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Rheumors Volume 6, Number 1: Winter 1995
NEW ROCKVILLE OFFICE OPENS!
9707 Shady Grove Road - Suite 100 - Rockville, MD 20850
After
several years of planning, and a full year of construction,
Arthritis & Rheumatism Associates, P.C. proudly opened
the doors to our beautiful new Rockville office on November
1, 1994. We remain on the campus of the Shady Grove Adventist
Hospital, but have moved into our long-awaited permanent
home.
We
are especially excited about our new facility because
it offers us the opportunity to better meet the needs
of our growing patient population. We are now able to
expand the number of hours we see patients at that location,
and for the first time in Rockville, we are able to provide
in-house X-ray services. These additions make us more
efficient and enable us to provide more convenient service
to our patients.
While
Dr. Baraf's and Dr. Rosenberg's Rockville office schedules
will remain the same, Dr. Siegel's and Dr. DiIorio's schedules
will be expanded. Therefore, if you are a patient of Drs.
Siegel or DiIorio and live or work in the Rockville area,
but currently see them for treatment in our Silver Spring
location, you might wish to consider transferring your
care to our Rockville office. The new, expanded hours
in that location may offer greater appointment flexibility
and the opportunity to be scheduled more quickly. As we
all embark upon the fast moving, and to a large degree
yet-unknown, changes in health care delivery systems,
we hope that our vision, expansion and continued commitment
to providing the highest quality of medical care, will
carry our patients and our practice, successfully into
the next century.
GUEST
COLUMN
In an on-going effort to keep Rheumors a timely and informative
patient newsletter, we have decided to introduce a "Guest
Column" to our publication. Its purpose is to present
topics of interest and relevance to our patients which
are written by a variety of physicians, representing numerours
specialties, from the Washington Metropolitan Area. This
is our introduction issue. We hope you will find our guest
columnists interesting and informative. We welcome your
feedback.
TOTAL JOINTS WHERE ARE WE?
by Jerry S. Farber, M.D.
Total
joint replacement has become almost a household word in
the past ten years. For most orthopaedic surgeons, and
the lay public, this means replacement of the knee and
hip joints. While joint replacement can be done at several
other joints in the body, such as the elbow, ankle, finger
joints, great toe and wrist, these are not as common and,
of course, not as dramatic as the large weight bearing
joints that allow us locomotion. Are these safe procedures?
How well do they hold up? Will they have to be revised?
How hard will one have to work after surgery to regain
strength and the ability to walk? How does one know when
to have the operation?
No
doctor can guarantee the results of an operation. The
physician must educate the patient as to the potential
risks, and benefits and the alternative procedures to
any given operative procedure. The patient must then decide,
given the available information, whether or not to have
joint replacement surgery.
Total
joints do hold up. While there have been changes in the
construction of the components used, most components are
metal but depend upon a plastic (Polyethylene) gliding
surface. There has been a period of progressive experience
and learning to improve the quality and longevity of the
plastic portion of the joint. Some components are routinely
cemented in place to fix them. Others use special surfaces
and chemicals to help them bind to the surrounding bone.
These special surfaces are still evolving and only time
will determine if they will continue to be used.
If
you are the patient, you will decide when to have the
operation. The decision should be based on quality of
life issues and not on changes, or lack of them, on x-ray
studies. When pain or limited motion significantly affects
the lifestyle of the individual, and the situation is
no longer acceptable, it is time to consider moving forward
with joint replacement. There must be "a joint" (pun)
decision by all of the patient's doctors that the non-operative
therapies have failed and that the patient's medical condition
does not pose an unacceptable risk for the procedure.
How
much effort does the patient have to put in to ensure
the success of the procedure? A great deal! The more effort
the patient is willing to put forth after the procedure,
the more likely the procedure will be successful. Appropriate
supervised physical therapy and home care programs make
the operation work. The patient who expects the physician
and the therapist to do all the work for them will not
achieve the maximum potential from the operation. Use
of a walker or crutches after the operation will be determined
by the joint replaced, the types of components used and
the surgeon's assessment of the Guest Column patient's
abilities. The amount of weight borne on the operated
leg will also vary depending on the joint and the components.
In non-cemented hip replacements, partial weight bearing
may be necessary for up to three months.
Revision
of a total joint will depend on many factors. The age
of the patient and the weight and level of activity of
the individual will influence how well the components
will "wear." The ability of a person's bone to accept
and bind to the components will also have an effect on
the longevity of the joint. Some problems recently have
come to our attention regarding debris, or wear from the
plastic or metal components, that can cause earlier failure
of the hip joint. As this technology continues to evolve,
we shall find unexpected successes and failures. In general,
revision surgery is not quite as effective as the original
procedure, but can still be quite helpful in relieving
symptoms related to replacement joints that have worn
poorly over time.
Total
joint replacement is a well developed and well designed
procedure that is economically reasonable, and extremely
satisfying, for the vast majority of individuals who make
a well informed decision to undergo this surgery.
POINTS
ON JOINTS
AUTOIMMUNE
DISEASE AND PREGNANCY
by Emma DiIorio, M.D.
As
physicians, rheumatologists have always been interested
in the effect of autoimmune diseases on pregnancy. Since
I am currently pregnant, my interest in the topic has
increased and prompted me to author this article. Because
autoimmune diseases show a peak in the childbearing years,
and generally occur more frequently in women, they are
seen with some regularity in association with pregnancy.
In 1890, Sir Archibald Garrod wrote, "It is curious to
observe the occurrence of pregnancy during the course
of the disease (arthritis) appears to exert opposite influences
in different cases, in some accelerating the process of
the malady, and in others acting as a temporary check
on its development."
Rheumatoid
arthritis (RA) affects one of every 1000-2000 pregnancies.
Women with RA often have remissions or improvement of
their arthritis during pregnancy. The majority will be
able to stop their medication. The reason for remission
is unclear. Cortisol, a naturally occurring steroid, increases
steadily during pregnancy and, by the third trimester,
is doubled that of a nonpregnant female. Hormonal changes
likely play a role. Recently, there is evidence to suggest
that remision during pregnancy may be related to a maternal
immune response to the fetal genes inherited from the
father. Unfortunately, the remission is not long lasting
and it is quite common to suffer exacerbations in the
first three months after delivery. Patients who experience
remission during one pregnancy may generally expect to
have further remissions during subsequent pregnancies.
Also, the initial onset of RA occurs more frequently than
expected in the first twelve months following delivery.
Fertility
and fetal outcome are not affected by RA. There is an
increased risk of RA among nulliparous women (women who
have never given birth). The reason for this is unclear.
It also appears that a large number of pregnancies and
younger age at first pregnancy may offer a protective
effect against the development of RA.
Systemic
lupus erythematosus (SLE) female to male ratio during
childbearing years is 15:1 and there is a 9:1 overall
incidence. SLE has multiple effects on pregnancy and vice
versa. Whether pregnancy places the patient with SLE at
an increased risk of exacerbation remains controversial.
However, numerous studies have shown that disease activity
at the time of conception and throughout the pregnancy
is detrimental. Therefore, it is strongly recommended
that SLE patients try to conceive during times of disease
remission. Active lupus kidney disease is associated with
a greater frequency of maternal deaths and postpartum
exacerbations.
Patients
with SLE are also at an increased risk of miscarriages,
fetal demise, and premature labor. This is especially
true in the setting of certain maternal antibodies, as
will be discussed below, and in women with active disease.
Neonatal lupus erythematosus is an uncommon type of lupus
seen in infants born to mothers with SLE. It is associated
with the presence of particular antibodies in the mother.
These antibodies are called anti-Ro and anti-La. Infants
with this syndrome will manifest skin changes and cardiac
manifestations, namely heartblock. These infants will
require permanent pacemakers. Luckily, most women with
these antibodies will have healthy babies, and only a
small percentage will have babies born with neonatal lupus.
Also, thanks to modern technology, infants with heartblock
can be detected in utero by fetal echocardiogram and treatment
to prevent permanent heartblock given before they are
born.
SLE
patients and patients without SLE may also make another
unique set of antibodies called anti-phospholipid antibodies.
Patients with these antibodies are prone to blood clots.
In addition, patients with these antibodies may be prone
to recurrent miscarriages secondary to the formation of
blood clots in the placenta, which is the fetus' lifeline.
Not all females who carry these antibodies will experience
recurrent fetal loss. However, for those who do, treatment
options do exist and healthy infants have been born to
these mothers. The pregnant SLE patient is monitored closely
throughout pregnancy both clinically and by laboratory
studies.
Miscellaneous
- Other autoimmune diseases like systemic scleroderma,
dermatomyositis, and mixed connective tissue diseases
are rare in the reproductive years and so their effects
on pregnancy are not well studied. There does appear to
be an increased risk for both mother and fetus. Also,
there is a documented increased risk of renal crisis in
patients with early diffuse scleroderma and these patients
are discouraged from becoming pregnant.
Carpal
tunnel syndrome, although not an autoimmune disease, is
seen more frequently with pregnancy. Carpal tunnel syndrome
is caused by compression of the median nerve at the wrist,
resulting in tingling and numbness in the first four fingers
in the palm side of the hand. Symptoms commonly occur
at night. Its increased frequency with pregnancy is secondary
to the hand swelling seen in the last trimester. Wrist
splints and local injections are very successful in relieving
the symptoms, as is delivery of the infant.
Treatment
- How do we treat the pregnant female with active autoimmune
disease? Steroid medications appear to be very safe during
pregnancy, without consequence to the fetus. Patients
with active disease may require steroids during the pregnancy
to control symptoms and protect maternal organs. In addition,
steroids are found only in low concentrations in breast
milk, and hence, can be used by breast feeding mothers.
Azathioprine (Imuran) and anti-malarials like Plaquenil
usually will be discontinued during pregnancy unless absolutely
necessary. Salicylates, non-steroidal anti- inflammatory
drugs, Gold, Methotrexate, and D-Penicillamine are absolutely
contraindicated in pregnancy. They are associated with
fetal defects and fetal mortality. Male patients on Methotrexate
are advised to discontinue the drug three months prior
to attempting conception and females are advised to wait
one ovulatory cycle prior to attempting conception. Breast
feeding is contraindicated with all of these medications.
Very few medications are permissable during pregnancy,
so before taking any medications, either prescription
or over-the-counter, please ask your physician.
In
summary, every pregnancy and every patient's disease is
unique. It is highly advised that, prior to planning a
conception, you discuss it with your doctor. This will
enable you and your physician to take the appropriate
steps to allow for the most successful pregnancy outcome.
Since
writing this article for Rheumors, Dr. DiIorio has become
the proud mother of a healthy and beautiful baby boy!
QUESTION
& ANSWERS SECTION
| Q. |
I
heard recently that Tylenol can cause serious damage
to the liver and kidneys. Should I be concerned? |
| A. |
Tylenol
is the most commonly sold brand name of acetaminophen
and has been available for the treatment of pain
for over 30 years. Although commonly regarded as
a very safe medication, it , like all medications,
can be associated with adverse effects in some people.
A recent study published in the New England Journal
of Medicine indicated that patients taking Tylenol
on a regular basis were twice as likely to develop
kidney failure as those who did not take the medication.
It has long been suspected that chronic use of simple
analgesics might be associated with kidney damage.
The present study is considered by many experts
to be flawed in several ways. Also, the reported
risk in absolute numbers is small, making the risk
to an individual minimal when taking the medication
properly.
A
second concern about Tylenol is related to abnormal
liver functions. It is known that overdosing on
Tylenol (more than 4,000 mg daily), can be associated
with liver function disturbance. The risks are further
enhanced by prolonged periods of fasting as well
as by excessive use of alcohol. No patients who
followed the dosing recommendations on the label
(maximum of 4000 mg/day-ie 2 tablets 4 times/day)
developed liver abnormalities.
In
a practice such as ours, where the majority of our
patients are on pain medications, many of whom are
on Tylenol, the type of kidney or liver failure
described in the recent reports has not been seen.
Over the years, the practice has seen in excess
of -2- 20,000 individuals with arthritis. Overall,
the use of Tylenol for control of pain or fever,
particularly in aspirin or anti-inflammatory sensitive
persons, is probably significantly safer than the
alternatives.
Tylenol
(acetaminophen) remains a safe and effective drug,
however, it is important to remember that all drug
therapy is associated with some risk. The lesson
to be learned from these studies is twofold. First,
dosing recommendations must be adhered to even on
presumably safe over-the-counter medications, and
secondly a frank discussion with your doctor should
be held before starting ANY chronic medication.
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| Q. |
I
have been told that I have a positive rheumatoid factor.
Do I have rheumatoid arthritis? |
| A. |
Not
necessarily. The rheumatoid factor is a substance
in the blood of eighty-five percent of patients
with rheumatoid arthritis but six to ten percent
of older patients will have a low titer rheumatoid
factor even though they do not have this illness
. The diagnosis of rheumatoid arthritis is made
after a thorough history, physical examination,
appropriate xrays and other laboratory studies have
been done. Your physician will use the criteria
set up by the American College of Rheumatology to
diagnose rheumatoid arthritis.
The
above two questions point out that the diagnosis
of rheumatic disease or any other disease, must
meet certain criteria which are present in the history,
physical examination and laboratory evaluation.
Some of the rheumatic diseases are quite similar
and frequently the physician will need weeks, months,
even years to clarify the diagnosis.
Norman
S. Koval, M.D.
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| Q. |
What recommendations do you have regarding estrogens
once the woman reaches the menopause? |
| A. |
Estrogen
therapy has long been used to control post menopausal
symptoms such as hot flashes. Additionally, it is
very helpful in retarding the progression of calcium
loss from bone that leads to osteoporosis.
There
has been some controversy that estrogens may promote
the development of breast or uterine cancer. Studies
relating to breast cancer are equivocal, some showing
an increased risk, others showing a decreased risk.
The risk of uterine cancer can be eliminated when
estrogen is given with progesterone. The combination
of these two hormones will cause a woman to resume
her menstrual flow however.
Just
recently, an important study showed that women treated
with estrogens after the menopause had a very significant
decreased risk in the development of heart disease
and stroke. It is now apparent that the increased
risk for cancer is very significantly outweighed
by the decreased risk for stroke and heart attack,
thus, we are strongly recommending the use of estrogens
in women who reach the menopause unless there is
a known significant risk factor for the development
of breast cancer. It is felt that the cardiovascular
benefits and the benefit to bone overshadows the
relatively small risk of breast cancer and improves
the woman's overall chances for a long healthy life.
Herbert
S. B. Baraf, M.D.
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STUDY
UPDATE
by Evan L. Siegel, M.D.
The
drug study section of Arthritis and Rheumatism Associates
has been very active in recent months. This section of
the practice allows access by our patients to new and
exciting drugs that are under investigation for the treatment
of rheumatic diseases. Participants in these studies not
only get the rare opportunity to use medications not yet
available to the general population, but also undergo
intensive evaluation/ re- evaluation of their ailment,
careful documentation of their progress, and the opportunity
to learn about the intricacies of how a new drug makes
its way to the marketplace. Participation in these investigations
is cost free. Our physicians and study coordinators are
constantly reviewing new protocols to determine which
ones would be best to offer our particular patient population.
The following is a partial listing of the study protocols
currently available to patients meeting entry criteria.
Osteoarthritis
(degenerative arthritis) of the knee: Patients with osteoarthritis
of one or both knees may qualify to participate in a study
of a new topical cream applied directly to the painful
joint. Earlier formulations of this product have already
been proven effective in controlling pain and improving
mobility, with a minimum of side effects.
Osteoporosis:
We are currently enrolling post-menopausal women with
osteoporosis with or without previous fractures in a protocol
to evaluate Raloxifene, a new drug with -2- estrogen and
anti-estrogen like properties. We expect this drug to
be effective in stabilizing or improving bone mass and
decreasing fracture risk. We continue to evaluate, but
have completed enrollment of patients in the Tiludrinate
and Risedronate osteoporosis protocols.
Tennis
Elbow: Patients with as yet untreated tennis elbow
(lateral epicondylitis) of less than 28 days duration
may qualify for enrollment into a study to evaluate the
efficiency of a skin patch impregnated with anti-inflammatory
medication placed directly over the elbow. This patch
has already met with great success in Japan, and is being
introduced in this country.
Rheumatoid
Arthritis: Patients with established Rheumatoid Arthritis
may qualify for entry into one of two protocols involving
new disease modifying agents for which we expect to begin
enrollment in Spring of 1995.
A quarterly
publication brought to you by Arthritis & Rheumatism Associates
Norman S. Koval, M.D. Herbert S. B. Baraf, M.D. Robert L.
Rosenberg, M.D. Evan L. Siegel, M.D. Margaret Dieckhoner,
Editor © 1990 Arthritis & Rheumatism Associates
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