Knee pain, arthritis and noisy knees

Many people are worried about their noisy knees.  Read my comments about this in this blog

https://www.drbadshamedical.com/why-is-my-knee-so-noisy/

Aplar 2017 in Dubai ( Asia Pacific Rheumatology Conference Dubai ) October 16- 20

We are so pleased and excited to be hosting doctors from around the world to teh rheumatology conference in dubai.

Please follow this link : http://www.aplar2017.com

Diet for Rheumatoid arthritis in Dubai. posted by Rheumatologist in Dubai

Many arthritis patients are sensitive to several foods. The mechanism by which food sensitivity is involved in arthritis remains unknown. Some evidence implicates the gut flora. Some of the commonly used drugs for arthritis increase the permeability of the gut, causing it to become “leaky”, allowing larger molecules of foods to pass through than would normally be the case, causing food sensitivity. Many studies have shown that 30-40% of rheumatoid arthritis (RA) patients can improve substantially by using an elimination diet to identify foods that precipitate symptoms and the avoiding of these foods. Some studies have shown, that gluten and/or dairy products may be involved in this food sensitivity at some arthritis patients.

Elimination diets typically involve entirely removing the suspected food from the diet for a period of time from two weeks to two months, and waiting to determine whether symptoms resolve during that time period. If symptoms resolve after the removal of a food from the diet, then the food is reintroduced to see whether the symptom reappear.

Some people feel that cutting out ‘acidic fruit’ such as oranges, lemons and grapefruit helps arthritis. Others believe that vegetables from the so-called nightshade family (which includes several foods – potatoes, tomatoes, sweet and hot peppers and eggplants) are bad for arthritis. There is no scientific evidence that leaving out either of these groups of fruits and vegetables helps arthritis, and such diets may have the undesired effect of reducing the beneficial antioxidants in the diet.

Food sensitivity is highly individual, and varies from person to person. Elimination diet should be done under the supervision of your doctor to eliminate the risk of nutrient deficiency.

Food intolerance tests which test for IGG Antibodies against 200 foods are available at our center

Recently we presented our findings - results of the immune pro food intolerance test on 35 patients with arthritis.  About 100 % were intolerant to cow's milk and 85% to gluten / wheat.  Eliminating these foods has shown to be beneficial to majority of patients.

Do you have steroids for arthritis?

You may have heard people with arthritis talk about what it was like to wean or taper off of prednisone. They describe varying degrees of withdrawal symptoms. For some, it was a nightmare.

It can be worse for people who took the drug for a long time or at a high dose. Prednisone is not a drug that can be stopped abruptly. It must be tapered gradually on a schedule determined by your doctor. Still, there may be withdrawal symptoms.

What has been your experience with discontinuing prednisone?

Doctors treating back pain incorrectly

According to a study published Monday in JAMA Internal Medicine, more physicians are ignoring national guidelines from the American College of Physicians when treating patients with back pain. The group recommends the use of “use of nonsteroidal anti-inflammatory drugs (NSAIDs),” such as ibuprofen and aspirin, combined with physical therapy. However, the study says physicians are instead, “increasingly” prescribing patients with back pain “narcotic drugs, ordering expensive imaging tests or referring them to other physicians.” Furthermore, the study’s lead author, John Mafi, a chief medical resident at Boston’s Beth Israel Deaconess Medical Center, claims that the guidelines “caution against early imaging or other aggressive treatments, except in rare cases.”

Rheumatoid arthritis treatment in Dubai

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Previous studies have shown that early, intensive intervention can help RA patients achieve remission, and reduce joint damage and disability. Treat-to-target (T2T) is a medical strategy that sets remission – or at the very least, low disease activity – as a goal; specific drugs and doses are stepped up systematically if remission is not reached within certain time periods.

Earlier findings of this Dutch study – called the DREAM trial – showed that remission can be achieved using the T2T strategy among patients with early RA (with symptom duration of one year or less) in the everyday world of daily clinical practice. But could the remission be sustained over the long-term?

A total of 342 patients from the DREAM trial had three-year follow up data for this phase of the analysis. Among them, nearly 62 percent were in remission at the three-year mark. Remission was defined as having a DAS28 score of less than 2.6. DAS28 measures disease activity in 28 key joints and certain blood markers.

Sustained DAS28 remission – defined as a DAS28 of less than 2.6 for six months or more – was achieved by more than 70 percent of patients at least once during the three years, with nearly 75 percent of those patients achieving a sustained remission for greater than a year. At the end of the three-year period, about 43 percent of the study subjects were in a period of sustained remission. The protocol called for a gradual decrease in medication for those experiencing sustained remission – and eventual discontinuation of drug therapy. At the three-year mark, a quarter of the subjects in the remission group were taking no medications.

new medication for psoriatic arthritis

Janssen, a Johnson & Johnson company, announced that it has submitted a supplemental Biologics License Application to the United States Food and Drug Administration (FDA) and a Type II Variation to the European Medicines Agency requesting approval of Stelara (ustekinumab) for the treatment of adults with active psoriatic arthritis. Stelara is a human interleukin (IL-12 and IL-23) antagonist. IL-12 and IL-23 are naturally-occurring cytokines thought to be associated with immune-mediated inflammatory diseases.

Stelara was approved by the FDA in 2009 for the treatment of moderate to severe plaque psoriasis in adults. The drug is currently approved in 69 countries for the treatment of plaque psoriasis. The applications requesting approval of Stelara for psoriatic arthritis are backed by Phase III clinical trials that evaluated the safety and effectiveness of 45 mg. and 90 mg. Stelara administered by subcutaneous injection.

New medicine rheumatoid arthritis

This is an oral therapy – only avaiable in Japan:
In a clinical study of iguratimod administered as a monotherapy in patients with rheumatoid arthritis, the agent demonstrated superiority over placebo and non-inferiority compared to an existing DMARD (salazosulfapyridine). In addition, in a trial of iguratimod in combination with methotrexate (MTX), the standard of care, conducted in rheumatoid arthritis patients who did not achieve satisfactory benefit with MTX alone, patients who were administered a combination of the two agents demonstrated favorable tolerability as well as significant improvements compared to those treated with placebo (MTX-only arm) in the study’s primary endpoint of ACR20 response rate at Week 24. Out of all the orally-administered anti-rheumatic drugs currently approved in Japan, iguratimod is the first agent evaluated in domestic clinical trials to demonstrate efficacy as an add-on therapy to MTX in patients who did not achieve satisfactory benefit with MTX alone

Anti-inflammtory diet for arthritis

Many types of foods can lessen inflammation in the body.  Examples are foods containing ginger, garlic , turmeric.  In addition diets high in Omega oils are good.  These include fish especially salmon, tuna and tilapia, cod, avocados, nuts such as walnuts and almonds.  Lean proteins such as chicken and fish and soya are advisable.  dairy products, especially low fat yogurt are beneficial.  Include at least 5 servings of fresh vegetables and fruits.  It is preferable to eat the vegetables closer to a raw or undercooked state.  Dark green and brightly colored vegetables have phytochemicals that are useful.  Avoid processed foods and meats, foods high in sodium, white breads, excessive starchy foods, and sugars.  There is no real evidence that night shade plants such as tomatoes, potatoes, egg plant or citrus fruits worsen arthritis. 

For Rheumatologists, Orthopedic doctors, Family doctors taking care of Bone and joint problems in Dubai , Abu Dhabi UAE

The 2nd Bone & Joint Conference is coming back to the Primary Healthcare Congress during the Abu Dhabi Medical Congress on the 16th of October, 2012.  After a successful conference last October, this This October 15th 2012, Abu Dhabi UAE This year’s program is looking to provide a comprehensive and in-depth one day agenda once again.   Covering new topics and the latest advances, there will be four sessions throughout the day: Orthopaedics Workshop, Back Pain Session, Rheumatology and General Rheumatology.  The presentations are geared towards GPs, who often see such cases and would benefit from learning the appropriate methods of diagnoses and treatment from specialists. Accreditation Statement The Cleveland Clinic Foundation Center for Continuing Education is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Cleveland Clinic Foundation Center for Continuing Education designates this live activity for a maximum of 7.25 AMA PRA Category 1 CreditsTM.   Physicians should claim only the credit commensurate with the extent of their participation in the activity. Participants claiming CME credit from this activity may submit the credit hours to the American Osteopathic Association for Category 2 credit. Advisory Board: Dr. Donald Ford, Cleveland Clinic Dr. Humeira Badsha, Dr. Humeira Badsha Medical Center Dr. Chris Whately, Medcare Hospital What are the main topics covered in this event? Orthopaedics Workshops Back Pain Session Physiotherapy Rheumatology Lupus

Arthritis in Arab patients (Rheumatology Dubai)

There is limited published data about arthritis in Arab patients.  A research study led by Drs. Thuraya Arissi in Doha , Robert Plenge in Harvard, and supported by Dr. Badsha in Dubai and others in jordan, SA, Syria, is attempting to determine which genes are associated with Rheumatoid arthritis in Arabs.  If you are of Arab ancestry, have rheumatoid arthritis and wish to participate please contact Dr. Badsha at info@drbadshamedical.com.

Rheumatologist in Dubai, UAE

Dr Badsha new location : Dr. Humeira Badsha Medical center, Beach Park Plaza , Jumeira Beach Road Next to Neurospinal hospital.  Phone +9714-3856009.  Email info@drbadshamedical.com

website: www.drbadshamedical.com

New Oral medication for Rheumatoid Arthritis!!

An FDA advisory committee has voted 8-2 in favor of recommending approval of the oral JAK inhibitor tofacitinib for the treatment of rheumatoid arthritis.
The agency's Arthritis Advisory Committee voted Wednesday that the efficacy and safety data support the use of tofacitinib for adult patients with moderately to severely active rheumatoid arthritis who have had an inadequate response to one or more disease-modifying anti-rheumatic drugs.
The panel was unanimous in its assessment of the drug's overall efficacy. "The evidence was compelling and was at least as good as for other biologics," said panelist Maria E. Suarez-Almazor, MD, PhD, of MD Anderson Cancer Center in Houston.
The efficacy was demonstrated in five phase III studies in which the primary endpoint was met, showing American College of Rheumatology 20% response rates ranging from 17% to 33% for the 5 mg dose and from 23% to 39% for the 10 mg dose.
"Statistically significant increases were seen on ACR20, 50, and 70 response rates in all five studies," said Nikolay Nikolov, MD, an FDA clinical reviewer.
Less clear was the efficacy as demonstrated on radiographic outcomes, which were assessed in only one study.
Analysis of this structural outcome was hampered by the fact that very little radiographic progression was seen in the placebo group.
In addition, the change in modified total Sharp scores seen in the 10 mg group appeared to be driven by one or more statistical outliers, and the small effect size was influenced by missing data and imputation methods.
"Radiographic outcome studies are difficult to do with limitations on the duration of placebo controls," said panel member David Blumenthal, MD, of Case Western Reserve University in Cleveland.
"We don't need certainty about radiographic outcomes today. That can be followed during postmarketing," Blumenthal added.
There also was considerable discussion about safety concerns that were raised in the phase III trials.
One area of concern was serious infections, which were seen at a rate of three per 100 patient-years, and most commonly were pneumonia and skin and soft tissue infections.
There also were 12 cases of tuberculosis, mostly in countries where the incidence is high, and 19 cases of serious herpes zoster.
Richard Riese, MD, PhD, of Pfizer noted that the company intends to have an action plan for zoster, in which immunization will be encouraged and follow-up data collected.

Women's health issues in Dubai, UAE

Gender-based approach needed to broaden understanding of women's health problems in Arab world

April 02, 2012

Dubai, UAE: On average women live six to seven years longer than men. However, the leading causes of death in women such as ischemic heart disease, stroke, lung disease, breast and cervical cancer can be easily prevented through simple screening tests and lifestyle modifications. In the past, work on women's health was focused on the health problems of women during pregnancy and childbirth. A gender-based approach has broadened our understanding of women's health problems and helped identify ways to address them for women of all ages.

The Obs-Gyne Exhibition & Congress 2012, organised by Informa Exhibitions in association with Arab Association of Obstetrics and Gynaecology Societies' (AAOGS), is a platform dedicated to the scientific debate of women's health in the Middle East. Taking place at the Dubai International Convention & Exhibition Centre, the event will continue tomorrow (3 April) with more than 800 industry professionals returning for another day of lectures on the latest practices in midwifery, Obstetrics & Gynaecology, women's healthcare and breast cancer.

According to Dr. Humeira Badsha, Consultant Rheumatologist, Al Biraa Arthritis and Bone Clinic in Dubai, and Advisory Board Member of the Women's Health Programme at Obs-Gyne 2012, cardiovascular disease, for example, is now known to be a major cause of death among women.

"The problem is that this is not well recognised leading to delays in treatment-seeking and diagnosis among women. The identification of gender differences in cardiovascular disease has made it possible to develop more effective health promotion and prevention strategies that have improved women's health in many countries," she says.

At the symposium, stroke and lung disease were also discussed as a major cause of death for women all over the world.

"About nine million women have a stroke each year and three million of these die as a consequence. High blood pressure, diabetes and high cholesterol are the main factors contributing to stroke. Although in this part of the world, women smoke less than their western counterparts, testing and controlling high blood pressure is the only way to prevent this killer disease," Dr. Badsha explains.

Hundreds of millions of women worldwide are affected by chronic lung diseases such as COPD (chronic obstructive pulmonary diseases), asthma and bronchitis with more than three million people worldwide dying from COPD alone. "COPD and asthma are the most common lung diseases in the region although the exact prevalence is unknown, it is under-recognized and the rates are rising," says Dr. Badsha. 

Steroids are a greater risk than methotrexate

In a study published in Annals of Rheumatic disease (feb 2012) the authors conclude that patients who use long term steroids are at a higher risk of non serious infections than patients who use methotrexate.  The risk of infections increases with increased steroid use.

How do you know if your arthritis medications are working?

If you have Rheumatoid Arthritis your Rheumatologist will prescribe medications called disease modifying drus.  In Dubai about 70 percent of Rheumatoid arthritis patients are eventually started on methotrexate.  How do we know if these medications are working?  The Rheumatologist should listen to your symptoms, and ask about you pain levels.  She should then do a thorough joint examination and make a note of how many swollen and inflamed joints you have.  A blood test called ESR and CRP is also used to track inflammation.  All these factors are then put into a computerized scoring system to give a DAS28 or disease activity 28 score.  A score < 2.6 means disease remission and < 3.2 means low disease activity.

Gastritis medications can increase your risk of fracture

According to a National Institutes of Health-funded study published online in the BMJ, "postmenopausal women who use proton pump inhibitors (medicines such as omeprazole, pantoprozole nexium etc) regularly are at increased risk for hip fracture, particularly if they have ever smoked. This is of concern especially in Dubai and the United Arab Emirates where people buy and use these gastritis medications over the counter.  In addition, women here have high levels of vitamin D deficiency and osteoporosis. " In fact, "the risk of hip fracture was increased by 35% among women who used these drugs for at least two years, compared with women who never used them (age-adjusted HR 1.35, 95% CI 1.12 to 1.62, P<0.01 for trend)." What's more, "the risk for fracture rose by more than 50% among women with a history of smoking (multivariate HR 1.51, 95% CI 1.20 to 1.91)," the study found.         For the study, researchers "collected data on almost 80,000 postmenopausal women. "Over the course of eight years, from 2000 to 2008, almost 900 hip fractures occurred -- a 35 percent increased risk for women using PPIs compared to women who didn't take the drugs.

Diagnosing Rheumatoid arthritis

Last week I saw a 50 year old lady from the UK and she had a 6 week history of pain and swelling in her right index finger and also toes.  When I examined her I found swelling and tenderness of 1 joint in the right 2nd finger (PIP) and 2 joints of the toes (MTP).  The signs were so minimal and even though she had a high titer positive Rheumatoid factor I did not believe she had full blown rheumatoid arthritis.  I repeated the rheumatoid factor which came back very high and she also had a positive test for anti- CCP.  Although she had minimal symtoms she was classified as early rheumatoid arthritis and we started her on methotrexate .  In this case the positive tests helped the diagnosis. 

Another patients I saw today had a 6 month history of swelling and tenderness of fingers and toes.  Many joints were involved but she had normal ESR CRP Rheumatoid factor and anti-CCP.  She was told she did not have rheumatoid arthritis.  I told her she has definite rheumatoid arthritis and she was started on treatment.  In this case the clinical signs are more important than the blood tests.

Classification criteria for RA (score-based algorithm: add score of categories A–D; a score of ≥6/10 is needed for classification of a patient as having definite RA)‡
A. Joint involvement §
1 large joint¶	0
2-10 large joints	1
1-3 small joints (with or without involvement of large joints)#	2
4-10 small joints (with or without involvement of large joints)	3
>10 joints (at least 1 small joint)**	5
B. Serology (at least 1 test result is needed for classification)††
Negative RF and negative ACPA	0
Low-positive RF or low-positive ACPA	2
High-positive RF or high-positive ACPA	3
C. Acute-phase reactants (at least 1 test result is needed for classification)‡‡
Normal CRP and normal ESR	0
Abnormal CRP or abnormal ESR	1
D. Duration of symptoms§§
<6 weeks	0
≥6 weeks	1

Milk powder can prevent gout flares. Posted by Rheumatologist in Dubai.

"Daily consumption of enriched skim milk powder could help prevent gout flares," according to a proof-of-conceptstudy published in the Annals of the Rheumatic Diseases. "Compared with patients randomized to receive control treatment with simple powdered lactose, those given enriched skim milk powder had greater reductions in flares of gout during a three-month period (P=0.044), according to Nicola Dalbeth, MD, of the University of Auckland in New Zealand, and colleagues." But "there was no difference in flare frequency for patients given plain skim milk powder rather than the enriched formulation, compared with those given lactose (P=0.81)," the study found.

        "In this study, researchers at the University of Auckland in New Zealand looked at the effects of drinking a skim milk powder enriched with two dairy components, glycomacropeptide (GMP) and G600 milk fat extract (G600), on the frequency of gout attacks in 102 people," WebMD (1/24, Warner) adds. "The people were divided into three groups" and "drank either the enriched milk powder, a plain skim milk powder, or a lactose powder mixed with water as a vanilla-flavored shake each day." The study found that "after three months, the frequency of gout attacks dropped in all three groups" but "those who drank the enriched skim milk had a significantly bigger reduction in gout attacks than those in the other two groups."

Knee replacements on the rise.

A new study published online on 17 January in the journal Arthritis & Rheumatism reports that rates of knee replacement surgery in Finland's 30 to 59-year-olds soared between 1980 and 2006, with women being the more common recipients throughout. Lead author Dr. Jarkko Leskinen, an orthopedic surgeon at Helsinki University Central Hospital, and colleagues also report that the greatest increase was among those aged between 50 and 59.

Knee replacement surgery is the common term for partial and total knee arthroplasty, an operation where part or all of the diseased or damaged surfaces of the knee joint are replaced with metal and plastic parts shaped to allow the patient to move the knee normally.

Arthroplasty is often the only treatment option for people who have severe osteoarthritis (OA) of the knee, as Leskinen explained the press:

"OA risk is shown to increase with age and for severe knee OA arthroplasty is a commonly used treatment option when patients are unresponsive to more conservative therapies."

But although arthroplasty has become increasingly more common, we don't have much information on rates among different parts of the population, and its effects in younger patients.

For their study, Leskinen and collegues looked at records of all unicondylar (partial) and total knee replacements performed between 1980 and 2006 in Finland. These records are kept by the Finnish Arthroplasty Registry.

They looked at how incidence rates of arthroplasty for knee osteoarthritis varied by gender, age, and hospital volume.

Their main findings show that:

• Rates of total knee replacement among those aged 30 to 59 went up 130-fold in the 27-year period.


• The incidence went up from 0.5 procedures per 100,000 of Finland's population to 65 per 100,000.


• The fastest rise happenend between 2001 and 2006 (from 18 to 65 per 100,000).


• There was a similar rapid rise in partial knee replacements: from 0.2 to 10 procedures per 100,000 of the population.


• In the last ten years of the study (1997 to 2006), the rate of total knee replacements was 1.6 to 2.4 times higher in women than in men.


• The rates of total and partial knee replacements were highest among 50 to 59-year-olds.

The researchers conclude that their study demonstrates "the rapid increase in incidences of arthroplasty among patients with primary knee osteoarthritis in Finland, especially in age group of 50 to 59 years of aged."

"There was no single explanatory factor behind this phenomenon though some of the growth might be due to the increase of incidences observed in low and intermediate volume hospitals," they note.

Leskinen said:

"Given that younger patients may be at higher risk of artificial knee joint failure and thus in need of a second replacement surgery, long-term data are needed before widespread use of total knee arthroplasty is recommended for this patient population."

In an accompanying editorial, Dr. Elena Losina, of Brigham and Women's Hospital and Harvard Medical School in Boston, Massachusetts, agrees with Leskinen. She writes that total knee replacement is an effective treatment for OA in older patients, those in their 60s, 70s and 80s.

"However, past performance may not guarantee future success, and with an increasing number of knee replacement recipients under 60 years old, more intensive study of arthroplasty outcomes in younger patients is warranted," she urges.

According to the World Health Organization (WHO), osteoarthritis is the fourth leading cause of years lived with disability worldwide.

Experts estimate that around 10 million people are living with osteoarthritis in the US, where over 600,000 knee replacements were carried out in 2009, according to a report from the Agency for Healthcare Research and Quality. A previous study estimated that by 2030 the number of such procedures could grow by over 670% to nearly 3.5 million a year.