Saturday, December 29, 2012

Come home to Haiku Home

Just in March of the year 2012, I was introduced to Haiku, (re-introduced perhaps) by a cousin who had nothing better to do while recuperating from illness, but to write her experiences in 5-7-5 graphic scenes that got me hooked. How soon she recovered is a testimony of how art therapy can work wonders!

As a medical professional in my almost-retirable years, I sought the "comfort" activities of my younger years, like playing the piano. It all went well for 3 years with one recital to my belt -  a general class recital with small children, and I was last number to play in the program. On my 4th year however, as my piano teacher patiently prepared the simpler of  Debussy's, a bad carpal tunnel syndrome struck, first my right dominant hand, then the left, (like the rheumatism knew exactly who to afflict). Having treated many patients with the malady, I could hear myself say, "rest for the hands and fingers from avoidable activities is first line treatment, otherwise, you will either receive an injection to the wrist or get the part opened up".

Haikus came as a welcome respite. Yes, I still have to write or type the poems, but this art form is less finger intensive in terms of force and repetitive motion. Soon, my cousin and I exchanged haikus daily through SMS, writing them down at the same time on notebooks. Friends started to join in, too. 

I told a friend that to write haiku is to breath, a brief moment with almost no thought taken,  just short punctuations of observations about nature, experiences, so short that the only imagination allowed is that of the reader's. The poet pens thoughts down in 5-7-5 cadence,  with no burden to explain, leaving the scene to someone else.
 
We now invite you to +Haiku Home . Come one, come all haiku-ers!

Wednesday, December 26, 2012

Ethnic preponderance of some important joint diseases


Behcet's Syndrome - Turkish, Mediterranean and Arab, Japanese
               Behcet's syndrome affects both men and women almost equally and manifests with painful mouth and genital ulcers, eye inflammation, arthritis and in severe forms, can involve the heart, brain and lungs.
     



Osteoarthritis - most ethnic groups worldwide
               Osteoarthritis is the most common joint disease of persons above 40 years of age. It affects  the joints of the fingers and knees but is most debilitating when in the knees and  hips, causing pain on walking. Osteoarthritis of the hips is reported more among Scandinavians/Europeans and less among Asians.




Gout - Polynesian, Chinese, Southeast Asian, Caucasians
               Gout is a severe, recurrent inflammation of one or more joints, most often in men. It is associated with high blood uric acid levels. It is reported to be related to lifestyle and obesity especially among Caucasians. Among Asians, gout is known to be due to problems in the elimination of uric acid by the kidneys. Uric acid deposits can cause masses to grow over joints and soft tissues in many parts of the body.




 Rheumatoid Arthritis - worldwide but probably more diagnosed among Caucasians

                Rheumatoid arthritis affects more women than men and affects more joints -  shoulders, elbows, wrists, hands, knees, ankles and feet and severely restricts most daily activity due to pain and stiffness, and later,  joint deformities. More severe forms can affect the lungs, eyes, heart and blood.

Lupus - Latin Americans, American Blacks, Southeast Asian
                Systemic lupus erythematosus or lupus is a form of arthritis that affects more women than men, and is also systemic, affecting the kidneys, skin, blood and joints simultaneously or appearing in a progression. Severe forms can also affect the brain, lung and heart. Severe disease are reported more among colored people.






Spondyloarthropathies including psoriatic arthritis, inflammatory bowel disease - Scandinavians, European ethnicity, Chinese
               This is a group of arthritides that affects the spine in younger individuals, causing back stiffness, hip pain and can also be associated with eye disease that can cause blindness in some cases. It can come with inflammation of the bowels causing repeated diarrhea,  inflammation of the skin and with the scaly rash of psoriasis.
             

This list is short and focuses on diseases that can affect many body organs and also cause severe disability due to pain, joint deformity and organ damage. The need to see a rheumatologist is emphasized, seeing that many of these arthritides affect many organs of the body and requires special forms of treatment.


All photos by Google Images











Monday, December 24, 2012

2012


2012 saw past December 21,  it is an old year now, with the remaining 10 days in a frenzy build-up for the next dated new year, 2013.


2012 saw in this Blogger 19 blogs -  from Thoughts on the new year to short expositions about osteoarthritis, gout, rheumatoid arthritis,  alternative medicine, back pain, sleep and inflammation, meetings in Jordan, and thoughts on aging.







                   




2012 saw Chikungunya fever outbreak in the Philippines and in my home, the "break bone" fever becoming real break bone (fracture) of my daughter with the Chikungunya arthritis severe enough to cause her to fall one day.




2012  saw my mother turn 90, outlasting friends (and perhaps foes alike), continuing to serve as auditor of the local association of senior citizens, getting crankier as her sharp mind blunts away and her quick body ever slower.


2012 meted out a personal warning, with two falls, only 10 days apart, for me to be more careful.




2012 saw a protracted Arab spring in Syria (dragging through summer, autumn and winter of 2011 and 2012) and the possibility that Damascus, the longest living city which has not been sacked or destroyed through all waves of empires it rode, may actually lay flat in ruins, desolate; and elsewhere in the Middle East, wars and rumors of wars.

2012 saw Europe do balancing acts for the teetering economies within, London's success as host of the Olympic games, a royal wedding; America re-electing Obama and hoping to survive the "fiscal cliff" and the burden of a wave of gun-related violence that killed innocents; Latin America preparing for another World Cup; African countries holding fast despite its cauldron of famine and share of wars; the "awakened" giant of Asia asserting its numbers, and the hermit kingdom handing power over  - nuclear at that, to a young progeny.

2012 saw earthquakes everywhere, storms, tornadoes and floods of "strange" dimensions.



Then I smile as 2012 saw hope - Aung San Suu Kyi, ever poised, with flowers in her hair, finally fly and take to wings. This phenomenon has shown how transformation is possible in unexpected places, like the rigid, inflexible mold of a military junta. A generation of leaders pass, the new generation decides to change for the greater good and for their own sakes.



The world will continue till its set time so 2012 is able to fold in its arms the bits of history it has collected. It will then add them to the Library of Man that contains what has been known since the beginning of time.










Saturday, November 17, 2012

All of 57 years: A synopsis


c. Nov 11, 2012

Soon, I will be all of 57 years.

The signs are here:
PHYSICALLY - the law of gravity for sagging skin;
Leaving the office one rainy day...
An anticipation of
days to come:-"leaving"
(retirement, that is : D)
for new ventures- exciting times
!
OUTDOORS - deference as I fall in line- "mauna po kayo, 'Nay"; ("nanay", is Filipino word for mother);  on purchase of hypertension medicine,"senior citizen card Ma'am?"
FAMILY -  enjoying long drives with hubby in silence- no words needed; children asking, "why do you know that song, Ma? Is this a remake then?"; weekly conversations with spritely 90 year old mother;
FRIENDS - more fb groups of past school years; uploaded photos with browned edges - authentic, not edited nor photoshopped;
MIND- more minutes spent trying to remember passwords, attenuated, sharpness gone which is sometimes irritating, sometimes a good thing; o_O
CAREER - signs like walking through the university hallways and meeting no one I can address as Sir or Ma'am, but instead, people who greet me "Hi, Ma'am";

These are just a few of my favorite things now!

And in all these, I praise the Lord Jesus, for His great brush strokes of retaining the love, beauty and peace in this canvas of life, despite the difficult and dark times. Necessarily, the lessons were many times painful, but He bore them all for me.

May all of us experience His Love in this life.

Sunday, September 9, 2012

Arthritis meeting in Amman, Jordan.

The APLAR (Asia Pacific League of Associations for Rheumatology) 2012 is on - previously scheduled in Damascus, Syria, it is pushing through in Amman, Jordan.

Many had been adamant in coming, in my case, mainly due to the extended Arab Spring phenomenon, just several hundred kilometers away, and the fact that geographically, Jordan is wedged between Israel and Iran. But in the airport I met several friends from other countries and  represented in the mix were attendees from Korea, Japan, Indonesia,  Malaysia, China, and some from western countries AND the trainees slinging poster canisters. It was a comforting sight.

Today will be the first day of meeting and I am hopeful that this Middle East meeting will still give us a good "harvest".

Some notes on the bus trip to the hotel: searing hot sun, immense expanse of red brown land, with sparse dots of palms, olive grooves, one camel herd, and one sheep and goat herd - as quick as my neck can turn. It's fantastic, given other countries that I have visited had trees and plants, asserting themselves between buildings - here it is a desert expanse, breath -taking for a first-timer. One cannot but praise God for His creation. We are in the Dead Sea - where the convention center is located, and it is 384 meters below sea level!

Tuesday, September 4, 2012

The "chick" - ever heard of Chikungunya fever (and associated arthritis)?

        This article is being written with a real time possibility that chikungunya fever is on the rise in Manila. It is a virus, the CHICV, that is also acquired from a mosquito bite (same mosquito as the dengue -  Aedes aegypti  and some other species). 

        This viral infection has also been described as the "neglected" infection since its course is more benign and has not hugged the lime light of public health concerns,  as say, dengue. There has been NO reported deaths from it since its first isolation in Tanzania in 1953, but the arthritis associated with it can be debilitating. The term chikungunya is from a Bantu (African) language, which means to "fold up." This is thought to refer to the patient's stooped posture due to joint pains and generalized body aches. This fever is unique since it makes its appearances in many African, Southeast Asian and even temperate countries like Italy, where it had been reported, then disappears for decades at length, then is back.

       Again, i reiterate that its course is benign.

       There is a possibility that in the Philippines where dengue is endemic, fever and rash and general body aches associated with most viral infections could miss the "chick." Since its course is benign, identification of this fever can spare many a hospitals' resources on intravenous fluids which is the main supportive treatment for dengue at this current time. Still, any infection for that matter needs increased fluid intake, and if it's the "chick", drinking water may suffice. If there is headache and vomiting, then intravenous fluids become necessary.

       Your internist, infectious disease specialist and your rheumatologist can help. Please seek any of these specialists. Testing can be done if the illness is 7 days or less in the NIH of UP Manila,  and if more than 7 days, testing is in RITM in Alabang.

Ref:
1. Alladi Mohan, DHN Kiran, I Chiranjeevi Manohar, and D Prabath Kumar. Epidemiology, clinical manifestations, and diagnosis of Chickungunya fever: Lessons learned from the re-emerging epidemic. J Dermatol. 2010 Jan-Mrch; 55(1): 54-63. doi: 10.4103/0019-5154.60355
PMCID: PMC2856377
2. Dieudonné Nkoghe, Roland Fabrice Kassa, Mélanie Caron, Gilda Grard, Illich Mombo, Branly Bikié,Christophe Paupy,Pierre Becquart, Ulrich Bisvigou, and Eric Maurice Leroy. Clinical Forms of Chikungunya in Gabon, 2010. Negl Trop Dis. 2012 February; 6(2): e1517.


Published online 2012 February 14doi:  10.1371/journal.pntd.0001517
 PMCID: PMC3279511



with permission from my daughter who came down with fever, arthritis and rash, and is being tested for the "chick"
      Updates are upcoming, and we are collecting data on this interesting cause of arthritis.

Saturday, September 1, 2012

Calisthenics: when was the last time you did it?

        The Merriam -Webster dictionary defines the word as systematic, rhythmic bodily exercises performed usually without apparatus.

        Fifty years ago, I recall my Grade 1 teacher, Ms. Rose Cabaron, (any current information about her is most welcome) leading us out of the classroom in a bee line, to bring us out to the sunny, grassy school quadrangle, for our regular calisthenics. She would have an empty can and a wooden stick to drum up counts 1 - 8, then 8 -1, for the head roll up, side, down, side and up again; for arms forward, upward, sideward, down, repeat, till you are down to count 1 again. Then while arms are in sideward position, we twist to the right and left, and the tin drum goes tang, tang, tang, tang 1- 8, 8-1. Then we should march in place, "feet high up" - she would holler, and the tin drum goes, tang, tang, tang. This was repeated several times, and when we were all sweaty and in all probability, smelly- she would then herd us back to the classroom for the rest of the lessons. (Thanks Ms. Cabaron!)

      Why talk about calisthenics after 50 years? It crosses my mind now why children in elementary grades had to go through such boring routine, when they should be jumping, running, climbing and even falling at that age.
      
       This is because calisthenics is the easiest exercise routine that can be done by ALL people, age 5 -95, with arthritis or not - as in, by all.  

      It can be done in the bedroom, on waking up, even while still seated at the edge of the bed (for those with knee or hip arthritis who have pain on standing), in the bathroom before dipping the "tabo" or opening the shower. It can be done by the busy mom who needs to fix kids for school before sun rise, for the business man who is averse to the gym, by the gym buff who knows that the body needs rest from heavy gym routines, and even by the teenager who is busy with, whatever- school, iPads, fb, etc. The stay at home moms can do this before doing the laundry, cooking, potato couching and even after!

       Calisthenics are essentially range of motion exercises, and for the uninitiated, heaviness and pain may be experienced as the limbs are moved. The muscles of the arms, legs and buttocks provide the natural resistance or weight. When done slowly -no jerky motion, please, the pain eases over a few weeks and the repetitions can then be increased.

       I used to attend a nice non air-conditioned gym, where I really sweated it out. But now, with less time and the distance of the place, I reverted to calisthenics. This way, I spend less, and has no more reason at all not to do the basic body maintenance required as we age. 

       This is an invitation to do calisthenics, add on the hula-hula for the hips, and any innovations you feel will move as many muscles there are in you. Just do it slow and deliberate, and feel the stretch (and pain) and enjoy the relaxing feeling after. Don't forget a good tall glass of 
WATER with it!
     

Monday, August 27, 2012

If you have arthritis, who you gonna call?

           Call the Rheumtatologist, the "lesser known" bone and joint doctor in the neighborhood.

          And if there is none, it is because the field is quite new, interest in the field is low, training centers are few or non-existent in many areas, and - this is a personal observation- arthritis as a disease is not as dramatic or life-threatening as, say, a heart attack, a stroke and diseases of the lungs, liver and kidney.

          In fact, in a 2nd year medical class, I asked for a show of hands for the question " is the joint an organ or not"? There was a handful, tentative yes answers. This is not surprising, and while the first year course on human anatomy surely carries this fact -  that an organ is a group of tissues serving a function -  it seems more tangible to hold the cadaver heart, lung or kidney and say, "this is an organ".

          In 2004, the Section of Rheumatology, Department of Medicine, University of the Philippines College of Medicine embarked on an academic program aimed at presenting rheumatology to medical students and training residents in Internal Medicine in a one day symposium consisting of diagnostic and treatment updates of common rheumatic diseases in the ambulatory, as well as, in -hospital settings. We called this now yearly symposium, The Dr. Lourdes Manahan Lectures in Rheumatology (LMLR) in honor of the first rheumatologist of the country. Dr. Lourdes Manahan attended all first 7 symposia  (in her wheelchair), and just after the 7th year, she passed on. 

          The 8th and 9th LMLR featured foreign academic collaborators from the University of Melbourne - Prof. Keith Lim and Dr. Lawrence Clemens, and this year, on the 9th LMLR, we had Prof. Tsutomu Takeuchi of Keio University of Tokyo, Japan.

          The University of the Philippines, as the state university, is mandated to provide health services for the Filipinos, and we have graduated more than 50 rheumatologists, presently serving in hospitals in all the big Philippine islands of Luzon, Visayas, and Mindanao.

           Now, the challenge is to retain trainees who will stay to be faculty of the university, bring new knowledge about rheumatology as it affects the Filipino and pursue honest to goodness research of rheumatic diseases. To date, our own bright graduates have checked out our program as a specialty to take, with 4 of them currently undergoing training with us. I would like to believe that the LMLR has partly achieved its goal. Dr. Manahan's legacy is strong and will sustain the next generations of doctors of the country to expand this field.

           Dr. Lourdes Manahan was a pioneer, a teacher, mentor and researcher. Her life continues on in us who have decided to follow in her footsteps.

Sunday, August 26, 2012

Of Vitamin D, sun exposure and falls

      June 27, 2012 was a a tiring day, having arrived in Seoul, Korea after a midnight flight for a 2- day meeting. Sleepy and trying to get a bath and some sleep after, I slipped and fell in the bathroom, hitting the left side of my face against the tub, which opened a 1 cm gash just at the side of the left eyelid. In ten days, July 7, 2012, after celebrating my Mama's birthday, I fell down the stone steps of our boulevard in Dipolog City and landed on my buttocks and right side of the face.

     Series of falls like these, in a post-menopausal 56 year old female should alert one to the possibility of a significant decrease in the bulk of Type 2 skeletal muscles, which are the fast acting, quick response muscle groups - especially those in the thighs. Type 1 muscles are retained and give the bulk of our body, arms and legs as we grow older, but  are slower  in responding to changes in position and balance.

From: Microsoft clip art
      Type 2 muscle fibers are known to be maintained by many factors, among these - Vitamin D. One can have his/her blood Vitamin D levels checked and take a daily dose of Vitamin D per your doctor's prescription.

     Sun exposure activates skin Vitamin D and supplies us with ample levels to maintain our muscles, especially Type 2, and improve calcium absorption from our food - when we are younger. But as we age, this is not as efficient.

      Still for the young and not so young out there, have a 15 minute noontime sun exposure daily (if the sun is out) for your Vitamin D. Sorry, it's not the early morning sun as previously thought.

                                          Careful.....




In celebration of life: Gifts for my 90 year old Mama

I have been away for a long time from my blogger's seat. This long August weekend certainly should be THE time to write some.

July 6, 2012 was the 90th day of my Mama. After some illness last April-May that increased her pain in the back, we were able to strike a good balance of pain relievers safely and so, on July 7, 2012, we honored her with a thanksgiving celebration in Valdia Resort, Sicayab, Dipolog City. My sister Nellie Crawford and her family were there, my family too - Ed, Tin and Grace and the celebration was attended by close relatives and friends who helped make it a success.

Here are some details: a 4- tier cake, banner with her photos and video loops of photos during her work days as an educator, with my deceased Papa, and her travels abroad - all contributed by her nieces and nephews. Many were called by the emcee, a niece - Cheche, to give some messages. One could hear several lines repeated - she cared for us, she taught us to pray, she told outrageous stories, she is a strong woman, intelligent, patient and helped some nephews in their schooling. Tio Vicente, my Papa's youngest brod made a quaint speech on the seasons of life
: ) There were Mama's cousins too, and their children were represented!

Dr. Val and Lydia Tiu, owners of the resort, came and we certainly were honored by their presence.

At the end of the day, Mama had a blast opening her gifts, and sure enough, gifts reveal the child in all of us! Look at her opening her gifts!

She is a most wonderful gift from God, given a long and full life. Praise the Lord!

Friday, April 6, 2012

Of Robot Mornings and 24/7 pain...

Morning experiences vary - you can have a jolt, or a lazy, dragging type, maybe a hangover headache, or the best...a pleasant refreshed feeling where bird tweets are musical and ethereal.These feelings wane off as the day goes, taken over by the concerns of the day.

Mornings for people with rheumatoid arthritis  is decidedly different. The joints of the hands, wrists, elbows, shoulders, knees, ankles and feet are painful and stiff - getting up is slow and robot-like. Being young to middle age and female does not help. Mornings are about being up and going -  for kids getting ready for school, for that new job assignment, that trip, the upcoming dinner with the boyfriend... the works. Many can be mislabeled as acting out or lazy. This is the age when life is at its peak, productively and reproductively!
photo from Microsoft clip art
Add to this the fact that the pain stays for the rest of the day and on to the tomorrows. What do we do when we have a headache or toothache or even other forms of arthritis? We take a pain pill and expect the pain to go. With rheumatoid arthritis, its a 24/7 proposition of pain and stiffness, which improves a bit with movement and activity, but comes back especially after resting.

Rheumatoid arthritis patients can avoid both the emotional and physical ravages of the illnes, through proper treatment. A rheumatologist should be the health care provider to consult. Check out one near you!

In the Philippines, check out: www.philippinerheumatology.org

  

Sunday, April 1, 2012

Thoughts on aging... A tribute to Mama



My mama is hitting 90 in 2 months and 5 days!

She:
         maintains:   a facebook account (with a little help  with typing from great grandkids),
                             the real "techy" great grandma
         says:           "my thoughts are clear, my memory, a bit slow..."
         complains: "my back, knees and legs are so painful on waking up, and..." (lumbar spondylosis)
         does:           "...without my routine morning stretching exercises, I can't rise from bed" 
         has:             hypertension, too
         eats:            whatever she likes, but notes not really feeling hungry, just vague fullness : /
         hollers:        at the dog
         sleeps:        odd hours, but sleeps well
         hates:          street urchins that steal her mangos or throw stones
         serves:        as auditor (active) of the Senior Citizens group of our baranggay
         observes:    that she seems not to fear death, because Jesus is in her heart
         loves:          her children (2), grandchildren (6) and great grandchildren (6)
       
She is TRANQUILINA D. ZORRILLA-GONZALES  (shown here clowning with a red ballpen holder that doubles as toy spectacles :D!)
          

Friday, March 16, 2012

While driving...

I was driving home to Pasig yesterday through the regular Friday night traffic of Manila, along a favorite route with less cars. Here is to share some observations and thoughts (with arthritis and rheumatism interface, of course):

1. During red lights, motorbikes invariably get ahead of your car and position themselves in front of all cars, so they go first on green. I counted 7 bikes in the UERRMM stop lights, 3 bikers with asymmetric backs, one shoulder carried higher than the other - this may create pain and discomfort over one side of the back and shoulder.

2. Officers manning traffic: some are, some are texting - the texter's thumb is a painful condition of the first finger due to overuse injury.

3. Jeepney drivers along side my car, or overtaking me: sitting almost sideways, either right shoulder or left shoulder rotated to the front. This may result in lowback pain and pain on one side of the back.

4. Street children threading in and out of rushing jeepneys, between cars and 18-wheelers! This one is life and limb matters - not arthritis or rheumatism! One wonders how far the DSWD programs trickle to the streets. By the looks of it, the programs do some and leave some on paper. Marvel at how we Filipinos thrive on lack [luck]!

5. Drivers driving and phoning/texting huhummmmm. Again, a matter of life and limb, but for those who survive, its still neck pains, stiff neck and texter's thumbs for you!

Back to the achievable and doable with results:

Check your riding posture! You may NOT need the doctor or pain medications at all!

Saturday, March 10, 2012

Diarrhea, urine infection, colds and arthritis: Any connection?

Could that have been just another cold and sore throat?

Was that just a mild diarrhea you had?

Well, some of these common infections can be followed by pain in the heel, swelling and pain of the ankles and knees, red eyes and some weird skin rash. This arthritis that follows a common cold, or a passing diarrhea, or infection in the urine, can be what is known as reactive arthritis (ReA). This condition is more common among young individuals, more in males, and can involve inflammation not just in the joints but also in the eyes and skin.

Infections cause arthritis in several ways:
  1. infectious arthritis - bacteria from infections found in other parts of the body like decayed tooth, infected gums and sinuses, skin, urinary tract etc., find their way into the joints through the blood circulation
  2. reactive arthritis - prior infection causes inflammation of joints, without bacteria actually growing in the joint. This can be associated with inflammation of the eyes and skin.
    • common sources
      • urinary tract infection
      • diarrhea due to specific bacterai like yersinia and shigella
      • strep infection of the throat or the "strep throat"
  3. infection-associated arthritis - when arthritis is part of the disease, though uncommon, the following diseases can include arthritis as part of the general presentation of the disease
    • hepatitis and other viral infections
Arthritis that arise from infections, whether infection in the joint per se, or as a reactive process, require specialty treatment.
  1. Infectious arthritis is a rheumatologic "emergency" and needs to be seen by an orthopedic surgeon or a rheumatologist.
  2. Reactive arthritis, likewise needs to be recognized fast, since the disease can be very disabling and recognizing its self- limiting nature is therefore very important. It can have a prolonged course and needs to be treated appropriately to avoid disability. A rheumatologist is the best doctor to consult for these types of arthritis.

Saturday, February 25, 2012

Excerpts from "Diagnostic Pitfalls in Rheumatology"

The Philippine Academy of Family Physicians hosted a very successful annual meeting last February 16- 20. I was invited to do this lecture and  while the title of the talk is "pitfalls", it really talks of misdiagnosis or missed diagnosis. In a nutshell, I identified four states where diagnosis is either difficult to come by, or actually missed, here are some excerpts:


 A. The monoarthritis muddle:
  • Gout is commonly overdiagnosed (other arthritis diagnosed as gout)
  • Psoriatic arthritis and pseudogout are usually missed for gout
  • Crystal arthritis (gout and pseudogout) are settings for misdiagnosis of septic/ bacterial arthritis
    • some cases get operated on
    • antibiotics are given
    • some would recommend management of acute monoarthritis as infectious arthritis until proven otherwise
  • Crystal arthritis can be complicated with bacterial arthritis
  • TB arthritis diagnosis is usually either delayed or missed. In reports, it is only considered once NSAIDs and antibiotic treatment fail.
B. The polyarthritis puzzle 
  • Underdiagnosis of polyarticular gout ("diuretic" gout)
    • among elderly females on antihypertensive medications with hydrochlorothiazides ( usually a "co" prefix or"plus"  suffix of common drugs for hypertension),  - for rheumatoid arthritis
  • Missed diagnosis of connective tissue diseases where arthritis is initial presentation, and other signs and symptoms take years to manifest
    • examples are systemic lupus erythematosus, scleroderma, mixed connective tissue disease
C. The early arthritis enigma - in the advent of technology and concepts of treat to target and personalized treatment, patients with early arthritis (less than 3 months to a year or 2 of arthritis) can be a treatment enigma, and the question is - do we treat aggressively to catch the reversible phase of joint destruction or wait for more symptoms and risk permanent joint destruction?    
  • Treatment entails expense and adverse events and these are the known outcomes of early arthritis:
    • 1/3 to half of cases resolve
    • another third develop to full blown rheumatoid arthirtis
    • less than a third of cases become other forms of arthritis
D. The similar sounding diagnoses (lay or medical personnel misuse of terms)
  • "rheumatic arthritis", rheumatic fever and rheumatoid arthritis
  • osteoarthritis (joint disease with bone thickening and cartilage thinning, etc) vs. osteoporosis (bone thinning, predisposing to fracture)
  • rheumatic heart disease vs. rheumatic fever




Thursday, February 16, 2012

World political climate and continuing medical education

Just 4 years back, the Asia Pacific League of Associations for Rheumatology (APLAR) picked Syria as the site of the 2012 APLAR Convention. This convention sees rheumatologists -clinicians, researchers and academics, from the region and the rest of the world come and sit around to discuss the future of rheumatology. It is held every 2 years. Hongkong hosted the 2010 meeting, which saw over 2000 delegates from all over the world. The Damascus meeting was much anticipated. There was a special value added to  learning rheumatology in the "seat of civilization".

Then came the Arab spring. There was not the faintest hint to this phenomenon, the extent of the upheaval, the geographic and human toll, and the global economic repercussions it would bring on an already unsettled world. Syria joined the fray, and the APLAR sat and waited for the sand storm to settle. As the rest of the Arab world claps the dust off their backs and tries to stand and get back on track, this would not be in Syria. To date, the internal war rages on, causing literally, internal hemorrhage - as media would show it.

We are in prayer for our friends there, the doctors, the rest of the citizens of Syria, as they go through this painful process of change- prayer for end of conflict so its citizens will again live in peace. We in the rheumatology community feels a special tinge of sadness on what we are seeing in Syria. We continue to hope that in the years to come, we can still get that chance to sit on the "seat of civilization" and learn.

Saturday, January 28, 2012

Arthritis and complementary and alternative treatment

Complementary and alternative medicine or CAM became a formal and recognized body of treatment for many diseases, including the arthritides. CAM joined mainstream medicine and has been offered as part of the medical curriculum by the mid 80's.

CAM include such diverse modes  of treatment- from balneotherapy, massage, acupuncture and other physical applications to plant products as herbal concoction either applied or taken in. CAMs was reviewed in the Philippine Rheumatology Association(PRA) Recommendations for the Medical Treatment of knee osteoarthritis (OA).

Natural is not necessarily safe, so it is important for prospective users to look for seal of approval by reputable organizations (ex. Arthritis Foundation) or certifications for specific standards of manufacturing (ex. ISO). Like other treatment forms, CAMs can have side effects. We still warn against CAMs markated as a panacea. There have been reports of sideeffects to the heart, liver, kidneys and infections that arise with indiscrimate use of some of these agents.

Among the CAMs reviewed by the PRA were those with scientifically conducted trials and research for its effects on knee OA pain and function.  The following is part of the 25 recommendations published in the Philippine Compendium of Medicine, 2010.

Recommendation for Complementary and Alternative Medicine (CAM)

A. Recommended
1. Herbal preparations
The use of concentrated standardized ginger preparation is recommended for its moderate effect in the control of pain and improvement of function in knee OA. Patients should be warned of gastrointestinal adverse reactions that can occur with this preparation.
Level of evidence: Moderate

2. Acupuncture
Manual or electroacupuncture is recommended as additional therapy to achieve pain relief lasting a few weeks in patients with moderate knee pain due to OA.
The procedure must be adequate and performed by a trained and experienced acupuncturist.
Level of evidence: High

B. Insufficient Data to recommend
1. Spa or balneotherapy
There is insufficient evidence to recommend spa treatment for the control of pain and improvement of function in knee OA.
Level of evidence: Low
2. Tai Ch’i
There is insufficient evidence to recommend Tai ch’i for the control of pain and improvement of function in knee OA.
Level of evidence: Low
3. Yoga
There is insufficient data to recommend yoga to control pain and improve function in knee OA.
Level of evidence: Low
4. Herbals
There is insufficient data on comfrey, Chinese herbal recipe, Chinese pills, rose hip, devil’s claw, to recommend their use in knee OA.
5. Massage
There is insufficient evidence to recommend massage (standard Swedish) for the treatment of knee OA.
Level of evidence: Low

Saturday, January 21, 2012

Arthritis in the throat (not the typical sore throat)

No, not the virus,  not strained vocal cords, not the singer's nodes on the vocal cords, but cricoarytenoiditis - what? Supercalifragilistiexpialidocious- yes, its arthritis of the joints between the two small laryngeal bones that hold the vocal cords and the larger cricoid bones of the throat, the cricoarytenoid joints.

Cricoarytenoiditis is felt as pain in the throat and hoarseness and can be part of rheumatoid arthritis, a systemic disease which causes pain and swelling in many joints of the body - wrists, fingers, ankles, knees. While rare, the condition adds to the already debilitating effects of this generalized form of arthritis.

A rheumatology clinic is the best setting for the treatment of rheumatoid arthritis. Optimum treatment will improve crycoarytenoiditis, as well as, the arthritis of the rest of the joints. Treatment is complex and consists of one or more drugs in combination - pain killers and low dose steroids as "bridge treatment" and disease modifying drugs, both synthetic and biologic. This is the best shot a patient can have to avoid disability arising from destruction of the peripheral joints as well as,  the throat joints.

Go, ask your doctor about it!

Saturday, January 14, 2012

Summer and rheumatism?

It's January yet, but the sun in Manila is already threatening to be blistering hot in another month or two! Thanks to the occasional cloud cover and some cold air, we still have a very lovely weather.

Summer and rheumatism? 
from clip art
Many believe that rheumatism/ arthritis  is linked to cold weather (2nd only to the Bean Story - several posts back). Some even say that arthritis is caused by cold weather (what? so all humans living in Iceland, Canada, etc have arthritis?)

I hear these complaints more during the short cold months that the Philippines have, but surely, the same patients come any time of the year with bad arthritis, weaving stories of other causes for the pains - ate this, drank that, hexed, etc.

Truth of the matter is that, patients truly feel the tightening and pain in the joints, arms, legs and back, during the cold season. This is partly due to a phenomenon called allodynia. This is that  condition where one reacts with  pain when exposed to otherwise non-painful sources, like cold weather, draft from the airconditioner or open window and even, touch. Allodynia is commonly observed in chronic pain conditions, including rheumatism and arthritis.

During the hot months of summer, indeed, a form of rheumatic disease - lupus- can be exacerbated by exposure to sun. This condition carries with it arthritis, skin rashes ( specially on sun exposure), and even kidney, lung and brain disease. This is an uncommon condition, though among the brown and black race, this disease can be seen more often. Lupus patients are advised to:

1. avoid sun exposure or wear enough sun screen if they have to (absolutely no sun bathing!)
2. check with their rheumatologist regularly
3. comply with maintenance medications. 

Once lupus is controlled, patients can be back working, marrying and having children, etc.

Cold weather and arthritis? Not really...

Summer and arthritis? Why, yes...

Sunday, January 8, 2012

Post holiday downtime, hightime for the gout!

At the start of each year,  I would expect gout arthritis patients, old and new, to rise like unwelcome spectre of the most painful of bodily retorts to dietary excesses, and come limping to the clinic. This would be followed by a week or maybe a month -long of resolve never ever to taste alcohol or the beans! This first week of 2012, one call from a patient (a doctor) came and then the week pulled off with several consults of gout patients without the gout attack and reporting a happy new year indeed!

I would like to think that after 2 decades of rheumatology practice, the returns of doing customized patient education during the clinic encounter is finally reaping some returns. However, gout patients being in so much pain with each attack, may have visited another rheumatologist, self-medicated with their favorite NSAIDs, visited the emergency room of some hospital where steroids may have doused the fire, or took steroids by themselves, or as advised by a well-meaning neighbor.

By customized patient education, I mean  giving a set or  combination of statements about the gout, its treatment and how to avoid it, as the case requires.

The first step, is to identify types of patients with gout:

(Look, these categories are not absolute or exclusive, nor are these the product of any indepth research, nor in any way intended to be derogatory. This list is anecdotal and culled from more than 20 years of observation. I suspect that these are actually patients' reactions to this severe malady, more than anything else)

1. humble and teachable (quite rare, the one with the best prognosis)
2. wife/ mother dependent
3. officemate/neighbor dependent
4. pseudo-doctor
5. late disease (nodes and masses stud the elbows, knees, and feet, kidneys and intestines bad)
6. one- consult patient
7. the returning one- consult patient
8. confused

First visit: all patients receive the complete set of educational instructions  and memorize their medications, and no looking to the caregiver, please...

2nd to the 5th consultation and still with recurrent attacks:  patients slowly fall into any item in the above list, so instructions are delivered "differently" per category, emphasized, and patient is required to write instructions down.

5th visit onwards: not to lose hope, patient still comes back, so, reiterate important points, use the" I agree, but..." or, "you are doing excellently, but..." approach, let him write down and read back instructions in the clinic, recruit wife or family members to help remind patient...

The single call received this week, is a looking up for an optimistic 2012-  could the patients attending this clinic have licked the gout? I will have to wait though, for the rest of January 2012. I'm keeping my fingers crossed!