AAOS.org - An evidence-based clinical practice guideline on “The Treatment of Glenohumeral Joint Osteoarthritis” has been approved and released by The American Academy of Orthopaedic Surgeons (AAOS). This major joint in the shoulder — the ball and socket joint — is sometimes affected by osteoarthritis, causing pain, loss of function, and reduced quality of life.

According to Rolando Izquierdo, MD, chair of the Academy work group on glenohumeral joint osteoarthritis, shoulder replacement surgery has been routinely performed since the 1970s for patients with advanced osteoarthritis of the shoulder. A review of the literature supports the use of both total and partial shoulder replacement for this population.

“The literature suggests, though, that pain relief is better and motion is better with total joint replacements than with partial replacements,” says Dr. Izquierdo. “We also have to consider the 14 percent failure rate of partial replacements, which then require revision to total replacements. This revision is required due to progressive arthritis and pain.

“Because of a scarcity of high quality prospective studies, however, surgeons have few measures to support non-operative therapies for treating osteoarthritis of the shoulder,” he adds.

The final treatment guidelines for treating glenohumeral joint osteoarthritis contain 16 recommendations. These include both operative and non-operative treatment options. Some important recommendations include the following:

• One industry-supported study demonstrated that viscosupplementation shows a statistically significant benefit in pain relief, range of motion, and quality of life in patients with osteoarthritis of the shoulder. Essentially, viscosupplementation is a synthetic reproduction of a naturally occurring joint fluid that lubricates joints. Doctors inject synthetically created molecules, similar to the natural joint fluid, into an arthritic joint. Viscosupplementation is, therefore, an option when treating patients with glenohumeral joint osteoarthritis. The U.S. Food and Drug Administration (FDA) considers viscosupplementation an implant. While they approved the use of this procedure for treating knees in 1997, they have not yet approved this treatment for use in shoulders.

• Surgeons should routinely take preventive steps to reduce the risk of potentially catastrophic complications caused by blood clots during and immediately following surgery. Exercises to increase blood flow and blood-thinning medications can also help avoid blood clots, as well. The Academy work group reached consensus with this recommendation, believing that the risk of not taking these preventive actions outweighs the risk of taking them.

The work group found a lack of quality prospective literature exists for recommending for or against the following treatments for osteoarthritis of the glenohumeral joint:

• Drug therapy;
• Injectable steroids; or
• Arthroscopy (a surgical procedure surgeons sometimes use to diagnose and treat problems inside a joint).

Further, despite an exhaustive review of the literature, not a single study exists to support the use of physical therapy either for treating osteoarthritis of the shoulder or for treatment after replacement, Dr. Izquierdo says.

“There is a great variety in the types of therapies utilized, but very little guidance. It would be nice to have some data by a physical therapist or orthopaedic surgeon, but the studies have not been done.”

The Centers for Disease Control and Prevention reports that more than 51 million Americans have been diagnosed with some form of arthritis. Shoulder replacements are the third most common joint replaced, following hips and knees.

While Dr. Izquierdo specializes in shoulder replacements, performing a high volume each year, most surgeons replace far fewer shoulders than hips or knees, he says. In fact, 75 percent of all shoulder replacements are done by non-specialists who perform two or fewer shoulder replacements a year. An option for reducing immediate post-operative complication rate, therefore, is for patients to avoid shoulder replacement by surgeons performing fewer than two shoulder replacements a year.

“One important take home message for a patient considering shoulder replacement therapy is to find a an orthpaedic surgeon who is trained in shoulder replacements to reduce immediate post-operative complication rates.

“These are the first guidelines for treating osteoarthritis of the glenohumeral joint,” says Dr. Izquierdo, “There is minimal data currently available related to non-operative management of osteoarthritis of this joint. We are hoping these guidelines will stimulate further research to fill some of the void in the literature that currently exists for managing glenohumeral joint osteoarthritis.”

Editor’s Note: These AAOS guidelines were developed by an AAOS physician volunteer work group and was based upon a systematic review of the current scientific and clinical information on accepted approaches to treatment and/or diagnosis. The entire process included a review panel consisting of internal and external committees, public commentaries and final approval by the AAOS Board of Directors.

The full guidelines along with all supporting documentation and workgroup disclosures is available on the AAOS website here:

Shoulder arthritis treatment guidelines

UCSD.edu - A kind of sugar molecule - sialic acid - that is common to chimpanzees, gorillas and other mammals but not found in humans provokes a strong immune response in some people, likely worsening conditions in which chronic inflammation is a major issue, according to researchers at the University of California, San Diego School of Medicine.

This non-human sialic acid sugar is an ingredient in some biotechnology drugs, and may be limiting or undermining their therapeutic effectiveness in some patients, the scientists report in a letter published in the advance online July 25, 2010 edition of the journal Nature Biotechnology. However, they also propose a simple modification to the drug-making process that could solve the problem.

The presence of the non-human sialic acid sugar contaminant, called N-glycolyneuraminic acid or Neu5Gc, has long been known but ignored because it was believed healthy human immune systems did not react to it, said Ajit Varki, MD, professor of medicine and cellular and molecular medicine at UC San Diego School of Medicine. “Now we know that to be untrue.” “We’re all exposed to this non-human sugar,” Varki added. “It’s part of our diet, and especially abundant in red meat. We all develop antibodies to Neu5Gc, but this immune response varies greatly in people. Meanwhile, Neu5Gc from animal foods can get incorporated into the human body. For most people, this may not be a problem. But for some, the immune response to incorporated Neu5Gc may exacerbate a chronic inflammation process. This isn’t the cause of any disease or condition, but we believe it might be akin to adding fuel to an existing fire.”

Every animal cell is cloaked in sugar molecules, which serve as vital contact points for interaction with other cells and their surrounding environment. At the same time, the attached sugars are targets for infectious diseases like influenza, malaria and cholera.

“Sialic acids are required for survival, but they’re also used to attack you,” said Varki, who is founder and co-director of the Glycobiology Research and Training Center at UC San Diego. “They are crucial for things like brain plasticity and kidney function, but lots of pathogens attach to them, and some even coat themselves with these sugars to avoid detection. In evolutionary terms, if you have sialic acid, you’re going to be attacked. But you don’t have it, you’re going to die.”

Perhaps because of this evolutionary pressure, different species can have different kinds of sialic acids. In mammals, there are two major types: Neu5Gc and Neu5Ac, which differ by one oxygen atom. Humans have only the “Ac” version; other mammals also have the “Gc” version. This human-specific change likely happened two or three million years ago, said Varki, who also co-directs the Center for Academic Research Training in Anthropogeny at UCSD. “No one knows why, but this may have been selected by an infectious disease, like malaria”

Although the Ac and Gc versions are very similar in structure, the single oxygen atom difference is recognized by the human immune system, which develops antibodies to the non-human sugar.

And therein lies the problem, said Varki. Antibodies are naturally circulating proteins that identify and neutralize invaders, such as viruses or bacteria. Part of that process involves inflammation, the host’s attempt to kill and remove invasive cells or tissues perceived to be harmful. If there is a strong antibody response to diet-incorporated Neu5Gc, the resulting inflammation could cause harm to the person. This may partially explain associations between certain foods and increased risk of diseases associated with inflammation, such as cancer and heart attacks – diseases that are rare in other primates.

The problem may also be exacerbated by the presence of Neu5Gc in drugs developed through recombinant biotechnology, some of which are actually used to treat inflammatory disorders. Neu5Gc contamination is unavoidable with current methods, said Varki, because many biotherapeutics such as antibodies, clotting factors or hormones are produced using cells, tissues or serum from mammalian sources, which naturally contain the non-human sialic acid.

Varki and colleagues studied several biotherapeutic agents currently in clinical use, and found the non-human sialic acid in almost all of them, although in varying amounts.

They also report that anti-Neu5Gc antibodies from normal humans interacted with a Neu5Gc-containing drug used to treat some forms of cancer, producing immune complexes in vitro. Mice with a human-like defect in Neu5Gc synthesis also generated anti-Neu5Gc antibodies when injected with the drug, and cleared it from the circulation faster.

These problems were not seen with another otherwise similar drug, which happened to be practically free of Neu5Gc.

“It’s reasonable to suggest that for some patients who have problems with some drugs, this may be part of the reason why,” although a lot more needs to be done to work out the details,” Varki said.

Meanwhile, the UCSD scientists have developed a novel yet simple solution: Add the human sialic acid to the drug-making process. The Ac version, said Varki, competes with the Gc version, reducing the chances of the Gc version making it into the final product.

“In our initial tests, it removes low-level Gc contamination in drugs,” said Varki. “It’s simple and should only require minor FDA approval for the process adjustment. We think that while we’ve identified a problem, we’ve also come up with an answer, at least for some drugs.”

The more people logged on and used an interactive weight management website, the more weight loss they maintained, according to a Kaiser Permanente Center for Health Research study published online in the open access Journal of Medical Internet Research.

The National Institutes of Health-funded study evaluated an Internet-based weight maintenance intervention involving 348 participants. Consistent website users who logged on and recorded their weight at least once a month for two-and-a-half years maintained the most weight loss, the study found.

“Consistency and accountability are essential in any weight maintenance program. The unique part of this intervention was that it was available on the Internet, whenever and wherever people wanted to use it,” said study lead author Kristine L. Funk, MS, RD, a researcher at the Kaiser Permanente Center for Health Research in Portland, Ore.

“This study shows that if people use quality weight management websites consistently, and if they stick with their program, they are more likely to keep their weight off,” said study co-author Victor J. Stevens, PhD, co-author and senior investigator at the Kaiser Permanente Center for Health Research. “Keeping weight off is even more difficult than losing it in the first place, so the fact that so many people (in the study) were able to maintain a good portion of their weight loss is very encouraging to us.”

This internet-based weight maintenance intervention was part of the Weight Loss Maintenance Trial, one of the largest and longest weight maintenance trials ever conducted - lasting three years and including more than 1,600 people at four study sites across the United States. To enroll in the trial, participants had to be overweight or obese based on their Body Mass Index and taking medication for high blood pressure or high cholesterol. For the first six months, participants tried to lose weight by attending weekly group meetings at which they were weighed, encouraged to keep food diaries, and given extensive information about exercise and healthy eating.

Participants had to lose at least nine pounds to remain in the trial for the weight loss maintenance phase, which lasted an additional two-and-a-half years and included three groups of randomized participants: one with no intervention, one that had monthly contact with a personal health coach, and one that was given unlimited access to a weight-maintenance website created specifically for the trial.

The internet group included 348 participants who were encouraged to log in at least once a week. If they didn’t, they received e-mail reminders and follow-up automated phone messages. Once on the website, participants were prompted to record their weight, their minutes of exercise, and the number of days they kept food diaries. If they went longer than seven days without recording a weight, the other parts of the website were disabled until they did record their weight. The website included an interactive bulletin board on which participants could talk with others involved in the study and pose questions to nutrition and exercise experts.

During the first six months of the trial, while they were attending group sessions and before they had access to the website, participants who ended up in the internet group had lost an average of 19 pounds. Once they were given website access, their objective was to keep off as much of that weight as possible. Consistent users who logged in and recorded their weight at least once a month for 24 months maintained the greatest weight loss—keeping off an average of nine of the 19 pounds they’d lost during the initial weight loss phase of the trial. Those who logged on less consistently - at least once a month for 14 months - kept off an average of five pounds. Those who logged on less than that kept off an average of only three pounds of their original weight loss.

At the end of the study, 65 percent of the participants were still logging on to the website. The study authors say they are encouraged by this level of participation because they say it is rare to see that kind of commitment – even in shorter-term weight maintenance studies that use the internet (Courtesy of EurekAlert!, a service of AAAS).

While the weight control study website is no longer available, there are many useful weight management websites that people can access. The study authors advise consumers to look for these important elements:

• Web sites that encourage accountability by asking users to consistently record weight, exercise, and calories consumed
• Web sites that include tailored or personalized information
• Web sites with interactive features that allow users to communicate with each other and with nutrition and exercise experts
• Web sites with accurate health information.

A PDF copy of the original study website is available free here:

Weight loss maintenance web site

The research article is available free online here:

Internet website use keeps weight off

Reference: J Med Internet Res 2010;12(3):e29. doi:10.2196/jmir.1504

IFT.org - Habitual consumption of coffee has been shown to reduce the risks of cardiovascular disease, type 2 diabetes, and Alzheimer’s, according to experts at IFT Annual Meeting & Food Expo® Session 253 “Emerging health benefits of coffee: Recent advances in epidemiologic and experimental knowledge” on July 20, 2010.

Frank Hu, Harvard Medical School, noted that coffee contains caffeine, numerous bioactive compounds, chlorogenic acid, minerals, and antioxidants, which may help explain coffee’s health-promoting properties. Hu referred to several studies that suggested that coffee consumption is associated with reduced risks of cardiovascular disease and type 2 diabetes. Others studies indicate that coffee consumption does not increase the risk of stroke or mortality.

Joan Lindsay, Univ. of Ottawa, discussed coffee consumption and brain function, health, and disease. Studies suggest that lifetime consumption of coffee in women was associated with higher cognitive function, better memory, and less cognitive decline with aging. However, there were no beneficial effects observed in men. A large Finnish study of men and women with a 21-year follow-up found that drinking 3 to 5 cups of coffee per day reduced the risk of developing Alzheimer’s by 65 percent. The Canadian Study of Health and Aging with a 10-year follow-up found that regular coffee consumption over 50 years resulted in about a 28 percent reduction in the risk of developing Alzheimer’s. Cognitive decline was seen less in coffee drinkers. The health benefits of coffee on the brain may be due to caffeine, antioxidants, as well as overall vascular wellbeing.

YiFang Chu presented research on how coffee may protect against oxidative stress and protect primary neurons in the brain. He also compared the antioxidants levels in green versus roasted coffees.

IFT.org - The 2010 Dietary Guidelines for Americans (DGA) - scheduled for release in December - will focus on recommendations for reducing obesity and improving health, stated Robert Post, Ph.D., Deputy Director of the U.S. Dept. of Agriculture’s Center for Nutrition Policy and Promotion, at a press conference hosted by USDA at the IFT Annual Meeting & Food Expo® on July 19, 2010.

In June 2010, the USDA released the Dietary Guidelines Advisory Committee (DGAC) Report. The upcoming 2010 Dietary Guidelines for Americans will draw heavily from this report, which is unprecedented in addressing the obesity epidemic - the single greatest threat to public health in this century, said Post. Every section of the report was developed to address the challenges of obesity. For the first time, the report addresses children, whose prevalence of obesity has tripled in the past 30 years. The report discusses the relationship between dietary intake and childhood obesity and the effects of sodium intake on blood pressure.

Also for the first time, the report addresses eating behaviors, such as breakfast consumption, snacking, and fast foods, particularly in relation to weight control. It recommends that Americans shift food intake patterns to a more plant-based diet that emphasizes vegetables, cooked dry beans and peas, fruits, whole grains, nuts, and seeds.

The DGAC report identifies four nutrients of public concern for Americans: fiber, potassium, vitamin D, and calcium. They are singled out from a longer list of nutrients because of evidence that their low intake is directly related to health issues of public health importance. It also recommends that consumers reduce their sodium intake to 1,500 mg per day from the current goal of 2,300 mg, and it advises Americans to consume less than 7 percent of their calories from saturated fat. Seafood consumption is recommended; the report encourages consumption of 8 oz or two servings of seafood per week.

“One of the roles of the Dietary Guidelines serve is to stimulate product innovation,” explained Post. “Given what we have learned from the 2010 Advisory Report of the Dietary Guidelines Advisory Committee, the formulation for the future means using food science to make more healthier food choices … choices with fewer calories but are flavorful and appealing, less added sugar but are sweet and flavorful and appealing, less salt but are flavorful and appealing and safe, less fat but are savory and appealing, and more fiber but are flavorful and appealing.

“It also means incorporating more vegetables, fruits, whole grains, nuts, seeds, beans, and peas into foods, along with seafood and fat-free and low-fat milk and milk products,” he added.

The food industry has contributed greatly to meeting public health through ingenuity in processing and formulating new foods, noted Post. He mentioned how canning and freezing alleviated vitamin C deficiencies, how fortification of grains with folic acid offset the problem of neural tube defects, and how processing and preservation increase the availability of products like seasonal fruits and vegetables year-round. “Once again, a public in need is calling on that ingenuity to contribute to a public health solution,” Post concluded.

ACS.org - Scientists are reporting that particle size affects the toxicity of zinc oxide, a material widely used in sunscreens. Particles smaller than 100 nanometers are slightly more toxic to colon cells than conventional zinc oxide. Solid zinc oxide was more toxic than equivalent amounts of soluble zinc, and direct particle to cell contact was required to cause cell death. Their study is in ACS’ Chemical Research in Toxicology, a monthly journal: “ZnO Particulate Matter Requires Cell Contact for Toxicity in Human Colon Cancer Cells.”

Philip Moos and colleagues note that there is ongoing concern about the potential toxicity of nanoparticles of various materials, which may have different physical and chemical properties than larger particles. Barely 1/50,000 the width of a human hair, nanoparticles are used in foods, cosmetics and other consumer products. Some sunscreens contain nanoparticles of zinc oxide. “Unintended exposure to nano-sized zinc oxide from children accidentally eating sunscreen products is a typical public concern, motivating the study of the effects of nanomaterials in the colon,” the scientists note.

Their experiments with cell cultures of colon cells compared the effects of zinc oxide nanoparticles to zinc oxide sold as a conventional powder. They found that the nanoparticles were twice as toxic to the cells as the larger particles. Although the nominal particle size was 1,000 times larger, the conventional zinc oxide contained a wide range of particle sizes and included material small enough to be considered as nanoparticles. The concentration of nanoparticles that was toxic to the colon cells was equivalent to eating 2 grams of sunscreen - about 0.1 ounce. This study used isolated cells to study biochemical effects and did not consider the changes to particles during passage through the digestive tract. The scientists say that further research should be done to determine whether zinc nanoparticle toxicity occurs in laboratory animals and people.

The full article is available online free here:

ZnO nanoparticles toxic to human colon cells

Reference: Chem. Res. Toxicol., 2010, 23 (4), pp 733–739. (Web): February 15, 2010. DOI: 10.1021/tx900203v