11522 NE 20th Street, Bellevue, WA 98004
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January

NEWS BULLETIN produced by Sue Romanick MD PLLC

SOME OF THE NEWEST DEVELOPMENTS FROM THE American College of Rheumatology ANNUAL MEETING
This is an exciting time in the field of arthritis, pain and autoimmune disorders (rheumatology). Research is a dynamic force in rheumatology. Never before has there been such optimism in restoring patients back to health and preventing disease!

In this bulletin, I would like to summarize some exciting developments in this field. Many patients would like to understand their conditions more fully and have some control over progress. Knowledge is power and we believe that we can empower our patients through what we teach patients in our clinic about their individual health. We are excited that the field of medicine recognizes the importance of lifestyle, diet, exercise and supplements in addition to conventional medical therapies.

DIET AND THE DEVELOPMENT OF ARTHRITIS
What you eat may affect how you feel. For some people, choosing certain foods can affect how much joint pain they have. Although some foods can be directly related to the development of autoimmune conditions (such as alfalfa consumption leading to the development of symptoms usually associated with "lupus"), other food groups such as gluten-containing foods (eg. wheat, barley, rye and even spelt) or dairy products can lead to pain flare-ups in autoimmune conditions associated with neck or low back pain, unilateral joint swelling, certain skin conditions and even eye inflammation. What's the link? While we don't know for sure for each individual, it appears that your genes influence your vulnerability to developing certain conditions which alone may not cause disease but further require exposure to additional factors in the environment which might include bacteria (or even pieces of bacteria), proteins or substances in food, environmental chemicals, even a lack of certain substances (such as vitamin D!) and even stress! To get back to diet, it is possible that certain foods cause irritation (inflammation) in the gut making it harder to separate bacteria (bad bacteria and possibly some types of good bacteria which reside in the gut) from the body's defense system which circulate to, or reside near, the gut walls. Even more exciting is the notion that the precise timing of when this type of contact has occurred in the development of the individual (including exposures in the newborn period where even the delay of one day could make a difference!) could be very significant!

BACK OR NECK STIFFNESS OR PAIN?  CONSIDER THAT YOU MAY HAVE A SPONDYLOARTHROPATHY!
In our clinic we have seen a shift in the number of patients complaining of neck or back pain (or stiffness). In fact, we are seeing a lot more than we used to! Patients with neck or back issues may have been told that "it's simply that you're getting older" yet they know it seems to early for the stiffness in the morning, perhaps creakiness in the joints, and aches and pains that just don't want to quit! As it turns out, patients are right on. It's NOT simply aging but a problem with a healing process "gone wrong".  In fact, the body's own immune system is amplifying the problem, instead of helping the body. So, what are the red flags for one of these conditions (spondyloarthropathies)? How might you figure that you could have a spondyloarthropathy (okay, let's call it a "spondy" for short!) ? Here are ten points to keep in mind: Neck or back stiffness for at least 1/2 hour upon awakening. Back pain that is worse if you have to sit still for awhile, better if you can get up and move around. A tendinitis like in the shoulder or elbow (or even the back of the heel) that just hangs on. Or pain in the bottoms of your feet when you take those first few steps in the morning. Or having had a finger or toe swell like a sausage at some time.

Remember that these symptoms do not have to all occur at the same time. Other red flags include feeling better with anti-inflammatory medications which suggest that true inflammation (this is bad) is present, the patient (or even a relative!) having a history of a skin condition called psoriasis, or a bowel condition leading to chronic diarrhea such as ulcerative colitis or Crohn's disease. The generalized stiffness should not be confused with fibromyalgia which is totally different from a spondyloarthropathy and requires a different kind of treatment. A spondyloarthropathy can be associated with excessive warmth or swelling of the joints as well as abnormal blood tests. In fibromyalgia, you don't characteristically see any inflammation such as if you were to look at body tissues which are painful, under a microscope. There are a few subtypes of spondyloarthropathies and our staff will help you figure out what precise diagnosis you have. In fact, we'll also tell you if you have additional diagnoses. And, by the way, both the spondyloarthropathies and fibromyalgia can flare under stress. 

VITAMIN D
There has been a lot of excitement about this vitamin in the past year. Initially believed to be important mostly for strong bones and teeth, we now know that this vitamin can directly help the immune system. In fact, there is some evidence that vitamin D has been important in fighting certain infections as well as influencing whether certain autoimmune disorders develop. In certain geographical locations where the population has less exposure to sunlight, conditions such as multiple sclerosis and sarcoidosis may be more prevalent. Sunlight can be helpful by helping the body to make active vitamin D, but sunlight can also lead to several skin cancers. Let us evaluate whether you may be at risk and we’ll help you decide whether supplementation with vitamin D makes sense.

SMOKING
There have now been associations between the development of several autoimmune conditions (such as rheumatoid arthritis and scleroderma) and smoking. In addition, smoking has been linked to chronic back pain. We’ve known all along that smoking is associated with many cancers as well as chronic lung disease. When I asked a prominent lung specialist about patients who have trouble quitting “cold turkey,” he answered that you benefit from each cigarette not smoked. So, start cutting down even if you can’t cut it out (yet) altogether! You’ll be helping your body.

SLEEP and STRESS
Remember the adage: “Early to bed, early to rise, makes a man/woman healthy, wealthy and wise”?  Well, there is wisdom in that saying! We now know that pain as well as conditions such as rheumatoid arthritis and fibromyalgia can be directly affected by sleep quality. In fact, there is evidence that poor quality (or quantity) of sleep can be associated with coronary artery disease and sudden death. We will work with you to learn how to optimize your sleep quality.

RHEUMATOID ARTHRITIS
We have seen dramatic improvements in patients with rheumatoid arthritis since the biologic agents were made available. We can prevent the crippling effects of this form of arthritis. Even more exciting, the increased risk of heart disease associated with rheumatoid arthritis appears to lessen with the use of certain of these agents. At the same time, you should make sure that your cholesterol and blood pressure are optimal. We will gladly work with your primary care physician on these issues. Finally, it is important to make sure patients beginning biologic agents are screened for tuberculosis and hepatitis. Because these agents can affect the ability of the body to fight infection, we recommend several vaccines before beginning these medications. These may include influenza, pneumococcal and possibly meningococcal vaccines, depending on the patient. If you are on one of these agents you must inform your doctor if symptoms of infections such as fever, cough or shortness of breath develop.

AUTOIMMUNE DISORDERS
Research is demonstrating subtypes of disorders rather than blanket categories. Previously, we knew that lupus comes in different forms. We now know that scleroderma similarly has approximately five subtypes. Thanks to research, new tests are available to help not only with diagnosis but to assist health providers in being able to give you an idea as to prognosis. In some of these conditions, the kidneys or lungs can be affected. In others we are concerned that ability to concentrate, mood or even serious complications that could lead to stroke can occur. Therefore, keeping your doctor informed about new symptoms is very important. Remember, the more we learn about these diseases, the more we realize the importance of considering the patient as a unique individual. We do not use a “cookie-cutter approach” with our patients!

FIBROMYALGIA
Fibromyalgia is a chronic pain syndrome associated with generalized body pains, disordered sleep, fatigue and a list of other possible symptoms including headaches, irritable bowel syndrome, problems with concentration and even with memory ("fibrofog"). This condition is common, especially in women, and offers further evidence of how the mind and body are truly connected. We feel it is important to look for conditions that can mimic its symptoms, including thyroid problems, vitamin D deficiency, spondyloarthropathies, chronic hepatitis B or C, and medication side effects. We consider the patient’s lifestyle and even past stressors. A wellness approach includes diet, appropriate supplements, exercise, sleep modification and non-addictive medications. Fibromyalgia can accompany other arthritic conditions. We are always dismayed when patients have been given a diagnosis of fibromyalgia and one or more other conditions, such as spondyloarthropathy (see separate section, above) were missed. In our clinic we help patients to understand and manage their own individual condition of fibromyalgia. To help with reasonable expectations we advise patients that 30% of the answer for appropriate fibromyalgia treatment involves medication or medication alternatives, whereas 70% of the treatment will depend on lifestyle changes including sleep hygiene, diet, appropriate exercises and counseling when appropriate.

GOUT
This condition is a common form of arthritis in men. Usually it presents as intense pain and swelling in one joint. It was known as the disease of emperors in Byzantine times. We now know that not only alcoholic beverages but also certain artificial sweeteners (such as corn syrup solids) can lead to a painful attack. Lifestyle, medications (some of which can contribute to an attack) and even weight must be considered on an individual basis. New research links gout with heart disease and high blood pressure. With a healthier lifestyle, you can enjoy a healthier outlook!

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