Monthly Archives: January 2010

What does Lupus have to do with mosquitoes?

First, read this to learn more about Lupus. One of the commonly used medications for Lupus is hydroxychloroquine, or Plaquenil. My patients always think it’s strange that they take malaria medicine for Lupus or Rheumatoid Arthritis. Yes, it is, but it can work.

Foodie Friday: poached eggs

I’ve been working on my egg poaching skills. It’s not going well. I am getting a lot of ghostly looking strands of egg whites in the water. I have read many online sources with tips and tricks and don’t currently have a favorite. Why am I poaching eggs? I happen to really like eggs and find them to be a perfect ingredient for many quick weeknight suppers. Beyond the traditional Eggs Benedict, you can pretty much top anything with a poached egg! A local diner favorite of mine is a vegetable hash – a big pile of roasted veggies – topped with a poached egg. The other night I needed to use up some baby spinach too wilted for a crisp salad and I sautéed it with garlic and EVOO, topped it with a poached egg and some feta, sprinkled with some black salt and it was delicious! Looking forward to hearing others’ favorite poached egg recipes.

Journal Club

What we discussed at this month’s Rheumatology Journal Club with our residents:

deVos et al. Platelet-Rich Plasma Injection for Chronic Achilles Tendinopathy. JAMA 2010; 303:2. PRP injection was no better than saline injection.

Merrill et al. Efficacy and Safety of Rituximab in Moderately-to-Severely Active Systemic Lupus Erythematosus. Arthritis and Rheumatism 2010; 62:1. No difference between placebo and Rituximab.

Peters et al. Does Rheumatoid Arthritis Equal Diabetes Mellitus as an Independent Risk Factor for Cardiovascular Disease? A Prospectove Study. Arthritis and Rheumatism 2009; 61:11. The risk of cardiovascular disease in patients with RA is elevated compared with the general population. Consider risk factor modification similar to diabetics.

Osteoporosis Roundup

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Many interesting articles and blog posts about osteoporosis have come out in the past few weeks. I’ve been “collecting” them and highly recommend the following:

NPR story on osteoporosis medication

New York Times article on FRAX

Blog post from Science-Based Medicine

Blog post from TBTAM on FRAX

Blog post on vitamin D

All very thought-provoking. In my practice, I read DXA scans weekly and see consultations for osteoporosis and osteopenia management. I have noticed that I have been reading DXA scans ordered on younger women. Note the following recommendation from the US Dept of Health and Human Services site:

The U.S. Preventive Services Task Force (USPSTF) recommends that women aged 65 and older be screened routinely for osteoporosis. The USPSTF recommends that routine screening begin at age 60 for women at increased risk for osteoporotic fractures.

There is good evidence that the risk for osteoporosis and fracture increases with age and other factors; bone density measurements accurately predict the risk for fractures in the short-term; treating asymptomatic women with osteoporosis reduces their risk for fracture. The USPSTF concludes that the benefits of screening and treatment are of at least moderate magnitude for women at increased risk by virtue of age or presence of other risk factors.

There is insufficient evidence to recommend for or against routine osteoporosis screening in postmenopausal women who are younger than 60 or in women aged 60-64 who are not at increased risk for osteoporotic fractures.

Despite these recommendations, many women seem to start their DXA screening around the time of menopause and continue to get scans every 2 years indefinitely. Why start at perimenopause or menopause when this is not the recommendation? I can only guess that it may have something to do with the pervasive marketing of osteoporosis medications and/or a belief that any test provides information and that must be helpful. Why every 2 years? That is the minimum interval many insurers will pay for the test. Note that there is no guideline as to frequency, like for mammography or pap smears. Subsequent DXA scans are recommended when the result would change clinical management. This forces us to think and is perhaps one area where checklists are not helpful. Women and their physicians should not think of the DXA as an every 2 year test to be done without considering the implications of the results. This may be part of the issue behind the above discussion regarding “osteopenia.” To take the debate a step further, are follow up scans needed in the first few years after a woman has started taking an osteoporosis medication? Likely not, according to this article from BMJ. The authors concluded that,

Monitoring bone mineral density in postmenopausal women in the first three years after starting treatment with a potent bisphosphonate is unnecessary and may be misleading. Routine monitoring should be avoided in this early period after bisphosphonate treatment is commenced.

I also recommend reading the accompanying editorial. The goal of identifying risk factors, screening for osteoporosis and using these medications is to prevent the morbidity and mortality from osteoporotic fractures. The challenge lies, as it does with all tests and treatments, is to use them appropriately and for good reason.

TV for good, not evil!

[picapp align=”center” wrap=”false” link=”term=television&iid=5063757″ src=”9/c/a/0/Man_in_swimming_2439.jpg?adImageId=9456306&imageId=5063757″ width=”380″ height=”254″ /]True confession time: I love TV. Reality, drama, sitcom, home and garden, cooking, sports. Truth be told I’m not a fan of the celebrity talk show, though. Imagine my personal dismay at this article, which cites the following:

Aussies who reported watching four or more hours of TV a day were 46% more likely to die during a 6.6-year period than those who watched less than two hours a day, according to David Dunstan, PhD, of Monash University in Melbourne, and colleagues. . . The associations were independent of leisure-time exercise and traditional risk factors such as smoking, poor diet, high blood pressure, and abdominal obesity.

“Even if you exercise, if you have a lot of sedentary living with the things that go along with it — the bad diet and everything else — you still have a net degree of physical inactivity, which is a coronary artery disease risk factor,” Fletcher told MedPage Today.

Is the typical scenario someone who gets home from work and plops down in front of the TV, dinner break, maybe in front of the TV as well, then crawls into bed to watch TV and fall asleep to Conan Jay? Wait, that might sound a little too familiar. What if we substitute other sedentary activities: blogging or working online, doing puzzles, playing cards, reading? I suppose those activities are not as mesmerizing as the flickering glow of the flat screen.

Many people have spent time and money on their entertainment setups, media rooms and the like. How can we use them for good instead of evil? Here are some ideas:

  • Wii Fit
  • On-demand or Fit TV programming (check with your cable company)
  • Fitness DVDs
  • Cooking shows with focus on healthy eating
  • Use your DVR so if there’s a show you really love you can fast forward through commercials and watch it in less time or you can save it up for a Friday night.
  • If you don’t have a DVR, do exercises or stretches during commercial breaks.
  • Ask yourself, as you sit down to watch another rerun, “Is this enriching my life?” If the answer is no, maybe you can find something that does and may help you be healthier in the long run.

Foodie Friday: cherrywinks

When I read that Shutterbean’s great-grandmother was famous for a cookie called cherrywinks, I thought this would be a perfect recipe to make with my 93 year-old grandmother. I had never seen or tasted this type of cookie before and grandma said it was familiar but nothing she had ever made. I gathered all my ingredients and tried to get grandma in on the action. As you can imagine, 93 years on this earth can take its toll on the body and grandma soon decided she’d rather relax in her recliner and await the finished product. Despite my pleas that rolling dough balls would be good for arthritic fingers (a disadvantage of having a Rheumatologist relative), I continued alone. Click on the link above for the recipe and her wonderful step-by-step directions. These pictures show my results. They were very tasty and leftovers brought to work disappeared in minutes. A definite recipe to save!

An oldie but a goodie: GOUT

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There are lots of useful sources online to provide more information about gout, such as WebMD or UpToDate for Patients. Based on what my patients ask me in the office, a lot of the patient education information seems to focus on management of diet to control gout. Certainly dehydration can precipitate a gout attack, so remaining hydrated is usually recommended (keeping in mind some patients may be on fluid restriction for other medical conditions). A 2004 article in the NEJM concluded that,

Higher levels of meat and seafood consumption are associated with an increased risk of gout, whereas a higher level of consumption of dairy products is associated with a decreased risk.

Among the medications used to treat and prevent gout is another oldie but goodie, a medication called colchicine. In early December some preliminary emails were circulated with rumors that this inexpensive generic medication was going to be removed from the market and a more expensive brand name medication would take its place. These rumors were confirmed and can be read about in more detail in this article, which appeared in several newspapers. According to the article,

In December, the American College of Rheumatology sent a letter to the FDA seeking to discuss how to keep colchicine affordable. “We want to express our concern that a medicine used for centuries to treat gout and rare conditions, which costs pennies, will now cost patients quite a bit more,” said Dr. Stanley Cohen, a Dallas rheumatologist who is president of the college, in an interview. “That doesn’t make sense in the setting of healthcare reform.”

I’m afraid it doesn’t make much sense to me either. Gout (and Familial Mediterranean Fever, the other condition for which colchicine is commonly used) is not a very fancy disease. No one is wearing gout awareness ribbons. But ask anyone who has suffered a severe gout attack how important it is to him or her to have treatment options. In our current healthcare climate, it seems like affordability of these options would be of particular importance. Wonder why we’re not hearing more about this.