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Insider Arthritis Tips March and April 2016
March 16, 2016
How wonderful it is that nobody need wait a single moment before starting to improve the world. Anne Frank
Doctors burning out with this new burden. That’s a cause for concern… next
Some physicians suffering burnout over EHR mandates
In a 1,200-word story, Russel in the Chicago Tribune discussed how the Federal government’s “elaborate – or maddening and onerous – system of electronic health records” is affecting physicians. According to the Tribune, medical associations nationwide are attributing “increasing doctor burnout to the demands of clicking through page after page of records, whether the patient shows up for a physical, a quick follow-up visit, or treatment for chronic disease.” Recently, “Mayo Clinic researchers, working with the American Medical Association, found that more than half of physicians felt emotionally exhausted.” Contributing to that exhaustion are “heavier workloads and ‘increased clerical responsibilities.’”
Comment: We recently started electronic medical records in the office. I feel more like a clerk than a doctor. How this makes medical care better is a mystery to me.
Methotrexate Safety with Chronic Hepatitis B Infection
Dr. Jack Kush writing in Rheum Now reported chronic liver disease, and in
particular hepatitis B infection, is considered a contraindication to
methotrexate (MTX) use. Specifically, the package insert states, "Patients with
psoriasis or rheumatoid arthritis with alcoholism, alcoholic liver disease or
other chronic liver disease should not receive methotrexate."
A median of 6 years after the diagnosis of CHB, of all RA patients developed
liver cirrhosis with no difference between those on or off MTX. They did not
find any association between liver cirrhosis in CHB patients and long-term MTX
use in RA. Furthermore, there was no occurrence of liver cirrhosis among 56 MTX
users after 97 months’ treatment.
Comment: comforting to know… for sure
Want a sustained remission if you have rheumatoid arthritis… then watch
Obesity decrease chances for sustained remission in RA
Amy Karon writing in Rheumatology News reported that obese patients with RA are significantly less likely to achieve a sustained disease remission than are patients who have normal weight or who are only overweight. The study was conducted at the Hospital for Special Surgery in New York.
Comment: Not new news but definitely important.
Got arthritis in your big toe… watch… next
Reducing pain in patients with osteoarthritis of the big toe
Reported in Medical Xpress, prefabricated foot orthoses and rocker-sole footwear (in which the sole of the shoe is curved) are effective at reducing peak pressure under the big toe in people with a condition called first metatarsophalangeal joint osteoarthritis, but new research shows that they achieve this through different mechanisms. Also, rocker-sole shoes exhibited lower peak pressure under the lesser toes and midfoot, while orthoses increased peak pressure in these areas.
Investigators found that both were similarly effective for relieving big toe joint pain in patients; however, prefabricated foot orthoses may be the intervention of choice because patients were more likely to use them, and they were less likely to cause back pain, discomfort, or impaired balance.
Comment: Owwww. My foot hurts just thinking about this.
Think diet may help arthritis… you’re right!
Prudent Diet Reduces Risk of RA
Dr. Jack Cush writing in Rheum Now reported on a study by Lu et al from the Brigham and Women’s Hospital and Harvard Medical School found that a typical Western diet (a "Big Mac" diet) may increase the risk of RA.
Using data from the NHS II Survey, they examined 93,859 women (without RA) and their dietary patterns from 1991 to 2011. Diets were categorized as prudent (diet high in fruits, vegetables, legumes, whole grains, poultry and fish) or Western diets (high in red and processed meat, refined grains, fried food, high-fat dairy and sweets).
With over 1.5 million patient-years of follow-up they identified 626 incident cases of RA. Those with a Prudent dietary pattern noted a reduced risk of RA.
At the same time, those on a Western diet were at increased risk for RA.
Psoriasis and depression… is there a link?
Psoriasis is a risk factor for depression
Amy Karon writing in Rheumatology News reported that a study from New York University revealed that psoriasis doubled the odds for depression. The cross-sectional study involved more than 12,000 patients from the National Health and Nutrition Examination Survey.
Comment: It’s been known for years that depression often accompanied psoriasis but this large study confirms it.
A tough problem faced by clinicians is whether to use TNF inhibitors in rheumatoid arthritis patients who have congestive heart failure. The guidelines formulated on old data says “No.” but maybe those guidelines need to be revised… next
TNF Inhibition and Heart Failure
Dr. Jack Cush writing in Rheum Now reported clinicians often face the issue of using a TNF inhibitor (TNFi) in patients with heart failure or cardiac disease.
Numerous studies and registries of RA patients have demonstrated a cardioprotective effect of TNF inhibition on heart attack and new cardiac events. A study by Wolfe and Michaud looked at more than 13 thousand RA patients in the National Databank, noting more cases of CHF in RA (compared with osteoarthritis); however this was not higher in patients receiving TNFi. A retrospective cohort study of 303 Veterans Administration RA patients, failed to show a higher rate of CHF admissions or mortality amongst those treated with TNF blockers.
The mistake in the recent RA treatment guidelines is to avoid TNFi based on the concerns raised in cardiology patients (not RA patients) and the package insert warnings; and to recommend other therapies (DMARDs, non-TNFi biologics) that have NOT been studied RA patients with CHF, nearly as much as TNFi has been.
Comment: Whew… confusing but probably reassuring.
A hidden danger with anti TNF therapy… next
Two-Fold Increase of Demyelinating Diseases with TNF Inhibition
Dr. Jack Cush writing in RheumNow reported despite the potential contributory role of TNF in the pathogenesis of multiple sclerosis, several trials have shown that TNF inhibitor (TNFi) use may lead to worsening of MS, optic neuritis and other demyelinating disorders. This particular safety warning has been in the product label for nearly 15 years, yet little is known about why this happens, how often or what the scope of potentially inducible neurologic disease may be.
Researchers in Denmark investigated this potential association between
demyelinating disease and inflammatory bowel disease (IBD) and those receiving
TNFi for their IBD.
Comment: A little known but important issue.
Weight loss… does it help knee osteoarthritis or doesn’t it?
UCSF Study Shows Weight Loss Protects OA Cartilage
Researchers at the University of California at San Francisco have shown that
>10% weight loss may impact the rate of cartilage loss as determined by MRI
scanning. They presented their findings at the annual
meeting of the
Radiological Society of North America.
Patients were divided into three groups: a control group (those who did not lose weight), a second group who lost < 10% weight, and a third group who lost > 10 percent of their body weight. MRI was used to quantify the amount of cartilage loss in the affected knee over a 4 year span.
They found evidence that weight loss has a protective effect against cartilage degeneration and that a larger amount of weight loss is more beneficial. Slowing of cartilage loss was greatest in the group that lost more than 10 percent of their body weight, especially in the weight-bearing regions of the knee. Surprisingly, those with 5-10% weight loss had no protective effect.
Comment: No comment.
Unbelievable Benefits Of Petroleum Jelly
What is Petroleum Jelly?
It is also known by its trademark Vaseline, which is a purified mixture of semi-solid hydrocarbons derived from petroleum. It is the same petroleum used to make diesel products, fuel and deodorants. It is really versatile and can be used for many purposes.
How nuts do we have to go?
Nut consumption has been associated with a reduced risk of major chronic diseases, such as heart disease and diabetes. Clinical trials have shown nuts help lower cholesterol and oxidation, and improve our arterial function and blood sugar levels.
Researchers at Harvard examined the association between nut consumption and subsequent mortality of over 100,000 people followed for decades. A conclusion was made that daily nut consumers had fewer deaths from cancer, heart disease, and respiratory disease, even after controlling for other lifestyle factors. Nut consumers lived significantly longer whether they were older or younger, fat or skinny, whether they exercised more, smoked, drank, or ate other foods that may affect mortality.
Since nuts are so filled with fat there is concern of weight gain. However, Harvard researchers found studies that have associated nut consumption with a slimmer waist, less weight gain, and lower risk of obesity. Studies show that the incorporation of nuts (around one to two small handfuls a day) would be advisable to ensure various health benefits without the risk of body weight gain.
Recipe By: John Millard
A dish that is sure to be a family favorite comfort food!
Reasons You Should Never Drink Soda
Weight Gain - Forget about beer belly, you can also get diet soda belly. Researchers from the University of Texas Health Science Center studied 475 adults over ten years. They noted a 70 percent increase in waist circumference compared to non-soda drinkers. Those who consumed two or more diet sodas daily resulted in a whopping 500% increase in weight size.
Cans - Soda cans have bisphenol A (BPA), which prevents acids from reacting with metal. BPA is linked to altering hormones, obesity, cancers, and infertility.
Plastic Bottles - You think switching from soda cans to plastic soda bottles is better? Think again. Plastic soda bottles and unrecycled plastic caps cause widespread damage to sea and wildlife, especially birds. The "Great Pacific Garbage Patch" is a mass of plastic debris in the Pacific Ocean and is responsible for thousands of animals dying each year unnecessarily, due to human ignorance.
Caramel Coloring - The caramel coloring found in many sodas is known to cause cancer, according to Consumer Reports.
Water Pollution - Artificial sweeteners do not break down in the body. So what happens? It enters water supplies. Scientists in Switzerland tested waste water treatment plants, rivers, lakes and found alarming levels of sucralose, saccharin and acesulfame K.
Caffeine - Sodas that contain caffeine can cause everything from heart palpitations to incontinence.
Sugar Content - One can of regular soda holds approximately 33 grams or 10 teaspoons of sugar. Can you imagine how much insulin your body needs to make to combat the excess sugar?
High Fructose Corn Syrup - High fructose corn syrup, found in most sodas, is manufactured using traces of mercury.
It's been an unseasonably warm winter so far in the Northeast (knock on wood). And with that comes the increased incidence of colds. I hate colds. They're not enough to incapacitate me but they are enough to make me feel miserable. I'm also faced with a decision: do I go to work and risk infecting patients, or do I stay home, look weak, and lose income? Despite all the handwashing and lavaging the hands with Purell, there's always the niggling doubt you'll become Typhoid Mary, spreading your virus to all who contact you. Plus, you feel lousy and wonder if you'll be able to devote your best efforts to the tasks at hand.
While academics might not understand this conundrum, those in solo private practice will.
I've always felt, because of my training in the "old days," that not showing up was a sign of weakness. My old chief of medicine at the University of Michigan, was tougher than nails. He expected 4 hours of sleep a night if you were not on call and no sleep if you were. Sick? Unless you were in the ICU, you weren't sick. One hundred hour work weeks were not out of the ordinary then.
Was that right? Probably not. But when you're faced with a situation where a patient needs your help, what do you do? Either help them with their acute problem and risk they'll catch something from you, or don't answer the bell.
I do remember days when I was a resident with a fever of 103 degrees, shaking from my chills, yet tending to patients on the ward who were immunocompromised. You did what your higher ups expected. But who are our higher ups now? Is it us, our patients, a higher moral authority, or even the insurance companies? (I really doubt the latter, since if you dropped dead, they would shrug their shoulders and say, "Next up.") What about the staff member that looks askance when you show up with the sniffles? It's not the plague but it is enough to put you out of commission for a day or so; they fear the same will befall them.
The edict by many is to stay at home. That's probably the right call.
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