Psoriatic Arthritis List NEWSLETTER

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News & Views Newletter
edited by Jack Nicholas, cornishpro@aol.com

PSORIATIC ARTHRITIS NEWS AND VIEWS
VOL. 3 ISSUE 12 July 15, 2003
PSORIATIC ARTHRITIS MEDICAL NEWS

DAM IN BRAIN MAY HALT CHRONIC PAIN
By Kathleen Doheny - HealthDay Reporter

THURSDAY, June 26 (HealthDayNews) -- Scientists have long been interested in a substance called nocistatin, a brain peptide that could play a role in stopping the chronic pain that plagues about 86 million Americans.

German researchers have discovered more clues about how nocistatin might stop the pain process, and how it might act as a kind of natural analgesic by inhibiting the release of a neurotransmitter that's crucial for the pain process to kick in.

"Our main finding is very much related to basic research and questions of communication between nerve cells," says Dr. Hanns Ulrich Zeilhofer, a professor of molecular neuropharmacology at Erlangen-Nurnberg University. He and his colleagues report their findings in the June 27 issue of Science.

The team focused on receptors in the spinal cord called NMDA (N-methyl-D-aspartate), which play a key role in the processing of pain. The receptors require two neurotransmitters, glutamine and glycine, to be fully activated. It is thought that special "transporters" sweep up most of the glycine before it reaches the receptors, so the receptors remain subdued and pain does not become chronic.

But when Zeilhofer's team induced acute pain in laboratory rats, the rats' neurons released enough glycine to overwhelm these transporters. Then the glycine spilled over to the receptors, setting into motion the neurological "cascade" that leads to chronic pain." This process is called spillover," says Zeilhofer. "It has long been thought that synaptically released glycine [released from the synapses, or junctions between cells] only acts on inhibitory glycine receptors located directly in the glycinergic synapses. We have shown, under certain conditions, synaptically released glycine can escape these synapses to act on neighboring excitatory NMDA receptors."

Then came the finding that nocistatin can act as an analgesic by inhibiting this spillover release of glycine.

"We do not know yet whether it really can prevent chronic pain, but it reduces NMDA receptor activation and NMDA receptors are believed to be important for the induction of chronic pain," Zeilhofer says.

"We have previously shown that nocistatin inhibits glycine release," he says. "Others have already shown that nocistatin can be analgesic," he says.

"We are the first to provide a cellular and molecular mechanism for the analgesic action of nocistatin," he adds.

"It's an interesting mechanism to help understand how chronic pain can be perpetuated and amplified," says Dr. Daniel B. Carr, a pain expert at Tufts-New England Medical Center in Boston. "It adds to existing knowledge," he adds, noting that the progression of pain from acute -- considered normal, as when the body warns of danger -- to chronic is complicated.

Acute pain is considered a normal sensation, triggering the nervous system to alert you to potential injury and the need to take action (such as removing your hand from a hot stove). But chronic pain can persist for weeks, months or years. It can involve headache, backache, arthritis pain, and other ailments.

The chronic pain that plagues about 86 million Americans leads to losses of about $90 billion a year, the American Chronic Pain Association estimates. Treatments currently include medication, electrical stimulation, surgery, acupuncture and a variety of other methods.

For more information on chronic pain, try the National Institute of Neurological Disorders and Stroke or the American Chronic Pain Association.

SOURCES: Hanns Ulrich Zeilhofer, M.D., Institute for Experimental and Clinical Pharmacology and Toxicology, Erlangen-Nurnberg University, Erlangen, Germany; Daniel B. Carr, M.D., professor of pain research, New England Medical Center, Boston; June 27, 2003, Science Copyright © 2003 ScoutNews, LLC. All rights reserved.

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DNA CHIP STUDY REVEALS GENE CLUES TO RHEUMATOID ARTHRITIS
By Stephen Pincock - Reuters Health

LISBON (Reuters Health) Jun 19 - French researchers have used micro arrays to identify 63 genes that appear to be linked to rheumatoid arthritis, findings they hope will improve diagnosis and treatment of the condition.

Dr. Gilles Chiocchia and colleagues from Institute Cochin in Paris described at the Annual European Congress of Rheumatology how they developed "home made" DNA chips of 5200 different genes to compare the RNA from synovial fluid of people with arthritis disease.

Among the 5200 genes, 90% were not specific to osteoarthritis or rheumatoid arthritis, but 48 known genes and 15 unknown were either overexpressed or underexpressed in rheumatoid disease compared to osteoarthritis.

"The differences in the gene expression profiles reveal molecular criteria which may allow novel genes and biological pathways involved to be identified," Dr. Chiocchia said in his Thursday presentation.

"At least two genes were located on chromosome 6, at the p21 region which is already known to be implicated in inflammatory disease," he said. "Four others were found on the X chromosome, which, given that the rheumatoid arthritis disease is more prevalent among women, also appears to be relevant."

Better understanding of these and other linked genes could lead to new diagnostic and prognostic tools, as well as potential new molecular targets.

"By being able to make a more precise diagnosis we will be able to offer treatments which are more personalized and specifically relevant to the particular form of the disease which the patient has," the researcher suggested.

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Editors Note: The following article is another example how medications that work for Rheumatoid Arthritis can also work for Psoriatic Arthritis.

NEW RHEUMATOID ARTHRITIS DRUGS WORK WELL
By Salynn Boyles WebMD Medical News Reviewed By Brunilda Nazario, MD

Early treatment of rheumatoid arthritis patients with a relatively new class of drugs appears to prevent the progression of the crippling disease.

New research about tumor necrosis factor (TNF) inhibitor drugs was presented last week at an international meeting of rheumatologists.

The findings are evidence that the drugs Remicade, Enbrel, and the newest drug in the class, Humira, should be used earlier in rheumatoid arthritis treatment, says one expert who took part in the European League Against Rheumatism (EULAR) annual meeting in Lisbon, Portugal.

"Most rheumatologists would tell you that somewhere around 20% to 25% of their patients with rheumatoid arthritis are on these medications," Arthur Kavanaugh, MD, tells WebMD. "We haven't really known if this was too many or too few, but the latest findings indicate that in people with severe disease they should probably be used more often and earlier."

"I Am Back to Normal" - Rheumatoid arthritis patient Betty Timms-Ford, 62, says she was virtually crippled by her disease before starting on Humira three years ago. Today she injects herself with the TNF inhibitor twice a month and also takes the drug methotrexate. She says the treatment has given her back her life.

"Getting up and taking a shower was a struggle," she tells WebMD. "I would come home from work at night and go straight to bed. I couldn't get out of a chair without my husband's help, and I had to have adapters for my toothbrush and car keys because I couldn't close my hands enough to grip them."

The Centennial, Colorado woman cannot conceal the excitement in her voice when she talks about her improvement since starting Humira. She can now enjoy old hobbies like gardening and skiing, and can keep up with her six grandchildren and three step-great-grandchildren.

"I am back to normal," she tells WebMD. "I go to the gym as many nights a week as I can, and I walk on my lunch hour. It is just wonderful."

Denver rheumatologist and clinical researcher Michael Schiff, MD, says Timms-Ford's experience is not unusual, and is even common, among rheumatoid arthritis patients put on TNF inhibitors. Some of his patients have been on the drugs for as long as six years with little evidence of disease progression.

Schiff, who is director of clinical research at the Denver Arthritis Clinic, cited three presentations at the EULAR meeting, which highlight the promise of TNF inhibitors:

Patients with both early and late rheumatoid arthritis responded well to combination treatment with Humira and methotrexate, but it seemed to work better in patients with early disease. The drug therapy improved signs and symptoms of rheumatoid arthritis in both groups as well as stopped the progressive bone destruction seen in X-rays of the joints. Researchers concluded that early, aggressive treatment of patients should lead to better outcomes.

Combination therapy with Enbrel and methotrexate improved disease symptoms and stopped disease progression among patients taking it for up to six years. Another group of researchers reported similar results among patients treated with the combination of Remicade and methotrexate.

"The take-home message from these studies is that anti-TNF therapy is here to stay. It works, and it slows, if not stops, progression of this disease," Schiff tells WebMD.

SOURCES: European League Against Rheumatism meeting in Lisbon, Portugal * Michael Schiff, MD, director clinical research unit, Denver Arthritis Clinic; clinical professor of medicine, University of Colorado * Arthur Kavanaugh, MD, rheumatologist, professor of medicine, University of California at San Diego * Betty Timms-Ford, rheumatoid arthritis patients, Centennial, Colorado.

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RHEUMATOID ARTHRITIS AND BIRTH WEIGHT
By Jennifer Warner - WebMD Medical News Reviewed By Brunilda Nazario, MD

Although the cause of rheumatoid arthritis remains unknown, a new study suggests certain factors surrounding a person's birth may affect the risk of developing the potentially disabling disease as an adult.

Rheumatoid arthritis usually develops after age 50 and affects nearly twice as many women as men. When it strikes, the disease causes a person's immune system to attack the tissues in the joints, which leads to inflammation and pain.

Researchers say little is known about the cause of rheumatoid arthritis, but a combination of genetic and environmental factors are suspected.

The study, published in the May 17 issue of the British Medical Journal, looked at a group of 77 adults with rheumatoid arthritis born between 1940 and 1960 in Malmö, Sweden, and compared their birth records with a group of 308 similarly matched healthy adults born during the same time in the same city. Researchers analyzed information about birth weight, mother's age, length of hospital stay after birth, start of breastfeeding, and the occupation of the father.

The study found babies who had a birth weight of more than 8.82 pounds were more than three times as likely to have rheumatoid arthritis later in life, but having a low birth weight didn't seem to affect the risk of rheumatoid arthritis.

Low frequency of breastfeeding while in the hospital after delivery also slightly increased the likelihood of rheumatoid arthritis as an adult, as well as having a father employed in manual labor. v No other birth-related factors appeared to affect rheumatoid arthritis risk.

Researchers say this is the first study that looks at markers of infant health before and after birth in relation to the development of rheumatoid arthritis as an adult. They say more research is needed to see what these factors might reveal about the development and causes of rheumatoid arthritis. SOURCE: British Medical Journal, May 17, 2003.

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LOW VITAMIN C LINKED TO GREATER ARTHRITIS RISK
By Karen Birchard LONDON The Medical Post

British researchers are suggesting a link between arthritis and vitamin C, with people whose diets are low in the vitamin appearing to be more at risk of developing the condition.

Researchers from the Arthritis Research Campaign (ARC), the University of Manchester and the Institute of Public Health at Cambridge University studied about 25,000 people over eight years to see the effect of diet on their arthritis risk.

"We wanted to find out whether fruit and vegetable consumption-the main dietary source of vitamin C-could affect a person's risk of developing inflammatory polyarthritis," said dietitian Dorothy Pattison.

Those taking part were among recruits in the EPIC-Norfolk study set up in 1993 to provide an ongoing database on the link between chronic diseases and diet.

Over an eight-year period, 73 people developed inflammatory polyarthritis. Their diets were low in fruits and vegetables, fructose and vitamin C.

Dr. David Scott, president of the British Society for Rheumatology, said: "It seems there is a particularly strong link between the risk of developing some forms of arthritis and a low intake of vitamin C. We feel these findings may have important implications for the role of diet in reducing the risk of inflammatory arthritis. More research is clearly needed in this area ©

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Editors Note: During the last few weeks, our Yahoo web site daily digests have been filled with discussions among our membership about severe fatigue. The

next two articles represent information from a British clinical study, and a well-written narrative describing the very personal side of this often-misdiagnosed condition.

PATIENTS COMPLAINING OF SEVERE FATIGUE OFTEN DO NOT HAVE CHRONIC FATIGUE SYNDROME By Stephen Pincock LONDON (Reuters Health)

Two out of three people presenting to British family doctors with unexplained fatigue do not meet the criteria for chronic fatigue syndrome, but the condition still significantly affects their life, researchers said on Friday.

Medical researcher Lucy Darbishire and colleagues from Guy's, King's and St. Thomas's School of Medicine in London collected data from 22 general practices in and around London on patients with unexplained fatigue lasting 6 months or more.

They applied the U.S. Centers for Disease Control and Prevention case definition and found that 69% of patients did not have CFS by these criteria.

Fatigue, functioning, associated symptoms and distress were higher in the CFS group, who were also twice as likely to be depressed and more than twice as likely to be unemployed, Darbishire and colleagues write in the British Journal of General Practice for June.

Nevertheless, 11 out of 12 additional symptoms assessed by the researchers were experienced by more than 60% of the non-CFS patients, the researcher told Reuters Health.

"I don't think we really found a characteristic difference, it really looked as if everything was just more severe in the CFS group. It supports that theory, that it's really just another end of the spectrum," she said.

"I think the take home message is to remember that there are these two-thirds of patients that present with fatigue that don't meet criteria for CFS because they don't seem as severe, but they do actually have quite distinct illness." Brit J Gen Practice 2003;53:441-445.

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THE THIEF OF MANY LIVES
By Kathleen Houghton © Kathleen Houghton - Alaska CFS-MCS Association 2002. cfs-mcs@gci.net

I am constantly on the prowl in search of new victims. I do not discriminate---health care workers, teachers, students, airline personnel, teens, moms, dads, and innocent children are my prey. If you are dynamic and have a lust for life, I will seek you out, and I will find you.

Just when you are at the peak of your endeavors, climbing that career ladder or building your family and home, I will find you. There is nothing that you have in your life today that I am not capable of destroying tomorrow, your career, your education, your goals, your dreams, your family, and your life. I will have it all. I will strip you of your ability to function at any level above minimal, and from this day on you will refer to that minimal as a "good day."

I have the ability to create an invalid out of you overnight, and I will. It will take a marathon effort for you just to get out of bed. At a cellular level, your immune system will be in a constant war battling itself and unnamed viruses, which will painfully be replicating in your brain. I promise you, I will bring you despair along with pain, isolation and losses far beyond what you can ever imagine.

Your mind will be in a constant "fogged" state, your expression will be unable to express, and your eyes will have a noticeable "glazed over/drugged out" look. You will find it most difficult to pay attention, concentrate, or even process the simplest of thoughts. Making change from a dollar may well be beyond your ability now. Your mouth may feel like it is full of marbles when you try to speak, as your tongue twists and nothing you try to say comes out right. Who would believe your level of education when you can't even string enough words together to make a complete sentence ... or one that makes any sense for that matter.

I promise, I will bring you at any unsuspecting time, severe abdominal pain, nausea, vomiting and diarrhea along with a host of gastro-intestinal disorders. I will make you weak and lifeless as one could be without being confirmed dead. You will be housebound or in bed for several years if not the rest of your life. As part of incapacitating you, I will make your heart race and your head pound; your throat will constantly be sore and your lymph glands will swell. That will all seem trivial after I inflame and spasm muscles throughout your body. Crushing a grape between your fingers may take too much energy or be too painful now.

On those nights that I allow you to sleep, you will awaken drenched with sweat or throbbing with pain. Perhaps I might even throw in a little seizure activity. On those nights that I do not allow sleep to occur; I will torture you with thoughts of death.... Not suicide, but death. Simply because you have not come to realize that this is your new life, and that you are not living. You will need to re-create your being every day, as every day I will bring you unpredicted symptoms and suffering.

I have also done a few things that you may not be aware of yet. I placed some lesions on your brain (have you noticed how you have difficulty with balance and memory yet?) and I have permanently altered your immune system. I have shorted out your nervous system so that you have intermittent numbness and tingling, which might resemble an electrical current zapping you from time to time.

This is called neuropathy. Nope, it's not curable either!

Now I have you. I have taken over your body and mind. I have stolen your life but left you alive, not very functional, but by clinical definition, you are still alive.

Your family will not be able to give you all the constant care that you need on a daily basis. As for your friends, well, they're still on that ladder climbing up. Rest assured, I am looking for them too. By now, chances are good that most of your family and friends have abandoned you, so you must have learned the definition of isolation. This newfound isolation will save you from having to explain how sick you really are to others, they won't understand anyway. Isolation will save you all that energy.

Your health insurance has already been or will shortly be discontinued as you lost your job from not being able to "keep up."

Perhaps you got caught dozing off or called in sick one too many times. Now that you are no longer employable or insurable, when you seek medical care, any medical professional that figures me out will diagnose you and say that what you have is presently not curable.

Now it is time for you to seek out medical care, nation if not worldwide. However, most so-called medical professionals will not even have the ability to recognize me when they see me, as they have not learned about me in medical school. So, chances are good that you will be misdiagnosed. You will give more blood samples and have more examinations than you ever imagined existed. Then you can take the results to dozens of doctors in search of a diagnosis. One that is valid as well as socially and medically acceptable. One that does not label you as depressed or say that "it is all in your head!!!" Most doctors will suggest a vacation, weight loss diet, new or increased love life, help with the children, or change of scenery as the "cure," mainly because you may look like the picture of health. This is my mask of deception.

You will pray for a positive word from current research. Research, which you will soon learn, is quite limited due to lack of funding and government support. You will learn new vocabulary which contains words like: T-Cells, Cytokines, Nuclear Antigens, Natural Killer Cells, Immunoglobulins, Cytomegalovirus, Serotonin, Cerebral lesions, and Immune Dysfunction are among a few. However, the most important words that you will need to know and fight for are Social Security Disability and Medicare.

At one point, I may give you a false sense of recovery or remission. Let me assure you, I will be back, as you are my prisoner and that makes me your keeper. I have placed the lives of millions of people nationwide in limbo, I continue to do the same worldwide. I would consider this an epidemic, wouldn't you?

Eventually I will bring the government, health care workers, and society to their knees in search of unraveling my complexities, which are crippling humanity. I leave it up to you, my victims, and your caretakers, to educate the public and let them know that I am very real and that you are very sick. Unfortunately, I have been given a totally ridiculous name, which will make your job even more difficult. Until that name is changed, I am. CHRONIC FATIGUE AND IMMUNE DYSFUNCTION SYNDROME

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VITAMINS DON'T STOP HEART DISEASE, CANCER
By Salynn Boyles WebMD Medical News Reviewed By Michael Smith, MD

The notion that you can fend off heart disease and cancer by taking vitamins always seemed too good to be true, and now the nation's top independent preventive health group says that it probably is.

After taking a look at the top studies evaluating the use of vitamins for preventing disease, the U.S. Preventive Services Task Force found no evidence that folic acid and the antioxidant vitamins A, C, E, and beta-carotene protect against heart disease and cancer. Two other major studies released this month also found no link between antioxidant vitamins and heart health.

BETA-CAROTENE WARNING - The Task Force warned against taking beta-carotene supplements to prevent heart disease and cancer because several studies have linked the antioxidant vitamin to an increased risk of lung cancer in smokers. A more recent study also found that heart patients who took beta-carotene had a slightly higher risk of dying than those who did not.

But the group stopped short of saying that people shouldn't take other vitamin supplements to prevent heart disease or cancer, even though there is little evidence to support the practice.

FOR OR AGAINST? - It concluded that the evidence is insufficient to recommend for or against the use of the antioxidant vitamins A, C, or E; multivitamins with folic acid; or antioxidant vitamin combinations for the prevention of cancer or heart disease. The findings are published in the July 1 issue of the Annals of Internal Medicine.

"This is pretty much a scientifically agnostic point of view, meaning that we didn't see strong evidence supporting a benefit for vitamins and we didn't see strong evidence against it," Task Force chairman Alfred O. Berg, MD, MPH, tells WebMD. "The studies haven't been conducted long enough for us to know the answer."

In the U.S., there are as many as 10 large, ongoing clinical trials evaluating antioxidant vitamins for the prevention of heart disease, and a similar number of prevention trials involving people who already have heart disease are under way in the U.S. and Europe. v The Task Force reviewed multiple studies on vitamins and prevention of disease -- including four beta-carotene trials, which found no evidence that the antioxidant vitamin decreased the risk of lung, prostate, colon, breast, or non-melanoma skin cancer in middle-aged and older adults. Two of these trials found an increased risk of lung cancer and death among smokers taking beta-carotene.

Major studies examining antioxidant vitamins A, C, E, multivitamins with folic acid, or antioxidant vitamin combinations found no evidence that any of them lowered the risk of heart disease, stroke, or cancer.

Berg says vitamin supplementation offers clear benefits for people with nutritional deficiencies and those at risk for them, including young children and elderly people with chronic illnesses. And women who take folic acid immediately before getting pregnant and early in pregnancy greatly reduce their child's risk of being born with birth defects.

A MATTER OF PERSONAL PHILOSOPHY - But for everyone else, he says, the decision about taking supplemental vitamins comes down to a matter of personal philosophy. "If you don't believe in taking something unless there is evidence to support it, this report would argue against taking vitamins," he says. "But if you are the type of person that will take something until it is proven to cause harm, this report also gives you permission to keep taking vitamin supplements." v SOURCES: Annals of Internal Medicine, July 1, 2003. Cynthia D. Morris, PhD, MPH, department of medical informatics and clinical epidemiology, Oregon Health & Science University, Portland. Alfred O. Berg, MD, MPH, USPS Task Force chairman; professor and chairman of the department of family medicine, University of Washington, Seattle.

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AETNA SETTLES CLASS-ACTION LAWSUIT FOR $470 MILLION
by Cathy Tokarski - Medscape Medical News 2003.

Health insurer giant Aetna and 20 medical societies representing more than 700,000 physicians reached a settlement on a national class-action lawsuit on May 22 that charged the insurer with systematically reducing payments to physicians and overriding their treatment decisions.

Under the settlement agreement, which requires approval by Florida's federal southern district court, Aetna will pay $100 million to physicians and make several business practice improvements valued at an estimated $300 million. Aetna will also pay $20 million to establish a new health foundation and up to $50 million in legal fees. The publicly traded company (AET) will take an after-tax charge of $75 million in connection with the settlement expenses in the second quarter of 2003.

The settlement, unveiled at a New York press conference, "represents a sea change in relations between physicians and Aetna," said Aetna Chief Executive Officer and President John Rowe, MD. Resolving the company's strained relations with its physicians, which date back to managed care's ascendancy in the early 1990s, "has been a major goal of the [Aetna] board and a personal goal," said Dr. Rowe. He was president of Mount Sinai NYU Health before joining Aetna in late 2000.

The $100 million that Aetna will pay to physicians will translate into approximately $150 per physician covered under the class-action lawsuit. But lawyers and medical groups involved in the settlement negotiations emphasized that the monetary rewards were less important than a fundamental change in the relationship between the insurer and physicians.

"We were never in this for the money," said Tim Norbeck, executive director of the Connecticut State Medical Society, one of the 20 state and local medical groups backing the agreement. Instead, the goal was "changing the system to make it more fair for doctors and patients," he told Medscape.

Simplifying the claims payment process, making the insurers' reimbursement policies more transparent and establishing firm deadlines for paying "clean" claims are among the major business improvements Aetna has vowed to undertake. To that end, the insurer will establish a national advisory committee of physicians to provide advice to Aetna, disclose the factors that determine how much Aetna pays physicians for services, and make additional investments in automatic claims adjudication systems.

Aetna will also work with physician groups to develop a claims-editing software package that incorporates claims coding and grouping procedures developed by the American Medical Association (AMA) and widely used by doctors, and establish a new mechanism for physicians to appeal claims payment decisions they disagree with.

"Complexity in claims payment has been one of the major stumbling blocks" contributing to "mistakes, misunderstandings, and increased expense," Dr. Rowe noted. "No other part of the interaction that we have with physicians has been as contentious and combustible as claims," he said. For physicians, the changes will "reduce the costly administrative burden and time away from taking care of patients," and will allow Aetna to serve its customers more effectively, Dr. Rowe said.

Medical groups welcomed the agreement, saying it could represent a thawing in the hostile relations between cost-cutting managed care companies and physicians who say such policies undercut their ability to care for patients.

"This is not a panacea. It is not a total end to the problems in for-profit managed care," said Jack Lewin, MD, chief executive officer of the California Medical Association. However, he said, the agreement "does represent a turning point, a historic moment" in healthcare's history, and "Aetna has to get a lot of credit for having the courage to step up."

AMA President-elect Donald J. Palmisano, MD, said the settlement vindicated physicians and medical groups that struggled for years for legal redress to their grievances. "Today's announcement is proof positive that these physicians and medical associations have not worked in vain. The AMA expects this settlement will raise the bar for the entire health insurance industry on fair and open business practices."

Legal and medical group representatives said they were hopeful that other health insurers still embroiled in the class-action lawsuit with physicians would take heed of Aetna's settlement. UnitedHealth Group, Cigna, WellPoint Health Networks Inc., and Humana Inc. remain defendants in the federal court case. "We are hoping other plans will look at it and embrace it," said Archie Lamb, an

attorney on behalf of the class-action plaintiffs. Reviewed by Michael W. Smith, MD

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The greatest danger for most of us is not that our aim is too high and we miss it, but that our aim is too low and we reach it.

Good Health to All,

Jack Nicholas
Newsletter Editor
Cornishpro@aol.com
Issue 2003 7/15/03-12