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Insider Arthritis Tips April 2013
April 16, 2013

"Resolve to perform what you ought; perform without fail what you resolve." -- Benjamin Franklin, statesman

April Arthritis News

Anti-TNF Drugs and the Placenta

Mary Ann Moon writing in Rheumatology News reported on the conclusions of two studies. One concern rheumatologists have had is what to do about pregnant patients who are on TNF inhibitors. Two observational studies (one from University California San Francisco and the other from Erasmus Medical Center, Rotterdam) provide some information. The upshot is that stopping Remicade and Humira at the end of the second trimester reduces the amount of antibody transferred to the infant and shortens the time for the infant to clear the antibody. Cimzia doesn’t need to be stopped since it doesn’t cross the placenta.

Comment: This is important since it reduces the likelihood of opportunistic infection in the infant.

Transcranial stimulation works for fibro

Jeff Evans writing for Rheumatology News reported on a recent study which showed transcranial direct current stimulation directed focally to the left primary motor cortex of patients with fibromyalgia significantly reduced pain compared with sham stimulation. The study involved 18 patients and was published in the journal of Pain.

Comment: Anything that works for fibro is OK with me.

Corticosteroids quadruple risk of tennis elbow recurrence

Bianca Nogrady writing in Rheumatology News reported that corticosteroid injections may offer short term relief but long term considerations may make one think twice about getting them. She commented on a one year study of 165 patients who were treated with either a steroid injection or physical therapy with a placebo injection. At the end of one year 83% of the steroid group were improved compared with 96% of the sham injection group. In addition the steroid treated group had a higher incidence of recurrence and non-healing.

Comment: I’m not surprised. Ultrasound-guided needle tenotomy with platelet-rich plasma is a much more physiologic treatment since it creates new tendon tissue in addition to relieving pain.

Vigorous Exercise Reduces Fibromyalgia Symptoms

Kathryn Doyle writing in Reuters reported that, according to research published in Arthritis Care and Research, exercising more often may help to reduce certain symptoms of fibromyalgia. The study included 170 fibromyalgia patients who were participating in a larger NIH-funded study.

Comment: Effective fibromyalgia treatment consists of non-impact aerobic exercise, cognitive behavioral therapy, and medication.

New Treatment For Osteoarthritis… Lessons From the Mouse

We may have a mouse to thank for a new treatment for osteoarthritis. The findings, in a paper by Gregory D. Jay, MD, PhD, of the department of emergency medicine, is published in the journal Proceedings of the National Academy of Sciences. The discoveries were made in part by studying the knees of mice, which genetically lack lubricin, causing an aggressive arthritis in spite of high levels of hyaluronic acid in the synovial fluid. A lack of lubricin, resulting in higher friction, leads to cartilage cell death -- even in the presence of high levels of hyaluronic acid, a viscous fluid that cushions the joints. This discovery appears to challenge the practice of injecting hyaluronic acid alone into a patient's joints. "The lubricant is a protein, not hyaluronic acid, and currently, there are no disease-modifying treatments for osteoarthritis," Jay said. "Patients suffering from this degenerative joint disease either go through a total joint replacement, or are forced to live with pain every day. This discovery, however, supports that adding a lubricin replacement to the fluid in joints may in fact prevent osteoarthritis in those who have a genetic predisposition to the illness, or who have suffered significant trauma to the joints."

Comment: I had never heard of lubricin before I read this. Interesting.

Patients With RA May Have Increased Incidence Of Diastolic Dysfunction

Nancy Walsh writing in MedPage Today reported, "Patients with rheumatoid arthritis (RA) have an increased incidence of diastolic dysfunction, meaning the heart doesn’t fill with blood properly. This may further raise their already high risk for congestive heart failure, a meta-analysis suggested." Researchers found that "mean left atrial size was larger in RA patients than in controls. The investigators also found that pulmonary artery pressure was higher. The findings were published in Arthritis Care & Research.

Comment: RA patients already are at risk for heart problems. This raises a whole other issue.

Omega-3s Associated With Longevity

Nicholas Bakalar writing in the New York Times reported, "Scientists have turned up ample evidence that consumption of seafood high in omega-3 fatty acids may help protect against cardiovascular disease." Now, a new analysis published in the Annals of Internal Medicine "confirms that higher blood levels of omega-3 fatty acids may reduce the risk for heart disease and death in people over age 65." For the analysis, "blood tests were used to track the levels of three different types of omega-3 in 2,692 randomly selected people, average age 74 at the start of the study, for 14 years."

Comment: Well then… eat your fish!

Exercise-Related Cartilage Damage Can Signal Osteoarthritis

Robert Preidt writing in Healthday reported an MIT study that finds "exercise-related damage in cartilage can help identify people with the earliest stages of osteoarthritis." Such findings "could improve early detection of the painful joint disease and could also be used to improve methods of repairing damaged cartilage," according to the author of the study, MIT's Alan Grodzinsky. To conduct the study, "researchers developed a method that identifies osteoarthritis-related changes that occur in cartilage in response to high-load activities such as running and jumping." HealthDay notes that "osteoarthritis affects about one-third of older adults and is the most common type of joint disorder."

Comment: Of note is this… exercise per se is not bad for you. It’s that certain people who may be prone to developing osteoarthritis may experience exercise induced cartilage damage.

Low Testosterone Linked To Future RA In Men

Albertina Torsoli writing in Bloomberg News reported, "Low testosterone levels in men may be an indication of future development of rheumatoid arthritis, a painful inflammatory disorder that primarily affects joints," according to a study published in the Annals of the Rheumatic Diseases. Charles Bankhead writing in MedPage Today stated , "Low testosterone raised the odds for subsequent diagnosis of rheumatoid factor (RF)-negative RA by 69% as compared with men who had normal values." The researchers also found that "men who developed RF-negative RA...had significantly higher levels of follicle-stimulating hormone prior to diagnosis."

Comment: Hmmm interesting. We know RA is more common in women so obviously hormonal factors play a role.

Handling Stress Poorly Increases Long-Term Risk For Anxiety, Mood Disorders

Nanci Hellmich writing in USA Today reported that handling "stress poorly...may put you at greater risk for anxiety disorders and other mental health issues 10 years later," according to a study published online in the journal Psychological Science. Researchers from the University of California-Irvine "analyzed data on 711 men and women, ages 25 to 74, who were interviewed two times 10 years apart." Investigators found that "people who responded to stress with more anxiety and sadness than the average person were much more likely to have self-reported anxiety/mood disorders and psychological distress 10 years later."

Comment: This study falls under the “duh” category.

One-Third Of Elderly Patients Experience Swallowing Difficulty After Hip Fracture Surgery

Lynda Williams writing in Medwire reported, "Around a third of elderly patients experience oropharyngeal dysphagia (OD) while recovering from hip fracture surgery, say Australian researchers who have identified markers for the complication." Investigators found that, "overall, 34% of the 181 patients, aged an average of 83 years old, who were assessed at a specialist orthogeriatric unit within 72 hours of surgery showed clinical signs of reduced swallowing efficiency, such as oral residue or multiple swallows per bolus, or had reduced swallowing safety, defined as coughing or choking after swallowing." The researchers found that "postoperative OD was significantly more common with increasing age, in patients with neurologic or respiratory comorbidity before surgery than those without, and patients living in a residential aging care facility ." The findings were published in Age and Aging.

Comment: My patients tell me, getting old is not for sissies.

Light Treatment Doesn’t Work For Achilles Tendinopathy

Lynda Williams writing in MedWire reported research suggests "that active intense pulsed light (ILP) does not benefit patients with chronic mid-body Achilles tendinopathy." Investigators did not find a "significant difference in the 6- and 12-week outcomes of 21 patients (27 tendons) who were randomly assigned to receive three weekly sessions with single pulse IPL designed to penetrate the and the 22 patients (27 tendons) given sham IPL." The findings were published in the Bone and Joint Journal.

Comment: It is sometimes difficult to separate effective treatments vs those that don’t work.

Hip Fractures More Common In Dialysis Patients Than in Past

Ed Susman writing in Medpage Today reported, "The hip fracture rate among older dialysis patients is still higher now than it was in the 1990s, but the fractures are less deadly than they once were, researchers reported" at the National Kidney Foundation meeting. Investigators found that "the hip fracture rate in these patients steadily rose until 2004, when the rate was 41% higher than 1996, and since then the rate declined from that peak, but is still 25% higher than it was in 1996." During "the same time frame, the 30-day mortality after hip fracture declined from 20% in 1996 to 16% in 2009."

Comment: There are many reasons for hip fracture in dialysis patients and people should be made aware of the increased risk.

Cost Of Treatment With Biologics Offset By Increased Ability To Work

Lynda Williams writing in Medwire reported, "The cost of treatment with the tumor necrosis factor inhibitor etanercept is offset by increased ability to work, suggests a study of US patients with moderate-to-severe rheumatoid arthritis (RA)." The researchers also reported that "the beneficial clinical impact of the drug...had a positive effect on functioning in or around the home." The study was published in Arthritis Care and Research.

Comment; Duh. Insurance companies that block biologic use should read this study.

Researchers Use Special MRI To "See" Pain

Marilynn Marchione writing in the AP reported, "In a provocative new study" published in the New England Journal of Medicine, "scientists reported...that they were able to 'see' pain on brain scans and, for the first time, measure its intensity and tell whether a drug was relieving it." While "the research is in its early stages, it opens the door to a host of possibilities." The researchers conducted four experiment involving "114 healthy volunteers" who were "tested with a heating element placed against a forearm at various temperatures, not severe enough to cause burns or lasting damage."

Comment: The test, functional MRI, has been shown to see the pain of fibromyalgia.

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Wei’s World April 2013

Annette Funicello died.

Those of us of a certain age fondly remember the Mickey Mouse Club. Every afternoon my siblings and I gathered around the black and white TV to watch the Mouseketeers.

Jimmy was the host and we looked forward to the show with characters like Bobby, Cheryl, Darlene, Cubby, and the rest. But by far, our favorite was Annette. Both my brother and I had a crush on her.

So.. what was the appeal of this show?

It represented wholesomeness and life the way we wanted it to be.


Let’s face it. Most of us grew up in a family situation that had some dysfunction associated with it. So watching Mickey Mouse Club, Leave it to Beaver, the Donna Reed Show, and others like it provided us with an escape. It gave us pleasure to see people living the perfect life we all aspired to having.

Today, with the publication of memoirs and other “behind the scenes” exposes, we’ve discovered that all was not so perfect… even in the Magic Kingdom.

But still… those weekday afternoons spent in front of the TV set were some of my most cherished childhood memories. Nowadays, if an idea for a show like The Mickey Mouse Club were to be proposed to television producers, it wouldn’t get off the drawing board.

My only quibble with the Mickey Mouse Club was that the show was too perfect. And that set us up for disappointment when our own lives didn’t live up to the ideal one we watched on our TV sets. Though one could say the same for a lot of shows and movies now where all the people are beautiful and there’s always a happy ending.

On the other hand, shows that portray the real disappointments of life- or worse- dramatize the seamy side of a horribly unreal life can be depressing.

So I guess it is “take your pick”. Be disappointed or be depressed. At least if you’re a child. As parents, my wife and I chose to show the rosy side to our children. I’m not sure if they were disappointed. But I bet they probably were. .. at least to some extent.

Part of being an adult is knowing life isn’t all peaches and cream and it’s not all a bed of thorns for most of us. It just is. And it is what we make of it.

As we get older we often tend to idealize the nicer events of our past. To view them as better than they were. When I heard about Annette’s death, what I heard in my head was…

M-I-C-K-E-Y…M-O-U-S-E… and what I saw was those black mouse ears.

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