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Patients with Celiac Disease Should Have Regular Follow-up

Celiac disease (CD) is a lifelong autoimmune intestinal disorder and runs in families. First degree relatives of individuals with CD may or may not manifest symptoms of the disease. It affects people to varying degrees, from being critically ill to being completely well.

Gluten is the common name for the offending proteins in specific cereal grains that are harmful to persons with CD. When gluten is ingested, it causes immunologically toxic reaction in the lining of the small intestine. The small intestine is lined by villi which help absorb the nutrients from the food we eat. The toxic reaction damages these villi thus interfering with the absorption of nutrients and leading to diarrhea and malnutrition.

Symptoms of celiac sprue in children appear when cereal is introduced in their diet, anywhere between the ages of four to 24 months. They present with diarrhea, impaired growth and abdominal distension. Vomiting, anemia and swelling of the body tissues with fluid occur due to malnutrition.

Celiac sprue can develop in adults as new cases. About 20 per cent of the patients may be diagnosed after the age of 60. Otherwise, most adults with celiac disease will have history of the disease going back to childhood.

What is the long term effect of celiac disease if it remains untreated?

Chronic diarrhea will result in fluid and electrolyte imbalance. Development of cancer of the small bowel is a possibility. Poor absorption of food nutrients will result in malnutrition and poor immune system. Iron-deficiency anemia is now the most common clinical presentation in adults with celiac sprue. Osteoporosis is another likely complication of celiac disease.

Approximately, 50 per cent of adult patients do not have clinically significant diarrhea. So, making a diagnosis and provide follow-up is not always easy.

Why regular follow-up is important?

An article in the Canadian Journal of Gastroenterology (August 8, 2010) says that long term follow-up of patients with celiac disease is important for monitoring three things: their clinical status, dietary compliance and complications.

Most guidelines recommended a scheduled annual review and regular measurements of body mass index, dietary review with a nutritionist and serial tissue transglutaminase antibody testing. Some recommend annual hemoglobin, ferritin and folate checks. One guideline recommended annual hemoglobin, electrolyte, calcium, albumin, ferritin, folate, fat-soluble vitamin, liver function test, parathyroid hormone and bone density measurements (approximately $400 per patient).

What is the science behind these guidelines?

Unfortunately, there are no evidence based guidelines to suggest exactly what needs to be done in follow-up to change the outcome of the disease or prevent complications from the disease itself.

The survey done by the authors of the article say that most gastroenterologists in Canada provide routine long-term follow-up to their patients with celiac disease. Those who do not, delegate this role to the patient’s family doctor.

The follow-up is most often provided on an annual basis, and includes reinforcement of the need to adhere to a gluten-free diet, dietary review, physical examination, laboratory tests and a recommendation to join a patient support and advocacy group, says the article.

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Video Blog: Other Methods of Managing Tennis Elbow

The letter referenced in the video can be read on Medicine Hat News’ website: http://www.medicinehatnews.com/letters-to-the-editor/massage-therapy-another-treatment-option-01212011.html

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Management of “Jeep Disease” Should be Individualized

During World War II, soldiers lost many man hours due to “jeep disease”. Poor personal hygienic conditions plus the trauma of sitting on hard seats of jeeps driving over difficult terrain were the main reasons why these soldiers suffered from “jeep disease”. But most people who have this condition have never been in the army or driven a jeep.

So, what is “jeep disease”?

Medical name for “jeep disease” is pilonidal disease. It is a spectrum of three conditions: acute pilonidal abscess, chronic pilonidal abscess or sinus, and the unhealed pilonidal surgical wound.

The pilonidal disease most commonly occurs between the buttocks, close to the tailbone. This condition has been described since 1847. The term pilonidal means “hair-nest”. It can also occur in other areas such as beard, the armpit, the belly button and the web spaces of the hands (in barbers) and feet.

For many years, experts believed that this was a congenital condition. In 1946, Patty and Scarff challenged this theory and drew attention to the role of hair in the origin of this problem. Current evidence strongly indicates an acquired origin for pilonidal disease, with most infections being related to penetration of the skin by hair through small midline pits.

Where do these pits come from? Some people believe they are congenital while others believe them to be enlargement of hair follicles. These pits have sinus openings through which the hairs penetrate. Hirsutism in the buttock and perineal area appears to be associated with the development of pilonidal disease.

Management of the condition depends on the type of presentation.

Acute pilonidal abscess needs to be drained immediately once the diagnosis is made. The area should be kept shaved. Daily bath or shower will keep the area clean. Once healed, it may become necessary to excise the midline pits under local or general anaesthesia to prevent recurrence.

Chronic pilonidal abscess or sinus – treatment of this condition remains controversial as no one treatment has proved superior. The choices are: non-operative treatment with repeated phenol injections; conservative excision of the sinus openings and midline pits; laying open the sinus tract and stitch the skin margins to fibrous tissue (marsupialization); or wide excision with or without different types of closures of the skin.

At medical conferences, I have listened to many experts of the subject and have found no consensus or strong evidence that one treatment is superior to other. Last year, in October, I was in Washington, D.C. attending the American College of Surgeons annual conference. At a luncheon “Meet the Professor” meeting, the subject of pilonidal disease was discussed in great detail. The consensus was that the treatment for this condition should be individualized to each patient according to the severity of the problem.

The unhealed pilonidal surgical wound and recurrence of pilonidal disease after initial treatment is very common. Management of this problem can be very difficult. To start with, the unhealed wound should be curettaged to control the excessive granulation tissue (healing tissue which fills the wound), and the surrounding skin should be shaved weekly. The wound should be kept clean and dry with gauze. Strapping the buttocks apart may help prevent the continuous shearing movement during walking.

The wound may take six to eight weeks to heal. Quite often healing does not occur. Then a skin graft or some form of plastic flap may help the healing process. Overall, treating pilonidal disease should not be taken lightly.

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Botox for Tennis Elbow?

Have you ever suffered from tennis elbow, golfer’s elbow or pitcher’s elbow?

You may suffer from any one or more of these conditions even if you have never touched a golf club or a tennis racket or ever pitched a ball.

Tennis elbow is in overload injury which causes pain on the lateral (outer) aspect of the elbow joint(s) where the common extensor muscles are attached to the bone (lateral epicondyle of the humerus).

Golfer’s elbow, also sometimes called pitcher’s elbow, affects the medial (inner) side of the elbow, is an inflammatory condition of the elbow which in some ways is similar to tennis elbow.

Tennis elbow, also called lateral epicondylitis, is an extremely common injury. About 50 per cent of the tennis players are estimated to suffer from this condition first described by Runge in 1873. Interestingly enough, the condition is prevalent in people who do not play tennis at all. There is much controversy about the real cause of pain due to this condition and its treatment.

An article on this subject in the Canadian Medical Association Journal (CMAJ) calls this condition a costly disorder that affects one to three per cent of the general population and up to 15 per cent of at-risk workers.

Tennis elbow affects men more than women. People of any age can be affected but it most often affects people between the ages of 30 and 50. The condition also affects other athletes and people who participate in leisure or work activities that require repetitive arm, elbow and wrist movement.

People at risk are golfers, baseball players, bowlers, gardeners or landscapers, house or office cleaners (because of vacuuming, sweeping, and scrubbing), carpenters, mechanics and assembly-line workers.

Current treatment of this condition is aimed at reducing inflammation and pain. These involve rest and avoid any activity that causes pain. Apply ice or heat to the affected area. Painkillers like ibuprofen are helpful.

A splint or a brace to reduce strain at the elbow can be tried. See an occupational therapist. If nothing works then see your doctor to try injection of local anaesthtic or cortisone. If this does not work then surgery may be an option.

The CMAJ article says that there is limited evidence for the effectiveness of current approaches to treatment. Although recent studies report that 90 per cent of patients in primary care improve or recover completely after one year, tennis elbow results in substantial disability, use of health care resources, loss of productivity and high costs. New, more effective therapies are needed so people can continue to be productive.

Espandar and colleagues present (in CMAJ) the results of a randomized placebo-controlled trial that investigated the efficacy and safety of botulinum toxin type A (Botox) for the management of tennis elbow in 48 patients. Botox, a neurotoxin, is a poisonous protein complex that acts on the nervous system to paralyse it. Here, the idea is to paralyse the affected muscles temporarily to allow them to rest and heal. Botox is also thought to have some pain killing properties.

Three other similar trials with Botox have had conflicting results.

The trial reported in the CMAJ shows significant reductions in pain at rest at four, eight and 16 weeks. In the treatment group the intensity of pain during maximum pinch decreased at all time points. However, there was no significant difference in pain during maximum grip or in grip strength at any point between the two groups. The limiting factor was the expected paralysis in the muscles of the third and fourth fingers.

So, is Botox injection the treatment of choice for tennis elbow? It depends on your symptoms and how far you want to go. The good news is, 90 per cent of patients in primary care improve or recover completely after one year with non-surgical and non-Botox treatment.

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