Cardiorespiratory Fitness and Mortality

SOURCE: Ehrman JK, Brawner CA, Al-Mallah MH, et al. Cardiorespiratory fitness change and mortality risk among black and white Patients: Henry Ford Exercise Testing (FIT) Project. Am J Med 2017;130:1177-1183.

In both men and women in the United States, levels of cardiorespiratory fitness are inversely related to mortality. An encouraging epidemiologic study of women (the Nurses’ Health Study, n = 72,488) found that even brisk walking for about 30 minutes daily was associated with near maximal cardiovascular (CV) health benefits. Additionally, even sedentary women who became physically active later in life enjoyed CV risk
reduction.

But does race make a difference? African-Americans demonstrate higher CV event rates and mortality than Caucasians, which has been linked to disparities in hypertension, access to care, and other causes. However, for similar levels of fitness, are outcomes different between ethnicities? Investigators performed a retrospective analysis of data from a nine-year follow-up of patients (n = 13,345) who had undergone exercise treadmill testing at Henry Ford Hospital in Detroit on at least two occasions.

Approximately 75% of the population was Caucasian and 25% African-American. An analysis of fitness level in relation to mortality showed no meaningful difference between groups: For both ethnicities, each one metabolic equivalent increment of cardiorespiratory fitness was associated with a 13-16% reduction in mortality.


Searching for Answers on Knee Osteoarthritis

SOURCE: Bartels EM, Henrotin Y, Bliddal H, et al. Relationship between weight loss in obese knee osteoarthritis patients and serum biomarkers of cartilage breakdown: secondary analyses of a randomised trial. Osteoarthritis Cartilage 2017;25:1641-1646.

It is well-recognized that overweight and obesity are associated with osteoarthritis. Lest one becomes overly simplistic and assigns degenerative joint changes solely to the extra stress of excess weight, one should recognize that osteoarthritis of the hands also is associated with obesity, although it would be difficult to conjure any additional joint-loading burden.

At the same time, data consistently show that for knee osteoarthritis, weight loss is associated with symptomatic and functional improvement. The mechanism of this is incompletely understood, since weight loss has not been shown to affect the progressive degradation of cartilage typical of osteoarthritis.

Bartels et al studied biomarkers of collagen breakdown in persons with knee osteoarthritis who lost weight, wondering whether these potentially more sensitive indicators would corroborate that the symptomatic improvements seen with weight loss were actually reflecting less cartilage degradation that was too subtle to be identified radiographically. At the conclusion of the trial, changes in biomarkers were not found to be associated with symptomatic improvements.


Considering Systemic Treatment for Atopic Dermatitis

SOURCE: Simpson EL, Bruin-Weller M, Flohr C, et al. When does atopic dermatitis warrant systemic therapy? Recommendations from an expert panel of the International Eczema Council. J Am Acad Dermatol 2017;77:623-633.

Most patients with atopic dermatitis can control their disease with topical agents, including corticosteroids, calcineurin inhibitors (e.g., pimecrolimus, tacrolimus), local hygienic measures (e.g., moisturizers), and, most recently, a topical phosphodiesterase-4 inhibitor (crisaborole). A recent panel of eczema experts convened to provide advice about when clinicians should consider systemic treatment.

Their first recommendation was to optimize topical treatments. Patients refractory to topicals should be assessed for the presence of contact allergy (e.g., patch testing), as well as for the presence of viral, bacterial, or yeast cutaneous disease. Prior to the institution of systemic therapy, a trial of phototherapy should be considered.

If none of these interventions are sufficient, there are five different systemic therapies to consider: azathioprine, cyclosporine, dupilumab, methotrexate, and mycophenolate. At this stage of disease, most patients will be best served by referral to a dermatologic specialist.