ARRS.org - New MR techniques show that facet joint effusion (the collection of fluid in the spinal joints) and interspinal ligament edema (swelling of the interspinal ligaments) are major sources of lower back pain, according to a study performed at Baskent University Hospital in Ankara, Turkey and Alanya Research Center in Antalya, Turkey.

During the study 372 patients with lower back pain and 249 healthy patients underwent MRI accompanied by STIR (short inversion time inversion recovery) sequences. “The most common imaging findings in patients with lower back pain were soft tissue changes, mainly facet joint effusion, 85.5 percent, and interspinal ligament swelling, 80.6 percent,” according to Nefise Cagla Tarhan, MD, lead author of the study.

“Soft tissue changes are important in the understanding of lower back pain and prevention and treatment options should focus more on these changes. A lot of patients (mostly younger) come to me with complaints of bad, lower back pain; it is a very common community problem,” said Dr. Tarhan. “With this new MR technique, prevention and treatment options for lower back pain can focus more on soft tissue degenerative changes that cause facet joint effusion and interspinal ligament swelling,” said Dr. Tarhan.

This study on soft tissue inflammatory changes as a major cause of low back pain appears in the October 2008 issue of the American Journal of Roentgenology.

Acfas.org - Autumn is not a fun time of year for women like Elaine Powers.

In the summer months, “like everybody else, I like to wear flip-flop sandals, open-toed shoes, a nice pedicure with good nail polish,” she says.

But as autumn arrives, the 49-year-old South Carolina hospice nurse is making the annual changeover to closed-in shoe styles more appropriate to the cooler weather. It’s a transition many women are making in their wardrobes. But it’s more painful for women like Powers, and not because she’s a slave to foot fashion. Powers has bunions.

“Even after you take your shoes off, or put your feet up, it’s just a throbbing… It’s almost like every time your heart beats, that bunion throbs,” she says.

Women with bunions are a common sight in the waiting rooms of many foot and ankle surgeons during this time of year, according to the 6,000-member American College of Foot and Ankle Surgeons (ACFAS).

St. Louis foot and ankle surgeon Karl Collins, DPM, FACFAS, gives two additional reasons for this annual trend. One is financial. Women are closer to meeting insurance deductibles near the end of the year.

“The other thing is, people are very active in the summer,” Collins says. “They’re always outdoors, they’re always at the pool or whatever, so they will decide to get their bunion fixed in the winter, because in their mind, they’re not missing anything fun.”

Powers has suffered with bunion pain for nearly 25 years. However, many women never experience pain from their bunions, even when the deformity looks severe. Shoes do not cause bunions, but they may cause bunion pain. That’s why foot and ankle surgeons recommend shoe modifications to new patients. Avoiding high heeled shoes and styles that crowd the toes together can help. Collins says proper shoe selection and adjustment can go a long way.

“If they have a shoe that fits well everywhere else, but there’s just a little bit of irritation at just that one spot, we may recommend that they have the shoe modified (by a shoe repair shop),” he says.

South Carolina foot and ankle surgeon Michelle L. Butterworth, DPM, FACFAS, treats a lot of teachers with back to school bunion pain. She says many women don’t understand what doctors mean about shoe width: It’s the front of the shoe that needs to be wide.

“Anything that’s real pointy is going to put more pressure on that (bunion) bump,” she explains.

In addition to recommending shoe changes, foot and ankle surgeons may also prescribe foam- or gel-filled padding, orthotics, anti-inflammatory medications, and injections for bursitis, nerve irritation and joint irritation. While these techniques address pain, they do not stop the bunion from getting worse. Only surgery can correct the deformity.

Bunion surgery boasts a high success rate. But surgeons agree that patients need to understand what their procedure and recovery will involve.

“Probably the biggest thing is, they think surgery’s not going to work and (the bunion is) going to come back,” says Butterworth. “It’s probably the biggest myth I dispel.”

Powers is one of her patients.

“That’s one of the reasons why I haven’t had this surgery before now,” Powers says. “A lot of people tell me once you have (bunions), you are always prone to have them, they’ll come back.”

Following the surgeon’s instructions for recovery can significantly reduce the chances of a bunion returning.

“If wearing four-inch heels and working on your feet all day wasn’t good for you before the surgery, it’s certainly not going to be good for you after the surgery,” notes Michael Loshigian, DPM, FACFAS, a New York City foot and ankle surgeon.

Powers hasn’t made up her mind about bunion surgery. She’s already tried prescription pain medication, and struggles to find comfortable shoes. This fall, Butterworth will perform bunion surgery on Powers’ 19-year-old daughter, who inherited her mother’s feet. Powers wants to see how that turns out. She also has to worry about finding someone to cover her 12-hour work shifts for several weeks.

But if she does choose surgery, she already knows how she’ll celebrate after her recovery.

“I’m buying a pair of stiletto heels and I’m wearing them everywhere I go,” she jokes.

The ACFAS provides a list of answers to frequently asked questions about bunion surgery on http://FootPhysicians.com.

AACR.org - In pre-clinical studies, vitamin C in higher doses appears to substantially reduce the effectiveness of anticancer chemotherapy, say researchers at Memorial Sloan-Kettering Cancer Center.

These new findings, published in the October 1, 2008 issue of Cancer Research, a publication of the American Association of Cancer Research (AACR), came from studying laboratory cancer cells and mice, but the study’s authors say the same mechanism may affect patient outcomes, although they add this premise needs to be tested.

“The use of vitamin C supplements could have the potential to reduce the ability of patients to respond to therapy,” said Heaney, an Associate Attending Physician at Memorial Sloan-Kettering Cancer Center.

Use of vitamin C during cancer treatment has been controversial. Some studies have suggested that because vitamin C is an antioxidant it might be beneficial to cancer patients. But some classes of chemotherapy drugs produce “oxygen free radicals,” unpaired oxygen molecules that can fatally react with other molecules in a cell, forcing cell death. In this theory, vitamin C could sop up the radicals, keeping the cancer cell alive despite chemotherapy treatment.

Heaney and his colleagues tested a wide variety of chemotherapy drugs – those that produce reactive oxygen and those that work in other ways – on cancer cells in the laboratory, that were pretreated with dehydroascorbic acid (DHA), the form that ascorbic acid (vitamin C) takes to enter cells.

They found to their surprise that every chemotherapy drug they tested – which included targeted agents like Gleevec – did not work as well if cells were pretreated with vitamin C, as they did on untreated cancer cells. In the cell culture experiments, 30 to 70 percent less cancer cells treated with vitamin C were killed depending on the drug tested.

They then checked these findings by implanting the cancer cells into mice, and again found that, in an animal model system, while chemotherapy kept untreated cancer in check, tumors grew more rapidly in mice that were given cancer pretreated with vitamin C.

The research team, which includes researchers from Columbia University, then delved into the mechanism by which vitamin C may be protecting these cells, and discovered that it wasn’t because the nutrient was neutralizing oxygen-free radicals.

They found instead that DHA was restoring viability to the cancer cell’s damaged mitochondria – the cell’s all-important power plant that, when injured, sends signals to force a cell to die.

“Vitamin C appears to protect the mitochondria from extensive damage, thus saving the cell,” Heaney said. “And whether directly or not, all anticancer drugs work to disrupt the mitochondria to push cell death.”

Heaney says that the amount of DHA used in the experiments resulted in an intracellular buildup similar to what could be seen in cancer patients using large supplemental doses of vitamin C.

Researchers at Memorial Sloan-Kettering Cancer Center have long been researching the connection between vitamin C and cancer therapy, and these new findings expand on their earlier observation that vitamin C seems to accumulate within cancer cells more than in normal cells.

“We recognized that DHA is the form of vitamin C that gets into cells, and that the tumor microenvironment allows cancer cells to convert more vitamin C into DHA,” he said. “Inside the cell, DHA is converted back into ascorbic acid, and it gets trapped there and so is available to safeguard the cell.”

Heaney says that he suspects that vitamin C is good for the cells of normal tissue because it provides more protection for the mitochondria, and thus probably extends cell life. “But that isn’t what you want when you are trying to eliminate cancer cells,” said Heaney, who notes that cancer patients should eat a healthy diet, which includes foods rich in vitamin C. It is use of large doses of over-the-counter vitamin C that is worrisome, he says.

ARRS.org - CT scans change the initial treatment plans of emergency physicians in over 25 percent of patients with suspected appendicitis, according to a study performed at the University of Washington Harborview Medical Center in Seattle, WA.

During the study 100 adult patients admitted to the ER for symptoms of appendicitis were evaluated. The treatment plans of these patients were assessed before and after CT and compared. Results showed that “treatment plans changed in 29 percent of patients as a result of CT. In many instances, CT ruled out appendicitis when the treatment plan prior to the scan was surgical consultation, eliminating the potential for unnecessary surgery on patients with a normal appendix,” according to Robert O. Nathan, MD, lead author of the study.

“The data suggest that CT can be withheld in patients in whom emergency clinicians rate the likelihood of appendicitis as unlikely but that CT findings are often of benefit when appendicitis is judged to be very likely,” said Dr. Nathan.

“Patients can be assured that CT scanning of the appendix adds value to therapeutic decision making, thereby improving their care,” said Dr. Nathan.

This abstract of the study, which appears in the October 2008 issue of the American Journal of Roentgenology, is available here:

Impact of CT scan of the appendix

AHRQ.gov - Obese school-age kids and teens can lose weight or prevent further weight gain if they participate in medium- to high-intensity behavioral management programs, according to a new report.

Children in the medium- to high-intensity behavioral management programs studied met for more than 25 hours, usually once or twice a week, for 6 months to 12 months. Effective programs included techniques to improve dietary and physical activity habits, with some featuring strategies such as goal setting, problem solving and relapse prevention.

Researchers found that after completing weight management programs, obese children would weigh between 3 pounds and 23 pounds less, on average, than obese children not involved in such programs. Among those enrolled, the weight difference would be greatest among heavier children as well as in those enrolled in more intensive programs. Researchers also found that weight improvements could be maintained for up to a year after the program ended.

“Effective prevention is the best way to stem the childhood obesity epidemic, but we also have to find effective and healthy ways of helping our children and teens who already are obese get to a healthier weight,” said AHRQ Director Carolyn M. Clancy, M.D. “AHRQ’s new evidence report helps identify possible solutions.”

About 17 percent of U.S. children and teenagers are obese, meaning they have a body mass index (a measure of weight adjusted for the height, age and sex of a child) at or above the 95th percentile for their age and sex. For example, a 16-year-old girl who is 5 feet 4 inches tall and weighs 168 pounds or more is considered obese. Obese children and adolescents are at higher risk for asthma, type 2 diabetes, fatty liver disease, sleep apnea and other weight-related medical problems. They may also suffer psychological harm from being stigmatized because of their appearance.

“Obese children and their families may be discouraged about their weight, but our review found there are programs out there that can help kids to either gain weight more slowly as they grow or, where appropriate, lose weight,” said Evelyn Whitlock, M.D., M.P.H., Associate Director of the AHRQ-supported Oregon Evidence-based Practice Center at Kaiser Permanente’s Center for Health Research in Portland that produced the report.

In a study of one high-intensity, 12-month program reviewed by the researchers, obese children 8 to 16 years old gained less than 1 pound on average, compared with obese kids the same age who gained nearly 17 pounds during the same time period. AHRQ’s report found that intensive, health care-based programs generally had greater effects than school-based programs. For example, the report found that obese 12-year-olds in a medium- to high-intensity health care program would weigh 17 to 18 pounds less than their obese peers. In contrast, children enrolled in school-based programs would end up weighing only 4 pounds less than their obese peers.

The report also showed that adding prescription drugs to a behavioral weight management program helped extremely obese adolescents lose weight. However, no studies evaluated maintenance of weight loss after drug treatment ended.

The two primary drugs reviewed were sibutramine (Meridia), which is an appetite suppressant, and orlistat (Xenical), which helps block fat absorption. In one 12-month study, adolescents taking sibutramine as part of a weight management program lost an average of 14 pounds, compared with a 4.2-pound weight gain among those who took a placebo. In another trial, adolescents who took orlistat as part of their weight management program gained an average of 1.2 pounds, compared with their peers who took a placebo and gained nearly 7 pounds.

While there were no reported harms from behavioral intervention alone, there were side effects from prescription drugs. These included mild increases in heart rate or blood pressure from the use of sibutramine. Among those taking orlistat, up to one-third reported abdominal pain, oily spotting or fecal urgency; 9 percent reported fecal incontinence.

The researchers also reviewed the effectiveness of weight-reduction surgery on morbidly obese adolescents who had a BMI of 41 or greater. Although the evidence is limited, results suggest moderate to substantial weight loss. The surgery can resolve weight-related medical problems such as sleep apnea and asthma. However, greater short-term risks are associated with surgery, and few cases have been followed more than 1 year.

The new report is available here:

Effectiveness of Weight Management Programs in Children and Adolescents

Copies of the report may be ordered free of charge by calling the AHRQ Publications Clearinghouse at 1-800-358-9295 or sending an e-mail to AHRQPubs@ahrq.hhs.gov. For information on how children’s and teenagers weight is assessed and a BMI calculator to use for them, see

BMI Calculator for children

AHRQ also has a free DVD for families and children age 5 to 9 called Max’s Magical Delivery: Fit for Kids. The 30-minute DVD teaches children and their parents about smart eating and physical activity. Copies are available by calling 1-800-358-9295 or e-mailing AHRQPubs@ahrq.hhs.gov.

NationwideChildrens.org - As the school year starts up again, parents, school nurses and pediatricians often have to respond to increased complaints of stomach pain. Many of these seasonal belly-aches are dismissed as nothing more than a case of the back-to-school blues or nervousness. However, in many instances the pain kids feel is the result of a complicated and often misdiagnosed medical condition that researchers at Nationwide Children’s Hospital now believe could be helped with the use of medications typically used to treat depression.

“Functional abdominal pain is one of the most common reasons children are referred to our gastrointestinal clinic,” said Carlo Di Lorenzo, MD, chief of Gastroenterology, Hepatology and Nutrition at Nationwide Children’s Hospital and a faculty member at The Ohio State University College of Medicine. “Each year, when students return to class, we see an increase in the number of patients complaining of abdominal pain.”

Functional abdominal pain is stomach pain that is not associated with any evidence of a physical disease or tissue damage. The condition is estimated to affect as many as 10 percent of children, many of whom also have a history of depression, anxiety, migraine headaches and/or fatigue. The pain also tends to occur more frequently during times of stress and anxiety, including during school, sports and other activities. Although the cause of the pain isn’t clear, the pain itself is very real.

“It really does hurt, and these kids really do suffer. Their parents suffer too, because they are often terribly worried that something very serious may be wrong and they see how the symptoms can interfere with the child’s life,” said John Campo, MD, chief of Child and Adolescent Psychiatry and a pediatrician at Nationwide Children’s Hospital. “We know that as a group, these kids miss more school than unaffected kids. They don’t do as well in school, either.”

Dr. Campo, Dr. Di Lorenzo and investigators at The Research Institute at Nationwide Children’s Hospital are now looking into ways to give kids some relief from the chronic pain. Currently, patients are taught coping techniques, such as relaxation training and guided imagery, to help manage the pain. Now researchers believe the use of medications, traditionally used as antidepressants, may help lessen the pain, or prevent it altogether.

Clinical trials are underway at Nationwide Children’s Hospital to test the effectiveness of selective serotonin reuptake inhibitors (SSRIs) in the treatment of functional abdominal pain. SSRIs affect the handling of serotonin in the body.

“People have thought about serotonin as being important in anxiety and depression,” said Dr. Campo, also a member of the faculty at The Ohio State University College of Medicine. “While that’s true, what’s really interesting is that 95 percent of our body’s serotonin is in our intestinal track.”

Serotonin transmits messages of pain to the brain and the local nervous system in the stomach. Researchers hope that changing the way the body handles serotonin may help ease functional abdominal pain. So far, a type of SSRI, known as citalopram, has shown promise. In a preliminary study of the medication, citalopram appeared to ease abdominal pain in approximately 80 percent of cases, but Dr. Campo stresses that more research is needed.

Doctors recommend that children with recurrent or persistent abdominal pain be checked out by a doctor. Medical treatment should be sought immediately if a child experiences blood in vomit or bowel movements, fevers, weight loss or persistent vomiting. Also, doctors should be informed if there is any history of bipolar or manic-depressive disorder in the extended family (blood relatives), which can be a clinical concern if a doctor is considering using SSRIs or other antidepressants.

Although functional abdominal pain tends to be more common in girls (especially after puberty), it affects both boys and girls. It often develops during two peak times in a child’s development: between 4 and 6 years of age or later in life, during late childhood or early adolescence.

Nationwide Children’s Hospital is still accepting patients for studies involving functional abdominal pain. For more information, contact Maureen Maher-Bridge by phone at 614-722-6432.