I was just reading a post from Dr RW about the need for stethescope skills and it reminded me of one of my previous posts from way back in 2008. It was one of three in a series concerning my S3 skepticism. It is called, The S3, Or Why I Became a Rheumatologist.
I was an R2 doing a mock oral exam with my senior, a third year resident who I knew was going into gastroenterology at the end of the month. The patient was a sweet elderly lady who had difficulty giving her complete history because she was very short of breath. The exam was fairly simple, an obvious case of congestive heart failure. A snap right? Should have been, but there was always the tricky question of that third heart sound, the S3. I had heard of the mythical entity, since the earliest days of medical school. During our first bedside lessons in second year we had a cardiologist who patiently let us all listen to the 'best' S3 he had heard in ages. We all listened intently, trying our hardest to parcel out that little lub or dub or whatever was supposed to be there. After we had all had a turn he asked me if I had heard it. Perhaps foolishly, I was after all only in second year, I admitted that I had not, even though it was the best he had heard in ages. Perhaps stiffened by my admission, every one of the six students admitted the same. The cardiologist looked at us with something between contempt and disgust and said, "what are you all bloody deaf?" He told us to listen again and promptly left as we fiddled with our stethoscopes. I then knew that the S3 must exist.Over the next few years I learned the the S3 was a sign of congestive heart failure, appeared in almost all charts of CHF patients. Apparently everybody could hear the damn thing, on an amazingly regular basis. Everybody, that is, except me. I had never, ever, ever, heard an S3. Sure I wrote it in the chart. Almost any patient with heart failure got a big S1S2S3 for heart sounds, but only because I knew it had to be there. I never sought help for my S3 handicap, though psychologically my stethescope became an instrument of shame. Oddly though, it didn't seem to have much impact on my day-to-day functioning. Occasionally a more senior resident would disagree with my assessment, but I was never given a hard time about it. As I got more experience though, I started to see signs that maybe I was not alone. My dirty little secret seemed to be shared by more than a few of the housestaff. I noticed that my juniors would often mention the S3 during discussion of the case with the same learned assurance I gave, but when I would ask them how sure they were, or if we examined the patients together, they would often add qualifiers. "Well at least I heard it this morning when she was worse, I'm not sure about this afternoon." Soon it seemed that rather than being a dirty secret, it was more like a secret society. A society of S3 deniers. With time, it began to seem like a rather large secret society, but with no membership list to prove it.So back to my oral exam. My R3 came in with a real seriousness that took the mock out of mock exam. I rolled through the history and physical right up to the heart sounds where there must have been a just-discernable pause where I might have hesitated a fraction before lying with conviction about the presence of the CHF-related S3. I then demonstrated all the signs I could think of to prove that the patient was in fact in heart failure, a heart failure so classical that surely the S3 was a given. The senior resident raised an eyebrow and slowly pulled off her stethescope that had been draped over her neck. She leaned over the patient and listened for what must have been a half-hour or so, flipping from bell to diaphragm a couple of times. Then she straightened, looked me in the eye, and said, " yup, a loud S3". A tiny smile then formed in the corners of her mouth as she wandered out of the room and into the saner world of gastroenterology where borborygmi are borborygmi, loud and clear. No secret handshake, no codewords exchanged, but no doubt either that I had just met a fellow member of the society of S3 deniers.
I won't pine too long over the disappearance of Aspirations of a Joint Doc, because there has since been other additions to the rheumatologic blog scene. Bruno Oliveira of All Joints Considered was interesting. Being part of Medscape allowed for a wide distribution and he did attract many comments. Some were a little out of the ordinary, such as 'I have seen some cases of sarcoidosis.In our part of the world chikungunya." Unfortunately, Dr Oliveira seems to have taken a break as well, not posting since June 2011 as far as I can tell. The Doctor's Rheum started up in 2009, not long before I bowed out. Her blog talks rheumatology and food . Good blog but makes me snack while I read. Post frequency has waned a bit this year, but you never know .
So the ancient blogs of two to three years ago seem to be struggling. What about today. Anything new out there?
Ronan Kavanagh blog. Holy shit have you seen this site? Two years off line and this guy makes me feel like Rip Van Winkle. A beautiful home page that invites patients to make appointments and get script renewals as well as patient information videos. A blog, active Twitter involvement. I wouldn't be surprised to see him singing a few tunes on MySpace. Sheesh, may be time to pack it before I embarras myself.
Dr Philip Gardiner's Blog was also started this year from what I can tell. Definitely a quality over quantity blogger with infrequent but very well thought out and researched posts. A blog for the thinking rheumatologist.
Dr Irwin Lim posts at Connected Care, a blog for the BJC clinic down under. He also has other bloggers from the same clinic contribute from time to time. Posts seem to be aimed more at patients but it's always interesting to read the treating philosophy of other rheumatologists.
La Rhumato is more of a patient information site and a good one at that. Dr Francis Berenbaum seems to have more of a Twitter presence. Great information for French patients, something I can take advantage of.
Rheumatologe, a blog by Dr. Lothar Kirsch is a wild ride through the world of rheumatology, travel, language and Haiku. Sometimes all in one blog post. As a bonus you get to say things like "Gelenkhypermobilitatssyndrom".
Well that's about it. I'm sure there are others out there, I've just started re-aquainting myself with the community. It's great to see that there are more bloggers and tweeters every year. I'm looking forward to joining the conversation. Off to brush up on my Haiku skills.
As the rheumatology hoards board post-ACR flights, it may be wise to consider their risk of an in-flight gout attack. The following is a discussion on an internet medical advice website called eHealth forum.
Is there any connection between long haul flying and gout attacks?
Certainly. Long flights can trigger gout attacks whether you fly high altitude or nap of the earth.
The health of the joints is maintained by healthy joint (synovial) fluids. There is nothing like blood vessels to circulate synovial fluids in the joints. The old fluids are squeezed out through the spaces between the cells in the joint capsules (synoviums) when we carry weight or exercise. The fresh fluids are produced by synovial cells when stimulated by exercise. That is why our joints feel better after walking, running, and other exercises.
In a long flight there is not enough exercise for a person to keep the joint fluids "fresh". This results in deterioration of joint fluids and joint tissues, which lowers the ph in the joints, causes the shedding of the coatings to expose the raw urate (msu) crystals, and triggers gout attacks. The same can occur when we sit down for too long anywhere. It's also part of the reason why gout attacks occur most often during the sleep hours. It may also be the reason why geniuses are more prong to gout -- unlike common mortals who run around for daily choirs, the geniuses sit down day and night keeping their brains busy but not their joints.
To prevent gout attacks and other arthritic discomfort, drink a lot of fluids, alkalize yourself, walk around often, and do some flying yoga in-flight. They can be helpful.
So, given that rheumatologists are clearly geniuses, and likely highly under-alkalized, it may be wise to tuck an indomethacin or two into the overhead.
My first blog was in April 2007, a time when rheumatology blogging was the domain of one pioneer,Carpus, of Aspirations of a Joint Doc. There may have been some rheum blogger associated with an organization or group blog, but Carpus was the only personal blogger that I ever found. His/Her blog was a mix of rheumatology, politics and Harry Potter. Who could ask for more? I based my own blog on his (I really do think it was a he) and was hoping the community would build to the hundreds, why not thousands. After all, there were already about 500,000 blogs registered at that time. Unfortunately Carpus did not keep up the blogging. His last post talked of getting a job at UUMC. Not sure where that is, but apparently it is not conducive to blogging. Maybe the town didn't have internet yet. Possibly he was prioritizing his research or family, or perhaps he got bored. No idea but too bad. As I said, I styled my own blog after his, a mix of rheumatology with occasional commentary on other interests. I also blogged and still do blog anonymously. That is apparently less cool now and something I may have to reconsider. We'll see.
So Carpus, whoever and wherever you are. We know there are no more Potter books to distract you. Drop the ACR poster plans for a minute and crank up Aspirations once again.
Minocycline for scleroderma. That was my last post more than two years ago and it drew a scary amount of attention from a scleroderma support group. It was by far my most commented on post and some thought that the experience chased me off the blogosphere. Not so. In fact, that is what blogging is all about, or at least should be. Actually I paused to pursue another writing project, one that took a lot longer than I anticipated, and no , it was not a "Best of Rheumination" collection.
So I am back, if maybe not at full speed. I'll acclimatize myself to the many changes that have occurred during my sabbatical. New bloggers have appeared, which is exciting, but old ones have faded, hopefully only temporarily. Twitter and Facebook now rule, for better or for worse. I'll see where they fit in.
I'll cheat a bit as well. Since I have undoubtedly lost all of my readers, both of them probably, I am going to repost some of my previous work, the least time-sensitive stuff, to reintoduce myself to the world.
It's good to be back.
I'm an ordinary clinical rheumatologist. Not an academic, not a researcher, just a run-of-the-mill rheumatologist who practices what I hope is good, standard rheumatology. This practice does not include treating scleroderma patients with antibiotics. Should it?
After a post of mine bemoaning the lack of treatment options for scleroderma patients, my site was deluged by visitors and commentors originating from a group I had not heard of before, the Road Back foundation. In respect to scleroderma, and I believe other diseases, the group believes that antibiotics, an in particular, minocycline, are an unrecognized, underused, but highly effective treament. The comments have ranged from the informative, to the pleading, to the accusatory.
From what the commenters and their links have provided, I think the major points are:
- Dr D Trentham, from Boston, published a research letter in The Lancet in 1998 where he showed that 4 of 11 patients were in complete remission after 1 year of minocycline treatment. 2 others improved and 5 did not complete the study.
- Since the publication of the study, many (?hundreds) have received the same treatment with great success.
-Minocycline is still not an accepted treatment because, among other things, doctors prefer using expensive new drugs, and no studies are being done on minocycline because, being past patent, there is no financial advantage in studying it. Other doctors are just ignorant.
I'm going to have to rebut a few of these claims here, but we'll return to whether I should be using antibiotics further on. First of all, minocycline is a very interesting molecule. It pops up in rheumatology all the time, not really for it's antibiotic properties, but because it does seem to have some immune modulating activity as well as metalloproteinase inhibition, which might be useful in preventing cartilage damage. It also causes drug induced lupus, immunomodulation gone bad. So rheumatologists are not put off by the suggestion that minocycline might be useful, and in fact there was a period in the early nineties when, following a few positive studies, that we, me included, gave it a try. It didn't work, or at least, didn't work nearly as well as methotrexate, hydroxchloroquine and other drugs.
The study by Trentham, you must admit, was tiny by any standards. Eleven patients, five of whom didn't finish. Two stopped because of a scleroderma renal crisis. Yikes. Of the six that finished, however, four were considered to be in complete remission. Interesting. Two really bad results and four really good. Doesn't matter though because the study was so small it doesn't really mean anything. Here, commenters have suggested that no further research has been done because big pharma isn't interested, and doctors prefer studying new, profitable drugs. This may be true in some areas, but not for scleroderma. Two of the biggest, more recent studies in the area have been with methotrexate and cyclophosphamide. These are old-timer drugs. No money to mine here. Even more interesting is the fact that there has been further research into minocycline treatment, using the exact same protocol. This study was small as well, only 36 patients, and it too was not controlled. It had 12 patients drop out, ten because of worsening disease and found no significant improvement in the others. ( I could not find this article on the Road Back website) I didn't find any further, better studies, but this is understandable. Scleroderma is a very rare disease and if it is to be studied, most patients have to be registered in a few select studies. Given the above two studies, I gather the trail did not look promising enough to go further.
So in summary, doctors are not averse to minocycline, use it when studies support it, have in fact studied it in scleroderma even though there was no financial gain in doing so, and have not been impressed.
So what am I to make of the many testimonials claiming improvement and cure with minocycline? I'm not sure. I'm certainly intrigued. I would love for it too be true, as would all rheumatologists, but why does only one rheumatologist continue to promote it. There have been other stories of stubborn scientists with whacky ideas that have subsequently proven true, think H pylori or prions, but why haven't we seen more evidence coming out of Boston if there are so many dramatic results. Until rheumatologists, scientists all, see something more substantial than the Lancet study, minocycline will probably remain nothing more than a very interesting molecule.
PS: If anyone is aware of more data, published or not, coming from Dr Trentham's work, I'm all ears.
Been to Vancouver?
It used to be that a trip to Florida was a big deal, and a vacation in Europe a once in a lifetime occurrence. No longer. Now it seems that every week I hear of patients packing up and flying off to climb Kilimanjaro or trek to Machu Picchu. There has been a recent surge in people heading off to Thailand and Vietnam. All very exciting, but it seems few ever consider their medical condition before they book their exotic voyages. They're are often disappointed and even mad at me when I suggest that more first-worldly destinations might be preferable. Not long ago I had to convince a young woman who had just started on cyclophosphamide and high dose prednisone for a Wegener's vasculitis that Laos was not the optimal travel destination for her. Three days later she called back to say he was going after all because he was feeling much better on the prednisone.
There are many reasons for her and other rheumatological patients to be cautious in their globetrotting:
First of all, you are much more likely to get sick in a third world country. 30-50% of travelers to these places develop gastroenteritis and the risk is highest amongst the immunosuppressed . Even simple meds like proton pump inhibitors for reflux can increase the risk. There are also many other nasty bugs out there, all more likely to infect patients on immunosuppressors.
You can't get all the vaccinations necessary if you are taking biologics or other immunosuppressors. Yellow Fever, for example is a live vaccine and therefore contraindicated. Fortunately, many countries deny entry without these vaccinces, preventing immunosuppressed patients from even getting in.
Tuberculosis. As anybody who has taken a biologic knows, TB is a big concern and all patients are screened before treatment is started. If their PPD test is positive, we treat them before starting. This cures the infection that was there, but doesn't prevent a new infection from occurring, something that is a lot more likely to happen in a third world country.
If you do get sick, what kind of medical care is available. I have no idea what the situation is in the vacation regions of Thailand. It may be fine for all I know, but what I have noticed is that the traveling patients of mine don't know either.
Even if there is medical care available, who's going to pay. Some of my patients aren't aware that their insurance has specific clauses concerning prior illnesses. Here, most insurances won't cover your illness or complications if there has been any modification in therapy in the three months prior to departure.
So now I include travel recommendations with my normal biologic blurb. Florida sounds nice. France is lovely. Been to Vancouver?
Dr. Jon Stewart
Strangely, immunology was put to good comedic use last night, and that's not something I get to say very often. Jon Stewart takes on Fox News, nothing new there. He suggests that Fox has detected a liberal pathogen at the other news stations, but that their reaction to it is over the top. They are producing way too many antibodies. Fox is the Lupus of News
Gout hurts. I've never had the mispleasure of an attack but it apparently feels as bad as it looks. Literature is rife with descriptions of the pain, but the most convincing I've heard to date came recently from a patient lying in the cardiac unit, foot red and swollen. "I came in with a heart attack, I was bayoneted in the Korean war, but neither compares to the pain I'm having in that foot!"