News in brief

Keep it simple with whiplash physio
AUSTRALIAN research published in The Lancet shows an intensive and comprehensive physiotherapy program is no more effective than simple advice in managing chronic whiplash-associated disorders. The pragmatic randomised controlled trial included 172 participants with chronic whiplash-associated disorder, defined as lasting for more than 3 months and less than 5 years. All participants were provided with an educational self-management booklet about whiplash-associated disorders, with advice on how to manage the symptoms and a simple exercise program to help reduce associated neck pain. They were followed up at 14 weeks, 6 months and 12 months after being randomly allocated to receive either advice or a comprehensive exercise program. In the advice group, participants received a 30-minute consultation with a physiotherapist, which included practising the booklet exercises. The comprehensive exercise program group received 20 individually tailored and supervised 1-hour exercise sessions over 12 weeks. The researchers said their results were in keeping with data from previous research that suggested a more comprehensive package of care, designed to address the heterogeneous nature of whiplash-associated disorders, had minimum to no additional benefit over treatments that can be delivered in a small number of sessions such as usual care or advice. “Education and advice is as effective as more costly interventions, but how to deliver these interventions to patients in the most effective manner needs to be better understood”, the researchers wrote. An accompanying commentary said the research advanced understanding of whiplash-associated disorders and provided physiotherapists with clear information about how to treat patients with whiplash. “These findings should not be interpreted as encouragement to abandon exercise therapy in these patients: the question is how and when to exercise people with chronic whiplash-associated disorders”, the commentary said.

Fast food a little less salty
A STUDY has found a statistically significant reduction of 2%–3% in sodium levels of fast food in Australia between 2009 and 2012. The research, published in the MJA, found the reduction in sodium was “encouraging” but levels in many fast-food products were still high. The researchers used the nutrient content data of 1410 fast-food products, including breakfast products, burgers, chicken products, pizzas, salads and sandwiches, available from menu items on the websites of six large Australian fast-food companies. They wrote that although there was no guarantee the information was accurate, most chains reported that the nutrient data were based on analysis by external parties. The overall mean sodium content fell by 43 mg/100 g between 2009 and 2012, from 514 mg/100 g to 471 mg/100 g. However, the mean sodium content per serving was not significantly different at 654 mg in 2009 and 605 mg in 2012, “reflecting wide variation in the serving sizes of items offered each year”, they wrote. “The wide variation in sodium content per serving highlights the need for standardisation of portion sizes.” There was also wide variability in the sodium content of similar products from the different outlets. “Salt reduction remains one of the most cost-effective options for improving public health in Australia and many other countries”, the researchers wrote. “The key question continues to be how to persuade industry and government to take the actions required to reap the benefits of reducing the salt intake of the population.”

Check autoimmunity and epilepsy links
DOCTORS caring for patients with either an autoimmune disease (AD) or epilepsy should be aware of the strong association between the conditions, according to research published in JAMA Neurology. A retrospective population-based study of more than 2.5 million people who had made claims to a nationwide US health insurance plan examined the relationship between epilepsy and 12 ADs — type 1 diabetes, psoriasis, rheumatoid arthritis, Graves disease, Hashimoto thyroiditis, Crohn disease, ulcerative colitis, systemic lupus erythematosus, antiphospholipid syndrome, Sjögren syndrome, myasthenia gravis, and coeliac disease. The researchers found that 0.4% of the study population developed epilepsy, with the risk of epilepsy significantly heightened among patients with any AD (odds ratio [OR], 3.8; 95% CI, 3.6–4.0; P < 0.001), particularly in children. Those with AD accounted for 17.5% of patients with epilepsy in the study population and the risk was seen consistently across all 12 ADs. “Indeed, nearly 1 in 5 patients with epilepsy has a coexisting AD”, the researchers wrote, saying because epilepsy and AD frequently co-occur, patients with either condition should undergo surveillance for the other. “The potential role of autoimmunity must be given due consideration in epilepsy so that we are not overlooking a treatable cause”, they wrote.

Case prompts black salve warning
A LETTER to the MJA has outlined a case of a 55-year-old man who developed a large facial tissue defect after using black salve on a lesion he thought was cancerous. The case prompted the letter authors to warn health professionals of the use of unlicensed red and black salves by patients which could lead to adverse outcomes, “and for consumers to realise that alternative therapies that have been described as natural are not necessarily safe or, by any standard, risk-free”. They wrote that there had been an increase in sales of lotions and salves claiming to eradicate skin lesions and promote removal of skin cancers. The Therapeutic Goods Administration issued a public warning in 2012 strongly advising patients against the use of red and black salves. “These products contain sanguinarine, a benzylisoquinolone alkaloid derived from bloodroot (Sanguinaria canadensis)”, the authors wrote. “This compound is hypothesised to induce tissue necrosis by blocking the sodium–potassium pump, inhibiting nuclear factor-κB or impeding cell cycle progression.” They wrote that some patients may start using alternative treatment without receiving a definitive biopsy-proven diagnosis of skin cancer, resulting in “a very real risk of recurrence and metastasis”.

“Superior” results from bariatric surgery
A 3-year follow-up of 137 patients with uncontrolled type 2 diabetes after they were randomly assigned to bariatric surgery plus intensive medical therapy or to intensive medical therapy alone, has found surgery was superior for sustained glycaemic control and weight reduction. The research, published in the New England Journal of Medicine, found that patients who had surgery were significantly more likely to achieve and maintain a glycated haemoglobin (HbA1c) level of 6.0% or less than those on medical therapy alone, and also had a reduced dependency on diabetes medications and insulin. “More than one third of the patients in the gastric-bypass group and a fifth of those in the sleeve-gastrectomy group, as compared with no patients in the medical-therapy group, had a glycated hemoglobin level of 6.0% or less without the use of diabetes medications”, the researchers wrote. “The results of surgery are particularly striking in this population with relatively long-standing uncontrolled disease.” There were also favourable results in the surgery groups for secondary end points, including body mass index, body weight, waist circumference, and levels of triglycerides and HDL cholesterol. The authors concluded that “bariatric surgery represents a potentially useful strategy for the management of type 2 diabetes, allowing many patients to reach and maintain therapeutic targets of glycemic control that otherwise would not be achievable with intensive medical therapy alone”.

COIs for academics on drug industry boards
US research into relationships between the pharmaceutical industry and academic medical centres (AMC) has found that 40% of drug companies had at least one member of their board of directors who concurrently held an AMC position. The research letter, published in JAMA, examined 47 companies with public data on governance, finding 41 board members who held an AMC position, with mean financial compensation for board membership of US$312 564. The researchers found 3% of all board members held 21 clinical or administrative leadership positions including two university presidents, six deans, six hospital or health system executive officers, and seven clinical department chairs or centre directors. As well, 5% of drug company board members held 28 positions as trustees or board members of US hospitals, medical schools or universities. The researchers said the US Physician Payment Sunshine Act would make all financial relationships with industry public this year. “Severing ties between companies and AMC leaders might eliminate the potential benefits of academic-industry collaboration; however, the extent to which individuals who hold coexisting leadership positions have fostered beneficial partnerships and at what potential cost remains unclear”, the researchers wrote. “These relationships present potentially far-reaching consequences beyond those created when individual physicians consult with industry or receive gifts.”

Walking benefits in predialysis CKD
RESEARCHERS have found “convincing evidence” that exercise has the potential to be an effective anti-inflammatory therapy in predialysis chronic kidney disease (CKD) patients and may also reduce the high risk of cardiovascular disease in these patients. The small study, published in JASN, included 15 patients and looked at the separate effects of acute and regular moderate-intensity aerobic exercise in patients with predialysis CKD. The main findings were that exercise enhanced neutrophil responsiveness to a bacterial challenge, without affecting T lymphocyte and monocyte activation, and induced a systemic anti-inflammatory environment. The researchers found even a single 30-minute (acute) bout of walking, which induced a normal pattern of leukocyte mobilisation and had no effect on T lymphocyte and monocyte activation, did improve neutrophil responsiveness to a bacterial challenge in the postexercise period. Six months of regular walking exercise (30 min/day, 5 times/week) exerted anti-inflammatory effects (reduction in the ratio of plasma IL-6 to IL-10 levels) and a down regulation of T lymphocyte and monocyte activation, but had no effect on circulating immune cell numbers, neutrophil degranulation responses, renal function, proteinuria or blood pressure. However, the researchers said further research was needed “to fully elucidate the impact of exercise on the complex state of immune dysfunction that accompanies CKD”.