Gold in the treatment of rheumatoid arthritis and its promise for other diseases

Photo by Pixabay on Pexels.com

While trying much not to preempt the coming soiree with CMA, to thank this mentor for his almost “solo”mentorship to my generation of rheumatologists, this piece has to be written before being presented in that gathering.

Did you  know that gold has a tablet form which is 29% gold by weight? This was circa 1980’s, during my first years of practice as a rheumatologist. Back then, the drug auranofin (Ridaura) was brought to the Philippines by GSK.

Apparently, the fascination with Au has not stopped with heavy ingots and delicate trinkets adorning the graceful of necks, waists, ankles and wrists. Gold in its liquid form in very tiny amounts was taken orally in those early days. One wonders if this could be out of that great desire to keep it within the body (as in hide it), or because it was so valued that other uses had to be invented to increase its worth even more.  Conveniently, the apothecary therefore, incorporated it into concoctions and salve for illnesses.

History points to the very name that substitutes for tuberculosis- Koch’s disease, as Robert Koch, in 1890, discovered that gold compounds could slow down the growth of Mycobacterium tuberculosis. This finding paved the way for  the use of gold as treatment for tuberculosis.  This use of gold for treatment of disease was termed chrysotherapy.

Chrysotherapy would soon be used in cancer therapy since gold is known to concentrate in areas of high vascularity. This was followed closely by its successful use  for rheumatoid arthritis (RA). Its use for RA as a disease modifying anti-rheumatic drug (DMARD), was promising but short-lived. By 1985, the anti-cancer agent methotrexate had become the first line DMARD for RA, till the present. And many more other ways to treat RA have flourished.

Not withstanding, the promise of gold in the realm of medicine continues to be explored, its fascination much like how the eyes would rivet toward its golden glow as light hits its surface. Currently, its use in the delivery of drugs where they are needed in the body is being investigated. Soon, if not already out, its use in HIV therapy may welcome it back to mainstream medicine as the drug to reckon.

One, it seems can never have enough of gold and so the wait continues…

Arthritis and the myth of the Mung bean (mungo, moong)

It must be something local to the Philippines.  This I yet have to hear as a significant educational gap of common (by this I mean, lay) knowledge of arthritis in other Asian countries where mung beans or moong or mungo is abundant. As one who specializes in arthritis and rheumatic diseases, it can be frustrating to hear as a matter of daily, per  patient encounter, the attribution of any joint malady to eating mungo. While it is unusual or even weird to pity food, I must admit that I have grown to “pity” the mung bean over my 35 years of practice.

The oft conjured story about mungo causing arthritis has actually no written  literature, scientific or otherwise, on review. It would therefore qualify as an old wives tale. And as old wives tales go, this belief is construed as fact and assured of its factual status and longevity as it is passed from one generation to the next. In recent years, the personal emotions that arise each time I hear the mungo “accused” of causing this painful neck or the bad knee, have grown from pity to “protective” and even defensive type of annoyance. I’d immediately counter the accusation, with a tirade of scientific facts about how the mungo is an innocent bystander during some food indiscretions that actually cause NOT just any arthritis, but only gout!  It can be surmised that since gout is the most severe of the arthritides, it is easily the one arthritis that needs a reason for being.  And the mungo, it is.

Gout is a severely disabling, painful, episodic and recurrent arthritis that affect males in their big toe, ankles and knees individually at first but in years, all together. Its episodic nature might well be timed after a generous meal of mungo served by the wife, and unbeknown to her, the man may have had a good serving of innards with alcohol earlier. The ensuing gouty attack therefore gets tagged on the mungo meal.

Whatever the source of this tale is not in Google. Philippine folklore publications carry various forms of  treatment for arthritis consisting of what is now considered as alternative or complementary medicine, others describe the “pasma” which supposedly does not have a known medical equivalent and nothing much else. Patient sites on mung beans, on the other hand, describe its medicinal value including as treatment for arthritis.  When actual patients are asked, their one universal answer is, they have been told that mung beans cause arthritis. Specifically who told them? Blank.

Going back to gout, we continue to find some internet sites listing beans as a possible cause of arthritis due to its purine content. In fact, one does NOT find the mungo listed under high purine containing food. It actually is known to contain just moderate  amounts of purine.

A patient education material produced by the Section of Rheumatology, Philippine General Hospital.  Ask your rheumatologist about it.

Foodstuff causing arthritis therefore need to be qualified to details of what food and which (of the more than one hundred types) arthritis, can be truly causally linked:

Gout can be caused by diet high in red meat (beef, pork, etc), small fishes and shell fishes, anchovy and innards, alcoholic drinks like beer and wine, and fructose based beverages like the soda and commercial juice drinks. Dehydration and physical stress are other common and immediate causes of acute attacks of gout and not just any arthritis.

Meanwhile, we urge all to leave alone the legend that the mungo or mung beans cause arthritis  and instead, eat it for it high nutritional value and perhaps even to treat arthritis if any.

 

 

It’s nice to be back; Can blog sites be hacked; The doctor is to comfort always

The Muses took a long time to prod me to open this site again. Today, a niece seemed unable to open her blog site and sought help.  And so off I went to WordPress to check out my long untended Mix trail and Arthritis. And lo, it still is here! I offered my niece some help and found out that her case was complicated, maybe, hacked. Can blog sites be hacked? What for?

Opening Mix trail and Arthritis felt weird, to say the least. I’ve forgotten the stuff I wrote, how many I did and was disappointed to see that there are less number of articles stored here than I thought. I now recall that I wrote more articles in another blog site which I had closed, and got this mixed up in my 63 year old brain.

So, today is the resurrection of this site. Apologies to the few who followed it, and have gone on to throw Mix trail and Arthritis into the trash bin. It’s time to pick up the more patient ones who did not lose hope and continued to check.

In giving a graduating class of the biggest teaching hospital of the country some inspiration to carry on, let me quote a part of my talk:

“Handling lives, counting pulses and breaths, you know how it feels to be “you the man” after you wrest a patient from the clutches of death.  And you have cowered in some inner sanctum for solace after some devastating clinical mishap.

After all is said and done, this portion of your journey has opened the reality (attributed to Hippocrates himself) that the doctor is to “cure sometimes, treat often and comfort always”. But I know you’d rather reverse the sequence – you’d really want to cure always, treat often and comfort some of the times.”

Forty years into the clinics, there is no mistaking of the wisdom of the Hippocratic adage, “the doctor should comfort always”. Years have mellowed the desire to defeat disease and deny death. Experience has finally made it clear that life is precious, to be lived fully, and death, inevitable and welcome at the opportune time.  Now there is only that sense of victory in having comforted the patients I had sent home well and healed, as well as, the  the ones who died. Yes, the doctor should comfort always.

A Graduation message

Former CNN field reporter and current CEO of Rappler, Maria Ressa is 105th Commencement Exercises Speaker of the University of the Philippines College of Medicine. “Meaning plus value equals purpose” was a statement that struck a cord in this aging parent of a graduate. Ressa’s ascendancy to speak on ethics is palpable and could only come from one who lives and breathes it. Might the excitement of all who heard her translate to just an iota of changed lives and purpose?

“Millimoments”

Photos are fun.

With a click, a “milli”moment of emotion or scene is captured.

A millimoment –

the elderly mom tries a tablet,

click,

then shouts of hurray!;

iridescent fireworks,

click,

then smoke;

proper smiles,

click,

then, raucous laughter or tired folding up;

baby prompted to blow a candle,

click, 

then parents blow the candle for him;

sunset in its golden grandeur,

click,

then the night;

a lively storm lashing at trees,

click,

then destruction and  stillness.

There is nothing untrue when one smiles for a portrait and is sad a second after, or the fireworks, or the golden sunset just because they were momentary.

Everything a photo can hold is true and real.

That is why, we snap away these millimoments,

for the face they give to a longing or reality,    

for making the past current,

for making memories real.

 

Is arthritis fatal?

As a big group of diseases lumped into one common knowledge named “rheumatism”, arthritis is, for the most part, not fatal. One often hears that once you have it, you have it for life. There is some truth to this belief. Indeed, arthritis can disable and relegate the arthritic to a life of pain.

However, there are arthritides that kill. Mostly, these are the undiagnosed  and consequently, improperly treated diseases. Many are rare and can be mistaken for other more common illnesses. Here is a short list of serious types of rheumatic diseases that may directly cause death if left untreated for long:

• Untreated lupus

nephritis or kidney inflammation
lupus lung hemorrhage
lupus blood disorders
lupus brain inflammation

• Lung and brain hemorrhage of Bechet’s syndrome
• Vasculitis or inflammation of blood vessels especially those in the heart, lungs and brain
• Blood clots in the lungs in conditions like antiphospholipid antibody syndrome (APS), and catastrophic APS when many other organs of the body are involved
• Progressive systemic sclerosis (generalized form of Scleroderma) and CREST syndrome with pulmonary hypertension

Surely a mouthful, but important to note. Diagnosis spells proper and timely treatment, and proper and timely treatment may offset the unwanted outcome of death.

But more common forms of arthritis that can be controlled in the primary care setting, may also take a  complicated spin- by the natural history of the illness, by poor patient adherence to treatment or by the treatment itself. Here’s a list of complications of arthritis and/or treatment that have proven fatal in the long run:

• Kidney disease resulting from complicated gout
• Stomach and intestinal bleeding due to unsupervised intake of pain medicines
• Kidney disease from unsupervised intake of pain medicines
• Presence of other diseases in the arthritic individual, like diabetes, infections anywhere in the body, heart failure, liver disease, high blood pressure
• Intake of alternative medicines that can have kidney and liver side effects

The above lists are by no means comprehensive but are contained herein by way of anecdotal experience in a (give or take) 25 year old rheumatology practice.

Aurora’s fingers

Aurora’s Fingers

If you are one who awakens at dawn to feel around for your first 3 fingers, you could well have carpal tunnel syndrome or CTS, a malady I have had for the past 3 years and which I fondly call Aurora’s fingers (did Aurora, goddess of dawn, have it?).

taken from google images

Carpal tunnel syndrome is a disturbing hand disease that causes sensation of pins and needles, and numbness of the first 3 fingers (start with the thumb) and half of the ring finger, especially at dawn (aurora).  During the first months, the symptoms can be fleeting – a few dawn awakenings due to numbness, relieved by shaking the hands. Later, these symptoms become more intense, prolonged and associated with weakness of the thumb and index finger grip, or the pincer grip. Each dawn becomes a misery as sleep and the pins and needles vie for the few more minutes of slumber till morning sun.

There are many possible causes including inheritance, age, work-related causes,  as those seen in jack-hammer operators and long distance drivers and situations that create higher pressures inside the carpal tunnel (where the nerve that gives sensation and strength to the 3 1/2 fingers, the median nerve, is lodged). Some acquire CTS during pregnancy. Perhaps for me, it’s stick driving, and the vibration of  the wheel during the frequent long drives to and from work.

Rest from repetitive or finger-intensive hand activities is paramount for relief during the early days of the disease. A CTS or wrist splint can be helpful, but only for a time. Nerve-pain relieving drugs, and injections into the carpal tunnel are also known to bring relief. Don’t wait though, for the pincer grip to be compromised to the point of being “clumsy” and frequently dropping things.  Decreasing carpal tunnel pressure by surgery can be a permanent cure, but some cases are known to recur.

For those with the inherited trait, prevention may not work, but disability can be minimized. For those who don’t have the symptoms yet,  avoiding  activities associated with the disease – operating jack-hammers, vibrating equipment, etc., can be helpful in delaying onset of CTS.  Vitamin B pills have been prescribed and should be temporarily effective.

Common and disturbing as it is, it is far from life threatening and many an elderly chap or lady have lived with the aurora fingers, albeit, with misgivings.

 

 

 

Chest Pain: Between the heart, joints and skin

Chest pain that is not a heart attack

Angina pectoris or chest pain is an ominous symptom which is caused by heart muscles not receiving enough oxygen for its work of “perpetual” pumping. This great mass of muscle actually gets its oxygen from blood brought by arteries that crisscross it. Yes, though the heart contains and pumps blood, it has its special delivery system of  oxygen-laden blood from small arteries springing right at the base of the aorta, that big artery that carries blood as it is pumped out of the heart to supply the rest of the body.

But what about chest pain that is not at all related to an oxygen-starved heart?

There are other causes of chest pain and among the most common is arthritis of the breast bone to rib joint or the costochondral joint. Costochondritis can be mistaken for a heart attack in many occasions and can cause unnecessary laboratory examinations intended to check the heart to be ordered.  ECGs are routine and can be superfluous in this condition. How then can costochondritis be discerned?

There are ways to differentiate costochondritis from a heart attack. First is to suspect it when the pain is movement-related (twisting the torso, for instance) and happens to occur in a young individual, especially females. A specific kind of costochondritis,  Tietze’s syndrome, affects females in their 20’s and involves the 2nd left rib to breastbone joint, so that the pain it produces is right smack where pain of heart attacks is felt – mid chest. Second, the pain is lancinating and quite severe, but is usually not associated with cold sweats and the “sense of impending doom”, which occurs with the chest pain of heart attacks. More so, save for the pain and the rapid heart rate it can produce, costochondritis is not related with serious breathing difficulty and blood pressure problems, as seen quite commonly during heart attacks.  Costochondritis cause pain in the affected chest when pressure is applied just over the side of the breast bone, something not seen in heart attacks, where the pain is deep and persistent.

The other cause of chest pain that is not a heart attack is the viral infection Herpes zoster, when it erupts along the spinal nerve of the nipple line. Chest pain is usually more superficial than deep, also severe, and then in about 2 weeks, chicken pox-like eruptions appear over the affected part of the chest. That would clinch the diagnosis, but in the early phase, the pain can be so distressing and cause the patient to be worked up for a heart problem. It is advised that superficial gnawing pain with unusually sensitive skin in localized areas of the chest warrants observation and monitoring for the appearance of skin lesions. Early treatment is necessary to shorten the course of the rash and the disease in general.

Do you have chest pain? In addition to heart attacks, think joints and skin conditions!

It is however, prudent to relate matters like these to family histories of heart attacks or ailments, as well as, lifestyle risk factors like smoking, sleep deprivation, dietary excesses and diabetes. Despite age, a person with chest pain will warrant a thorough check when the above conditions are present.

Come home to Haiku Home

Awake in the dark…

I ponder at my being…

There is light in my heart.

       5:35 a.m. April 4, 2012

Just in March of the year 2012, I was introduced to Haiku, (re-introduced perhaps) by a cousin who had nothing better to do while recuperating from illness, but to write her experiences in 5-7-5 graphic scenes that got me hooked. How soon she recovered is a testimony to how art therapy can work wonders!

This re-introduction to the haiku was timely. As a medical professional in my almost-retirable years, I sought the “comfort” activities of my younger years, like playing the piano. It all went well for 3 years with one recital to my belt –  a general class recital with small children, and I was last number to play in the program. On my 4th year however, as my piano teacher patiently prepared the simpler of  Debussy’s, a bad carpal tunnel syndrome struck, first my right dominant hand, then the left, (like the rheumatism knew exactly who to afflict). Having treated many patients with the malady, I could hear myself say, “rest for the hands and fingers from avoidable activities is first line treatment, otherwise, you will either receive an injection to the wrist or get the part opened up”.

Haikus came as a welcome respite. Yes, I still have to write or type the poems, but this art form is less finger intensive in terms of force and repetitive motion. Soon, my cousin and I exchanged haikus daily through SMS, writing them down at the same time on notebooks. Friends started to join in, too.

I told a friend that to write haiku is to breath, a brief moment with almost no thought taken,  just short punctuations of observations about nature, experiences, so short that the only imagination allowed is that of the reader’s. The poet pens thoughts down in 5-7-5 cadence,  with no burden to explain, leaving the scene to someone else.