You fucking moron! Do you have any idea how hard I worked to get this guy to take this stuff in the first place? Do you know how long it took, how many visits over how many months of teaching, explaining, describing, convincing, persuading, cajoling and begging to get him to agree to even try this medication in the first place? Are you even aware of evidence-based guidelines that recommend statins for patients with diabetes and CAD?Yikes. And this is the much-abridged, family-friendly version. I must say that when I discuss my plan of action with the patient I am aware that discontinuing a cardiac med can have consequences and I tell them that if the pain does resolve, that some substitute will have to be found. But what does the patient hear. Statins =pain. If the pain goes away it must be a battle to convince them to try another. If the pain resolves only somewhat, the patient may still attribute it to the statin and then what are the chances of trying another. In this scenario, the statin is stopped even though it's very unlikely to be involved at all. But still, what choice is there. The only diagnostic test is to stop the statin. So I need a plan B. I won't stop the drug or even suggest it. I'll inform the primary physician that it could be the cause and that a trial of discontinuation is warranted. Maybe his/her notes clearly demonstrates that the myalgia preceded the statin. The primary care physician also knows better how critical the statin is in the big picture. Maybe myalgia is a price worth paying. Certainly he/she will be in a better position to discuss this with the patient. Maybe then I can avoid the wrath of #1 Dinosaur and his like-minded friends. Hmm. Common sense or cowardice?
Just got back from NYC and saw The Phantom one more time. The title reminded me about a question I've been considering for quite some time about total knee replacements. Is it possible to have phantom knee joints post-op? This question first came up after a recent case. A 70 year old patient of mine had been followed for run-of-the-mill osteoarthritis of the knee for some time. After a couple of years we had tried, with varying success, all of the usual medical treatments. When they finally failed, and rest pain started to become a problem we agreed that surgery was required. Ortho was consulted and a total knee replacement was performed rather uneventfully. Unfortunately, it was altogether too uneventful, in that the pain in the knee did not improve at all, not a bit, neither post-op nor four months later. At each visit the patient told me, rather accusingly, that the pain was exactly the same. On further questioning, the "exactly" she referred to was not just the intensity but also the quality of the pain. Constant but increased with weight bearing,primarily in the medial aspect of the knee. Now I know that post TKR pain is not that unusual, but I would think that hacking out the entire offending joint should at least modify the pain somewhat. Infection, incision, prosthesis, soft tissue or muscular pain could all contribute, but surely the pain would be at least somewhat different. One possiblity is that the original pain was not from the knee in the first place. I looked for soft tissue explanations and investigated the possibility that this was referred back or neuralgic but with no success. Granted it is difficult to completely rule out some referred source or peripheral neuralgia. In the end we did achieve partial relief with gabapentin but I'm still not sure what I am treating. The fact that the pain was identical made me wonder whether TKR can have phantom joint pain. It doesn't seem inpossible that a chronic persistant joint pain syndrome might have a central representation that persists after surgery. There is at least partial support in that some rheumatoid patients do continue to suffer from joint stiffness in their amputated limbs. This confirms that neuroplastic changes in the CNS can occur secondary to chronic arthropathy, and so it's not such a great stretch to suggest that the joint removal alone could be associated with a phantom joint. But how to prove it?
In 2007 it appears that rheumatologists rocketed ahead of the endo guys and left the geriatric types in our dust as we jumped to third worst pay in medicine. We may even see, within the next decade, the day we match the pay the GI guys made in 1998. Keep up the good work!
Just got back from the Laurentian Conference. As usual, it was a pleasant combination of rheumatology gurus (Paul Plotz), Canadian stars (Janet Pope), and us. The theme of the meeting was "Between skin and bones" and concentrated on scleroderma and inflammatory myopathy. Janet Pope, noted scleroderma researcher, started her talk with the title "Scleroderma: We've come a long way!", and ended her talk with "The outlook is promising". Sandwiched between those statements was no sign of progress and very little hope. In fact, since the last time I heard her speak a couple of years ago, she seems to have dropped cyclophosphamide as a treatment, and is suggesting that methotrexate may, if you look at the evidence in just the right way, have some effect. I guess, though, in scleroderma terms, that's progress. On the other hand, if energy and positive thinking play any part in scientific research, I'm glad Dr. Pope is involved as she provides megadoses of both. On the bright side, well at least the not so dark side, is the canadian scleroderma registry. Started up by Dr. Baron and his associates across the country, we finally see some concerted effort to tackle the problems presented by small numbers of patients. Not much news yet, but maybe this is what's getting Dr. Pope so excited.
Dr. Plotz presented a short history of the study of autoimmunity and his own personal perspective. It was interesting to hear from someone who has an opinion on the big picture, somebody with over forty years of thinking of the big picture. I won't even try to summarize his talk but would suggest you give him a listen if you ever see him giving a similar talk in future meetings. His second talk was on myositis. No groundbreaking news here, after all, he shaped the way we all treat the disease. He suggested though, that infliximab doesn't look great, that cellcept is gaining popularity despite a lack of evidence (and didn't sneer at its use without such evidence). It was nice to see him give exact treatment regimens, right down to the mg/kg. Probably the most interesting statement was that he treats Inclusion Body Myositis, not because he's absolutely convinced that it is treatable, but because, unlike neurologists, he finds it hard not to do something. So after more than forty years of NIH level research, a pillar of evidence-based medicine, Dr. Plotz treats patients because he feels bad for them. Gotta love that.
Being in ski-country reminds me of this video I saw of Jennifer Heil, Canadian mogul ski champion. Besides being an impressive exhibition of joints in motion, I think researchers might well look at this as a possible human model for the development of osteoarthritis of the knee.
Finally some R&R, rest and rheumatology. I'm off to the Laurentian Conference. This is a local conference that attracts all of the rheumatologists from Quebec and a few that wander in from neighbouring provinces. It's a neat mix of french and english rheumatologists escaping to the mountains to enjoy the spring weather. (Spring in the Laurentians is defined as the period that starts with skiing without neck warmers and goes until the blackflies arrive). The organizers almost always come up with good speakers and the intimate setting allows you to corner some of slower moving ones for questions during coffee break. It also seems that the mountain air, resort town feel and of course, Quebecois hospitalité, seems to loosen up even the biggest names. Can't wait.
If there was one disease where we could use a break it would be Lupus. Well okay, scleroderma too, you're right. And I think just about everybody had high hopes for rituximab, B-cell depletion in SLE seemed like a gimmee. The results are in, however, and they couldn't look much worse. In a tear-stained release by Genentech we find that rituximab did no good during a 52 week trial of non-nephritic lupus patients. It didn't reach either of it's primary endpoints nor any of it's six secondary endpoints. The trial appears pointless. To be optimistic, however, there is still an ongoing trial in lupus nephritis. Don't hold your breath. Of course, there's always scleroderma.