Monthly Archives: March 2010

Foodie Friday: healthy nachos?

Can you make “healthy” nachos? I think you can. And they’re easy. Take a bag of tortilla chips. You can do baked. You can do multigrain (and I’m checking with those NuVal folks to see if there’s a significant advantage to the multigrain). I did plain old regular tortilla chips. Add a can of vegetarian refried beans. You can do regular. I looked at the nutrition info and there wasn’t much difference, but the non-vegetarian ones contain lard. Now here’s the important part: You have to use a knife and individually spread some refried beans on each tortilla chip, then put them in a single layer on a cookie sheet. That way each chip has bean and it works out better. Top with whatever you want: sliced black olives, green chilis, tomatoes, shredded cheese (OK, lowfat cheese if you want). You don’t need that much. Since your nachos are in a single layer each chip gets toppings. Bake/broil until cheese is warm and bubbly and there you go! I whipped up in the food processor an avocado with some 0% Greek yogurt and lime juice for a little guac dipping sauce, with salsa for dipping on the side. They were incredible!

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Didn’t the bionic man run?

[picapp align=”left” wrap=”false” link=”term=hang+glide&iid=184215″ src=”0180/28acefb5-5b41-4526-be46-4810a69a9645.jpg?adImageId=11353302&imageId=184215″ width=”380″ height=”253″ /]A story about playing sports after knee replacement came this week in one of my daily medical news emails. You can read the MedPage Today article here.  I send a lot of patients to the Orthopaedic surgeons for joint replacements. Unless there is something else I see them for, sometimes they don’t need a Rheumatologist anymore and don’t come back, so I don’t know how they’re doing. A fair amount do come back, though, for their RA or OA of other joints, and we talk about life after knee replacement. According to the article, here are the accepted and discouraged post-replacement activities:

Encouraged activities include bowling, croquet, golf, doubles tennis, table tennis, ballroom dancing, square dancing, stationary biking, swimming, low-resistance rowing, walking, hiking, and low-resistant weight lifting.

Discouraged activities include baseball, basketball, football, hockey, soccer, high-impact aerobics, gymnastics, jogging, power lifting, rock climbing, hang gliding, and parachuting.

I think we have to first decide if we’re talking about an elite athlete or just an every day person trying to remain fit and active. Not many of my patients wanted to rock climb or hang glide BEFORE their surgery, let alone after. I have a hard enough time trying to convince people with arthritis that they CAN and SHOULD exercise (check out my prior post on exercise resolutions). Sports medicine doctors are probably seeing a different patient population than I am. I also found this interesting:

The revision rate for mechanical failure of the implant was lower in the patients who participated in high-impact sports (8.5% versus 11%), although the difference was not statistically significant.

How can I use this information in my practice? Well, if it seems to be OK for super athletic patients to get out there and occasionally do high-impact exercise after joint replacement, then us average Joes and Janes can certainly keep up a healthy low to moderate intensity workout post surgery. Good news!

Has Spring Sprung?

[picapp align=”left” wrap=”false” link=”term=daffodil&iid=303764″ src=”0300/7a8694e7-a29f-4793-bd09-8d3d90a27cb8.jpg?adImageId=11271962&imageId=303764″ width=”337″ height=”507″ /]The last 3 days in Massachusetts have been about 40 degrees, driving wind and rain. Not too spring-y! But the 3 inches of daffodil shoots sticking out of the yard say otherwise. Here are some tips for avoiding and treating spring allergies.

I said, “DOES YOUR KNEE HURT?”

Have you heard this? (Pun intended). There was a recent article in the American Journal of Medicine on analgesic use and risk of hearing loss in men. [picapp align=”right” wrap=”false” link=”term=man%27s+ear&iid=5066105″ src=”f/9/4/7/Young_man_with_bf0a.jpg?adImageId=11190073&imageId=5066105″ width=”337″ height=”506″ /] The full text of the article can be found here. The study concluded that regular use of aspirin, NSAIDs, or acetaminophen increases the risk of hearing loss in men, and the impact is larger on younger individuals. In the days after this study was published, I saw these findings quoted on dozens of websites, news programs, blogs and twitter. Haven’t had any patients ask about it yet.

It is difficult to know how to interpret this. People aren’t typically throwing back handfuls of analgesics for no good reason. Use of these medications always requires a careful risk/benefit analysis. Might it cause someone to pause and consider whether he/she really needs an oral analgesic? Sure, but many times the other options are limited. Interesting to note, but at this point not something that will change clinical practice.

Foodie Friday: Time to make the donuts!

 

No, not THESE donuts.

THESE donuts:

Many years ago I purchased a nonstick mini donut pan and promptly forgot about it. Last week I found it shoved in the back of a kitchen cabinet and decided to give it a try. I don’t actually recall EVER using it before, but there was a tiny bit of dried batter stuck in one of the wells, so I guess I did. Or else some random family member made mini donuts and didn’t share. I searched the internet for baked mini donut recipes and came across one on a blog, and one on recipezaar I plan to try in the future. First, the photos, then the commentary:

As you can tell, the first batch looked like mini muffins that had a “bellybutton” rather than donuts. I learned that you barely need to fill the little wells. It really is about a tablespoon of batter. I think next time I will try using a pastry bag (or plastic bag with a hole cut out of a corner since I don’t have a pastry bag). They were delicious, however! Frosted them with a powdered sugar/water glaze and dipped in sprinkles (or jimmies depending on your geographical location). I can see lots of opportunities to be creative with the decorating as well. Donut craving satisfied, though it’s still no Dunkin’ . . .

Does MTX=BX?

[picapp align=”left” wrap=”false” link=”term=pills&iid=264092″ src=”0260/7b527e62-4510-44d3-9f43-b1afc1fd9d15.jpg?adImageId=10953550&imageId=264092″ width=”323″ height=”480″ /] Last month, for Rheumatology Journal Club, I chose an article about liver biopsy recommendations with methotrexate (MTX) use. The citation is: Lindsay et al. Liver fibrosis in patients with psoriasis and psoriatic arthritis on long-term, high cumulative dose methotrexate therapy. Rheumatology 2009 48(5):569-572.

The guidelines for MTX monitoring differ when comparing Dermatology with Rheumatology sources. According to a 1998 consensus conference of the American Academy of Dermatology, recommendations include a baseline liver biopsy at 2-4 months if there are risk factors for fibrosis and thereafter at a cumulative dose of 1-1.5g MTX. However, newer recommendations  suggest liver biopsies may not be needed, especially in low-risk individuals. (Here is the abstract, but I’m not on the hospital network so I can’t get the full article). The 1994 ACR guidelines recommend monitoring liver enzymes, CBC, creatinine every 4-8 weeks, although more recent information (ACR meeting abstracts) suggests a 12 week interval may be appropriate. Certainly, monitoring interval is dependent on an individual’s risk factors. What are some risk factors that might cause us to pay closer attention to the liver? Diabetes, obesity (includes risk of NASH/NAFLD), impaired renal function, alcohol use and any history of prior abnormal liver biopsy.

So, back to the article. This study of 54 patients with psoriasis or psoriatic arthritis were on MTX (for an average of 6.5 years at a dose of about 15.5mg per week). Liver biopsies were done on all the patients and nearly 65% had normal biopsies. The rest had early mild fibrosis or fatty change. There were no cases of advanced fibrosis or liver disease.  The authors did not note any significant correlation between risk factors and the likelihood of fibrosis. Alcohol use came closest but was not statistically significant. They also looked at a serum marker of liver fibrosis, pro-collagen 3 N-terminal peptide (PIIINP), which also did not correlate with liver fibrosis. This test is not approved in the US (that I could find, and according to my commercial office lab).

What does this mean for patients taking or contemplating MTX? Perhaps we can think of it as somewhat reassuring that the guidelines for monitoring became less strict with subsequent investigations. Clinical guidelines are backing away from liver biopsy, aside from circumstances where it is clinically indicated. Intervals between lab tests are lengthening. This is good news for patients, who are required to visit the lab less. However, the presence of risk factors, especially multiple risk factors in a patient, may warrant closer monitoring. This may be especially true with the prevalence of diabetes and obesity. Continued reminders against alcohol consumption when taking MTX are important, as is encouragement of weight loss. (Translation: If you take MTX, try to lose weight if you are overweight and do not drink alcohol and make sure you do your labs at the appropriate interval decided by you and your doctor)!

Quinine and Muscle Cramps

Patients ask me all the time what to do about their leg cramps. Barring any major electrolyte imbalance, there really is no good answer why this happens or what to do about it. This article from the SCOPE Blog sympathizes with this issue. I used to recommend a glass of tonic wather, but as they say,

Forget about quinine water. You’d have to drink a few liters of it to get any efficacy for muscle cramps, and by the time you were done you’d probably have cramps in another important organ.

As for all the patients who claim that putting a bar of soap under the sheets at the bottom of the bed, no idea why this helps but I can’t see how it would hurt, so feel free to try it and report back!