Raynaud’s phenomenon is a result of deficient blood flow in the extremities, in particular the fingers and the toes. It is a condition named after the physician who first described it, Dr. Maurice Raynaud in France. This condition classically occurs after exposure to the cold. At times, it may be persistent and individuals suffering from Raynaud’s phenomenon may have constant discoloration of the fingers and toes associated with pain, burning sensations and numbness. Cold exposure may be as little as walking through an air conditioned room or a supermarket or may occur after holding a cold drink from the refrigerator.

While Raynaud’s phenomenon may occur in otherwise healthy individuals, it is frequently a symptom of one of the rheumatic diseases. The rheumatic diseases in particular that are associated with Raynaud’s phenomenon include: systemic lupus erythematosus, scleroderma, Sjogren’s syndrome, rheumatoid arthritis and mixed connective tissue disease.

What happens in Raynaud’s phenomenon is that the blood vessel in the fingers or toes goes into spasm, usually for a short time, resulting in deficiency of blood to these extremities. As this happens, the extremities will change colors, first turning white when they are without blood, then blue when the blood that remains in the extremities becomes deprived of oxygen and finally red, as blood flow returns to normal when the spasm relaxes. At time, only one color may be distinguished by the patient as the changes may be very subtle. The course of events may take only a few minutes or may last for many hours.

In addition to exposure to cold, emotional stress can also cause spasm of the blood vessel. The symptoms of Raynaud’s vary depending upon the severity of the disease. In most individuals, they are relatively mild and are simply uncomfortable with exposure to cold. However, in more severe instances, the symptoms can persist and one may actually get ulceration of the fingers or toes and because of the deficiency in blood supply, gangrene may even set, with the potential to lose the involved finger or toe. If you think you may be suffering from this condition, it is very important to rule out the possibility of other pre-existing illnesses as mentioned, although in the majority of people, there is no underlying cause.

There are a number of ways to manage Raynaud’s phenomenon. Obviously, the first thing to do is to avoid cold exposure and this may mean wearing gloves or socks and limiting exposure to air conditioning, cold refrigerators, etc. Raynaud’s phenomenon is far worse in the cold northern climates than it is in Florida, as we do not have the cold extremes that so often provoke this condition. Smoking is absolutely contraindicated in this condition, as cigarette smoking can further cause spasm of the blood vessels and by smoking one is, in fact, adding insult to injury. It is also very important to try to be relaxed and to try to limit emotional stress and, in fact, one of the treatments for this condition is biofeedback training, which has been shown to help relax the blood vessels by being more relaxed. Other causes of vasospasm such as migraine headache medications and certain blood pressure pills should also be avoided in this condition.

There are certain medications that are now being shown to be very helpful in this condition. The calcium channel blockers, a new group of medications, initially introduced for the treatment of angina have been helpful in reducing vasospasm. The topical use of nitroglycerin ointment may also cause some vasodilatation and counteract the spasm. Finally, if all else fails and the symptoms are persistent and ulcerations are occurring, a surgical procedure called a sympathectomy may be done with some degree of success. Overall, however, people with this condition can usually control their symptoms by avoiding emotional upsets, avoiding cold, taking care of their skin and making sure they do not have any underlying rheumatic disorder.

Author: Norman B. Gaylis, M.D., F.A.C.P., M.A.C.R.

Of the more than 25 years that I have practiced medicine as a Rheumatologist, I have been asked many times “what is a Rheumatologist?”. When I give the explanation that “he/she is a specialist in arthritis and autoimmune diseases”, the question that is often asked is “why did I choose to become a Rheumatologist out of all the specialties in Internal Medicine’?”. I can honestly say that a recent article in the Sun Sentinel on the outcome of a patient of mine with rheumatoid arthritis has answered this question very simply.

The patient, Lucille, was first seen by me when she was in her mid thirties. She was a hairdresser at that time who presented to me with multiple painful swollen joints. She was unable to work either at home or in her occupation without severe pain and discomfort and essentially her life was falling apart.

After performing the appropriate examination and blood tests, the diagnosis of rheumatoid arthritis was made. Since that time, I have treated her with multiple medications. As we have discovered and made advances in different forms of therapy over the years, we have been able to provide Lucille with progressively more function, less pain and improved quality of life.

Lucille is an artist who went from being unable to grasp a paintbrush, to producing award winning art that is being progressively recognized more and more by the art community as extremely high quality work.

From my perspective, the few paintings that are hanging up in my office that she personally painted for me, are the answer as to why I became a Rheumatologist. It has always been extremely frustrating for me to hear people state that there is no treatment that will help patients with arthritis. There is also nothing worse than seeing a patient brought into my office with crippling disease who has been misinformed and has ultimately waited far too long to seek treatment. By the time I see them, there is very little that can be done for them.

The fact is that while there are over one hundred types of arthritis, some of which can be extremely devastating, in the majority of cases, I know I can effectively help relieve my patients’ pain and symptoms dramatically. This will allow them to have a very productive life with much happiness and pleasure. There is on the one hand, nothing more gratifying than to see someone who is crippled by inflammation of their joints becoming pain-free and more functional and conversely, nothing more frustrating than seeing someone being mistreated, not treated or misinformed.

We have reached a point in the treatment of rheumatic diseases that we truly have made breakthroughs with rheumatoid arthritis and various other forms of arthritis to an extent that I would not have dreamt of when I first started practicing rheumatology.

Obviously, all forms of treatment have risks and side effects and it is my job to balance the pros and the cons and to heal my patients and not to make them worse with my treatment. I can honestly say that the majority of patients, once they have given medications a chance and learn how to adjust their behavior, lifestyle and body habits to work with their medications. usually are very receptive and responsive to treatment.

I also strongly believe that the pleasure that I see in a patient’s family and friends by the smiles that appear as their loved one’s response becomes more and more improved is another very gratifying feeling. Thus, the answer to why I became a Rheumatologist does not need to be explained when this type of reaction is recognized.

My hope is that an example like Lucille is used to make people aware that we can help everyone with arthritis, no matter what type or to what extent it has affected their life. The statement that you “don’t have to live with arthritis,” is absolutely correct and more appropriate now than ever.

I hope to continue to be able to enjoy my chosen specialty, which unfortunately is needed to help patients reduce their pain and disability. It is also something that provides me with tremendous satisfaction in being able to change their pain and disability to situations that are in fact completely different and improved.

Please, if you have any concerns about your arthritis or believe that you have some type of arthritis, seek treatment, look for a Rheumatologist and find out what is available to improve your symptoms and the quality of your life.

Author: Norman B. Gaylis, M.D., F.A.C.P., M.A.C.R.

Dr. Norman B. Gaylis

One of the most common complaints that I am asked to treat in my practice is the early retired male or female patient who has waited his/her whole life to be able to have the time and opportunity to essentially play golf or tennis seven days a week. I mention these two sports as they are probably the most common sports that retired individuals either take up for the first time or start increasing their playing time dramatically upon retirement.

While the desire, the concept and the enjoyment of being able to play golf or tennis daily as opposed to only on the weekends sounds fantastic, in fact, it probably causes more people to have shattered dreams and depression rather than actually providing the anticipated pleasure that had been expected.

Unfortunately, our bodies as they grow older are not meant to play repetitive sports on a daily basis. Furthermore, most people who have been working for most of their lives do not have the skills or mechanics to avoid problems occurring when they start utilizing their body inappropriately on a repetitive basis. In golf, the most common problems that I see are tendonitis of the elbows and fingers, and pain from pinched nerve – like symptoms occurring in the neck and the back.

I can treat the acute inflammation with a combination of anti-inflammatory medications, local anti-inflammatory steroid injections, however, these forms of treatment serve only to reduce the acute pain. It is extremely important that the player/patient understands that they should try and stretch and warm up prior to their golf game. The older one gets, the more time should be devoted to stretching. In fact, spending more time loosening up and stretching would provide more benefit to swinging a golf club on the range. Right now, most golfers go straight to the range where they touch their toes twice, swing a few clubs and go out on to the course. Further important advice includes adequate rest after having had a flare up. This could be reducing the schedule from five rounds of golf a week to two, or most importantly, allowing adequate time for the body to recover from the time of the acute inflammation to the resumption of play.

I strongly recommend for my golf patients who have problems with their hands, that they consider built up club handles which reduce the pressure across the joints and the allow the grip to be firm without being harmful. I also recommend cardiovascular activities to increase one’s stamina and muscle tone, and as mentioned, performing stretching exercises on a daily basis in particular, before a round of golf is critical.

For my tennis-playing patients, their main complaints relate to their back and knees and to a lesser extent, their neck and shoulders. The recommendations are very similar in some ways to my golf patients. They need to reduce their regular repetitive action of one game and cross train by performing other activities such as swimming or biking.

This would be extremely beneficial. The choice of a soft clay court surface is far more desirable than beating ones joints up on a hard surface as we often find here in Florida. And finally, as in golf, building up the racquet handle and performing gentle range of movement exercises for the upper body allows the player to gradually increase their stamina and ability on an ongoing basis.

In summary, having more time to play may unfortunately result in less playing time due to injuries. To get the most out of ones retirement with regards to golf and tennis, one needs to approach it in a sensible and methodical fashion. There needs to be more emphasis on choice of equipment, improving cardiovascular and muscle tone, and stretching prior to playing, than on actually playing the game itself.

I hope this article will help some people get more fun out of life and I welcome your comments one way or another.

Definition

Paget’s disease of bone is a chronic disorder that typically results in enlarged and deformed bones in one or more regions of the skeleton. Excessive bone breakdown and formation cause the bone to be dense but fragile. As a result, bone pain, arthritis, noticeable deformities, and fractures can occur.

Causes

The cause of Paget’s disease is unknown. Recent studies, however, have suggested that the disease may be caused by a “slow viral” infection of bone, a condition that is present for many years before symptoms appear.
In addition, there is also a hereditary factor, since the disease may appear in more than one member of a family. The hereditary factor may lead to susceptibility among family members to the suspected viral infection.

Prevalence

Paget’s disease is most common in Caucasian people of European descent, but it also occurs in African-Americans. It is rare in those of Asian descent. Paget’s disease is rarely diagnosed in people under 40 but may occur in up to 3% of the American population over 60. Both men and women are affected.

Symptoms

Bone pain is the most common symptom. The pain may occur in any bone affected by Paget’s disease and often localizes to areas adjacent to the joints (e.g., hip pain may occur when the pelvis or thigh bone is involved). Headaches and hearing loss may occur when Paget’s disease affects the skull. Pressure on nerves may also occur when the skull or spine is affected. Deformities of bone, such as an increase in head size, bowing of a limb, or curvature of the spine, may occur in advanced cases. These deformities are due to enlargement or softening of the affected bones. Although Pagetic lesions may occur in multiple sites, it does not spread from bone to bone. When it is in the hip, however, damage to the cartilage of joints adjacent to the affected bone may lead to arthritis. Pagetic bone is susceptible to fractures with even moderate stress.

Diagnosis

Bones affected with Paget’s disease have a characteristic appearance on x-rays. Sometimes, the patient’s doctor is alerted to the possibility of Paget’s disease when a blood test reveals an elevated level of alkaline phosphatase. In this case, more specific tests, such as the bone-specific alkaline phosphatase test, x-rays, and bone scans, are done. After the age of 40, siblings and children of someone with Paget’s disease may wish to have a standard alkaline phosphatase blood test every two or three years.

Hearing Loss in Paget’s Disease

When Paget’s disease affects the skull and the temporal bone (the bone that surrounds the inner ear), severe and progressive loss of hearing may occur. This may involve both sides or one side predominantly. If the loss of hearing is progressive and due to Paget’s disease, treating the underlying Paget’s disease may slow or stop the progression of the hearing loss. Hearing aids may sometimes be helpful.

Exercise

Exercise is very important in maintaining skeletal health and is recommended for some patients with Paget’s disease. Before beginning any exercise program, it is wise to discuss the program with your physician, since undue stress on affected bones should be avoided. Exercise is also helpful in avoiding weight gain that may put additional stress on the bones and in maintaining the mobility of the joints.

Medical Treatment

Two classes of drugs are approved by the FDA for the treatment of this disease. Both classes of drugs suppress the abnormal bone remodeling that is associated with Paget’s disease:

1. Bisphosphonates. Bisphosphonates are drugs that inhibit abnormal bone resorption. Three bisphosphonates are approved in the U.S. for treatment of Paget’s disease: Alendronate sodium (Fosamax®), which is given in tablet form; Etidronate disodium (Didronel®), which is also given in tablet form; and Pamidronate disodium (Aredia®), which is given intravenously.
2. Calcitonin. Calcitonin is a hormone secreted by the thyroid gland that also inhibits abnormal bone resorption. Synthetic salmon calcitonin is taken by injection; the brand names for this drug are Calcimar®, Miacalcin®, and Osteocalcin®. At this time, Cibacalein® (synthetic human calcitonin), which is another drug approved by the FDA for treating Paget’s disease, can only be obtained if a physician requests it directly from the manufacturer. Talk to your physician about the treatment that is most appropriate for you.

Surgical Treatment

There are generally three major complications of Paget’s disease for which surgery may be recommended. The first complication occurs when Pagetic bone fractures. Surgical fixation of Pagetic fractures may allow the fracture to heal in better position. The second complication occurs when the patient develops severe degenerative arthritis. If medication and physical therapy are no longer helpful, and if disability is severe, surgery may be considered as an option. Total joint replacement of the hips and knees should be reserved for the most severe cases of arthritis, when other methods of treatment are no longer effective. The third situation involves bone deformity, especially of the tibia. The surgical cutting and realignment of a Pagetic bone may help painful weight-bearing joints, especially the knees. Medical therapy prior to surgery is recommended to decrease bleeding during surgery and to prevent other complications during and after surgery.

Quality of Life

Some of the same issues that affect patients with osteoporosis and other chronic disorders affect patients with Paget’s disease. There has, however, been little research on the impact of Paget’s disease on quality of life. A study by Dr. Deborah Gold et al. that was published in the Journal of Bone and Mineral Research entitled “Paget’s Disease of Bone and Quality of Life” (vol. 11, no. 12, pp. 1897-1903) addressed the psychological,
social, and physical consequences of Paget’s disease as well as the impact they had on quality of life. This study was based on previous studies of patients with another prevalent chronic skeletal disorder — osteoporosis -because many of the physical consequences of these two disorders are similar.

Results of the study suggest that a substantial portion of the individual’s perception of quality of life depends on his or her physical condition and disease state. The greater the illness-related problems, the worse the quality of life. Income and education enhanced self-reported quality of life as did excellent self-rated health and health that had improved from 5 years previous. From this study, the researchers concluded that Paget’s disease of bone affects the psychological functioning of its sufferers considerably, and this finding may have an impact on treatment of Paget patients. If physicians and other health care professionals are aware of the likelihood of psychological issues, they may tailor treatment plans to include psychological outcomes, which may ultimately improve quality of life for patients with Paget’s disease of bone.

Specialists in Paget’s Disease

Endocrinologists (physicians that specialize in hormonal and metabolic disorders) and rheumatologists (physicians that specialize in joint and muscle disorders) are internists that are generally knowledgeable about treating Paget’s disease. Also, orthopedic surgeons, otolaryngologists (physicians that specialize in ear, nose, and throat disorders) and neurologists may be called upon to evaluate specialized symptoms in Paget’s disease.

Dr. Norman B. Gaylis

What is osteoarthritis? How does it happen? Why you? How will it effect your daily life?

If you have recently found out that you have osteoarthritis or know someone who has osteoarthritis, these are probably some of the questions you have been asking. In this two-part article I would like to try and help you understand osteoarthritis and help you to learn to live with this condition. While this condition is not curable, it is very treatable, and there is no reason why your quality of life should significantly suffer due to this disorder.

Osteoarthritis is a name given to a condition that results when the smooth lining that covers the bones and the joints, namely the cartilage, starts to wear out. As the wearing away of the cartilage occurs, bones rub against bones and accounts for some of the noise heard when these joints move. Also, as a result of the friction, small spurs can form within the joints. As a result of this process, cartilage, which is a physiologic shock absorber, is destroyed and pain and discomfort on moving the joints starts to occur. In addition, muscles that support the joints may be come weak as people protect their joints by not moving them when the joints hurt.

It has to be remembered that osteoarthritis and its symptoms vary from individual to individual. The pain can be mild or very severe, and at times it may come and go. Some people may be disabled by it, while others may feel only a few twinges during damp, humid or cold weather.

The most commonly affected joints in osteoarthritis are those subjected to the most wear and tear during our lives, and this would include all weight bearing joints, in particular the hips, the knees and the feet. The thumb, which is the most actively used joint in the body, often gets osteoarthritis. There is a hereditary form that effects the joints at .the end of the finger, and this type causes the swelling and deformities of the distal knuckles of the hands. These deformities are called Heberden’s nodes. The spine, in particular the back and the neck, is also commonly affected by osteoarthritis and this is usually as a result of bad habits and bad body mechanics over a period of a lifetime. Bad body mechanics can include reading or watching TV in bed, sleeping on one’s stomach, wearing the wrong prescription lenses, being overweight, lifting and bending over without first bending at the knees.

In general, osteoarthritis develops slowly. One does not just wake up with it one day. While this condition is very prevalent in people over the age of sixty because of the wear and tear that their bodies have been subjected to, it can also occur in younger people for various reasons. In general, between 20 to 30 million Americans have osteoarthritis at this time.

As far as treating this disease is concerned, the important thing is to have it diagnosed and treated as soon as possible. It is important to try and eradicate any possible causative factors and to prevent long-term problems that can occur without therapy. The diagnosis should be established easily enough after a physical examination by someone who is an expert in the field of arthritis. At times, certain blood tests, which in fact in osteoarthritis are all normal, are needed to rule out other arthritis conditions. X-rays of the involved joints are usually suggested and if there is any fluid in the joint, this too can be examined and hell in establishing the diagnosis. Once the diagnosis is established, the goal? are to ease the pain and discomfort, reduce or prevent further disability and to help the patient to continue his/her usual activities as independently as possible.

It is important to recognize that the treatment does not depend or rely on drugs alone. While the anti-inflammatory medications and the aspirin-like drugs may be very important in reducing symptoms of inflammation, they do not correct the underlying problems that have caused the situation nor do they prevent the long-term disability that can occur.

Multicenter Study

Open-label, pilot protocol of patients with rheumatoid arthritis who switch to infliximab after an incomplete response to etanercept: the opposite study

For the complete article in PDF format, please click here: full article

Objective: To incorporate a new trial design to examine clinical response, cytokine expression and joint imaging in patients with rheumatoid arthritis (RA) switching from etanercept to infliximab treatment.

Methods: A randomised, open-label, clinical trial of 28 patients with an inadequate response to etanercept was conducted. Eligible patients received background methotrexate and were randomised 1:1 to discontinue etanercept and receive infliximab 3 mg/kg at weeks 0, 2, 6, 14 and 22, or to continue etanercept 25 mg twice weekly. Data were analysed for clinical response, serum biomarker levels, radiographic progression, MRI and adverse events.

Results: At week 16, 62% of infliximab-treated patients achieved American College of Rheumatology 20% criteria for improvement in RA (ACR20) responses compared with 29% of etanercept-treated patients. A 30.8% decrease from baseline in Disease Activity Score 28 was observed in patients receiving infliximab, compared with a 16.0% decrease in patients receiving etanercept. ACR20 and American College of Rheumatology 50% criteria for improvement in RA responses correlated at least minimally with intracellular adhesion molecule-1 and interleukin 8 in patients receiving infliximab. 38% of patients who were switched to infliximab showed reductions in Health Assessment Questionnaire scores (>0.4), compared with 0% of patients receiving etanercept. MRI analyses were inconclusive. Both drugs were well tolerated; 54% of infliximab-treated patients and 50% of etanercept-treated patients reported adverse events.

Conclusions: In this exploratory, open-label trial (with single-blind evaluator), patients were randomised to continue with etanercept or switch to infliximab. The small sample size of this hypothesis-generating study was underpowered to show statistical differences between groups. There was a numerical trend favouring patients who switched to infliximab, therefore warranting further study with a more rigorous design.

This study was carried out at several centers:

Daniel E Furst ¹, Norman Gaylis ², Vance Bray ³, Ewa Olech ⁴, David Yocum ⁵, Jeffrey Ritter ⁶, Michael Weisman ⁷, Daniel J Wallace ⁸, John Crues ⁹, Dinesh Khanna ¹, Gregory Eckel ¹⁰, Newman Yeilding ¹¹, Peter Callegari ¹¹, Sudha Visvanathan ¹¹, Jeannie Rojas ¹¹, Ronald Hegedus ¹¹, Laura George ¹¹, Khalid Mamun ¹¹, Keith Gilmer ¹¹, Orrin Troum ¹²

¹ Division of Rheumatology, Department of Medicine, University of California Los Angeles, Los Angeles, California, USA
² Arthritis and Rheumatic Disease Specialties, Aventura, Florida, USA
³ Denver Arthritis Clinic, Denver, Colorado, USA
⁴ Oklahoma University Health Sciences Center, Oklahoma City, Oklahoma, USA
⁵ University of Arizona Health Sciences Center, Tucson, Arizona, USA
⁶ Center for Arthritis and Rheumatology, South Miami, Florida, USA
⁷ Cedars-Sinai Medical Center, Division of Rheumatology, Los Angeles, California, USA
⁸ Wallace Rheumatic Study Center, Los Angeles, California, USA
⁹ Pronet Imaging, Los Angeles, California, USA
¹⁰ Department of Radiological Sciences, University of California Los Angeles, Torrance, California, USA
¹¹ Centocor, Malvern, Pennsylvania, USA
¹² Keck School of Medicine, University of Southern California, Los Angeles, California, USA

Dr. Norman B. Gaylis, following a holisitc approach, recommends all arthritis patients to review their diet and makes the following recommendations:

Do Eat

• All seafood
• All vegetables, including avocados
• Vegetable oils, particularly safflower and corn Margarine free of milk solids, such as Mazola Egg whites
• Honey
• Nuts, sunflower seeds, soybean products
• Rice of all kinds: brown, white, wild
• Bread to which nothing listed below has been added
• Tea and coffee
• Plain soda water
• Parsley, onions, garlic, bay leaf, salt
• Any kind of flour

Do not Eat

• Meat in any form, including broth
• Fruit of any kind, including tomatoes
• Dairy products, including egg yolks, milk, cheese, yogurt Vinegar, or any other acid
• Pepper (definitely)
• Chocolate
• Dry roasted nuts (the process involves monosodium glutamate)
• Alcoholic beverages
• Soft drinks (I have never found one without additives)
• All additives, preservatives, chemicals. most especially monosodium glutamate. One exception to this rule is the lecithin in margarine.
• Salt
• Sugar

Perhaps Ocasionally

• Breast of chicken and chicken broth
• A small amount of wine in cooking
• A small drink of scotch
• A small pinch of spicy seasoning such as curry powder
• Noodles or spaghetti, since the amount of egg is relatively small and somewhat broken down in the cooking
• White wine with some plates

Persons who have gout, or who have been diagnosed as having what is called gouty arthritis, will do well to avoid certain things. This sensitivity must be determined by the individual, since it varies from person to person, but in general mushrooms, asparagus, spinach, artichokes, peas, and beans are possible offenders. As for alcohol, bourbon does not seem to be right for some people with gout; I would suggest vodka for their rare indulgence.