Scorpion venom may lead to improved treatment option for rheumatoid arthritis

What are the best foods to reverse symptoms of rheumatoid arthritis?

Image: What are the best foods to reverse symptoms of rheumatoid arthritis?

Rheumatoid arthritis is a debilitating disease that causes the joints, usually in the hands, to become inflamed and painful. It usually affects older individuals, although people as young as 30 can suffer from the disease. Like most autoimmune diseases, there is no cure for rheumatoid arthritis, but effectively managing it begins with eating the right food.

There is strong evidence supporting the link between food and the symptoms and effects of rheumatoid arthritis, which can include swollen joints, pain, and disability. In a study published in the journal Frontiers of Nutrition, researchers found that the state of a person’s microflora, the bacteria in the gut, as well as a leaky gut, all contribute to the occurrence of rheumatoid arthritis.

Changes in a person’s diet, they found, can also have pronounced benefits. For instance, fasting produces ketones that help suppress the pro-inflammatory molecules that cause pain in rheumatoid arthritis. Shifting to a plant-based diet has also been found to reduce immune reactivity to antigens found in certain foods.

The Mediterranean diet against rheumatoid arthritis

Because of the close link between rheumatoid arthritis and inflammation, it goes without saying that the best diet for sufferers is one that incorporates a lot of anti-inflammatory foods. When it comes to ingredients that fight inflammation, nothing does it better than the Mediterranean diet.

The Mediterranean diet places a lot of emphasis on fresh fruits and vegetables, high-quality proteins, and whole, unrefined carbohydrates. According to experts, this diet is so healthy that it gives over 1,500 mg of polyphenols every day. Polyphenols are natural compounds with anti-cancer, anti-diabetic, and anti-allergenic properties.

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The Mediterranean diet is linked to a lower incidence of cardiovascular disease. One explanation for this is the liberated use of anti-inflammatory ingredients in almost any dish. Research has proven that many of the staples in this diet can help reduce the expression of pro-inflammatory compounds that may worsen rheumatoid arthritis. (Related: Study finds Mediterranean diet more effective cure for acid reflux than meds.)

Here are some of the pain-relieving and anti-inflammatory nutrients found in many of the foods under the Mediterranean diet:

  • Anthocyanins – These plant pigments are found in blueberries, blackberries, and eggplants. They are powerful antioxidants that reduce oxidative stress and help prevent inflammation.
  • Reservatrol – This antioxidant is abundant in grapes and red wine. Just like anthocyanins, it is a powerful antioxidant that helps protect the joints from inflammation and damage.
  • Mangiferin – Another antioxidant, this time found in mangoes, mangiferin is so powerful that it has been described as having the ability to prevent the destruction of joints.
  • Kaempferol – A compound found in grapefruit, kaempferol reduces the molecules that destroy the bones and the cartilage. The degradation of these parts is one of the main causes of pain of rheumatoid arthritis.
  • Bromelain – This compound from pineapples is known for being a potent anti-inflammatory agent. Studies vouch for its efficacy as a pain reliever that does not cause any adverse effects.
  • Oleic acid – Found in olive oil, this is one of the hallmark ingredients in the Mediterranean diet. This compound is known to provide therapeutic and protective effects from rheumatoid arthritis. When consumed by people without the condition, oleic acid can lower the risk of developing the disease.
  • Curcumin – This compound is found in turmeric and is known for its antioxidant and anti-inflammatory effects. Some studies say that turmeric is best combined with ginger, yet another anti-inflammatory food, to maximize its ability to relieve rheumatoid arthritis pain.
  • Probiotics – These “friendly” bacteria help promote digestion and improve the overall health of the gut. They can help prevent the negative effects of leaky gut and offset bad bacteria that may be causing damage to the body. Probiotics are found in fermented foods. Lactobacillus casei, for instance, is found in yogurt.

Learn which foods you need to eat to relieve body pain at

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A potential remedy for rheumatoid arthritis may be found in this Ayurvedic medicine

Image: A potential remedy for rheumatoid arthritis may be found in this Ayurvedic medicine

The classical Ayurveda medicinal system offers a potential remedy for the often crippling pain of rheumatoid arthritis. Indian researchers recently tested the efficacy of two Ayurvedic medicines – Bhallatakadi Churna with guda and Bhallatak guggulu – in relieving the painful symptoms of the chronic autoimmune disease.

Ayurveda describes rheumatoid arthritis as “Amavata.” Over the centuries, many herbal remedies have been devised to treat this disease.

Ama is a slimy substance similar to mucus. It is produced by digestive and metabolic problems and clogs the channels of the body. Ama combines with the harmful substance vata to create amavata, an agonizing disease that can cause deformities.

The Ayurveda’s description of amavata matches etiopathogenesis of rheumatoid arthritis. Modern medicine traces the disease to inflammatory mediators that injure the micro blood vessels in the joints.

Researchers from the Government Ayurvedic College – Burhanpur (GAC Burhanpur) and the National Institute of Ayurveda (NIA) tested an Ayurvedic medicine prescribed for rheumatoid arthritis. Bhallatak guggulu yoga is made from four herbs that prevent inflammation, control immune response, scavenge free radicals, protect cartilage, and exhibit anti-arthritic activity.

Furthermore, the researchers hoped to improve the management of patients with rheumatoid arthritis, thereby allowing the latter to enjoy higher quality of life. (Related: Natural remedy for rheumatoid arthritis found in this traditional Chinese ethnomedicine.)

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Two Ayurvedic medicines tested on rheumatoid arthritis patients

The clinical trial involved 60 patients with rheumatoid arthritis in the age range of 20 to 60 years, with many of them being 41 to 50 years of age. The majority of them (85 percent) were female. They were randomly divided into two groups of 30 participants.

The first group received daily doses of 2.5 grams of Bhallatakadi churna with guda, another Ayurvedic medicine recommended for treating Amavata. The second group was given 500 milligrams of Bhallatak guggul medicine, the primary target of this study.

The intervention period lasted for three months. Every 15 days, the researchers performed follow-ups on the participants.

At the end of the trial, the researchers analyzed the results of the Ayurvedic therapy based on the following criteria: body ache, loss of appetite, listlessness, heaviness of body and joint, thirst, fever, indigestion, and pain.

Participants also rated the pain, swelling, stiffness, and tenderness of their joints. Finally, the researchers measured the effects of either substance on the rheumatoid arthritis factor, the antiseptrolysin O titer, and C-reactive protein level of the patient.

Effects of Bhallatak guggul on Amavata considered to be statistically significant

The researchers found that Bhallatakadi churna with guda and Bhallatak guggul were both able to improve the primary symptoms of rheumatoid arthritis. Statistics-wise, the effect of the two Ayurvedic treatments were considered to be very significant.

The results on general symptoms – which included pain, stiffness, and tenderness of the joints – were also regarded as statistically significant. So were the effects of the trial medicines on the rheumatoid arthritis factor, the antiseptrolysin O titer, and C-reactive protein of patients.

The data matched the etiology of Amavata as described in the Ayurvedic classics. This supported the similarities between the description of this disease and the etiology of rheumatoid arthritis.

Bhallatak Guggulu is made up of four herbs: Haritaki, Bhallatak, Tila and Guda. Each herb played important roles in stopping the pathogenesis of Amavata, thereby alleviating the symptoms of the disease.

The researchers concluded that both Ayurvedic regimens were able to provide significant relief for patients with Amavata. However, patients who received Bhallatak Guggulu enjoyed faster and greater improvement of their symptoms when compared to the Bhallatakadi churna with guda treatment group.

Therefore, Bhallatak Gugguli was considered to be the superior Ayurvedic remedy for reducing the painful effects of rheumatoid arthritis.

Additional articles about Ayurveda-based natural remedies that can alleviate rheumatoid arthritis can be found at

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2 Weeks Off Methotrexate OK for Flu Vaccine

Immunogenicity improved with no increase in RA disease activity

Stopping methotrexate for 2 weeks after the administration of flu vaccine led to improved immunogenicity without increasing disease activity among patients with rheumatoid arthritis (RA), a prospective Korean study showed.

Among patients in whom methotrexate was withheld for 2 weeks, a satisfactory vaccine response was seen in 75.5% compared with 54.5% of those who continued on the drug, according to Eun Bong Lee, MD, of Seoul National University College of Medicine, and colleagues. A satisfactory response was an increase of at least four-fold in the hemagglutination inhibition antibody titer from baseline 4 weeks after the vaccination against two or more of four of the current vaccine strains.

The difference between the group with temporary methotrexate discontinuation and those who continued was 21% (95% CI 10.6%-31.7%, P<0.001), the researchers reported online in Annals of the Rheumatic Diseases.

RA patients are more susceptible to infections than the general population because of the underlying immune dysfunction and the immune suppression associated with treatments, so vaccines are strongly recommended for these patients by groups such as the American College of Rheumatology and the European League Against Rheumatism.

Methotrexate remains the anchor drug for the treatment of RA, but it can interfere significantly with the response to influenza and pneumococcal vaccines. The researchers previously conducted a pilot study of methotrexate discontinuation for 4 weeks after the seasonal flu vaccine, finding increased immunogenicity but also a 1.4-fold risk of disease flare.

They conducted a randomized, parallel-group study comparing a 2-week methotrexate discontinuation versus continuation in 316 patients with RA.

Participants were recruited from October 2016 to January 2017. That year’s seasonal quadrivalent vaccine included the H1N1, H3N2, B-Yamagata, and B-Victoria strains. Serum was collected before the vaccine was administered and again at week 4.

During the discontinuation period, patients who experienced flares could take acetaminophen, nonsteroidal anti-inflammatory drugs, and prednisone in dosages up to 10 mg/day.

More than 80% of patients were women, mean age was 53, and mean disease duration was 6.9 years. Baseline Disease Activity Score in 28 joints (DAS28) was 2.3 in the discontinuation group and 2.2 in the continuation group. About half were taking glucocorticoids, with mean doses of 1.8 mg/day. Mean methotrexate dose was 13.2 mg/week.

The proportion of patients who achieved at least a four-fold increase in antibody titer in more than one of the four strains was 89.4% in the discontinuation group versus 75.6% in the continuation group, for a difference of 13.8% (95% CI 5.4-22.1, P=0.001). The proportions having a response to three of the four strains were 61.9% versus 36.5%, for a difference of 25.4% (95% CI 14.3-36.4, P<0.001), and for all four strains, the proportions were 45.6% versus 21.8%, for a difference of 23.8% (95% CI 13.4-34.3, P<0.001).

For the specific influenza antigens, the discontinuation group had a higher frequency of response, with differences of 11.9% (95% CI 0.9%-22.8%, P=0.033) for H1N1, 16.8% (95% CI 6.1%-27.4%, P=0.002) for H3N2, 22.7% (95% CI 11.7%-33.7%, P<0.001) for B-Yamagata, and 32.8% (95% CI 21.8%-43.6%, P<0.001) for B-Victoria.

Baseline seroprotection against the four antigens was similar between the discontinuation and continuation groups, but postvaccination seroprotection rates were higher in the discontinuation group, with differences of 10.7%, 15.9%, 13.7%, and 14.7%, respectively.

No differences in vaccine response was seen for patients whose methotrexate dosage was 7.5 mg/week or less, but significant differences were observed for those on 15 mg/week or more.

No serious adverse events were reported.

For disease activity, the change in DAS28 was only 0.1 point in both groups. Flares occurred in the 4 weeks after vaccination in 5.1% of the continuation group and in 10.6% of the discontinuation group, which was not a significant difference (P=0.07). Rescue medications for joint pain were used during that follow-up period by 4.5% of the continuation group and in 6.3% of the discontinuation group (P=0.487). For all patients who experienced a flare, disease activity declined to baseline when methotrexate was restarted.

The researchers noted that the vaccine response was more prominent for the type B strains of the virus, to which fewer individuals have had prior exposure. For the more common H1N1 and H3N2, response rates increased by 11.9% and 16.8%, respectively, whereas for the B-Yamagata and B-Victoria strains, the increases in response were 22.7% and 32.8%.

“These results suggest that this methotrexate discontinuation strategy might be more crucial for response to influenza viruses relatively new to humans,” they observed.

A study limitation was its inclusion of only Korean patients who had stable disease. “Further studies testing the generalizability of our results to patients with moderate to high disease activity or other ethnicities are warranted,” the authors concluded.

Biologics Seem to Protect Against Sepsis in RA

Sepsis risk spikes with discontinuation of biologics.

Patients with rheumatoid arthritis (RA) who were being treated with biologic therapies and developed serious infections had a lower risk of sepsis than if they were on conventional agents, German researchers reported.

Among patients on biologics at the time of the infection, the risk of sepsis was almost halved, with an odds ratio of 0.56 (95% CI 0.38 to 0.81), according to Anja Strangfeld, MD, of the German Rheumatism Research Center in Berlin, and colleagues.

Sepsis results from a dysregulation of the inflammatory response following exposure to an infectious agent. It “is a major concern in patients with serious infections because it results in a case fatality rate of 30 to 50%. Older patients are particularly susceptible to sepsis because of hospitalization, comorbidity, and impaired physical function,” the researchers wrote in the September Annals of the Rheumatic Diseases.
Patients with RA are at increased risk of infections, and this is further elevated by the use of immunosuppressive therapies — including biologics — as well as disease comorbidities and complications of joint surgeries.
Several decades ago it was shown that tumor necrosis factor (TNF) was a key player in the cascade of events comprising sepsis, but early clinical trials using TNF inhibitors found no survival benefit, until an animal study suggested that the timing of anti-TNF exposure was crucial for ensuring survival following infection.
None of the earlier trials examined whether being on TNF inhibition at the time of serious infection influenced progression to sepsis, either aiding in recovery or worsening the risk. Therefore, Strangfeld and colleagues analyzed outcomes from the German biologics register, which had enrolled more than 12,000 patients on biologics or conventional disease-modifying anti-rheumatic drugs (DMARDs) by 2013.
Among the cohort, 1,017 serious infections were reported, with the most common being pneumonia, in 28.4%, bone and joint infections in 11.2%, and respiratory tract infections other than pneumonia in 10.3%.

A total of 11.7% progressed to sepsis within 1 month, and the case fatality rate was 63%. Among the patients whose infections did not lead to sepsis, the fatality rate was 6.2%.
Compared with the register cohort in general, patients who developed serious infections were older, had longer duration of disease and greater disease activity, as well as more comorbidities.
In a generalized estimating equations model, older age was associated with a higher risk of both sepsis (OR 1.41 for each 10 years, 95% CI 1.15 to 1.74) and death (OR 2.47, 95% CI 1.61 to 3.79). Underlying chronic renal disease also was associated with an increased risk of sepsis (OR 1.93, 95% CI 1.19 to 3.14), while heart failure was linked with a significantly higher mortality risk (OR 3.56, 95% CI 1.73 to 7.33).
Compared with conventional DMARDs, treatment specifically with a TNF inhibitor at the time of infection lowered the risk of sepsis (OR 0.64, 95% CI 0.42 to 0.97) and death (OR 0.48, 95% CI 0.24 to 0.95). Treatment with other biologic agents also was protective against sepsis (OR 0.45, 95% CI 0.25 to 0.80) and mortality (OR 0.16, 95% CI 0.05 to 0.54).
“The effective immunosuppression via biologic DMARDs may prevent an unregulated host response to serious infection and the development of sepsis,” Strangfeld and colleagues stated.

The researchers then compared outcomes among patients who had not previously received a biologic at the time of the infection (n=134), those who were on a biologic (n=517), and those who had been on a biologic but stopped it more than a month before (n=212).
There were 133 serious infections in the biologics-naive group, 515 in the current biologics group, and 211 in the biologics-discontinued group. Sepsis developed in 17.3% of the biologics-naive group and in 18.4% of the biologics-discontinued group, compared with 11.3% of patients currently on biologics.
After adjustment for age, sex, steroid dose, physical function, and comorbidities, the odds ratios for sepsis (OR 0.97, 95% CI 0.56 to 1.70) and death (OR 0.96, 95% CI 0.42 to 2.17) among those who had discontinued biologics did not differ from those who had never received a biologic.
In contrast, the adjusted risk for sepsis (OR 0.57, 95% CI 0.34 to 0.97) and death (OR 0.34, 95% CI 0.15 to 0.80) was significantly lower for those currently receiving a biologic compared with those never given biologics.
The impact of discontinuation of biologic therapy on sepsis was an important finding of the study, according to the authors.

“It is common knowledge that initiation of biologic DMARD therapy increases the risk of serious infections. Further, discontinuation of biologic DMARDs is supposed to decrease the risk of serious infection,” they wrote.
“Our results suggest a different mechanism: adverse outcomes of serious infections (sepsis and death) were more likely in biologics-naive patients than in patients exposed to biologic DMARDs at the time of serious infection, which could indicate a protective effect of biologic DMARDs,” they explained. But that protective effect was lost when biologics had been stopped, they pointed out.
“Discontinuation of biologic DMARDs seems to shift the risk from an increased susceptibility to serious infections to more severe outcomes,” they observed.
However, the results of this study need to be confirmed.
A limitation of the study was the possibility of “suspicion bias,” with patients on biologic therapies possibly being hospitalized more quickly and followed more closely if they developed serious infections.

MRI Findings Match Patients’ Experience With RA

Patient-reported outcomes in rheumatoid arthritis (RA) correlate independently with measures of inflammation and structural damage on MRI scans, according to data from a longitudinal study.

For example, at 1 year, the change in MRI-detected synovitis was significantly associated with changes in physical function on the Health Assessment Questionnaire (HAQ) (beta = 0.53, 95% CI 0.029-0.077, P<0.001), according to Joshua F. Baker, MD, of the University of Pennsylvania in Philadelphia, and colleagues.

In addition, change in synovitis at 1 year was associated with pain scores (beta = 0.16, 95% CI 0.058-0.25, P=0.002) and patient global assessment (beta = 0.16, 95% CI 0.066-0.25, P=0.001), the researchers reported in Annals of the Rheumatic Diseases.
The association between longitudinal MRI measures and changes in patient-reported outcomes had not been assessed previously. For this analysis, the researchers used a cohort of 291 patients with MRI scores for synovitis, osteitis, and/or bone erosion from a larger group enrolled in the Go-BEFORE placebo-controlled clinical trial, which randomized methotrexate-naïve patients to golimumab (Simponi), methotrexate, or the combination.
MRIs were obtained at the patient’s dominant wrist and second to fifth metacarpophalangeal joints, and the images were scored by two independent readers.
Correlations between the RA-MRI scoring system (synovitis, osteitis, and bone erosion) and physical function, pain, and global patient scores, were determined at weeks 0, 12, 24, and 52. Patients then were followed for an additional year.
MRI measures were associated with scores on the HAQ at all assessments, while MRI measures were increasingly associated with pain and patient global scores at later follow-up time points.

“Improvements in synovitis at 12, 24, and 52 weeks were generally associated with greater improvements in HAQ, pain and patient global scores,” wrote Baker and colleagues. Changes in bone erosion were associated positively with changes in pain and patient global at later follow-up times.
In longitudinal regression models, synovitis was significantly associated with HAQ independent of the disease activity score in 28 joints (DAS28) using C-reactive protein (CRP). Synovitis was also associated with pain and patient global scores independent of CRP and swollen and tender joint counts.
Further, longitudinal models demonstrated that progression in bone erosion was associated with worse physical functioning, independent of synovitis and DAS28-CRP. These findings suggest that MRI measures are valid as RA biomarkers, and that the associations are independent of clinical disease activity.
“Thus, for two individuals with similar clinical assessments, the individual with greater synovitis on MRI is likely to have worse pain and function. These data indicate that synovitis and bone erosion are complementary to other clinical parameters in terms of relevance to the patient experience.”
“The current study suggests that progression in the MRI erosion score (>0.5) is associated with a change in HAQ of 0.35 at 1 year,” the investigators wrote. “In addition, a 4.4-unit change in MRI erosion score would translate into a change in HAQ of 0.2.”
There was no relationship found between x-ray progression of disease and functional decline over 1 year, which suggests that MRI may be a better discriminator of functional decline, the authors suggested.
“Of note, we found that changes in synovitis were more strongly correlated with HAQ during the treatment of active inflammation in year 1, while changes in bone erosion were correlated similarly throughout the 2-year period,” the authors added.
The correlations between patient-reported outcomes and MRI measures were similar regardless of the treatment received.
They concluded that, “improvements over time in MRI inflammation and deterioration in MRI damage correlate with changes in function, pain and patient global scores, suggesting that these objective measures reflect how patients experience their disease.”
Because of the correlation found between patient-reported outcomes and MRI measures, these measures may serve as a reasonable surrogate endpoint in observational and early interventional studies, they noted.
The findings of this analysis may not be entirely generalizable beyond the study population, according to the authors. The study also was limited in the patient-reported outcomes that were available as part of the randomized trial. Furthermore, there have been advances in MRI since the study was undertaken some 10 years ago, which may improve visualization of inflammation and structural changes.

Rheumatoid arthritis patients suffer sexual dysfunction

Over one-third of patients with rheumatoid arthritis are sexually dysfunctional and suffer from low libido, painful intercourse, orgasmic dysfunction, and overall sexual dissatisfaction, according to research presented during the European League Against Rheumatism (EULAR) annual congress held recently in London, England.

“Sexuality is an important dimension of personality and human body, therefore any involvement in this area should be considered as important,” the researchers said. “Sexual disturbances in rheumatoid arthritis patients are poorly described in literature.”

The researchers interviewed a sample of 1.290 patients from a specialized rheumatoid arthritis clinic of whom 1,048 (80.74 percent) were women and 250 (19.26 percent) were men. Average disease activity was low and average age was 55.1 years. The researchers did not control the study with non-rheumatoid arthritis patients. [EULAR 2016, abstract OP0308-HPR]

Forty percent of women reported no sexual activity. Of the sexually active women (59.8 percent), 60.1 percent reported satisfactory sexual activity while 16.1 percent reported no satisfactory sexual activity, 7.8 percent reported lack or loss of sexual desire, 13.7 percent reported dyspareunia, and 2.2 percent reported orgasmic dysfunction.

Thirty-one percent of men reported no sexual activity. Of the sexually active men (69.2 percent), 49.1 percent reported satisfactory sexual activity while 12.1 percent reported premature ejaculation, 13.2 percent reported no satisfactory sexual activity, 5.8 percent reported a lack or loss of sexual desire, 16.1 percent reported orgasmic dysfunction, and 3.4 percent reported dyspareunia.

“There was statistical significance between patients reporting no sexual activity and higher disease activity,” the researchers said.

Though there were no statistically significant precipitating factors associated with sexual disorders and disease activity, and in a majority of patients there were no precipitating factors at all, non-significant precipitating factors included infidelity, insecurity in sexual role, and biological or physical causes, all of which were more common among women.

Maintenance factors were similarly statistically non-significant and in the minority, but these included biological causes, infidelity, changes in relationship, partner’s sexual dysfunction, and depression and anxiety, again, more common among women than men.

“There are many factors that may influence the prevalence and worsening of sexual disturbances; higher [disease activity score] is correlated with [less] sexual activity,” said lead author Dr. Pedro Santos-Moreno of the Biomab, Center for Rheumatoid Arthritis in Bogota, Colombia, citing prior work that showed improving disease activity does improve patients’ sexual drive, but that drug therapy may not be enough.

Santos-Moreno suggested clinics with a high volume of rheumatoid arthritis patients might benefit from the presence of a psychologist familiar with sexuality issues.

Rheumatologists more likely to underestimate impact of osteoarthritis than rheumatoid arthritis

Despite having a higher burden of disease, individuals with osteoarthritis (OA) are more likely to have their condition underestimated by rheumatologists than individuals with rheumatoid arthritis (RA), according to a study presented at the European League Against Rheumatism Annual Congress (EULAR 2016) held in London, UK.

To analyse the discordance between physician global estimates (DOCGL) and patient global estimates (PATGL) in patients with RA (n=216) or OA (n=243), patients were asked to complete a multidimensional health assessment questionnaire/routine assessment of patient index data (MDHAQ/RAPID3) while physicians used the RheuMetric checklist, both of which enabled evaluation of disease severity on a visual analogue scale (VAS). [EULAR 2016, abstract OP0094]

Patients with RA were more likely to be in concordance with their physicians (67 percent, n=144) compared to OA patients (56 percent; n=136).

Patient perception of disease severity exceeded that of physician perception (PATGL>DOCGL) in 82 OA patients (34 percent) and 39 (18 percent) RA patients, while physician perception was higher than patient perception of disease severity (DOCGL>PATGL) in 33 RA (15 percent) and 25 OA patients (10 percent).

There was an almost two-fold greater likelihood that rheumatologists would underrate OA compared to RA, said study author Dr. Isabel Castrejón from the Rush University Medical Center, Chicago, Illinois, US who presented the results.

Dr. Isabel Castrejón

In both diagnosis groups, higher perception of disease severity was more likely in patients with lower education levels, higher levels of pain, disability, fatigue, and joint counts, and more symptoms. Experiencing higher levels of pain was found to be a significant predictor of discordance for both diagnosis groups, said Castrejón.

Previous studies have pointed to discordance between patient and physician assessment of rheumatic disease severity. [Arthritis Care Res (Hoboken) 2014;66:934-942; Arthritis Care Res (Hoboken)2012;64:206-214]

“Concordance by patients and physicians has been associated with greater expectations for improvement and better outcomes. It is important to be able to recognize discordance by patients and physicians because that can influence treatment adherence, compliance, and future outcomes,” said Castrejón.

“RA is generally thought to be more severe than OA, not only by physicians but also by patients and the public,” said Castrejón. “Rheumatologists need to revise their generally held views that OA is less severe than RA,” she said, while stressing on the importance of good communication between patients and physicians.

Do You Smoke to Cope With Pain? Research Finds Surprising Effect

If you find yourself lighting a cigarette when you’re in pain, you’re not alone. Many people smoke to cope with chronic pain. But here’s the kicker: Research shows that tobacco use overall – both smoking and chewing tobacco – can actually trigger pain. It also can make pain medication less effective.

The situation is complicated for smokers. More than half of chronic pain sufferers who seek pain management therapies smoke.

Tobacco use plays an active role in a wide variety of pain types, says pain management specialist Benjamin Abraham, MD.

In many cases, if you stop smoking, you can reverse the impact. In other cases, the damage is permanent.

The many pains of smoking

Tobacco use affects different areas of the body and the body’s systems in different ways.

Circulatory system: The nicotine in cigarettes and chewing tobacco decreases circulation, a condition also called peripheral artery disease (PAD).

The condition leads to atherosclerosis, a stiffening of the arterial walls that contributes to coronary artery disease. PAD also starves the heart muscle of needed oxygen and causes chest pain, called angina.

Lower back: Research shows that current and former smokers are 2.7 times more likely to have pain in the lower back than people who have never smoked. This link is strongest among adolescents, Dr. Abraham says.

Several factors contribute to the link between smoking and back pain:

  • Constricted blood vessels make it harder for necessary nutrients to reach the intervertebral discs responsible for spinal movement.
  • Decreased blood supply can cause degenerative lesions on these discs.
  • Smoking increases the risk for osteoporosis, which can cause fractures and deformities in the lower spine.

Joint pain: Smoking also contributes to joint pain linked to other conditions, such as rheumatoid arthritis (RA), Dr. Abraham says.

Recent studies label smoking as one of the biggest contributing environmental risk factors for developing RA.

Male smokers are twice as likely to develop RA, and female smokers are 1.27 times as likely as non-smokers. Smokers who have a genetic risk for RA are four times as likely to develop the condition.

Central nervous system: Smoking increases the level of pro-inflammatory cytokines floating in the blood stream.

Cytokines trigger the central nervous system, amplifying existing pain from the very first cigarette, Dr. Abraham says. Consequently, smokers require greater amounts of both over-the-counter and narcotic medications to control pain.

Menstrual cycle: According to a study in the British Medical Journal, women who begin smoking by age 15 are 50 percent more likely than non-smokers to have cramps that last two or more days during their period.

Tooth pain: Research shows smokers face a 30 percent increase in the risk of tooth pain. Researchers suspect the pain develops because tobacco reduces saliva and also leads to progressive tooth decay and poor wound healing.

Headache: Smokers are also 1.5 times more likely to get headaches than people who have never smoked.

Cluster headaches – severe headaches that last between 15 minutes and three hours – are common among smokers. Eighty percent to 90 percent of cluster headache sufferers have a significant history of smoking tobacco, Dr. Abraham says.

Can the painful damage be reversed?

The medical industry currently doesn’t know if there is any safe level of cigarette use, Dr. Abraham says. Much depends on gender, age and other contributing factors of disease, but some research suggests that as few as 10 cigarettes can induce an increase in general pain, slower healing, worse surgical outcomes, and more pain after surgery.

Tobacco-induced damage to structures linked to long-term pain, such as degenerative disc disease, does not heal on its own. However, in some areas, including the circulatory system, smoking cessation can reverse tobacco’s effect on pain, Dr. Abraham says.

Medical case..A 52-year-old woman was admitted to the ICU

A 52-year-old woman was admitted to the ICU because of respiratory failure. She originated from India but ran a coffee shop in Canada for 10 years. She developed right knee arthritis 3 years earlier. Following consultations from orthopaedics and rheumatology, she was diagnosed as having rheumatoid arthritis and eventually treated with methotrexate for 18 months. This was stopped 1 month prior to admission because of the development of anemia and nausea. She presented to the hospital with bilateral leg swelling and pain of 3 days’ duration and marked dyspnea worsening over 2 to 4 weeks.

On examination, she was afebrile with a clear chest. There was bilateral leg swelling and the right knee was warm and tender and flexed at 10°. Her laboratory test results revealed the following values: hemoglobin, 11.1 g/dL (111 g/L); WBC count, 34,000/ μL (34.0 × 10^9/L); sodium, 129 mEq/L (129 mmol/L); creatinine, 2.0 mg/dL (176 μmol/L); BUN, 30.5 mg/dL (10.9 mmol/L); and calcium, 11.9 mg/dL (2.97 mmol/L). Her initial chest radiograph (posteroanterior and lateral) (Figs 135-A, 135-B, respectively) and representative images of a chest CT scan (Figs 135-C, 135-D) as well as a knee radiograph (Fig 135-E) are shown. Two days later, she developed worsening lung infiltrates shown on her repeat chest radiograph (Fig 135-F) and was admitted to the ICU to receive mechanical ventilation support. Bronchoscopy and BAL findings were negative. An open lung biopsy was performed, and specimens are shown in Figures 135-G and 135-H. The most likely diagnosis is:

A. Methotrexate-induced lung disease.
B. Miliary TB with ARDS.
C. Metastatic osteosarcoma.
D. Sarcoidosis.

This patient presents with a long history of a monoarthritis treated aggressively as rheumatoid arthritis with methotrexate. She has evidence of systemic infection and hypercalcemia. The knee radiograph demonstrates marked destructive changes compatible with an infectious process. The chest radiographs show a miliary pattern confirmed by the CT scan. The hematoxylin-eosin-stained lung biopsy specimen (see Fig 135-G) demonstrates granulomatous inflammation. Areas of diff use alveolar damage with hyaline membranes consistent with ARDS (not shown on the
biopsy) were also seen. Tissue culture confirmed the presence of Mycobacterium tuberculosis and the Zeihl-Neelsenstained specimen (see Fig 135-H) demonstrates acid-fast bacilli (choice B is correct).

A negative BAL finding in the setting of miliary TB is not uncommon and cannot be used to exclude the diagnosis. Hypercalcemia has been reported with all granulomatous diseases, including TB. While methotrexate can cause drug-induced lung disease, it less frequently causes granulomatous lung inflammation compared with TB and would not account for the hypercalcemia and knee changes (choice A is incorrect). There is no evidence of a malignancy in the lung biopsy (choice C is incorrect). Sarcoidosis certainly could account for the military pattern seen on chest CT scan and hypercalcemia. However, this diagnosis would not explain the rapid progression to respiratory failure with ARDS or the finding with the Zeihl-Neelsen stain (choice D is incorrect).

Occasionally, patients with TB develop respiratory failure and require support by mechanical ventilation. A retrospective 2-year study in two medical ICUs in France identified 99 patients with pulmonary TB, most with immunodeficiency. Mechanical ventilation support was required in 50 of these patients, and 22 patients met criteria for ARDS. The 30-day mortality rate was 26%. Factors predictive of a poor outcome included delay in diagnosis, increased number of organ failures, serum albumin level > 2 g/dL (>20 g/L), and increased number of lobes involved on chest radiograph. A previous study indicated that hospital mortality in patients with TB who required support by mechanical ventilation was significantly greater than patients with nontuberculous pneumonia requiring support by mechanical ventilation and similar to the hospital mortality for patients with ARDS of any cause. The majority of the patients with TB requiring support by mechanical ventilation developed ARDS. This observation appears more common among patients with miliary TB than patients with tuberculous pneumonia.