Posts Tagged ‘Rheumatologist’
The hedonistic lifestyles of certain musicians will be familiar to many readers, but the unexpected dangers of playing a musical instrument may not.
Aware that I have an interest in musicians’ health, last week a medical colleague alerted my attention on Twitter to an interesting article in the October 2013 edition of Der Hautarzt (German dermatology journal), describing a condition I hadn’t heard before of called ‘fiddler’s neck’.
Fiddler’s neck is a condition where the afflicted violin (or viola) player develops an unsightly mark on the neck — just beneath the angle of the jaw. Although not that well recognised among dermatologists, it is better known among musicians as ‘violin hickey’ because of its resemblance to a more common condition (of quite different aetiology) seen in teenagers. The abnormality is due to an area hyperpigmentation and lichenification of the skin due to the rubbing of the instrument on the neck (erythema, scaling, cyst formation, scarring and inflammatory papules or pustules also occur). The article describes the development of a ‘violin hickey’ in (an undoubtedly embarrassed) 72-year-old lady.
Reading about this curious affliction prompted a ‘knight’s move’ wander through the literature on instrument-specific afflictions — and there’s lots to choose from.
Violinists who succumb to violinist’s hickey are also, presumably, susceptible to a condition known as ‘fiddler’s jaw’ (a condition akin to temporomandibular joint disorder, which comes about because of the way the violin is ‘clamped’ between the angle of the jaw and the shoulder), ‘fiddler’s finger’ (Garrod’s pads of the dorsal interphalangeal joints of the left index and middle fingers) and ‘pizzicato paronychia’ (infection in the nail-fold in string players secondary to pizzicato playing). A similar condition can also develop in pianists.
‘Fiddler’s neck’ is better known among musicians as ‘violin hickey’ because of its resemblance to a more common condition seen in teenagers
Jazz aficionados will immediately recognise the ballooned-cheeked appearance of ‘Satchmo’s syndrome’ in trumpet player ‘Dizzy’ Gillespie. The condition, originally named after Louis ’satchel mouth’ Armstrong, occurs in trumpet players, trombonists and French horn players comes about as a result of rupture of the orbicularis oris muscle (due to high pressures generated while playing high notes). Pressing the hard metal mouthpiece hard against the soft tissues of the lips without warming up can also cause injury; Freddie Hubbard, the well known jazz trumpeter, allegedly tore his lip during an “ill-advised high-note cutting contest” with another trumpeter, according to the Jazz Times in 2009.
Other hidden dangers of playing wind instruments include ‘flautist’s chin’ — a dermatological condition brought about by irritation from saliva and possibly nickel allergy, and ‘clarinetist’s cheilitis’ (perhaps explaining the ubiquity of the ‘jazz goatee’ in certain musicians). The spread of herpes, HPV and hepatitis have also been described due to the use of instruments that have not been cleaned properly (again, much like ‘violin hickey’, other aetiologies may need to be considered).
Both ‘guitarist groin’ (lower-limb DVT due to the pressure of a guitar held in the classical posture for long periods on the flexed thigh) and ‘guitar nipple’ have also been described. The latter is a form of ‘traumatic mastitis’ and was originally described in a letter to the BMJ in 1973. The case series describes a series of younger female guitarists, who all developed a cystic swelling about the base of the nipple. The cause, it seems, was the playing of full-sized guitars (by younger musicians) and direct trauma to the nipple area by the instrument.
Shortly after the ‘guitar nipple’ report was published, the BMJ published a letter describing an intriguing condition known as ‘cello scrotum’. The eight-line letter, published in 1974, describes the case of a professional cellist who developed an inflamed scrotum which, the author suggested, came about as a result of playing the cello for several hours a day.
Whereas the accuracy of the report was later questioned by other commentators (one suggesting that scrotal friction against the supporting chair was more likely to be responsible than direct cello trauma, per se), it was frequently cited in the literature over the years until the original author finally wrote to the BMJ in 2008, admitting that the case had been fabricated. The original letter had actually been signed and submitted by the Chairman of a brewery in Suffolk (the husband of a doctor) as a practical joke — never expecting that it might be published.
Hopefully there’s no practical jokers among the authors of the reports of the other conditions described.
This article was originally published in The Medical Independent
Anyone who’s been in my office in the last year or so might have noticed two little girls looking down at them from my wall.
The photo caught my eye at an exhibition by Galway photographer Joe O’Shaughnessy a few years ago so I bought it, not really knowing where to put it. Recently, in an effort to cheer up my office a bit, I decided to dust it off and hang it on my office wall.
It has been a great hit with patients. There’s something about the cheeky, defiant pose of these twins (pictured on their first day at school), that raises a smile in most who notice it. I recognise the flicker of distraction in patients eyes as they register the picture behind me, the pause, smirk and then the questions. ‘Are they your girls?’ they ask. ‘Aren’t they just great!’ ‘Are they twins?’ ‘I’ve seen that look before!’
Truth be told, the time it takes to explain how the picture came to be there, and answer questions about it slows me down and probably contributes to my running behind a little. Nonetheless, its here to stay. People seem to take strength from these two brave girls as they prepare for their journey into the unknown.
A first visit to a hospital can be intimidating, disorientating, and stressful for patients. Much like our first day at school, it may not be as bad as you think.
Thanks to Nicole and Rachel Healy and their Mum Mairead for permission to use this picture. Good luck in the Leaving Cert girls.
There used to a be small record shop in my home town called Zhivago Records. It’s owner, Pat Pyne, stocked most of the stuff in the music charts, some ‘The Cure’ and ‘Led Zepellin’ T shirts, blank audio cassettes, and a ‘local interest’ section comprising (largely dodgy) Irish music for tourists. Although I sometimes found the limited selection of music available frustrating, choosing was easy and it largely satisfied my musical tastes at the time. Zhivago went out of business 2 years ago.
My first visit to Tower Records in London’s Picadilly Circus in the 80’s, opened my mind to a new world of musical posibilities that I didn’t even know existed. The 25,000 sq ft shop in Picadilly Circus housed what seemed to be an infinite collection of music and catered to every imaginable taste.
Although the having so much more music to choose from was exhilarating, I confess that I also found the the experience made me anxious (that I might miss THAT one special album or make a choice that was deeply unfashionable), frustrated (not knowing where to start looking or forget what it was I came into buy in the first place) and even a little hostile towards the knowledgeable (but sometimes patronising) shop assistants working within the genre subsections of the shop.
What should have been the ultimate shopping experience sometimes ended in my leaving rather overwhelmed and disappointed by the experience and feeling guilty that I didn’t make a purchase at all.
Despite years of growth and expansion, Tower records is now gone too. Like everyone else these days I buy all of my music online. Tower record’s once impressive calatogue is now dwarfed by what’s available from iTunes’ 20 million plus online song library.
What makes this iTunes so successful is not just the wide choice of music available, but the incredible sophistication of the filtering system that helps me choose what I want to buy. Using my previous purchase history, iTunes has worked out my musical tastes and from that presents similar kinds of music to me. When I choose a track for download, I get to see what other people who have purchased this music have also bought, exposing me to new music and thereby broadening my own musical tastes. It seems to know what I want, even before I realise it myself.
This week, I’m ‘shopping’ at EULAR in Berlin, one of the Megastore medical meetings for my specialty, for information. Information that I hope will improve the lives of my patients and my working day. Like the 15,000 other delegates who’ve travelled distances and who have taken time off work to attend, I will be presented with an impressive choice of hundreds of presentations and over 3000 cutting edge scientific abstracts to choose from.
The curators of the meeting have gone to some trouble to divide up the meeting in to specific disease ‘genres’ sections, have put together a number of ‘Whats Hot’ plenary sessions, summary sessions and even a searchable app.
And yet, I’m beginning to get a familiar feeling…
Lets just hope that I bring home something that I like.
This is a brief video I have prepared which may be of use to patients who have rheumatoid arthritis or psoriatic arthritis (or other arthritis illnesses) considering taking Methotrexate as an arthritis treatment.
It outlines some of the important side effects of methotrexate but also puts them in perspective based on my many years using the drug as a rheumatologist.
This is my first attempt at providing medical information using youtube.
I’d be interested in what people genuinely think of the information posted.
Is it too detailed?
Isn’t it detailed enough?
Are there other topics you’d like to see covered? Please let me know.
Woody Allen’s 1970 movie ‘Sleeper’ introduced its audience to a fictional, futuristic device called the Orgasmatron. This remarkeable invention was capable of inducing physiological changes (of a pleasurable kind) in those placed within it. I sometimes wonder how much Woody Allen’s contraption was influenced by a device with a similar name from the early 1960’s in which the earliest scientific experiments on the effects of weather on arthritis symptoms were performed.
The Climatron, as it was referred to in media reports of the time, was used by Professor Joseph Hollander, a Philadelphia based rheumatologist to determine the effects of the weather elements on the symptoms of arthritis patients. The device was basically a hotel room sized chamber (with room service) which was designed to comfortably house two patients for periods of two to four weeks. Using a system of valves and dials, it was possible to adjust the temperature, humidity, rate of air flow, barometric pressure within the chamber.
In his experiments, a small group of largely ‘weather sensitive’ arthritis patients, were recruited to come and stay in the Climatron. A number of times a day they completed a diary documenting various aspects of their health including assessments relating to their joint symptoms. They were also examined by a doctor and had their joints assessed. None of the subjects were aware that the main focus of the research was their joint symptoms and were not informed about changes being made to the weather variables within the chamber.
When individual weather variables were adjusted in the Climatron, none of the subjects noted any difference in their joint symptoms. However when an attempt to reproduce the weather conditions of imminent stormy weather (simultaneous increase of humidity and reduction in atmospheric pressure) the effect on symptom worsening was significant in 7/8 of the rheumatoid patients and in 4/4 of the osteoarthritis patients. When this experiment was completed a number of times, those who noted a worsening did so about 3/4 of the time.
This was one of the first scientific attempts to correlate arthritis symptoms and the weather. Whereas the results are tantalizing, its hard, in view of the small numbers of patients studied, to draw any firm conclusions.
Arguments for there being a link
The strongest suggestion that arthritis symptoms are affected by weather is from patient surveys. About 2/3 patients in some studies state that their pain is worsened by certain weather changes. Some report how their joints help them predict the imminent arrival of wet weather, some note a dramatic improvement in their pain while on holidays in the sun (only to deteriorate on their arrival home ) and some even notice a worsening of their symptoms during heat waves. Whereas surveys are interesting, they don’t necessarily prove the link.
However, there are also some semi-plausable mechanisms as to how weather might affect joint symptoms; We know that joints contain pressure receptors (baro-receptors) for example. Couldn’t changes in atmospheric pressure therefore be detected within joints ? The problem is that the sorts of barometric pressure changes seen with weather fluctuations are small and only of the sort of magnitude that might be experienced going up and down in a lift or on an airplane journey. It is also true that the physical properties of tendons and cartilage can be altered by temperature changes but again, this has only been shown in laboratory experiments using extremes of temperature not usually seen in the environment . There’s even some evidence that levels of inflammatory proteins (cytokines) have been shown to decrease in patients undergoing hot spa therapy with inflammatory arthritis and of course heat (or cold) applied directly to joints also seems to help some patients too.
What’s surprising therefore is how prospective scientific studies over the years have failed to show a consistent relationship between various weather variables and arthritis symptoms.
This is at least partly due to the fact that these studies are difficult to do. If the weather were a new drug and researchers were trying to determine its effectiveness in the treatment of arthritis, we would be obliged to ‘blind’ both the patients AND their assessors to their weather treatment (a wet day, dry day etc). Its hard to be ‘blind’ to the weather. Unless you spend all of your time indoors – but then you are not being exposed to the weather changes (other than barometric pressure) either. People also wear clothes most of the time, which alter the humidity and temperature around joints and which could ‘blunt’ any effect that external factors might have.
Other investigators point to the difficult confounding role of psychological factors. Where someone with arthritis holds a belief, for example, that damp cold weather worsens their symptoms, they are psychologically more likely to place emphasis on information that reinforces this idea. They might be more likely therefore to remember those days where their joints were bad AND where the weather was damp and cold but not place emphasis on days where the weather was damp and cold and their joints were good. It has also been suggested that bad weather causes patients to feel depressed or to become inactive – both factors which have been shown to worsen pain.
What’s the bottom line:
Although the data is confusing, I tend to believe my patients when they tell me there joints are effected by the weather. This is true for some patients but not for all.
In my opinion, and despite and firm to data to back it up, I believe the following;
1. That arthritis is not caused by cold or damp weather. There is no evidence whatsoever that this is the case.
2. Where weather has an effect on arthritis, it is solely on the symptoms of the disease and has no effect on disease progression or structural damage.
3. The effect of weather on arthritis symptoms varies from patient; as a rule I would have said that most patients prefer dry warm weather to cold damp weather. Patients with poorly controlled rheumatoid arthritis can occasionally flare when its very hot.
4. The better controlled a patients disease, the less they will notice fluctuations with weather changes. This is particularly true of patients with inflammatory arthritis (eg rheumatoid arthritis, psoriatic arthritis).
5. Emigrating for a better life with your arthritis is probably not a good idea. If an improvement is noted on moving to another country it is quite often temporary. Uprooting yourself from the support network of your family and friends isn’t a good idea and then there’s the stress of moving to another culture, negotiating another health system etc.
6. As with all things that you can’t control its probably better not to stress about it too much. You can’t control the weather…
When I was training as rheumatologist in the 1990’s, it would have been fairly common for a rheumatologist to offer reassurance to a newly diagnosed patient with Osteoarthritis (OA) by telling them how lucky they were not to have rheumatoid arthritis. At that time rheumatologists weren’t terribly good at effectively treating Rheumatoid arthritis (RA) or Osteoarthritis (OA) but as RA tended to get worse much more quickly, it was a consolation of sorts.
Modern treatments for RA are now very effective at reducing symptoms of the disease and are also capable of dramatically slowing its progression. The treatments are so good in fact, that it has made us all realize how poor we still are at treating OA. It is ironic therefore, that I find myself 20 years later, contemplating that some of my OA patients might fair better if they had RA. If recent media reports are to be believed, help may be on the way for OA sufferers in the form of a nutritional supplement. Sound familiar? Read on….
OA is by far the commonest form of arthritis. It is thought to be a largely degenerative disease but its cause is unknown. The disease can effect any joint but commonly affects the hands where is affects 50% of the population over the age of 60 years. Although it tends to be a more slowly progressive condition than untreated RA, severe OA can be every bit as disabling and destructive as bad rheumatoid arthritis. Originally thought to be primarily a disorder of cartilage (cartilage becomes damaged all OA patients), we now know that this may not be the whole story. There’s some evidence from MRI scans, that one of the first structures to become affected in OA is the ligaments around joints and theres also some evidence of problems occurring the bone and in the lining cells (synovium) of the joint.
Treatments for OA
Chondroitin Sulphate – New trial published
A recent publication in the Sept 2011 edition of the Arthritis and Rheumatism journal has confirmed that Chondroitin Sulphate, another fish derived dietary supplement is safe and is more effective than placebo treatment in the treatment of some symptoms of osteoarthritis of the hand. The study suggests that patients who have hand OA and who take 800mg of pharmaceutical grade Chondroitin Sulphate every day for 3 months, have pain scores which are significantly better than those who have taken placebo tablets. Pain scores in the treatment group improved by an average of 8.8 (on a scale ranging from 0 to 100) more than in those those taking placebo treated patients. Despite the apparent small improvement in pain scores, the requirement for additional pain relief in the form of paracetamol / acetaminophen was unchanged in the Chondroitin sulphate taking patients.
There was also a statistically significant improvement in hand function (patients could do more with their hands) amounting to 3 points on a 30 point scale and they loosened out more quickly in the morning (by about 4 mins) compared to those on placebo. These benefits only occurred in those who have been taking the drug for 3 months. The study didn’t report what happened patients after the 6 month protocol ended so its not clear whether any of the benefit was sustained.
Does is work?
The reported improvement in arthritis pain in the Chondroitin Sulphate treated patients was small. Whatever the small improvements in these outcome measures, there is no evidence from this study that chondroitin sulphate had any effect on the metabolism of cartilage.
It is a measure of the low expectations that we have for the treatment of OA that a study like this would have been published at all. Most studies of the effectiveness of a new treatment in RA, for example, would demand an improvement of at least 20% in a number of outcome measures and most rheumatologists wouldn’t be happy with response rates of at least 50 – 70% or complete remission. We have along way to go before we achieve anything near this OA. OA is likely to derive from disease processes in a number of structures within joints, and perhaps its naiive to expect that a drug directed at one component like cartilage might have an effect on all of the others.
Better than nothing?
Although Chondroitin sulphate may be a little better than taking nothing at all, I would be surprised if many rheumatologists will be routinely recommending it to their OA patients. It is unlikely that any scepticism within in the rheumatology community will prevent the inevitable marketing push from nutriceutical companies promoting this product on the basis of these largely disappointing results.
Fortunately there are many options available that make this disease more bearable for people but the search for a treatment to halt its progress continues.
In the last year I’ve taken to wearing theatre scrubs at work instead of my usual suit, shirt and tie attire. This was initially because I started cycling to work and it was simply too much hassle to put clean shirts in my backpack or drop clean clothes into the office over the weekend. After a few days wearing them in my clinic, I haven’t gone back.
As scrubs are usually the preserve of better paid medical specialists such as surgeons, anaesthetists and cardiologists, people tend to look twice when they a rheumatologist wearing them. Once you get over the funny looks and questions, wearing them has had some unexpected bonuses which I’d like to share.
Scrubs are comfortable to wear, cool and make me feel much more relaxed than a stuffy shirt and tie.
As a rheumatologist, I perform minor surgical procedures for most of my working day as part of my clinic (such as joint injections). These require a degree of sterility. Scrubs are almost certainly more hygienic than my suit and most certainly more hygienic than my favorite tie which I bought 4 years ago (it looks and smells fine but has never been to the dry cleaners – and it has certainly never been inside an autoclave).
3. Less Ironing
4. Far less money spent on suits and ties
Prior to this I would have bought a couple of suits each year, a few ties and work shirts. As I don’t wear suits and ties outside work, I haven’t bought any this year at all.
5. Looking important.
Unfortunately rheumatologists are not always taken as seriously as we should be in the pecking order of hospital medical hierarchy. Whilst in scrubs, medical and surgical colleagues and nursing staff seem to treat me more deferentially because they mistake me for a surgeon or interventional cardiologist. Although I’m still waiting for my income to increase accordingly my new outfit (which makes me look like I mean business and on my way to something more pressing than a rheumatology clinic) I find it easier to jump the queue in the canteen.
6. Patients don’t mind
Patients don’t seem to care either way. As long as you treat them well and come up with the goods most don’t mind how you’re dressed (up to a point). I explain to them it’s for all of the reasons above (but not necessarily the reasons listed below).
7. Early de-stressing from the work environment
Putting the scrubs on in the morning and taking them off in the evening allows you to treat them as a kind of theatrical costume. I ‘get into character’ by putting them on and then ‘get out of character’ by taking them off. By removing your work clothes before leaving work allows you to divest yourself of any unpleasant work associations before you leave the building and facilitates an early start to your out of hours relaxation time. I have also found that being dressed in my shorts T-shirt and cycle helmet is a deterrent to colleagues thinking of asking me to do that last minute consult on my way home for the evening. It’s harder to say no in a suit.
The Bottom line
For those physicians amongst you thinking about doing it, just go for it. You’ll feel more relaxed, do less ironing, spend less time shopping for suits and you might even get home sooner. If changing what you wear to work is the most adventurous thing you do this year, you should probably get out more.
Dr. Ronan Kavanagh is a Rheumatologist who works in private practice at Western Rheumatology in Galway, Ireland. He also runs The Musicians’ Clinic in Galway.
Offices are based in Suite 19, Galway Clinic, Doughiska, Galway Tel +353 91 720095. Email firstname.lastname@example.org. He’s on twitter @RonanTKavanagh