Tuesday, June 25, 2013
Antibiotics could cure 40% of chronic back pain patients
After the discovery of helicobacter pylori, medical researchers went all out loking for bacterial causes of everything -- without much result. The remarkable finding below might revitalize that focus
Surgeons in the UK and elsewhere are reviewing how they treat patients with chronic back pain after scientists discovered that many of the worst cases were due to bacterial infections.
The shock finding means that scores of patients with unrelenting lower back pain will no longer face major operations but can instead be cured with courses of antibiotics costing around £114.
One of the UK's most eminent spinal surgeons said the discovery was the greatest he had witnessed in his professional life, and that its impact on medicine was worthy of a Nobel prize.
"This is vast. We are talking about probably half of all spinal surgery for back pain being replaced by taking antibiotics," said Peter Hamlyn, a consultant neurological and spinal surgeon at University College London hospital.
Hamlyn recently operated on rugby player Tom Croft, who was called up for the British and Irish Lions summer tour last month after missing most of the season with a broken neck.
Specialists who deal with back pain have long known that infections are sometimes to blame, but these cases were thought to be exceptional. That thinking has been overturned by scientists at the University of Southern Denmark who found that 20% to 40% of chronic lower back pain was caused by bacterial infections.
In Britain today, around 4 million people can expect to suffer from chronic lower back pain at some point in their lives. The latest work suggests that more than half a million of them would benefit from antibiotics.
"This will not help people with normal back pain, those with acute, or sub-acute pain – only those with chronic lower back pain," Dr Hanne Albert, of the Danish research team, told the Guardian. "These are people who live a life on the edge because they are so handicapped with pain. We are returning them to a form of normality they would never have expected."
Claus Manniche, a senior researcher in the group, said the discovery was the culmination of 10 years of hard work. "It's been tough. There have been ups and downs. This is one those questions that a lot of our colleagues did not understand at the beginning. To find bacteria really confronts all we have thought up to this date as back pain researchers," he said.
The Danish team describe their work in two papers published in the European Spine Journal. In the first report, they explain how bacterial infections inside slipped discs can cause painful inflammation and tiny fractures in the surrounding vertebrae.
Working with doctors in Birmingham, the Danish team examined tissue removed from patients for signs of infection. Nearly half tested positive, and of these, more than 80% carried bugs called Propionibacterium acnes.
The microbes are better known for causing acne. They lurk around hair roots and in the crevices in our teeth, but can get into the bloodstream during tooth brushing. Normally they cause no harm, but the situation may change when a person suffers a slipped disc. To heal the damage, the body grows small blood vessels into the disc. Rather than helping, though, they ferry bacteria inside, where they grow and cause serious inflammation and damage to neighbouring vertebrae that shows up on an MRI scan.
In the second paper, the scientists proved they could cure chronic back pain with a 100-day course of antibiotics. In a randomised trial, the drugs reduced pain in 80% of patients who had suffered for more than six months and had signs of damaged vertebra under MRI scans.
Albert stressed that antibiotics would not work for all back pain. Over-use of the drugs could lead to more antibiotic-resistant bacteria, which are already a major problem in hospitals. But she also warned that many patients will be having ineffective surgery instead of antibiotics that could alleviate their pain.
"We have to spread the word to the public, and to educate the clinicians, so the right people get the right treatment, and in five years' time are not having unnecessary surgery," she said.
Hamlyn said future research should aim to increase the number of patients that respond to antibiotics, and speed up the time it takes them to feel an improvement, perhaps by using more targeted drugs.
The NHS spends £480m on spinal surgery each year, the majority of which is for back pain. A minor operation can fix a slipped disc, which happens when one of the soft cushions of tissue between the bones in the spine pops out and presses on nearby nerves. The surgeons simply cut off the protruding part of the disc. But patients who suffer pain all day and night can be offered major operations to fuse damaged vertebrae or have artificial discs implanted.
"It may be that we can save £250m from the NHS budget by doing away with unnecessary operations. The price of the antibiotic treatment is only £114. It is spectacularly different to surgery. I genuinely believe they deserve a Nobel prize," said Hamlyn. Other spinal surgeons have met Albert and are reviewing the procedures they offer for patients.
Are superfoods that super?
The alleged benefits of so-called superfoods is often based on flimsy research
I’m not happy. Last week I discovered I’ve been wasting my time every Sunday for most of my adult life. I refer to my weekly meal of mackerel, which I force myself to eat despite the repulsive taste and texture, and the smell that lingers for days after. Not only do I hate the slimy fish, but twice I’ve nearly died (or at least it felt that way) when a bone has stuck in my throat.
So new draft guidance published by the National Institute of Health and Care Excellence (Nice) suggesting that the impact of an oily fish diet in preventing heart attacks or strokes "could be minimal" is far from welcome. Minimal? I’ve been missing out on a lovely, wholesome fry up – my preferred choice, naturally – for a decade or more because I, and millions of others, believed that oily fish was key to health and longevity.
Like any good psychiatrist, I blame my mother. When I was a child, she bought a book called Superfoods and, in her determination to guarantee my sister and I would live long enough to look after her in her old age, it became her bible. Each time we found an unusual or exotic foodstuff on our plate, she would take great pleasure in informing us it was a "superfood" and would help ward off diabetes or cancer or evil or whatever it was she’d read about.
We all know that certain foods are better for us than others, but the idea that some possess almost mystical properties is very seductive.
Suppliers and manufacturers exploit a belief in some elixir of health and market, and price accordingly, or promote in various ingenious ways even more "super" versions of superfoods.
Despite six years at medical school and well-developed cynicism when it comes to food fadism, I admit I have bought into the superfoods phenomenon. In addition to oily fish, I make sure I consume pomegranates, blueberries, kiwi fruit, broccoli and brazil nuts regularly, even though I know that if it’s not deep fried, coated in lard or caked with sugar, pretty much any vegetable or fruit is good for you.
The specific marketing of goods as "superfoods" is prohibited in the European Union unless backed by scientific evidence. But research into the benefits of many of these foods is, at best, provisional and based on small preliminary studies that are open to multiple factors that can skew the results.
In 2011, the NHS looked at these wonder foods and examined some of the claims made for them. The findings were critical not just of the media’s sensationalist reporting of the research, but also of the research itself. They pointed out that the plethora of contradictory reports was such that "often the same food is declared healthy one day and harmful the next". (I’m still not sure if red wine and chocolate will save my life or kill me.)
There are many reasons why the research is often not as promising as it first appears. One problem is confounding factors – this is when a factor other than the one being investigated is responsible for the effects. A study of alcohol consumption by Dutch men over 40 years, for example, found that those who consumed an average of half a glass of wine a day lived five years longer than those who didn’t. While the researchers took into account some factors that might explain the disparity – such as smoking and weight – they didn’t consider exercise. So there’s no way of knowing if the results were down to the wine, or because the men who drank half a glass a day took more exercise, or a combination of both.
Another problem is that often the researchers use surrogate end points, in which the studies measure outcomes not directly related to people’s health. One widely reported study that claimed that eating oily fish could improve people’s memory compared changes in the blood flow to the brain in those who ate the fish and those who did not – but it didn’t actually test memory, which is the only way to say for sure that oily fish bestows that benefit.
Also, many reported studies are performed on animals or in vitro in laboratories, making any findings impossible to extrapolate in a meaningful way to the average person.
And there are other factors that can affect the reliability of research, such as bias and conflicts of interest over who funds the study and what they want from it. In short, few claims that a food has a miracle benefit live up to scrutiny.
So my advice is this: ensure you have a balanced, sensible diet and don’t eat too much sugar, salt or fat. That’s pretty much it. While it might be tempting to believe in miracles, the reality is more prosaic.
The good news for me is that for the first time in years, I can now look forward to a decent Sunday brunch.
Posted by jonjayray at 12:22 AM