Tag Archives: Rheumatology

How Vitamin D Supplements May Help Lupus Patients

It seems like every week brings a new study about the benefits of vitamin D: It builds bones, tames psychotic symptoms in bipolar teens, and strengthens the immune system. It is the immune system benefit that attracted the interest of Dr. Benjamin Terrier and colleagues at the Pitié-Salpêtrière Hospital in Paris, France.

Courtesy of Mikael Häggström, via Wikimedia Commons

The researchers studied 24 people with lupus to determine the possible benefit of vitamin D supplementation on their immune systems. They presented their findings at this year’s annual meeting of the American College of Rheumatology.

So, did it help? Yes, to some extent. The patients received 100,000 IU of vitamin D weekly for 4 weeks, and then the same amount monthly for 6 months. Serum 25(OH)D levels, which had been below normal in all patients at baseline, were normal when measured after 2 months and 6 months.

Most importantly, the number of regulatory T cells increased and the number of T helper lymphocytes decreased after 2 months and also after 6 months of vitamin D supplementation. In addition, antibody-producing memory B cells decreased after 2 months, and activated CD8+ T cells (thought to be associated with lupus in particular) decreased after 6 months.

An added bonus: None of the patients reported adverse events associated with vitamin D, including hypercalcemia or lithiasis.

The findings are preliminary, Dr. Terrier said, and large, randomized controlled trials are needed to confirm the results.

Currently, no one is advocating that lupus patients increase their vitamin D with heavy supplementation, said Dr. Sam Lim of Emory University in Atlanta, Georgia. Dr. Lim served as moderator at the press conference in which the findings were presented.

However, “the study is very important because it is a link to take [the research] to the next step,” Dr. Lim said.

–Heidi Splete (On Twitter @hsplete)

Image courtesy of Mikael Häggström, via Wikimedia Commons

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Rheumatology’s PR Problem

Overheard on the steps of the ExCeL London convention center on the last day of the annual European Congress of Rheumatology:

Attendee 1: “What is rheumatism?”

Attendee 2: “You know. Achy legs and such.”

Attendee 1: “Sounds dull.”

Attendee 2: “They’re probably saying that about us.”

Attendee 1: “Doubt it.”

In the interest of full disclosure, I should explain that not only was it the last day of this year’s EULAR congress, it was also the second day of the MCM Expo London Comic Con, which was taking place at the west end of the same convention center. The above discourse occurred between a giant insect and an anime character.

Photo by Diana Mahoney

It was impossible not to be amused by the unlikely juxtaposition of the two gatherings, particularly because the facility’s main entrance was on the building’s west side,. To get to the EULAR events, thousands of suited and serious rheumatologists had to weave in, out, and around the Comic Con crowd, all of whom were dressed as their favorite comic, manga, anime, film, game, and cult entertainment stars and were engaged in various modes of role play.

Despite the apparent incongruity, however, the above discourse seemed inherently relevant, as it came on the heels of a presentation that elucidated some persistent obstacles to the early diagnosis and optimal treatment of early rheumatologic disease, which I have come to think of as collective symptoms of rheumatology’s PR crisis.

In short, a lot of people don’t know what rheumatology is, and the opinions of those who have some vague sense of it continue to be colored by myths and misconceptions, including the belief that arthritis (or “rheumatism,” as per the arachnid quoted above) is a single entity and that there’s not much that can be done for it.

With respect to rheumatoid arthritis, in particular, this lack of awareness contributes to diagnostic and treatment delays that can have devastating consequences. While much effort has been spent recently on the development of early arthritis clinics within rheumatology centers as a way to streamline patient management, their success is limited. They can address the needs of only those patients who walk through the doors, not those of people who don’t seek treatment when their symptoms develop and persist or whose symptoms are inadequately assessed and managed initially by primary care physicians, according to session panelist Dr. Vivian Bykerk from Brigham and Women’s Hospital in Boston. “We have to remove all of the  roadblocks that are keeping very early inflammatory arthritis patients from getting to the rheumatologist,” she said.

Among the strategies recommended by Dr. Bykerk and co-panelist Dr. Paul Emery, EULAR president and head of musculoskeletal diseases at Chapel Allerton Hospital in the United Kingdom, were the possibility of prescreening referrals, the development of a specialized rheumatology referral form to help primary care physicians identify urgent referrals, the implementation of central triage clinics, and protocols for educating physicians and patients about the signs and symptoms of rheumatologic diseases and the value of early intervention. In other words, rheumatology needs better PR.

—Diana Mahoney

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Filed under Allergy and Immunology, Health Policy, health reform, Hospital and Critical Care Medicine, IMNG, Internal Medicine, Physical Medicine and Rehabilitation, Practice Trends, Primary care, Rheumatology

Researchers Urged to Empower Arthritis Patients

 The European League Against Rheumatism (EULAR) has developed recommendations on how clinical researchers can partner with patient representatives. They’re not talking about simply including patients as the subjects of studies, but about having selected patients team up with the researchers in every step, from identifying what needs to be studied to how to conduct the study.

Apparently, having one or more patient representatives in EULAR scientific projects has become standard practice. Until now, however, researchers had no guidelines for the best ways to put this concept into practice, M.P.T. de Wit of VU Medical Centre, Amsterdam and associates wrote in an article published by the Annals of Rheumatic Diseases.

They crafted eight recommendations and bounced them off 28 patients and 53 professionals, who didn’t always see eye to eye. For example, a recommendation to include a minimum of two patient research partners in every project was embraced by 93% of patients but by only 68% of professionals. Read more in my full story.

The article points to previous efforts that successfully employed advance concepts of patient participation, including the Cochrane Musculoskeletal Consumer Group, which invites consumers to fill out an online survey and help set research priorities. The article also cites patient participation efforts at conferences on Outcome Measures in Rheumatology (OMERACT), and in creating the Rheumatoid Arthritis Impact of Disease (RAID) scoring system.

I have to admit, this was all news to me. I’m wondering if this is a concept that has taken hold in the United States, and in other fields besides rheumatology. If you’re a clinician, a clinical researcher, or a patient research partner, I’d love to hear your thoughts and experiences.

— Sherry Boschert (@sherryboschert on Twitter)

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Hands-On Medical Education: Still a Place for Cadaver Training

 From the annual scientific meeting of the American College of Rheumatology:

Sometimes technology is at its greatest when it works together with the traditional methods. I like baking from scratch, but I love melting chocolate in the microwave. 

 Despite the huge technological advances in simulators and virtual medical conditions, medical students still benefit from the hands-on experience of cadaver training.

 Two neighboring posters presented at the annual scientific meeting of the American College of Rheumatology this week suggest that both old and new education methods have their places.

courtesy of flickr user uicahs (creative commons)

 In one study conducted at the University of South Florida in Tampa, a virtual medical education program called “Arthur” was used to teach fourth-year medical students about joint pattern recognition in musculoskeletal disorders. Of 64 students who completed a survey after using the program, 35% said it was helpful for learning joint pattern recognition, 43% found it helpful for learning differential diagnoses of rheumatic diseases, and 20% said it was a handy visual aid. But Arthur isn’t perfect. Almost half (48%) of the surveyed students said that they’d like more explanations for the differential diagnoses, which the researchers promised to add in the next version of the program.

 But there is still value in hands-on training for rheums-to-be. In a study led by researchers from the Hospital for Special Surgery in New York, 43 second- and third-year medical residents took part in teaching module featuring two sessions with cadavers during a month’s time. Students practiced examining knee and shoulder joints and tried out different approaches to injecting the joints.

courtesy of flickr user The University of Adelaide (creative commons)

Although cadaver training was brief, it seems to have made an impact. All 24 students who responded to surveys after the program reported significantly improved confidence in their knowledge of knee and shoulder anatomy and in their ability to inject and examine the knee and shoulder joints.

–Heidi Splete (@hsplete on twitter)

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Got Gout? Put Down that Coffee and Cola

As if suffering from gout isn’t bad enough, new research presented this week at American College of Rheumatology’s annual scientific meeting in Atlanta adds insult to injury.

Researchers led by Dr. Tuhina Neogi of Boston University reviewed data from their study of more than 600 adults with gout. Although previous studies have suggested that long-term caffeine use might relieve gout pain, short-term caffeine used might bring it on.

courtesy of flickr user doug88888 (creative commons)

 In this study, people who drank more coffee, tea, or soda, were significantly more likely to have a gout attack, even after controlling for all the other drinks they had. More specifically, 3-4 caffeinated drinks within the 24 hours prior to a gout attack was associated with a 40 to 80 percent risk of recurrent gout.

And there’s more bad news for gout patients, but this is just for women. Another Boston University research team led by Dr. Hyon Choi presented 22 years’ worth of data from the Nurses’ Health Study showing that women who drank more than two fructose-rich beverages daily (such as orange juice and Atlanta’s lifeblood, Coke) were more than twice as likely to develop gout as those who drank less than one of these beverages per month.

The good news? Diet soda was not associated with any increased risk for gout. Phew! But what about the caffeine? Ok, here’s the deal: Women with gout should stock up on caffeine-free diet soda, at least until the next study comes out. And if I look hard enough, there might be a study about the benefits of chocolate for people with arthritis around here somewhere . . .

–Heidi Splete (@hsplete on twitter)

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When RA Gets in the Way, and When It Doesn’t

There are people who don’t want to exercise, even though they are physically capable of doing so. Ironically, many people with rheumatoid arthritis want to exercise, but they are unable to do so because of chronic pain.

from flickr user dglider (creative commons)

The physical and psychological benefits of exercise are no secret, but in a study by Dr. Vibeke Strand of Stanford (Calif.) University, 49% of women reported that RA pain prevented them from participating in sports and exercising. Dr. Strand’s study, presented at the annual European Congress of Rheumatology (EULAR) in Rome  included nearly 2,000 women with RA.

Of these women, approximately two-thirds said that they experienced pain on a daily basis, including a majority of those who reported taking pain medication regularly. The study participants also reported that RA interfered with leisure activities and personal relationships, and even contributed to the deterioration of friendships and the end of marriages, Dr. Strand said in an interview.

The complete study data highlight the challenges of assessing and treating pain in patients with RA. The study results were limited by the use of self-reports of RA, but approximately 67% of the women said that they were constantly searching for new forms of pain relief.

Another event at the meeting highlighted how exercise empowers RA patients, including some who are severely disabled. An organization called Biking Against Rheumatism in Europe (BARIE) sponsored a multiday event in which a group of bikers, including individuals with severe RA riding on customized bikes, rode from Brussels to Rome, arriving on the first day of the meeting. Dr Strand’s data suggest that most of them were battling chronic pain. The goal of BARIE is to raise awareness of rheumatism. Ideally, more awareness will lead to more support for research, so more patients can live pain free for better physical and psychological health.

–Heidi Splete (on twitter @hsplete)

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Filed under Alternative and Complementary Medicine, IMNG, Rheumatology

What Rheumatologists Do When No One Is Looking

From the Seminar in Advanced Rheumatology 2009, New York:

When assessing 12-month mortality in rheumatoid disease, the data gathered with a 10-item questionnaire known as the RAPID 3 are as accurate as measurements of serum C reactive protein level, erythrocyte sedimentation rate, number of swollen or tender joints, and other components of the rheumatologist’s standard examination.

Better yet, the patient can complete the self-administered Routine Assessment of Patient Index Data (RAPID 3) or any other self-assessment questionnaire (the Multi-Dimensional Health Assessment Questionnaire [MDHAQ], from which the RAPID 3 is distilled, for instance) while waiting to see the rheumatologist, a practice that seems to get patients more involved in their own care.

Questionnaire findings can be entered in the patients’ electronic medical record—which has the two advantages of being at hand to document compliance with the six Physician Quality Reporting Initiative (PQRI) standards for rheumatology issued by the Centers for Medicare and Medicaid Services in the start of 2009 (and which seem to be the best kept secret in rheumatology) and for office-based research.

But when attendees at NYU’s seminar in advanced rheumatology were asked for a show of hands, few used self-assessment questionnaires, and even fewer had EMRs in place. Speakers urged rheumatologists to adopt office-based quality of care documentation (another use for the questionnaire data) and EMRs. The answer to what treatment works in rheumatologic diseases can be found in data generated by patient self -assessment.

Dr. Theodore Pincus told the audience: “Rheumatologists should be leading the way with functional assessments and not following diabetologists with [their heavy reliance on] lab tests [to assess patient well being].”

—Sally Koch Kubetin
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Waiting for Febuxostat

The annual meeting of the American College of Rheumatology, San Francisco

Here at the annual meeting of the American College of Rheumatology, the talk between investigators is about how the Food and Drug Administration has stopped approving new drugs. This case of regulatory paralysis makes no sense, according to people who talked to me on the subject. FDA advisory panels have recommended approval of drugs like febuxostat for gout and tocilizumab for rheumatoid arthritis. Rheumatologists are not by nature a cynical bunch but no one I spoke with expected either of these agents to be approved in 2008. Why?


Like everything in rheumatology, the answer seems to be multifactorial. The FDA has been diagnosed here with a case of post-Vioxx PTSD. The agency seems terrified of making a mistake of that magnitude again. The other factor is more practical: FDA is awaiting the results of the presidential election, with its attendant new administration and eventual appointment of a fresh FDA commissioner.


The exhibit floor is jammed with booths, some large to promote approved agents and others describing agents that are hanging fire in the approval process. I felt relieved by the sight of products that do not require FDA approval-such as equipment for office–based ultrasound, fluoroscope of small joints, and DXA scans. My favorite booth promoted the large handled kitchen products of OXO. How clever to market these thick gripped peelers and ergonomically responsible lettuce spinners (priced rather steeply as all fans of Williams and Sonoma know) to rheumatologists and physical and occupational therapists who will in turn recommend them to patients whose hand pain makes it difficult to grip smaller kitchen tools. And who is to say that the pain relief offered by these thoughtfully designed gadgets does not make a significant improvement in the quality of life of patients with rheumatic diseases of the small joints?


—Sally Koch Kubetin

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