RA Impacts Much More than Bones and Joints

When people hear the general term arthritis, they typically think of an older person with joint pain as in osteoarthritis – common wear and tear on the joints. But this term can miss the mark when describing the systemic impact of autoimmune rheumatoid disease on the entire body. One of the first symptoms that doctors often examine for establishing a diagnosis of RA is bone erosion – typically in the fingers. But as an autoimmune disease, RA can impact much more than the bones as it can damage a variety of soft tissues including the eyes (iritis), lungs (fibrosis), heart, blood vessels (vasculitis), nerves (carpal tunnel), and skin (nodules, ulcers), and connective tissue (cartilage, tendons, ligaments)

. Often-times, the soft tissue damage occurs long before bone erosion is visible or even before an official RA diagnosis comes.

Besides bone erosion, RA can impact other parts of the joint including the surrounding connective soft tissues comprised of tendons, ligaments, and cartilage. Chronic tenosynovitis, inflammation of the sheath of a tendon, is common in rheumatoid arthritis and can result in the permanent damage and tearing of the involved tendons. Such tendon problems caused by RA are well known by the scientific community and are linked to joint deformities.^{1, 2} Tendon problems have even been posited as being one of the most powerful predictors of early RA.³ Sophisticated imaging techniques developed in the last few decades, such as MRIs and ultrasound, can reveal connective tissue damage in joints caused from RA that are not seen in x-rays.⁴ Bursitis, inflammation of the fluid-filled sacs that protect joints⁵, often accompanies tenosynovitis. RA is also implicated as a cause of cartilage damage in knees.⁴

In my particular RA case, damage to soft and connective tissue before bone damage to joints occurs is a typical presentation. Two symptoms now linked to RA which I personally experienced before an official diagnosis were iritis – inflammation in the eyes, and torn Achilles tendons and bursitis in myankles resulting in three surgeries. An MRI taken at the onset of my RA diagnosis revealed cartilage damage in one knee. And just last week, an MRI revealed a 50% tear of a tendon in my elbow. Theelbow joint, while actively inflamed, did not yet show bone erosions.

Although not publicly well known, scientists and doctors have recognized for some time that rheumatoid arthritis is also linked to an increased risk for cardiovascular disease (CVD) including heart attack, stroke and diabetes. Systemic inflammation inherent in rheumatoid arthritis may play a role in the increased CVD risk.⁷ Some researchers have even called for the development of specific CVD predictors for RA patients as a special population with unique characteristics.⁸ Systemic inflammation involved with RA can impact the complex metabolic processes of the body including use of food for energy, sugar processing, insulin production, production of fats and lipids, body weight, and physical activity. Whenever one of these interconnected systems gets out of normal parameters, a cascade of problems may occur which can impact cardiovascular health. This is called metabolic syndrome and involves a set of interconnected risk factors which are related to cardiovascular disease and diabetes.⁹In a study published in 2013, it was found that 18-49% of RA patients also had metabolic syndrome which was significantly higher than general populations.¹⁰ These researchers also found that RA patients with higher inflammatory blood markers and those who used corticosteroids were more likely to show signs of metabolic syndrome leading to increased cardiovascular risk which can have serious and fatal consequences.

As an autoimmune disease, RA can cause the body to attack itself in many different ways – not just in bones and joints. RA patients and doctors need to be aware of the numerous extra-articular (outside the joint) manifestations of the disease, carefully monitor them, and treat as needed. The stereotype of RA as “just arthritis” needs to be challenged and it needs to be seen as a hideous disease that can attack many different tissues and systems in the body.

Osteoarthritis

What Is Osteoarthritis (OA)?

Osteoarthritis is a condition that affects the joints. It is as a result of the wearing off of the cartilage that serves as cushion where two bones meet. Cartilage is slippery and firm and works by allowing the joints to move without friction. When it gets worn out, the surface roughens and gradually it deteriorates completely leaving the bones to rub against each other. Although it can affect any joint in the body, the most affected joints remain those of the knees, hips, hands and the lower back. Of all forms of arthritis, OA remains the highest ranked in patient numbers with over 27 million people in the U.S.

Signs and Symptoms of Osteoarthritis

Progression of the disease can be very gradual sometimes taking years to develop. Symptoms may begin with a single joint and progress to others.

1. Pain
This is the first symptom you will experience with OA. It may be painful to move your joint or the pain may come after flexing it.

2. Stiffness
When you stay inactive for some time, your joints become stiff. This may be common in the morning after waking up. It ceases after the joint becomes active again.

3. Loss of Flexibility
He joint becomes rigid and painful to move it around

4. Reduced Range Of Motion
The ability to turn your joint to a full range motion is lost.

5. Tenderness
When little or much pressure is applied to the joint, it feels tender

6. Swelling
You may notice hard or soft swelling on the joint. The hard is caused by bone spurs while the soft is as a result of the thickening of synovial fluid.

7. Specific Joints Are Affected
Pain will be common in specific joints in the body. These are the knees, hands, spine and the hips.

8. Grating Sensation
A small movement of the joint causes a grating sensation.

9. Noisy Joints
Joints become creaky on movement especially when you stand from a sitting position.

10. Changes in Joint Appearance
Inflammation, growth of bone spurs and swelling may deform the joint and change its appearance altogether.

11. Bone Spurs
In advanced OA, the bones around the joint develop outgrowths known as spurs which appear as painful hard lumps.

What Causes Osteoarthritis?

Osteoarthritis is as a result of the deterioration of cartilage that serves as a cushion at the end of bones. That deterioration (wearing off) can be as a result of several factors

A. Joint Injury
A joint that suffered a serious injury or underwent a form of operation is likely to suffer OA later in life. People who engage in strenuous jobs and extremely physically demanding chores are at risk of OA.

B. Getting Older
As one’s age advances, joints and bones wear out slowly. The body’s ability to heal itself weakens too and one becomes susceptible to getting OA. It is common to people above the age of 40.

C. Obesity
Knee osteoarthritis is common in overweight people. If you have excess weight, it means that the body exerts more pressure to the knees than they can bear. This poses a risk to the knees.

D. Genetics
Genes play a small yet an important part on OA. Some forms of the condition run through a blood line. Nodal OA which is known to affect middle aged women particularly in the hands is inherited.

E. Inactivity
If you stay inactive for long periods of time, it means the muscles and tendons around your joints become weak. Strong muscles and tendons keep the stability of joints and when this is altered you are at the risk of OA. Light exercises like walking, cycling or swimming will keep your muscles strong.

F. Joints That Are Not Properly Formed
Sometimes one is born with malformed joints. You may also develop this in childhood. Such can lead to getting OA earlier in life of increase the severity of the condition in people.

G. Stresses on the Joints
Some activities like sports can impose a lot of stress on joints. Games like basketball involve jumping and landing which may stress the joints, reduce cartilage and risk OA.

Types of Osteoarthritis

1. Primary Osteoarthritis
This is the type of Osteoarthritis which is as a result of natural wear and tear of the cartilage. Medics associate it with aging and it does not have a specific trigger.

2. Secondary Osteoarthritis
This type of OA is initiated by a secondary factor. These factors may include injuries, obesity, genetic make-up or diseases.

Risk Factors

The risk factors involved with osteoarthritis include old age, gender, obesity, injuries on joints, occupations that stress joints, genetic make-up, malformed bones and infections or diseases.

Complications

Some of the complications of osteoarthritis include an increased risk of contracting gout and chondrocalcionosis. Gout sets in when uric acid forms crystals which are deposited around joints. The changes that occur to a joint when you get OA can lead to the formation of these crystals. On the other hand, having chondrocalcionosis means calcium pyrophosphate crystals have formed around your joints. It may be a joint with OA or without. The severity of OA worsens when you get these crystals around the same joint.

Who Gets Osteoarthritis?

Anybody can get OA whether young or old. However, primary OA is basically associated with age and is common with the aged. Secondary OA however affects both the young and the old.

How Does Osteoarthritis Affect People?

Osteoarthritis affects people in every aspect of life; emotionally, socially and economically. People with OA perceive their health status as ill. The limitations that come with OA impose anxiety, pain and emotional distress to patients. Treating or finding means to deal with the condition can also be expensive and burdensome to one’s finances.

How Do You Know If You Have Osteoarthritis?

When you experience symptoms that relate to OA, it is not advisable to be conclusive. Seek a medical practitioner who will test and deduce whether it is OA. Early testing will keep you away from many complications.

What Research Is Being Done On Osteoarthritis?

Research on OA is at an advanced state with medics digging to know how to counter this disease which has affected people for ages. At a congregation of researchers at American College of Rheumatology, several research reports revealed the possible causes of OA, the concept of patho-mechanics and how this is going to affect the treatment of OA.

New research being conducted in Harvard seems to be shedding light on this condition. Dr. Antonios Aliprantis says “we’re beginning to realize that there are important changes happening in the bone underneath the cartilage and in the joint lining itself”. There is a new development to incorporate strontium effectively, a drug which has been used in Europe to treat osteoporosis.

How Is Osteoarthritis Diagnosed?

There is no single method that is defined to diagnose osteoarthritis. Your doctor will ask you a series of questions and your health history. He may then perform some blood tests on you which will rule out other diseases that pose similar symptoms.

Arthroscopy may also be used where by the doctor inserts a viewing tube into the affected joint. From this tube the condition of the joint can be seen and at times repaired through the same. Repair of the joint through arthroscopy heals faster than the usual open operation

X-rays and MRI imaging are also used. They help the doctor in evaluating the extent of the condition and also rule out other similar conditions. Repeats of imaging also give the rate of progression of the disease.

How Is Osteoarthritis Treated?

Treatment of Osteoarthritis will depend on the extent of the disease and also the joint involved. Your physician will advise on possible treatment procedures that best suit you.

1. Surgery
This may be the last resolve after the rest have failed. Your physician will advise you on the kind of surgery. It may involve total replacement of the affected joint, bone realignment or lubrication injections on the joint.

2. Therapy
There are therapeutically effective measures that can help you in managing OA. Your doctor will advise on the need for a therapist. He may also recommend braces or shoe inserts which will minimize the pain when you move. They also take up the pressure exerted on the joint.

3. Supplements
You may consider taking nutritional supplements to curb pain.

4. Physical Measures
Giving physical support to joints like bracing them will relieve the pain and improve flexibility. You can also combine these with a regular exercise program to obtain maximum benefits.

5. Using Heat or Ice on the Painful Joint
Some people will respond to heat while others cold. Find what is appropriate for your pain.

6. Exercising
Exercising strengthens the muscles and joints. It also allows you to lose extra weight and thereby reducing the pressure you place on your joints.

7. Lifestyle Changes
Your lifestyle will define how far the severity of OA will go. Eat a healthy diet, maintain your weight and avoid foods that trigger flare-ups.

8. Losing Weight, If You’re Overweight
Extra body weight strains your joints. Getting involved in a program that allows you to shed it does your joints a lot of good.

9. Medications 
Osteoarthritis remains without a cure but there are drugs that help to relieve pain. They may include non-steroidal anti-inflammatory drugs and other pain killers. Flexoplex is a drug that has been proved to counter OA by lubricating the joint, repairing it and curbing the pain with all these benefits packed in a single tablet.

10. Alternative Treatments
Complementary or alternative therapy may include aromatherapy, taking supplements like glucosamine and chondroitin or application of gels and creams. It is essential that you involve your physician when you choose to take alternative therapy.

Prevention

Although all of us develop OA at some point in life as we age, it is possible for you to control the onset or progression of the disease. Indulge in regular exercises and check your weight. These will ensure the strength in your muscles and joints and that you do not strain your joints excessively.

Conclusion

With OA, you can live a meaningful and productive life if you learn how to manage the pain in early stages. Leading a healthy lifestyle in vital in a person with OA.

Raynaud's phenomenon: a whiter shade to winter's pale

Raynaud's phenomenon is a circulatory disorder, characterised by episodic attacks where arteries in the fingers and toes spasm, restricting blood flow and causing pain and marked colour changes of the skin.

During the winter months, complaints of pain associated with cold fingers and toes increase. 

In New Zealand, it is estimated that 19% of females and 5% of males experience symptoms 

consistent with Raynaud’s phenomenon.¹ This is a circulatory disorder, characterised by 

episodic attacks where arteries in the fingers and toes spasm, restricting blood flow and

 causing pain and marked colour changes of the skin.² In some people it may also affect 

other peripheral areas, such as the tip of the nose and ears.

In New Zealand, Raynaud’s phenomenon is reported to affect Māori and people with 

manual occupations more severely.¹ Initial vasoconstriction causes a white appearance 

to the skin as blood flow decreases, which is often followed by a cyanotic blue phase, as 

the trapped blood deoxygenates.² Attacks may last from minutes to hours and usually end 

with rapid perfusion of blood back into the digits, which then appear red. Episodes of

 Raynaud’s frequently cause pain and a “pins and needles” sensation due to sensory nerve 

ischaemia.² The cause of Raynaud’s is unknown, however, it is likely to involve increased 

activation of sympathetic nerves due to cold, or emotional stimulus.² In secondary
Raynaud’s, abnormalities of vascular structure and function from the underlying
condition contribute to the phenomenon.

Diagnosis is based on clinical symptoms and signs

A diagnosis of Raynaud’s phenomenon is based on a history of repeated and sudden

 episodes with the characteristics as described above. Patients may report attacks being 

triggered by cold weather, or other cold environments such as refrigerated areas in 

supermarkets or from cold air conditioning.³ There may be a family history present. 

An occupational history should be taken – people who use vibrating hand tools or 

have ongoing exposure to cold, e.g. meat packers, are at an increased risk of
 Raynaud’s.³

Raynaud’s can be primary or secondary

It is important to distinguish between primary and secondary Raynaud’s so that a
potentially serious, underlying condition, is not overlooked. Primary Raynaud’s has 
no underlying etiology and clinical examination may be normal, therefore it is a diagnosis
of exclusion.

Secondary Raynaud’s can occur due to a number of connective tissue diseases such as 

systemic sclerosis (scleroderma), systemic lupus erythematosus and rheumatoid arthritis, 

but can also occur with a range of other conditions, including carpal tunnel syndrome and 

hypothyroidism. Raynaud’s may also be secondary to medicines or trauma, particularly 

vibration injury.³ Patients with secondary Raynaud’s may have skin changes such as 

ulcerated or necrotic patches around the affected area.⁴

The presence of any of the following factors suggest a diagnosis of secondary Raynaud’s:³

• Age of onset > 30 years
• Intense, painful, asymmetric attacks or attacks associated with ischaemic skin lesions
• Symptoms suggestive of an underlying disorder, especially a connective tissue disease
•  – such as systemic sclerosis, where in up to 90% of cases Raynaud’s is one of the 
• presenting symptoms.⁵

Laboratory testing is unhelpful in people with primary Raynaud’s, but if a diagnosis of 

secondary Raynaud’s is suspected, testing may help confirm the presence of an
underlying condition. Initially, testing may include complete blood count, CRP and 
antinuclear antibody (ANA), however, other tests may be indicated depending on the 
clinical findings and suspected underlying condition. In some cases, treating the 
underlying condition will also ameliorate Raynaud’s phenomenon.⁶

Conservative treatment is often the best

Behaviour modification is the first strategy for alleviating symptoms of Raynaud’s 

phenomenon. A “common sense” strategy of avoiding abrupt changes in temperatures, 

therefore preventing peripheral vasoconstriction, can be effective. Considerations include 

clothing, home heating and workplace conditions.

Practical tips for avoiding or minimising episodes of Raynaud’s include:⁷

• Keep the whole body warm and wear warm socks, gloves and a hat when going out 
• in cold weather
• Avoid carrying objects in the hand, e.g. a handbag, which can restrict blood to the 
• fingers when gripped
• Maintain regular movement, e.g. squeezing a stress ball or walking round the room
• Avoid smoking as this causes vasoconstriction
• The consumption of “warming” foods such as porridge or chilli has been reported by
•  some people to ameliorate symptoms⁶
• When an attack occurs, place hands in warm water or under the armpits, or rotate
•  arms in a windmill pattern

People who experience Raynaud’s should avoid medicines which reduce blood flow to the 

peripheries, such as:⁴

• Serotonin receptor agonists, e.g triptans used to treat migraines
• Ergots (Claviceps fungi derivatives), e.g. ergotamine used to treat migraines
• Clonidine (which decreases cardiac output)

Historically there have been reports that non-selective beta-blockers, e.g. propanolol, 

carvedilol, nadolol, exacerbate Raynaud’s. Recent studies have shown that beta blockers 

with beta-1 selectivity, e.g. metoprolol, are less likely to cause vasoconstriction in patients 

with Raynaud’s. However, beta blockers should be used cautiously, in people who 

experience severe Raynaud’s symptoms.⁸

Medication is the second option

In severe cases of Raynaud’s, the use of medicines that cause vasodilation of the digits may be 

considered. Calcium channel antagonists such as nifedipine, amlodipine and felodipine are
frequently  effective in the treatment of Raynaud’s and are all fully funded in New Zealand.
However, calcium channel blockers are less effective for treating patients with secondary Raynaud’s,
 notably Raynaud’s secondary to systemic sclerosis (sclerodoma).⁹

Adverse effects of treatment are experienced by up to three-quarters of patients with Raynaud’s
and may include headache, flushing, dizziness and peripheral oedema. However, these effects can
be controlled with careful dosing and if mild, are often considered by the patient to be preferable to
the symptoms of Raynaud’s itself.⁹

Table 1: Calcium channel blockers for Raynaud’s phenomenon9

Medicine Dose Nifedipine (sustained-release) 30 – 120 mg/day Amlodipine 5 – 10 mg/day Felodipine (extended release) 2.5 – 10 mg/day

It is recommended that patients are started on the lowest dose of the chosen medicine (Table 1). 

The dose can then be increased incrementally as required and tolerated. If a patient reports that one 

calcium channel blocker is ineffective then another can be trialled.⁹ Primary Raynaud’s may 

spontaneously remit, therefore treatment can be stopped from time to time in order to confirm

 persistence.⁴ Some people report that intermittent use of the medicine prior to exposure to cold 

weather is sufficient.

Patients with secondary Raynaud’s, who find calcium channel blockers ineffective, may benefit 

from the concomitant administration of an additional vasodilator such as transdermal nitroglycerin.⁹

Many other medicines, such as other vasodilators, endothelin antagonists, phosphodiesterase-5 

inhibitors, prostaglandin derivatives, statins, botulinum toxin and N-acetyl-cysteine have been

 trialled in patients unresponsive to calcium channel blockers, however, there is limited evidence 

as to their effectiveness.

Rarely, in severe cases, surgical destruction of sympathetic nerves (sympathectomy) may be 

required to alleviate symptoms.

For video- Raynauds-real time

For further information: Centre for Arthritis & Autoimmune Rheumatic Disorders

Raynaud’s: An Unwelcome Winter Guest

Hello Kelley, It’s Me Raynaud’s….

I will never forget the day my fingers went numb and turned white, just like you see in the picture. It was in the middle of winter, my husband and I were teaching a Sunday school class to a group of 3-year old kids. I did not get a chance to have breakfast that morning so I just grabbed a caramel light Frappuccino. After I drank the ice cold drink I remember my fingers began to tingle. All my life I had cold hands and feet but this time felt different. The tingling was immediately followed with numbness. I put my gloves on and tried to warm my hands. After 10 minutes of rubbing my gloved hands together and blowing hot air over my gloves, my fingers were still ice cold. Out of concern, I took my gloves off and was shocked at what I saw. I noticed that the the last inch of my middle, ring, and index fingers were pure white. I remember thinking to myself, “My fingers are dead!” I started to panic.

I showed my hands to my husband and ran to the bathroom. In the bathroom I turned on the hot water and ran it over my fingers. I remember it seemed like hours before my fingers returned to their “normal” color and sensation. The tips of my fingers first turned bright red and then after 20 minutes of running hot water over my hands my fingers were pink. My heart was racing so fast, from the horror of what had happened. The loss of control in being able to warm up my hands left me feeling extremely fearful that something was medically wrong. I remember hearing a little about Raynaud’s in nursing school so as soon as we got home from church I turned to the internet to find out more about the condition.

Winter’s Guest

Every winter Raynaud’s moves into my life. I refer to Raynaud’s as an unwelcomed guest. Raynaud’s shows up unexpectedly. Sometimes when I’m all bundled up, gloved up, and warm but have had an extra cup of coffee earlier that morning, Raynaud’s appears. Raynaud’s can show up when I’m warm but stressed from a lack of sleep. Even after I take an extremely hot shower and step out of the shower still warm, Raynaud’s reminds me I’m not alone.

Since Raynaud’s is basically unknown to the general public, I wanted to look into the current information available on this peculiar phenomenon. Here is what I found.

Raynaud’s Phenomenon

Raynaud’s phenomenon was named after Maurice Raynaud who discovered the condition in 1862. Although Raynaud’s phenomenon has been identified for 150 years the causes and treatment of the disorder are still somewhat of a mystery.

For those of us who experience Raynaud’s, wintertime is often met with trepidation of when Raynaud’s will strike. If you have had a long history of extremely cold hands and feet, taking piping hot baths or showers, chilling easily, needing to wear gloves when the temperature is just slightly cool, owning several pairs of thick wooly socks because the tips of your toes can feel numb when exposed to cold air, or wearing hand warmers, you might be a risk for developing Raynaud’s phenomenon.

What is Raynaud’s?

Raynaud’s is referred to as Raynaud’s disease, Raynaud’s phenomenon or Raynaud’s disease throughout the medical literature. The discoloration of fingers or toes, in Raynaud’s results after being are exposed to cold conditions, an emotional event, or excessive intake of caffeine. An abnormal spasm in the vessels of the digits diminishes the blood supply to the affected areas. The fingers and toes typically turn white and then blue, from a lack of oxygenation. When the vessels open back up, the fingers turn red, revealing a return of blood flow. When the color changes occur the individual often feels a tingling sensation in the fingers and toes. This tingling sensation can at times be slightly painful as blood rushes back into the vessels.

Who is Affected by Raynaud’s?

Research suggests that 5% of the American population has Raynaud’s, although it is purported to be larger due to lack of reporting. It affects women in their 20′s, 30′s, or 40′s, more than men.There are two categories of Raynaud’s.

1. Primary Raynaud’s. This is the most common form of Raynaud’s. Primary Raynaud’s is when the symptoms of the disease occur alone without any underlying medical disease. Other terms for this category of Raynaud’s include: Raynaud’s disease or Raynaud’s phenomenon.
2. Secondary Raynaud’s . This is what is known as Raynaud’s phenomenon and typically occurs around or after age 40, as a result of an underlying medical condition. This category of Raynaud’s is less common but potentially more dangerous than primary Raynaud’s.

Secondary Raynaud’s is found in individuals who often have a history of one of the following disorders: Scleroderma, Rheumatoid Arthritis, Lupus, Sjogren’s Disease, Atherosclerosis, thyroid gland diseases, certain medications, Carpal Tunnel Syndrome, overuse injuries, and history of frostbite.

Long-Term Consequences of Raynaud’s

Most cases of Raynaud’s do not cause severe problems. Typically Raynaud’s is simply a sporadic event that can be uncomfortable and embarrassing. In individuals with a weak immune system or serious untreated infection, skin ulcers can appear which if left untreated could potentially lead to gangrene (tissue death). In cases of gangrene, amputation is performed to prevent further complications.

Preventing Raynaud’s Attacks

Sometimes Raynaud’s attacks cannot be prevented. They sneak up on me like an unwelcomed winter guest. However, there are certain things you can do to decrease the chances of experiencing Raynaud’s phenomenon.

• Wear thick warm gloves in cool temperatures with a finger heated glove liner.
• Dress in layers. Always prepare to be overly dressed. You can always remove the extra layers if needed.
• Avoid standing out in the wind. Wind is often a greater factor in the development of Raynaud’s than being in a cold environment.
• Do not drink cold drinks if you are cold already, if you have had more caffeine than normal, or if you have been fighting an infection or are sleep deprived. Any extra stress on your body from being cold, fighting an infection, or overcoming sleep deprivation is an invitation to Raynaud’s phenomenon.
• Change clothes as soon as possible after working out or sweating. A cold sweat, even in warm temperatures can lead to Raynaud’s.
• Use gloves when removing frozen food from the freezer. Just a brief encounter with ice or frozen food can trigger Raynaud’s.

When Other People Stare

When you see someone experiencing Raynaud’s in public keep in mind the embarrassment that individual feels. Also if you are the one experiencing an attack in public remind yourself of the shock you experienced when you first observed your own white lifeless looking fingers.  I try to have a pair of gloves with me at all times so I can just cover up my hands in public.

Hopefully you will never have to welcome the uninvited winter guest of Raynaud’s phenomenon. However if Raynaud’s decides to knock on your door this winter you can experience less fear knowing Raynaud’s is typically harmless.

https://www.youtube.com/watch?feature=player_embedded&v=NSn8PTJndBA

Choosing a Doctor

Without a doubt one of the most important factors for getting quality health care is to have a gooddoctor. For patients with rheumatoid arthritis, this is doubly important because proper treatment can halt the progress of a disease that can cause severe pain and lifelong disability. Receiving the righttreatment and stopping the destruction of RA can be life altering.

As a child it took a long time for my family to find the right doctor. First it was a struggle to get mediagnosed and find a doctor who could recognize that my symptoms signaled a serious disease. Lucky for me, I had a great pediatric rheumatologist. He did what he could with the available treatments and helped us to educate us about how to manage RA for the long term.

As an adult I learned to be discriminating in choosing all my doctors. When I am looking for a new doctor, here are some items that I keep in mind:

• Conduct pre-meeting research—One of the great things about the Internet age is being able to research doctors online. You may start with a list from your health insurer to see who is covered. From there you can research their background and practice. You can also ask around for referrals and references from other patients. Be sure to also confirm location and accessibility (if applicable) to make sure the office is convenient.
• Interview the doctor—Just because you need a new doctor does not mean the first candidate is a good fit. Yes, they are a candidate and must qualify if they want you as a patient! Ask them questions about their knowledge of RA, their approach, their education and experience. How do they handle an emergency like a flare or medication reaction?
• Make sure it is a personality fit—Do you feel comfortable talking with the doctor? Do they listen and answer your questions? Do you feel rushed? Do you feel they are compassionate and caring with patients?
• Ask about office procedures—How does the office handle getting test results to patients? How do they approach emergencies like a flare or infection? How do they handle paperwork needs, such as insurance forms or reports? How will the doctor coordinate care with your other providers?
• Test out the new doctor—If you like the responses on your first visit, try them out for a few visits. Is the doctor responsive to calls? Are they working with you on treatment options and checking back to see how you are doing? Are you receiving test results promptly? Are they answering your questions and concerns? Because it can take time to adjust to a new doctor and differences in their practice, it’s good to give it time.

I’ve become increasingly selective about doctors over the years. I realized my health, time, and money deserve the best care and so I take the interview process seriously.

The best doctors have a combination of experience with RA, compassion for their patients, and ability to coordinate on related conditions. With RA resulting in various health complications, recognizing different problems and referring treatment is crucial for managing overall health.

I also learned recently that it’s vital for doctors and their offices to be able to competently handle paperwork needs. This may sound like a no-brainer, but correctly handling paperwork can seriously support or damage your interactions with health insurance and getting bills paid. One misfiled form can result in weeks of headaches and appeals—a lot more work that we do not have the time and energy to manage.

So don’t be afraid to interview your doctors and make sure you’re selecting the best fit for your health!

Gout attacks 'twice as likely at night as during the day

People with gout are significantly more susceptible to flare-ups of their condition at night than during daylight hours, a new US study has shown.

Led by Boston University School of Medicine and published in the medical journal Arthritis & Rheumatology, the research utilised data from the Boston Online Gout Study - which investigated triggers for gout attacks from 2003 to 2013 - to see when these attacks were most prevalent.

A total of 724 gout patients were recruited and followed for one year, providing dates and hours for when gout attacks occurred, as well as answering questions on their symptoms, medication use and certain risk factors (such as alcohol use and seafood consumption) during the 24 and 48 hours preceding the gout flare.

Findings indicated that participants experienced 1,433 gout attacks during the study period. Of these, 733 were recorded between midnight to 07:59, 310 were between 08:00 and 14:59, and 390 took place between 15:00 to 23:59.

This means the risk of a gout flare was 2.4 times higher overnight and 1.3 times higher in the evening compared to daytime hours. This trend persisted even among those with no alcohol intake and low purine intake during the 24 hours prior to the attack, and after accounting for gender, age, body mass index and use of various medications.

Lead author Dr Hyon Choi, a former Boston University researcher who is currently at Massachusetts General Hospital and Harvard Medical School, said: "Our findings provide the first prospective evidence that the risk of gout flares is higher during the night and early morning hours than during the day. As a result of our study, prophylactic measures that prevent gout flares, especially at night, may be more effective."

A spokeswoman for Arthritis Research UK welcomed the findings as clinically useful, adding: "It could be that people at risk of gout attacks are more dehydrated at night, because they may have eaten a rich meal with red wine or drunk alcohol in the evening and this has a knock-on effect, causing a flare-up." - See more at: http://www.arthritisresearchuk.org/news/general-news/2014/december/gout-attacks-twice-as-likely-at-night-as-during-the-day.aspx#sthash.f1OrdcSh.dpuf

Raynauds Phenomenon (Cold sensitivity)

Raynaud’s phenomenon is a condition in which the body reacts to strong emotions or exposure to the cold by restricting blood flow to the extremities, such as fingers and toes, resulting in colour changes in the skin and some discomfort. Raynaud’s phenomenon can last from just a few minutes to many hours.

Around five per cent of the population has the condition to some degree. It is much more common in women and girls, with those under the age of 25 more commonly affected.

Raynaud’s phenomenon doesn’t usually cause permanent damage. However, it can be a symptom of more serious underlying illnesses, so it is important to see your doctor if you experience it.

Symptoms of Raynaud's phenomenon

The body prevents heat loss in cold weather by redirecting the blood away from the extremities. In a person with Raynaud’s phenomenon, this reaction is exaggerated. The blood vessels constrict tightly, starving the tissues of blood and causing the characteristic blue or white colour change. 

When blood flow returns, the skin turns from blue to red and finally back to the normal pink colour. Circulation to the rest of the body is generally perfectly normal.

Primary Raynaud's phenomenon

Primary Raynaud’s phenomenon (or Raynaud’s disease, or just Raynaud’s) is the most common form of Raynaud’s phenomenon. It is called ‘idiopathic’ because there is no clear underlying cause. It is often so mild that the person never seeks medical attention.

Secondary Raynaud's phenomenon

Secondary Raynaud’s phenomenon is generally more complex and serious than primary Raynaud’s. The most common causes of secondary Raynaud’s are underlying autoimmune disorders such as rheumatoid arthritis, scleroderma and systemic lupus erythematosus (SLE or lupus). 

Other common causes of secondary Raynaud’s phenomenon are:

• mechanical vibration – such as using a power tool for long periods. This is known as ‘industrial white finger’. It is thought that the vibrations disrupt the nerves
• atherosclerosis – in which a narrowing of the arteries is caused by a build-up of fatty plaques. Blood flow to the extremities may be hampered by this condition
• smoking – constricts blood vessels
• some medications – such as beta blockers, medications that contain ergotamine, certain chemotherapy agents and medications that cause blood vessels to narrow
• frostbite.

Complications of Raynaud’s phenomenon

In most cases, Raynaud’s phenomenon is harmless and has no lasting effects. In severe cases, however, loss of blood flow can permanently damage the tissue. 

Complications of severe Raynaud’s phenomenon include:

• impaired healing of cuts and abrasions
• increased susceptibility to infection
• ulceration
• tissue loss
• scarring
• gangrene.

Diagnosis of Raynaud’s phenomenon

It is not hard to diagnose Raynaud’s phenomenon, but it is sometimes hard to tell the difference between the primary or secondary form of the disorder. Your doctor may use a range of methods to decide which form a person has, including:

• a complete medical history
• physical examination
• blood tests
• examining fingernail tissue with a microscope.

Treatment for Raynaud’s phenomenon

For most people, primary Raynaud’s phenomenon is a nuisance rather than a disabling condition. However, if Raynaud’s phenomenon does occur, warming the body and the extremities is helpful. Retreat indoors, and soak fingers or toes in warm water. If a stressful situation triggers the attack, try to remove yourself from the situation and relax.

The general response to secondary Raynaud’s phenomenon is to treat the underlying illness. In severe cases, vasodilating medications (that dilate the blood vessels) may be prescribed to prevent tissue damage. Surgery may be needed if a person has skin ulcers or serious tissue damage.

Prevention of Raynaud’s phenomenon

• There is no cure for Raynaud’s phenomenon. Managing the condition requires avoiding known triggers, particularly exposure to cold temperatures. Some suggestions include:
• Avoid prolonged exposure to cold weather or sudden temperature changes, such as leaving a warm house on a cold day.
• Make sure your whole body is kept warm, using several layers of clothing to trap body heat. Keep your extremities warm with gloves and woollen socks.
• Be aware that even holding something cold, such as a can of drink, can trigger symptoms.
• Don’t smoke cigarettes or drink caffeinated beverages, since nicotine and caffeine constrict the arteries.
• Avoid medications such as vasoconstrictors, which cause the blood vessels to narrow. Avoid beta blockers, many cold preparations, narcotics, some migraine headache medications, some chemotherapeutic medications and clonidine (blood pressure medication). Of course, decisions about the use of medications need to be discussed with your doctor.
• Learn to recognise and avoid stressful situations. Stress and emotional distress can trigger an attack, particularly for people with primary Raynaud’s phenomenon. Relaxation may decrease the number and severity of attacks you experience.
• Keep a journal of when episodes occur. Triggers for these episodes may become evident.
• Hand care – dry hands can cause skin cracks. Moisturise your hands to prevent dryness and protect hands when in water with barrier creams. Speak to your doctor about which type to use.
• Exercise regularly to maintain blood flow and skin condition. Physical activity can also help increase your energy levels, control your weight, improve your cardiovascular (heart) fitness and help you to sleep better. Talk to your doctor before starting any exercise program.

Where to get help

• Your doctor

Things to remember

• Raynaud’s phenomenon is the short-term interruption of blood flow to the extremities, such as the fingers and toes.
• Raynaud’s phenomenon may be a sign of an underlying autoimmune disorder such as scleroderma or lupus so it is important to see your doctor for diagnosis.
• Management options include avoiding cold weather and sudden temperature changes.