The next time you by keara


									 medical news from the office of Dr. Dan Frank
 1001 Broadway, Suite 309 • Seattle, WA 98122 • voice 206.292.0700 • fax 206.709.0600              December 2003

Osteoarthritis                                                                             Autoimmune Diseases:
                                                                                           We Have Met the
Something We Can All Look Forward To                                                       Enemy and He is Us
        he next time you

        curse the $500                                                                                 hat does premature gray-
        brake job on your                                                                              ing of the hair have to
car, think of what it would                                                                            do with juvenile onset
be like if you couldn’t re-                                                                 diabetes? How about the connec-
place those pads and turn                                                                   tion between rheumatoid arthritis
those rotors so easily. In                                                                  and hypothyroidism? Can we also
humans, osteoarthritis is                                                                   put lupus, colitis, and vitiligo (the
a condition similar to the                                                                  disease that made Michael Jackson’s
wearing out of brakes on                                                                    skin so light, but does not account
automobiles, but it takes                                                                   for his other bizarre behavior) in the
a whole lot more than                                                                       same category? Yes we can. They are
$500 and two hours of a                                                                     all disorders of the immune system.
mechanic’s time to fix.                                                                     Amazing as it may seem, a similar
    We all start out in life with a thick,        But for now, we’re stuck with bod-        mechanism of disease underlies all
firm cushion which lines most the            ies that have joints subject to wear           these problems and many others in
joints in the body. This is cartilage.       and tear. The knee, hip, and base of           medicine.
I don’t mean to be gross, but when           the thumb, for example, often wear                 One of the ways that physicians
you eat chicken and see that hard,           out and become painful. We all devel-          organize the large number of disor-
rubbery white material along the             op osteoarthritis, but in some people          ders that can afflict the human body
joint lines in the leg and thigh, you’re     the process is relatively painless and         is to classify them as to underlying
looking at joint cartilage. Without it,      generally ignored. In others, unfor-           cause. For example, pneumonia,
your knees, ankles, and hips would be        tunately, the wearing out of joints is         meningitis, and strep throat are very
bone on bone, not a very comfortable         quite uncomfortable and quality of             different disorders, but they are all
prospect.                                    life is affected.                              caused by infection. Another way
    With age and repeated stress to               Patients who are overweight,              they are unified is that if your im-
a joint, the cartilage unfortunately         like drivers who ride the gas and              mune system is too weak, you are
wears out. When Homo Sapiens Ver-            brake simultaneously, wear out the             predisposed to getting more than
sion 2.0 comes out sometime in the           cushioning sooner. Heavy use, such             your fair share of these diseases.
next 50,000 years, I hope that joints        as compulsive tennis playing for 30                But can immunity go the other
will be more like hair or nails, better      years is going to be a little tough on         way? Can you have a too strong of
able to re-grow over time.                   the shoulder. One patient, whom I’ll           an immune system? Yes, you can.
                                             call “Dad” to protect his anonymity,           If your immune response is too ag-
                                             no longer has a functioning shoulder           gressive, it will over-react to minor
                                                joint. His bones in that region are         threats. This is seen in disorders
                                                  essentially fused and the cartilage       such as asthma, eczema, and sea-
                                                    is completely gone, but he is           sonal allergies. For example, pollen
                                                        still able to play tennis by        never killed anyone, but try telling
                                                           the motion he has in his         that to the nose of a hay fever suf-
                                                            shoulder blade.                 ferer. His nose reacts with extreme
                                                                One of the challenges       force during allergy season.
                                                                  in osteoarthritis is          Another problem the immune
                                                            that we don’t have great        system can have is to fail to tell the
                                             treatments. There is an axiom in               difference between self and foreign
                                             medicine: the more treatments that             invaders. You certainly don’t want
                                             are available for a given condition,           your immune system attacking your
                                             the less effective they are.                   own kidney as if it were a big pile
                                                   The first line approach for osteo-       of bacteria. But sometimes, the im-
                                                 arthritis is Tylenol, Motrin, Advil,       mune system does just that. And
                                                  Vioxx, etc, basically pain medica-        when your body’s immune system
                                                         tions. There is no compel-         attacks your body, we call it an
                                                             ling research to show          “auto-immune” disorder. (Auto =
                                                              that one drug is vastly       self, as in automobile not needing a
                                                              superior to any other.        horse to go).
                                                               Patients may need to             In some cases, an infection starts
                                                               try a few until they find    things off. If you are predisposed
                                                             what works for them.           to develop an autoimmune disease,
                                                                 continued on page 2                           continued on page 3

                                                                                                DANIEL S. FRANK, MD, PLLC        1

     The next step is physical activity
and mobilization. It may seem coun-
terintuitive to exercise and increase
the use of a painful joint, but several
research studies show that aerobic
exercise and strength training do                                                     Joint
lessen pain and limitation of mo-            Joint                                   Space
tion in osteoarthritis, especially of        Space
the knee.
     Many elderly patients with osteo-
arthritis have entered a vicious cycle
where pain limits their activity and
with greater inactivity comes more
pain. A regular exercise program, at
least 3-4 times per week of walking,
cycling, or swimming will improve
gait, walking speed, joint pain, and
quality of life, not to mention the           When you look at an x-ray of a joint with osteoarthritis, the most
benefits of improved cardiovascular           obvious change is that the joint space is narrowed. In a normal joint,
health.                                       there is a moderately large black space between the two bones that
     In some patients, joint pain leads       are “joined” in the joint. But that black space is not air, it is filled
not only to physical inactivity, but          with tough, resilient, cushioning cartilage. The cartilage doesn’t
also social isolation. Group programs         show up on x-rays. With the development of osteoarthritis, that space
that improve social contact and also          narrows, just like your brake pads wear down. The other change is
provide education on osteoarthritis           that the bone around the joint begins to develop small, narrow pro-
show benefits at least as good, if not        jections, called “osteophytes.” These can also be a source of pain.
better, than drugs such as Tylenol or
     Glucosamine and Chondroitin are       also the chance of thinning the skin      a “sham” surgery where they had
over-the-counter medications which         around the injection site. Synvisc is     anesthesia and a small skin incision
can help osteoarthritis patients.          injected once per week for 3 weeks        but no actual work done inside the
The typical dose is a combination          and can give up to 6 months of relief.    knee. The group who got the fake
pill containing glucosamine 500 mg         We’ve had good results with Synvisc       surgery and the group who received
and chondroitin 400 mg taken three         in our office. With any injection,        the traditional laparoscopic knee
times daily. Early studies, funded         there is also a low risk of joint space   surgery both had identical outcomes
by drug companies were uniformly           or skin infection.                        in terms of pain and function. This
positive. Later studies, not funded            After Tylenol, Motrin, a Cox II       study suggests that any improve-
by drug companies have been more           inhibitor like Vioxx, glucosamine         ments in knee osteoarthritis from
mixed. I still recommend this agent        and chondroitin, a physical activity      this form of surgery was just due to
for my patients to try. There has been     program, and injections of steroids       the placebo effect.
little concern for toxicity and the        and/or Synvisc into the joint, the            Total joint replacement is the
hope with glucosamine is that it im-       next step for some patients to con-       final and most drastic step in os-

                                                            Several research studies show
                                                 that aerobic exercise and strength training
                                                improve pain and limitation in osteoarthRItis.

proves the strength of the joint itself,   sider with severe pain and limitation     teoarthritis. Many thousands of
instead of just treating the pain.         is surgery. There are two surgical ap-    patients receive joint replacements
    Other pain medications, such as        proaches. The first is to “wash out,”     every year. Do they work? Well, as
topical capsaicin, which is a cream        trim, and smooth the joint surfaces       you can imagine, it would be hard
applied 3-4 times daily to the pain-       with a scope. If your problem is the      to convince people to sign up for a
ful joint can help with discomfort,        joint locking up or suddenly giving       randomized trial. But most studies
although it can take a month for it to     way, then this surgery may be helpful.    suggest that 80-90% of patients are
start working.                             But only a minority of osteoarthritis     helped substantially by having a
     Injections of medications into a      patients have this problem. The vast      joint replacement. It is not a step to
painful, arthritic joint can be helpful    majority of patients have pain and        be taken lightly, however. Complica-
as well. The two most common are           limitation of motion. This form of        tions, including infection, the need
steroids (Cortisone) and Synvisc,          surgery is probably not effective for     for repeat surgery, and continued
which is a synthetic fluid designed        these patients and I don’t recom-         pain do occur. An excellent surgeon,
to replace the normal fluid in a joint.    mend it.                                  first-rate hospital, and state of the
Steroids, with repeated use, can               In a recent study, patients were      art prosthesis are important. If you
weaken a joint, but they are gener-        randomized to receive the stan-           are contemplating joint replacement
ally safe for occasional use. There is     dard laparoscopic knee surgery or         surgery, call me.

   continued from page one

your body kills off the foreign in-         in the pancreas that make insulin.              In some diseases, such as type I
vader, but some of your own cells re-       Patients who are genetically pre-           (juvenile onset) diabetes and hypo-
semble parts of that viral or bacterial     disposed not to recognize their own         thyroidism, the attack by the body’s
invader. So your immune system gets         pancreas end up with an immune              immune system is complete within a
confused and starts attacking your          response attacking the insulin-mak-         few months and the target organ is
own cells. This is what we did to the       ing cells. When they are all destroyed,     destroyed. Current treatment strate-
Japanese in World War II by putting         diabetes develops.                          gies are directed at replacing the
American citizens who “resembled”               In hypothyroidism, for reasons          function of the lost organ. In other
a foreign invader into internment           unknown, the body starts thinking           disorders, such as multiple sclerosis
camps.                                      its own thyroid gland is a foreign in-      and rheumatoid arthritis, the at-
    The scientific term for this process    vader. The body attacks and destroys        tack is ongoing over many years. In
is “molecular mimicry,” meaning that        the thyroid gland and patients need to      these latter conditions, treatment is
the molecules on the surface of the         take thyroid pills for the rest of their    directed at suppressing the immune
virus “mimic” those on our own cells.             lives.                                system with drugs such as predni-
There is an evolutionary advantage
for a virus to mimic, or disguise itself,
                                                    Initially, your                        sone, methotrexate, cyclosporin,
                                                                                           and other more esoteric agents.
to look like part of our own body. It                immune system                            Why are autoimmune diseases
hopes to slip in undetected, kind                      builds attackers                    so common? Why can’t our im-
of like if Al-Quaida got some
blonde-haired, blue-eyed ter-                          which will go                       mune system, with several billion
                                                                                           years of practice, get it right and
rorists to sneak into the United                         after almost                     not attack our own bodies? I return
    During fetal development,                            every conceivable                to the analogy of our country and
                                                                                          national defense. The problem is
your immune systems “learns”                          protein, even the                   that so many people out there want
what your own body looks like. It
responds by either killing off the                   cells in your                        to kill us. Bacteria, viruses, and
                                                                                          parasites have been trying to invade
immune cells which would target                      own body.                             and use the bodies of multicellular
your own tissues or by making “im-                                                         organisms for as long as we’ve been
mune cells of peace” which recognize               In diabetes and hypothyroid-         in existence.
the various body tissues as a friend        ism, the body’s attack on itself is pain-       Telling friend from foe can be a
and refuse to attack.                       less. But in rheumatoid arthritis, the      huge challenge. Even a great country
    So that is the connection between       attack on the joints is quite painful.      like the United States can occasion-
these seemingly different diseases:             In vitiligo, the immune system          ally overstep its bounds and misuse
they are all caused by auto-immunity.       starts destroying the pigment cells         the military and police, because un-
In each case, the body has destroyed        in the skin. Patients who grey pre-         fortunately, we have a lot of people
a strategic part of itself.                 maturely have an autoimmune attack          who hate us and want to destroy us.
    Since insulin is made in the pan-       going on against the cells which put        Similarly, our highly evolved immune
creas, you certainly don’t want your        pigment in hair. In multiple sclero-        system, under constant threat from
immune system to wrongly conclude           sis, your body is attacking myelin,         many invaders (some masquerading
that the pancreas is a foreign object       a protein found in the brain. Other         as part of our own cells), occasionally
sitting behind the stomach. But in          diseases, including psoriasis, Crohn’s      errs on the side of “autoimmunity”
type I (juvenile onset) diabetes mel-       disease, premature menopause, and           and attacks a structure which is not
litus, a viral infection occurs where       most forms of vasculitis are all auto-      really the enemy, but is just a normal
part of the virus resembles the cells       immune disorders.                           part of our body.

                        Vaccines to Treat Cancer
       Certain types of cancer cells arise in the body with some regular-
    ity and are immediately recognized as “foreign” and killed off by the
    immune system. But others may fool the body into thinking they are
    really “self,” and this allows certain cancers to grow and be ignored.
    Scientists are trying to find ways to stimulate the body’s immunity
    against these cancer cells with a vaccine. It is an area under investi-
       For example, in malignant melanoma, a cancer of the pigment cells
    in the skin, there is a vaccine under development where patients with
    melanoma have a piece of their cancer ground up and bonded to oth-
    er molecules which stimulate the immune system. This protein is then
    injected into the patient, just like a flu shot, in the hopes that the
    body will finally “see the light” and kill off all the melanoma cells.                          Melanoma cells

                                                                                             DANIEL S. FRANK, MD, PLLC       3
                                                                                            monitoring approaches, but they are
                                                                                            less accurate.
                                                                                                The most common treatment for
                                                                                            obstructive sleep apnea is to wear a

                                                                                            device on your nose that blows air
                                                                                            in. It is called a CPAP (Continuous
                                                                                            Positive Airway Pressure) machine.
                                                                                            If you have daytime sleepiness and
                                                                                            frequent apnea spells during sleep,
    Snoring Your Way                                                                        you are likely to benefit from a CPAP

     to Poor Health                                                                         machine. Your bed partner will also
                                                                                            sleep more soundly if you do. If you
                                                                                            are not sleepy during the day, then
                                                                                            even if you have laboratory diagnosed
     Signs & Symptoms of Sleep Apnea                                                        sleep apnea, you probably will not
                                                                                            gain anything from using a CPAP
•Excessive daytime sleepiness                     •Usually fall asleep at night
                                                                                                The biggest problem in sleep ap-
•Overweight                                        after only 1-2 minutes                   nea is that sleeping with something
•Neck size greater than or equal                  •Dry mouth in the morning                 strapped to your face blowing air in
 to 17 inches                                     •Loud snoring, gasping, not               your nose is a little disconcerting. Not
•Low sex drive                                     breathing at night (usually              everyone can make friends with the
                                                   noticed by bed partner)                  CPAP mask and not everyone can use
•(Less common) morning head-
                                                                                            CPAP successfully. Other approaches
 ache, depression or irritability                 •High blood pressure                      include a dental appliance which
                                                                                            keeps your mouth open so the air
                                                                                            doesn’t have to go through your nose,

         ow would you like to have               may have obstructive sleep apnea.          and surgery. The dental appliance is
         someone shove a pillow in               Generally, patients are overweight,        less effective than a CPAP machine.
         your face and try to suffocate          have a neck size of 17" or greater, and    Surprisingly, you might think that
you while you’re sleeping? What if               often report they fall asleep as soon as   surgery is highly effective, but it re-
they did it 240 times per night? Well,           their head hits the pillow.                ally only helps less than half of the
that is sleep apnea. “Apnea” means                   Although not all sleep apnea pa-       patients. In the old days, patients
not breathing. Sleep apnea is ex-                tients snore loudly, a bed partner is      with severe sleep apnea would get a
tremely common. Getting poor sleep,              often the first to complain, especially    tracheostomy. A drastic measure that,
night after night, causes all sorts of           about extremely loud snoring, along        certainly, did help their disorder.
havoc with the body.                             with periods of no breathing at all.           If you have daytime sleepiness,
    Sleep apnea is usually divided into          (Physicians use the term “bed part-        come and talk to me about sleep ap-
two types. In central sleep apnea,               ner” to describe the person you sleep      nea. We can decide if a sleep study is
the less common form, your brain                 with. However, if this person is truly     in order. If you do have sleep apnea,
“forgets” to tell you to breathe dur-            just a bed partner, please contact the     treating it can help control hyperten-
ing sleep. In obstructive sleep apnea,           office to see about some Viagra.)          sion, decrease your blood sugar, low-
which is what most people have, the                  To actually diagnose sleep apnea,      er your risk of a car accident, improve
airway closes off during sleep.                  the best way is to sleep in a sleep lab    your and your bed partner’s quality
    Shouldn’t your airway be smart               and have your breathing monitored          of life, and give you more energy and
enough to stay open during sleep?                during the night. There are home           vitality.
Well, that would be ideal, but as
people gain weight and as collagen
relaxes with age, it becomes more                    Approach to the Patient with Fatigue
likely that the upper airway tissues
will collapse during sleep. When this
                                                        It is not unusual for me to get a
happens, you try to take a breath but               new patient in the practice complaining
can’t. After 30-60 seconds of decreas-              of “fatigue.” Often they’ve been seen
ing oxygen and rising carbon dioxide,               elsewhere, perhaps for years, without a
your body wakes up just enough for                  resolution. Sometimes I can’t help either.
you to roll over, gasp, open your
mouth, or whatever, so that you can
                                                    But other times there is an overlooked
get a breath. In some patients, this                issue that just needed more effort to
is happening every minute or two                    fix. Untreated sleep apnea is one such
throughout the night.                               diagnosis. Others include improper thy-
    If you are frequently sleepy during             roid hormone replacement, unrecognized
the day and snore loudly at night, you
                                                    anxiety or depression, adverse reactions
                                                    to medications, low testosterone in men
Daniel S. Frank, MD                                 or women, and improperly treated high blood pressure or diabe-

 Internal Medicine                                  tes mellitus. If you suffer from excessive sleepiness or fatigue,
      Primary Care   PREMIUM SERV ICES
                                                    come and see me.

                     1001 Broadway, Suite 309
                     Seattle, WA 98122              All of the articles published in this monthly newsletter are the
                                                    original work of Dr. Dan Frank and intended for his patients.
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