity activity five days a week.  The variables most strongly related to activity were not physical health or physical environment, but hours spent sitting, having sex, functional ability, mental health and employment status.
Age and Aging 2015, DOI:10. 1093/ageing/AVAFV042 


GOUT

Serum uric acid levels and multiple health outcomes
Despite a few hundred systematic reviews, meta-analyses, and Mendelian randomisation studies exploring 136 unique health outcomes, convincing evidence of a clear role of serum uric acid level only exists for nephrolithiasis and gout. So uric acid itself is not associated with hypertension and cardiovascular disease.
BMJ 2017;357:j2376

Gout: multicentre study proves ultrasound’s utility
The presence of synovial monosodium urate monohydrate (MSU) crystals is the gold standard for diagnosing gout.However, a new study, funded in part by the American College of Rheumatology (ACR) and led by rheumatologists, evaluated the effectiveness of ultrasound in diagnosing it. The study found that ultrasound can be useful in discriminating gout from non-gout.
Arthritis Rheumatol Feb 2017;69(2):429-438

Cardiovascular risk in people with gout
Urate lowering treatment is moderately effective in preventing relapse in people with gout. Whether this approach does anything to reduce the raised cardiovascular risk associated with this inflammatory arthritis is another matter. A systematic review of randomised controlled trials of urate lowering drugs finds no reduction in cardiovascular events compared with placebo, but the trials were too short and the cardiovascular events too infrequent to be sure.
Rheumatology doi:10.1093/rheumatology/kex065.

Corticosteroid for gout
A simple head-on comparison with indomethacin has demonstrated that a short course of prednisolone relieves gout very effectively. This may be of additional benefit to patients who cannot take NSAIDs due to heart failure and those who cannot tolerate colchicine.
Ann Intern Med 2016, doi:10.7326/M14-2070

Diet may stop gout flares
The Dietary Approaches to Stop Hypertension (DASH) diet, which is high in whole grains, fruit and vegetables, and low in red meat and saturated fats, may significantly reduce serum uric acid, a randomised study reported in Arthritis and Rheumatology showed. This may help to reduce flares in patients with gout, the authors said.
BMJ 20-27/09/16:254 (10.1136/bmj.i4464)


RHEUMATOID ARTHRITIS

Treatment of rheumatoid arthritis
On 07/04/17, the Institute for Clinical and Economic Review (ICER) published its final report, Targeted Immune Modulators for Rheumatoid Arthritis: Effectiveness and Value. The good news is that there are eleven immunomodulators that are effective in the treatment of rheumatoid arthritis.
The Rheumatologist; June 2017:27

Regular fish may help rheumatoid arthritis
Eating fish at least twice a week was associated with reduced disease activity in patients with rheumatoid arthritis in a study reported in Arthritis Care and Research. Each additional serving of fish consumed each week reduced symptom scores further. The good news is that cod is no longer an endangered species.
BMJ 2017;357:j3108

Gender differences in rheumatoid arthritis
Why is rheumatoid arthritis two or three times more common in women than men? A large case-control study from Sweden explores the influence of breast feeding and exposure to oral contraceptives but fails to find much in the way of explanation. Women who had used oral contraceptives had a slightly lower risk of seropositive rheumatoid arthritis than women who had never used them, but breast feeding made no difference.
Ann Rheum Dis doi: 10.1136/annrheumdis-2017-211620

The defeat of rheumatoid arthritis
In patients with early rheumatoid arthritis, combination therapy results in faster clinical improvement and targeted treatment determines long term outcomes, drug free remission with prevention of functional deterioration and clinically relevant radiographic damage, and normalized survival and realistic outcomes.
Ann Intern Med 2016, doi:10.7326/M15-0919

In another study, combination therapy is superior to methotrexate alone, and similar to methotrexate plus biologic DMARDs for controlling disease activity in rheumatoid arthritis. This is excellent news for rheumatoid arthritis.
BMJ 2016;353:i1777

Rheumatoid arthritis and risk of non-melanoma skin cancer
Biologic naïve patients with rheumatoid arthritis are at a 20% increased risk of basal cell carcinoma (BCC) and a near doubling risk of squamous cell carcinoma (SCC) compared with the general population. TNF inhibitor treatment does not have a clinically meaningful effect on the risk of BCC but may increase the risk of SCC by a further 30%, irrespective of TNF inhibitor treatment. Vigilance regarding skin malignancies may be advisable in patients with rheumatoid arthritis.
BMJ 2016;352:i262


DRUG THERAPIES 

By the banks of the silver Tay

Folk are taking ten medicines a day.

There are too many polypharmacists

And it is high time we called an armistice.

—NSAIDs
NSAIDs are linked to cardiac arrest risk
Use of non-steroidal anti-inflammatory drugs diclofenac and ibuprofen was associated with a significantly increased risk of cardiac arrest, a study found in the European Heart Journal – Cardiovascular Pharmacotherapy. Use of any NSAID was associated with a 31% increased risk of cardiac arrest; diclofenac was associated with a 50% increased risk and ibuprofen a 31% risk.
BMJ 2017;356:j1435

Risk of acute myocardial infarction with NSAIDs in real world use
A cohort of 446,763 individuals, including 61,460 with acute myocardial infarction was acquired.
Naproxen was associated with the same risk of myocardial infarction as that documented for other NSAIDs. The risk associated with celecoxib was comparable to that of traditional NSAIDs and was lower than for rofecoxib.
BMJ 2017;357:j1909

Celecoxib and cardiovascular death
A cardiovascular safety trial of celecoxib (Celebrex) has been published, called the PRECISION (Prospective Randomized Evaluation of Celecoxib Integrated Safety Versus Ibuprofen or Naproxen) Trial. In total more than 24,000 patients with osteoarthritis (90%), and rheumatoid arthritis (10%), with increased cardiovascular risk, were involved, and the trial duration was ten years. The data shows that celecoxib has better cardiovascular safety than ibuprofen and naproxen, and the use of celecoxib also led to fewer GI events than either NSAID, and fewer adverse renal events compared with ibuprofen.
N England J Med. 2016 doi: 10.1056/NEJMoa1611593

NSAIDs offer little benefit for back pain
It has been reported that NSAIDs offer little clinical benefit to patients with spinal pain and it is estimated that only one in every six patients treated with an NSAID experiences any benefit. In addition, patients taking NSAIDs were two and a half times more likely to experience adverse gastrointestinal events.
BMJ doi:1136/bmj.j605

—OTHER MEDICATIONS
Population oral steroid use is high
In a recent survey 3% of the Danish population were prescribed corticosteroids at least once a year between 1999 and 2015. In the oldest age groups, who were at the highest risk of harm, this approached 10%.
BMJ 2017;357:j2677

Hyaluronic Acid for knee osteoarthritis
An international task force convened by the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) recommends systematic repeated intra-articular hyaluronic acid injections as second-line treatment for patients with knee osteoarthritis. This is the first time a group of experts has made this recommendation, which is directed toward treatment of patients who have had a beneficial response with a previous cycle of treatment.
The Rheumatologist; June 2017:34

Tocilizumab receives FDA approval for giant cell arteritis (GCA)
In February 2017, a supplemental biologics licence application was accepted by the FDA for tocilizumab to treat GCA. Subcutaneous tocilizumab is a humanized interleukin 6 receptor antagonist that is already FDA approved for treating rheumatoid arthritis and polyarticular juvenile idiopathic arthritis (PJIA) or systematic juvenile idiopathic arthritis (sJIA) in patients two years of age and older. The FDA approval is the sixth for tocilizumab, which is also the first new treatment for GCA in more than 50 years.
The Rheumatologist July 2017: page 34

Study backs statins for high LDL patients
Treatment with statins reduced deaths from coronary heart disease by 28% in men with very high levels of low density lipoprotein (LDL) cholesterol but no other risk factors or signs of heart disease, a 15 year follow-up study has reported in the journal Circulation. The authors said that the findings provide the first direct randomised trial evidence to confirm current guidance that patients with LDL above 190mg/dL should be considered for statin treatment regardless of other risk factors.
BMJ 2017;358:j4171

Gabapentinoids do not help chronic low back pain
Gabapentinoids, including pregabalin and gabapentin, are increasingly being used off label to treat chronic low back pain, but a systematic review and meta-analysis in PloS Medicine has concluded that the existing evidence does not support such use. In the USA pregabalin is a controlled substance, and calls have been growing for it to be reclassified in the UK to tackle widespread misuse and addiction.
BMJ 2017;358:j3870

Risk of serious infections associated with use of immunosuppressive agents in pregnant women with autoimmune inflammatory conditions
An observational cohort study has shown that in pregnant women with systemic lupus erythematosus (SLE), ankylosing spondylitis, psoriatic arthritis, and inflammatory bowel disease, use of steroids, non-biologicals, and TNF-inhibitors is associated with similar risk of serious infections. Steroid dose is an independent risk factor for serious infections in pregnancy. Pregnant women using high dose steroids should be monitored closely for development of serious infections.
BMJ 2017;356:j895

Excerpt from NICE guidelines for treatment of low back pain and sciatica
- Paracetamol is not effective alone.
- Consider oral NSAIDs.
- Do not offer acupuncture.
BMJ 2017;356:i6748

Paracetamol is ineffective in osteoarthritis
Paracetamol had virtually no effect on pain or function in patients with osteoarthritis, a large meta-analysis in the Lancet showed. Results showed that diclofenac (150mg/day) was the most effective in reducing pain and improving physical function, whereas paracetamol had nearly a null effect on pain symptoms at all doses. In an editorial, commentators concluded that many patients could be suffering needlessly because of perceived NSAID risks and paracetamol benefits which might not be real.
BMJ story doi:10.1136/bmj.i1609

Don’t take a kiloton of paracetamol
Britain gets through 6300 tons of paracetamol every year but France tops this with 10 kilotons. What pain killing power results from these nuclear weapon levels of consumption? The answer is very little: fast acting formulations of non-steroidal anti-inflammatory drugs work better for acute pain, and there is no evidence that paracetamol works for chronic pain. Its potential harms, however, are very measurable.
European Journal of Hospital Pharmacy;doi:10.1136/ejhpharm-2016-000952

Opioids for low back pain
Opioid analgesics (e.g. codeine phosphate) provide modest short-term pain relief but the effect is not likely to provide significant long term benefit. Recent Lancet review suggest that diclofenac 150mg daily is more effective but this may have cardiovascular risk. To complicate matters we know that paracetamol is useless for chronic pain. So the way forward is to use cox2 selective NSAIDs (e.g. etoricoxib and celecoxib) for short periods of time when required.
JAMA Intern Med 2016, doi:10.1001/jamainternmed.2016.1251

Paracetamol is ineffective in reducing low back pain
Paracetamol is ineffective in reducing pain or disability in patients with low back pain, and provides small and non-clinically important effects for those with hip or knee osteoarthritis.  People taking paracetamol are also more likely to have abnormal results on liver function tests.
Efficacy and safety of paracetamol for spinal pain and osteoarthritis: systematic review and meta-analysis of randomised placebo controlled trials (BMJ 2015;350:h1225)

Drug interactions
Between 1995 and 2010 a proportion of adults dispensed five or more, and ten or more drugs, doubled to 20.8% and tripled to 5.8% respectively.  The proportion with potentially serious drug interactions more than doubled to 13%
(BMJ Medicine 2015;30:74). 


TALKING THERAPIES

Mindfulness better than medication for back pain
Mindfulness meditation is better than medication at easing chronic low back pain. This study compared Mindfulness, Cognitive Behavioural Therapy (CBT), a type of talk therapy and other usual treatments for back pain, including physical therapy and meditation. The researchers examined a specific kind of mindfulness meditation called Mindfulness Based Stress Reduction (MBSR). This involves observing and accepting thoughts and feelings, including pain, and simple yoga poses. The trial involved 342 chronic back pain patients aged 20-40 years who were split into three groups, each receiving a different type of treatment. After six months 61% of patients receiving MBSR, and 58% having CBT, showed improvements in their functional limitations compared to 44% of those in the usual care group. There was also a 44% improvement in self-reported “pain bothersomeness” in the MBSR group, and 45% in the CBT group, compared to 27% receiving usual care treatments. We will all need a lot of these therapies if Donald Trump is elected!
JAMA 2016, doi:10.1001/jama.2016.2323

Mind your backs
The Mindfulness based stress reduction programme has apparently featured in over 100 randomized controlled trials, this latest one being in people aged 65 years or more with chronic back pain. In a highly selected population of mean age 74.5 years, the overall effect of Mindfulness training was small and poorly sustained, although a few participants showed noticeable benefit. Worth a try then? Possibly something to be mindful of.
JAMA Intern Med 2016, doi:10.1001/jamainternmed.2015.8033

Does Mindfulness work? Reasonably convincing evidence in depression and anxiety
Mindfulness is defined as the process of paying attention to the present moment in a non-judgemental manner. There is convincing evidence for its use in the treatment of depression and anxiety and it is effective in increasing perceptual distance from distressing stimuli.
BMJ 2015;351:h6919


OTHER THERAPIES

There is little role for arthroscopic surgery in degenerative knee disease?
An expert panel makes a strong recommendation against the use of arthroscopy in nearly all patients with degenerative knee disease, based on linked systematic reviews; further research is unlikely to alter this recommendation.
BMJ 2017;357:j1982

Spinal manipulation may help acute low back pain
Spinal manipulation therapy for acute low back pain is associated with modest improvements in pain and function, a meta-analysis published JAMA found. In 15 randomised controlled trials including 1711 patients it found moderate quality evidence that spinal manipulation was associated with improvements in pain. This is about the same as the benefit from non-steroidal anti-inflammatory drugs in acute low back pain found in a Cochrane review.
BMJ 2017;357:j1901

What is the most effective treatment for frozen shoulder?
What you need to know:
- There is insufficient evidence to reliably recommend a treatment approach.
- Moderate evidence supports corticosteroid injection or hydrodilatation and physiotherapy in reduction of pain and stiffness.
- Consider specialist referral if the patient does not respond to conservative treatment or if the diagnosis is in doubt.
BMJ 2016;354:i4162

Treatment for low back pain
It has been shown that multidisciplinary rehabilitation is more effective than using just one method of treatment.  The end result is that patients receiving these programmes are likely to gain small long term benefits in pain and disability.  Conclusion: see a rheumatologist and a physiotherapist.
Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis (BMJ 2015;350:h444)

Homeopathy is not an effective treatment for any health condition
A large review by the Australian National Health and Medical Research Council has said that homeopathy is not an effective treatment for any health condition.  People who choose homeopathy may put their health at risk if they reject or delay treatment, for which there is good evidence.
Homeopathy is not an effective treatment for any health condition, report concludes (BMJ 2015;350:h1478)


OSTEOPOROSIS AND FRACTURES

Osteoporosis screening – studies show patterns of underutilization
In one study of screening rates between 2008 and 2014 among 1,638,454 women, dependent upon age overall screening rates were low and ranged between 26.5% and 12.8%. One reason suggested for low utilization of osteoporosis screening was the misperception that drugs used to treat osteoporosis were not safe.
Solution: it is important to educate patients about the need for maintaining bone strength into older age. This is why the London Rheumatology Clinic offer an osteoporosis screening service.

Testosterone in men
Over a one year period, using testosterone gel increases trabecular bone density more than peripheral bone density, and more in the spine than the hip, but does it actually prevent fractures in the longer term?
JAMA Intern Med 2017,doi:10.1001/jamainternmed.2016.9546

Ten years too long: cardiac safety of strontium ranelate: key messages
- Regulatory documents from 2006-07 show that strontium ranelate increases the risk of myocardial infarction and congestive heart failure.
- The EMA did not act on these data at the time or make them publicly known until 2013, indicating regulatory failure.
- The risks of strontium ranelate outweigh the benefits, and it should not be prescribed for fracture prevention.
BMJ 2016;355:i5109

Drug changes after fragility fracture
What should you start and what should you stop after a patient has had an osteoporotic fracture?
In a recent report (JAMA Intern Med) fewer than 25% of patients with fragility fractures in the USA received drugs to enhance bone mineral density, even after the event.  Drugs such as opioids, and other sedatives associated with risk of falls were rarely discontinued, and patients taking oral steroids usually remained on them at the same dose.  Medication vigilance is essential after an osteoporotic fracture.
JAMA Intern Med 2016,doi:10.1001/jamainternmed.2016.4814

Prevention of falls in older people living in the community
According to the World Health Organisation, 28-35% of older people (> 65 years) fall each year globally and prevalence increases with age. A longitudinal study found that 68% of people who fell reported some injury; healthcare was required in 24% of cases, functional decline was reported by 35%, and social and physical activities were impaired for more than 15%. Close to 95% of all hip fractures are caused by falls. After a first fall, people have a 66% chance of having another fall within a year.
BMJ 2016;353:i1419


VITAMIN D

Low vitamin D levels as a risk factor for cancer
It would appear that the consequences of low vitamin D levels are ostensibly associated with bone health as there is no causal relationship with the risk of a variety of cancers.
BMJ 2017;359:j4761

Will vitamin D supplements for healthy adults help prevent disease?
Meta-analyses of randomised controlled trials (RCTs):
- show that vitamin D supplementation alone does not improve musculoskeletal outcomes.
- vitamin D on non-musculoskeletal outcomes suggest ongoing uncertainty.
Patients should therefore be counselled about sunlight exposure and diet; low dose vitamin D supplements (400-800 IU/day) can be considered on an individual basis.
BMJ 2016;355:i6201

Low levels of vitamin D3 may increase osteoarthritis (OA) pain
Vitamin D3 can influence bone health. Studies have demonstrated that vitamin D3 is an immunomodulator (i.e. reduces inflammation). IL-17A promotes inflammation in the body and decreased serum levels of vitamin D3 seem to be associated; in a recent study IL-17A was increased and vitamin D3 decreased in patients with osteoarthritis.
The Rheumatologist 2017:Volume 11/number 1: page 30

More good news about vitamin D….
Vitamin D is in the British Medical Journal and the national news again. The proven benefits are now included in the guidelines for treatment of early osteoporosis and vitamin D insufficiency. The latter can lead to soft bones (rickets in children and osteomalacia in adults). There is evidence that it can influence immunity in various models, and the latest news is that it might reduce the risk of colds and flu.

Illness from a respiratory infection is a balance between exposure to the amount of virus encounter at close quarters, and the immune defence of the individual at the time. It is wise therefore, as pointed out by the editor, to await results from a larger study on the fuller and collateral effects (good or bad) of vitamin D supplementation before citing this as evidence for its use as a preventative treatment for colds!
http://emails.bmj.com/c/17bcjUCapwted93aWlhjQWf3q

Vitamin D and calcium supplementation in falls
The US Preventive Services Task Force (USPSTF) has reviewed nine vitamin D supplementation randomized trials and found that a median oral daily dose of 800 IU of vitamin D with/without calcium was associated with a 17% reduced risk of falling and has therefore recommended vitamin D supplementation to prevent falls in community dwelling older adults.

Vitamin D and Dementia
A study by the University of Exeter (Journal of Neurology) of 1658 American adults aged 65 years and over, who were free from dementia, heart disease and stroke at the start, found that those who were moderately deficient in the vitamin had a 53% higher risk of developing any kind of dementia. So vitamin D is not only good for your bones, it may prevent neurological disease.

As a reminder, vitamin D levels can be maximized by:
- 20 minutes of midday sun on the face and forearms three times a week;
- fatty fish, e.g. salmon, tuna, mackerel, eggs and fortified foods;
- 25mcg (1000 IU) supplementation every day.
The Daily Telegraph: August 2014

HOWEVER, there are some things that vitamin D3 supplementation cannot help: a study from New Zealand set out to determine whether supplementation with vitamin D improved resilience to the adverse effects of earthquakes. Unfortunately, it did not.
Effect of monthly vitamin D3 supplementation in healthy adults on adverse effects of earthquakes: randomised controlled trial (BMJ 2014;349:g7260)

Calcium & vitamin D – you’ll feel it in your bones …
Don’t leave bone health to chance
Did you know that bone is a living tissue that continues to regenerate and change throughout our lives? Or that our bone mass increases from birth until our mid-twenties, when it reaches its peak? Put like that it is a scary thought – but thankfully we have the power to keep our bones healthy beyond our twenties, thank goodness, by adopting a diet that is rich in both calcium and vitamin D, not to mention a few rays of sunshine which help to create more vitamin D in our bodies, whilst making us naturally feel happy and healthy too.

It is really important to remember that calcium intake is directly linked to bone mineral density; and that calcium can’t be made naturally by the body, but only from our dietary intake, which makes a calcium-rich diet all the more essential!

Vitamin D, otherwise known as the sunshine vitamin, works together with calcium to keep bones healthy and good levels of sunlight and vitamin-D rich foods can assist in its production.

So it is more important than ever to engage in a healthy diet that can significantly diminish our predisposition to bone-related diseases and keep our bone health to an optimum for as long as possible.

References available on request


DIET & HEALTH

Coffee gets a clean bill of health
Moderate coffee consumption seems generally safe and may even be beneficial with regard to cancer and liver disease prevention.
BMJ 2017;359:j5356

Weight loss
Weight reducing diets, with or without exercise advice or programmes, might reduce premature all-cause mortality in adults who are obese.
BMJ 2017;359:j4849

Improving adherence to healthy dietary patterns, genetic risk, and long term weight gain
This study suggests that improving adherence to a healthy diet could counteract part of the influence of genetic susceptibility to obesity on long term weight gain.
BMJ 2018;360:j5644

A tipple a day keeps diabetes away?
That’s what the research says. A Danish study hit the headlines this week, showing that people who drink alcohol three to four days a week had around a 30% lower risk of developing type 2 diabetes than teetotallers. The lowest risks of diabetes were in men who consumed 14 alcoholic drinks and women who knocked back nine drinks a week.
BMJ 2017;358:j3672

The importance of being PURE
PURE is a five-continent observational study of diet in relation to cardiovascular disease in mortality in nearly 150,000 people. It is probably the best of its kind ever done. The main message was negative: there was no specific connection between carbohydrate intake and cardiovascular disease: the association was with total all-cause mortality. By contrast, eating more fat, including saturated, was associated with lower cardiovascular disease, meaning we can abandon the saturated fat-cardiovascular disease hypothesis with some certainty.
Lancet doi:10.1016/50140-6736(17)32252-3

Alcohol consumption and brain health
Dr K A Welch, a consultant neuropsychiatrist from the Royal Edinburgh Hospital, cautions that even “moderate” drinking is linked to changes in brain function and structure. It has long been shown that heavy drinkers have higher incidence of dementia, more evidence of diminished executive brain function, and brain scans showing damage. Whilst it is difficult for anyone to state the optimal level of consumption, it appears that 1 unit of alcohol/day has the lowest risk, apart from no intake which has the best outcome for brain health.
BMJ 2017;357:j2645 doi: 10.1136/bmj.j2645

Alcohol and cardiovascular disease
In a population based cohort study, in adults without cardiovascular disease, it has been shown that moderate drinking is associated with a lower risk of initial presentation of several, but not all, cardiovascular diseases. This has implications for patient counselling, public health communication, and clinical research.
BMJ 2017;356:j909

Meat consumption and risk of mortality
Dietary data from 536,969 individuals aged between 50 and 71 years, and studied for 16 years, showed that a high red meat intake was associated with an increased risk of death. Cows are also bad for the health of the planet e.g. to produce 1kg of meat protein requires >110,000L of water and results in the production of 37% of methane.
BMJ 2017;357:j2190

“Five a day” may help to keep dementia away
The cognitive status of 17,700 dementia-free older patients was followed over six years. The researchers found that those consuming at least three daily servings of vegetables and two of fruit had lower odds of developing dementia.
BMJ 04/03/2017: Seven days in medicine

Ten portions are better than five, finds analysis
Eating five a day reduces the chance of heart attack, stroke, cancer, and early death, but the greatest benefit comes from eating ten portions a day, according to a meta-analysis of 95 studies including almost two million people.
BMJ 04/03/2017: Seven days in medicine

Dietary therapy for irritable bowel syndrome
Irritable bowel syndrome (IBS) is a common disorder of the digestive system, affecting approximately 10% of the global population.  The most popular treatment option among patients in recent years has been a dietary approach, the “low FODMAP diet.”  The term FODMAP refers to fermentable oligosaccharides, disaccharides, monosaccharides and polyols.  This broad dietary class includes fructose (in fruits/sweeteners, lactose (in dairy products), fructans (wheat based products), and galacto-oligosaccharides (legumes).  The full spectrum of FODMAPs may not be responsible for symptoms in a given patient.  An experienced dietitian can help manage patients on a low FODMAP diet and facilitate controlled reintroduction of individual components.
BMJ 2016;354:i3902

Fruit and vegetable consumption in adolescence and early adulthood and risk of breast cancer
Studies suggest that higher intake of fruit during adolescence could reduce the risk of breast cancer.
BMJ 2016;353:i2343

Body mass index and mortality: patters and paradoxes
The bottom line of this research is that you are at least at risk of dying if your BMI is between 20 and 22.
BMJ 2016;353:i2156

How smaller portion sizes might help tackle obesity
People consistently consume more food or non-alcoholic drinks when offered larger size portions or when they use larger tableware.
BMJ 2015;351:h5863

Advice on safe alcohol drinking may be about right
The US National Institute of Alcohol Abuse and Alcoholism has advised that women should drink no more than the equivalent of 4.5 units/day or 10.5 units/week and that men should drink no more than
6 units/day or 21 units/week. For those over 65 years the American Geriatric Society has defined high risk drinking as more than 4.5 units/day or 10.5 units/week in men and women. Australian guidelines for this age group recommend no more than 2.5 units/day for men and women.
BMJ 2015;351:5082

NICE recommends small improvements to help people stay at a healthy weight
Making any improvements, however small, to physical activity or dietary habits is likely to help individuals stay at a healthy weight or prevent further weight gain.
NICE recommends small improvements to help people stay at healthy weight (BMJ 2015;350:h1427)

Have you ever wondered, when you lose weight, where does the fat go?
Most people believe that fat is converted to energy or heat, which violates the law of conservation of mass.  The authors suspect this misconception is caused by the energy in/energy out mantra.  They have calculated that the lungs are the primary excretory organ for fat.  Losing weight requires unlocking the carbon stored in fat cells thus reinforcing that often heard refrain “eat less move more.”
BMJ 2014;349:g7257

Fruit and vegetable consumption in relation to mortality
A report in the British Medical Journal sought to ask the question about the association between the consumption of fruit and vegetables and mortality from all causes, cardiovascular disease, and cancer.

The answer, not surprisingly, showed that higher consumption of fruit and vegetables is associated with a reduced risk of mortality from all causes, particularly cardiovascular disease.   Higher consumption was not however appreciably associated with cancer mortality.  The bottom line therefore is to continue to consume palatable quantities of fruit and vegetables in our diet.
BMJ 2014;349:g4490  


Article about Anorexia Nervosa: published in Tatler Magazine

Part 1
Part 2


LONDON DIETITIANS

Reset your breakfast routine and wake up to the health benefits of breakfast cereals
It has long been documented that breakfast is the most important meal of the day, but one in five of all adults and children are still skipping breakfast, which amounts to lower energy levels and poor concentration. Can you imagine the damage this is doing to the productivity levels of the school and working population? Research has shown that eating a good breakfast has an even bigger part to play in disease prevention and weight management over the longer term.

Still don’t have time for breakfast?
So ditch the excuses today and invest in some whole grain breakfast cereals to start your day and give your body the nutrition it needs. It only takes ten minutes to eat a bowl of cereal in the morning, and you could well be banking more energy for a more fulfilling and productive day.

Eat more cereals and lower your BMI
The evidence is stacking up in favour of breakfast cereals as they represent an important source of fibre and whole grains which are associated to lowering the risk of obesity, and the low GI of many breakfast cereals (when taken with milk) could also have a positive impact on appetite control.

Ideas for a perfect breakfast:
1. Whole rolled oats porridge with 200ml low fat milk and 80g berries
2. Wholegrain breakfast cereal (e.g. bran flakes, shredded wheat, Weetabix) + banana and 200ml low fat milk
3. Wholegrain bread/toast + 2 eggs + grilled tomato + 125ml low fat yoghurt with 80g berries
4. Smoothie made from lots of green vegetables (cucumber/kale/spinach etc) + 1 serving fruit (e.g. apple/pineapple/melon) + 2 tbsp oatbran + 1 tbsp linseeds + protein powder

So make the switch and take some time to think about breakfast! Go to www.breakfastcereal.org for more facts and information on ideas for a healthy breakfast.


MISCELLANY

Trivalent vaccine no use against influenza B strain
Public Health England influenza vaccination programme has been disappointing this year with poor patient education and much conflicting evidence for its efficacy. Now we know that the trivalent vaccine was of no use against influenza B strain that appears to be predominantly circulating this year.
BMJ2018;360:k78

Influenza infection may raise MI risk in first seven days
The risk of myocardial infarction is six times higher in the first seven days of a laboratory confirmed influenza diagnosis, research in the New England Journal of Medicine found. The risk is highest in older adults, people with influenza B infections, and patients have a first MI. The Canadian researchers said the findings reinforce the importance of vaccination and that patients should not delay evaluation for heart symptoms, particularly in the first week of an acute respiratory infection.
BMJ 2018;360:k323

Low cigarette consumption and risk of coronary heart disease and stroke
Smoking approximately one cigarette a day carries a much greater than expected risk of developing coronary heart disease and stroke, around half that for people who smoke 20 cigarettes a day.
BMJ 2018;360:j5855

Feeling it in your bones: association between rain and joint or back pain
- Data on millions of outpatient visits of older Americans linked to data on daily rainfall showed no clinically meaningful relation between daily rainfall and outpatient visits for joint or back pain.
- No statistically significant relation was found between the proportion of claims for joint or back pain in any given week and weekly rainfall.
BMJ 2017;359:j5326

Choose a female surgeon
Patients treated by female surgeons had significantly lower 30 day mortality than those treated by male surgeons and similar surgical outcomes (i.e. length of stay, complications, and readmission).
BMJ 2017;359:l4366

How the month of your birth can affect which diseases will afflict you
Spanish scientists mapped birth months to 27 chronic diseases to see if it made a difference and were surprised to find it has a significant impact for some conditions. Women born in November and December, and men in March, May, June, November and December were not susceptible to musculoskeletal diseases, confirming my observation that all people are susceptible to musculoskeletal diseases.

The CEP
You know, the CEP. Close friend of the STP, the IFR, and the RTT.It is the capped expenditure process – another lovely phrase straight from the NHS Acronym Referral Site for England (ARSE).

It is a way of ensuring that “those geographies that are significantly out of balance now confront the difficult choices they have to take.”

It has been put on hold; but not really, NHS finances are still Full of Underlying Cost Deficits (FUC…you get the picture).
BMJ 2017:357:j3189

Pass me an anti-boredom pill, please doctor
Evidence suggests that almost half our time is spend mind-wandering and that negative mind-wandering is associated with unhappiness. One patient suggested, “Boredom has probably been my biggest problem and enemy.” Surprisingly, patient boredom is missed entirely in NICE’s report on the patient experience.

Ennui is associated with time passing slowly; a lack of meaning, challenge, and focus; and even higher mortality rates.

Could boredom affect recovery, pain, fatigue, and relationships with staff?

The time has come to make the most of precious time in hospital.
BMJ Opinion July 2017;358:77

Increase in life expectancy in England has halted
The increase in life expectancy in England has almost “ground to a halt” since 2010 and austerity measures are likely to be a contributor, a leading expert on public health has said. The warning came from Michael Marmot, director at University College London’s Institute of Health Equity, after new indicators showed that the rate of increase in life expectancy in England has almost halved since 2010 and it close to stalling.
BMJ 2017;358:j3473

Medicolegal negligence claims rise 14%
The NHS paid out more than £1.08 billion in damages to claimants in 2016-17, up £132 million (14%) on the previous year, a report by NHS Resolution (formerly the NHS Litigation Authority) showed. This was despite a 2.5% fall in new clinical negligence claims, to 10,686.
BMJ July 2017: page 128

Keeping up with the Johanssons:
How the UK’s health spending tallies with the rest of Europe
- The UK spends roughly the same on health as the average of other EU-15 countries.
- Its spending on different areas of care is also in line with EU averages.
- Decisions about the appropriate amount to spend on health require more than a simple comparison with other countries.
BMJ 2017;358:j3568

Noisy knees may be early sign of osteoarthritis
During a four year US study, 75% of the 646 patients who developed symptomatic osteoarthritis had signs of osteoarthritis on x-ray but no knee pain at the start of the study. The odds of developing symptomatic osteoarthrosis were higher with greater frequency of self-reported crepitus.
BMJ: 2017;357:j2263

Keep smiling
The World Happiness Report 2017 says that Norway is the happiest country in the world. The USA ranks 14th of 155 countries, the UK is 19th, and France is 31st. The Central African Republic is last.
BMJ 2017;356:j1539

Migraine and risk of perioperative ischaemic stroke and hospital readmission
Patients with migraine, and in particular migraine with aura, are at increased risk of perioperative ischaemic stroke and 30-day hospital readmission after surgery. Migraine should be incorporated in the perioperative stroke risk assessment.
BMJ 2017;356:i6635

More talk, less action
The Choosing Wisely campaign in the UK, launched by the Academy of Medical Royal Colleges in October 2016, lists 40 tests and treatments that are unlikely to benefit patients. The campaign aims to encourage doctors and patients to have a conversation about the risks and benefits of interventions.
BMJ 2017;356:j370

Five questions patients should ask their doctor or nurse to make better decisions together:
1. Do I really need this test, treatment or procedure?
2. What are the risks or downsides?
3. What are the possible side effects?
4. Are there simpler, safer options?
5. What will happen if I do nothing?

Keeping pace with society
The UK has an ageing population – the median age rose from 33.9 years in 1974 to 40 years in 2014, a rise of 6.1 years. By 2024, there are predicted to be more people aged over 65 than aged 0-15. The number of people living with multiple chronic conditions is also growing rapidly. In England, this is forecast to have increased from 1.9 million in 2008 to 2.9 million by 2018.
BMJ 2017;356:i6738

Cost of smoking
Smoking consumes almost 6% of the world’s healthcare spending, and nearly 2% of global GDP, and nearly 40% of the £1156 billion cost is borne by developing countries. Would you believe it, but in Norway and Sweden, SNUS is a form of tobacco that is sold in pouches and stuck under the top lip, and some people claim to find this sexy! The author is not sure that whiffy breath and lots of pouch litter are ever going to be sexy outside Sweden, but stranger things have happened such as self-assembly furniture!
BMJ 2017;356:j536

Dutch and Swiss top Euro health index, with UK languishing mid-table
For the third year running, the Netherlands and Switzerland lead the way in providing good consumer friendly healthcare, as judged by the 2016 Euro Health Consumer Index. For your information – the UK came 15th.
BMJ 2017;356:j522

Explaining laboratory test results to patients: what the clinician needs to know
Minor test abnormalities in well people may have no clinical relevance. By definition, 5% of healthy people will have test results that fall just outside the 95% healthy population reference interval.

Outside of formal screening programmes, speculative screening tests in well asymptomatic people have little value and may result in over-investigation and unnecessary treatment.
BMJ 2015;351:h5552

GP job satisfaction
GPs become less positive about their job prospects the further they progress in their careers, while surgeons become more positive, researchers from the University of Oxford have found.

The researchers surveyed 37,332 doctors in nine cohorts of medical graduates from 1974, 1983, 1988, 1993, 1996, 1999, 2000, 2002 and 2008.  Questionnaires were sent to the doctors at different times after graduation ranging from 3-24 years and received responses from 20,940 doctors.

There are many theories; mine is that surgeons are just late developers.
BMJ Careers 24/09/16 (page 458)

The Royal College of Physicians – five point plan for the next government
Jane Dacre, the new President of the Royal College of Physicians and Rheumatologists, is spearheading the RCP’s five-point plan for the next government.  These are as follows:
- Remove the financial and structural barriers to joined-up care.
- Invest now to deliver good care in the future.
- Prioritise what works in the NHS and improve what doesn’t.
- Promote public health through evidence-based legislation.
- Adopt the Future Hospital model as a template for service redesign.
Membership magazine of the Royal College of Physicians (June 2015;issue 3:4) 
 
And finally for your amusement – Darwin Awards: sex differences in idiotic behaviour
A review of the winners of the Darwin Award over a 20 year period has recently been published.  Winners of the Darwin Award must eliminate themselves from the gene pool in such an idiotic manner that their action ensures one less idiot will survive.  The paper reported a marked sex difference in Darwin Award winners: males are significantly more likely to receive the award than females.  This finding is entirely consistent with “male idiot theory” (MIT) and supports the hypothesis that men are idiots and idiots do stupid things.  Examples of male idiot theory are the man who attempted to get home by hitching a shopping trolley to the back of a train, and a terrorist who posted a letter bomb with insufficient postage stamps and who, when it was returned, unthinkingly opened his own letter.
The Darwin Awards: sex differences in idiotic behaviour (BMJ 2014;349:g7094)


INTERESTING QUOTES

Ann Louise Kinmonth
It is hard to better Donald Winnicott’s prayer, “May I be alive when I die.”
BMJ 2017;356:j362

Prof Timothy Evans
- What is your pet hate?
Physicians who tell patients, “I don’t know what’s wrong with you, but it’s not your (insert organ of specialisation),” before sending them back to their GP.
BMJ 2016;354:i5059

No Holds Barred: Margaret McCarthy
The NHS is being allowed to fail.  This is not simply a matter of underfunding but also of what we spend our money on.  The time for short term political populism must be over.  It’s either evidence based policy making, starting with how we treat the staff, or no more NHS.
BMJ 2016;354:i4690

Mr Paul Marks (neurosurgeon)
- Where does alcohol fit into your life?
I adhere to the old adage that a person doesn’t have a problem with alcohol if he drinks less than his doctor.
- What is your pet hate?
Colleagues whose confidence is inversely proportional to their ability.
BMJ 2016;355:i5824

Voltaire (1694 – 1778)
“The art of medicine consists of amusing the patient while nature cures the disease.”

Ara Darzi
What was the worst mistake in your career? 
Answer: I have made so many bad mistakes that I am not sure of the worst. Once you have made a few, however, you begin to recognize that each brings a learning opportunity.
BMJ 2016;352:i67 

Robin Ferner
Do you support doctor assisted suicide? 
Answer: I prefer to live (and die) with the ambiguity of the principle of double effect, namely, that it’s defensible to give treatment with the intention of alleviating suffering, even if the treatment hastens death.
BMJ 2016:352:i67

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