Science and the Scleroderma Girl: The Only Point in Common

Two years ago I was getting bounced around between several doctors as they tried to figure out why I was struggling to breath. The rheumatologist felt I should see a cardiologist. The pulmonologist felt that I needed to be treated by the rheumatologist. The internist insisted that the pulmonologist needed to intervene. The rheumatologist was very reluctant to give me an inhaler even though he had ordered the PFT that indicated that I needed one.

I was getting close to pulling out my hair! Literally, there were too many cooks in the kitchen and no one could manage to get the meal assembled. I was the cake in the oven, and I had just collapsed into an ugly, doughy mess…

“Look”, said the rheumatologist in the middle of this, “you are the only point in common between all of your doctors. Each one of us sees just one slice of your health, but you are the one getting all the info…” In effect, she was telling me to take charge of my health. Uh…

Spock: He is intelligent, but not experienced. His pattern indicates two-dimensional thinking… (Star Trek II: The Wrath of Kahn)

Seriously? I’m expected to organize this circus? I have skills, but to suggest that I should run this show is ludicrous…

Except, from a certain viewpoint, I am running the show; I AM the show. I have a serious illness, and I have a team of doctors to address my symptoms and halt my disease’s progression. I need to be proactive and ensure that I get the treatment that I need. Clearly, I needed help to sort through the conflicting advice and to assign priorities to the elements of my treatment plan.

There needed to be one doctor who knew me well, understood the big picture, who could also cut through the red tape and facilitate immediate medical response from the most appropriate provider if needed.

I made an appointment with my internist, who was also my primary care physician, and laid out the problem. I told her that I needed someone to review all the notes and test results from the other doctors on a regular basis to understand the big picture. I shared with her my concerns about differing information from the other physicians: I needed an expert to work with me to coordinate my treatment plan. There needed to be a doctor who saw me on a regular basis, who knew me and my situation, who could take a “snapshot” of my health situation, and who could see me almost immediately if I got into trouble. One of the problems that I struggle with is knowing which doctor to call when I develop problems; with this arrangement I have a designated first contact who will decide which specialist needs to be contacted next.

We agreed that I should come in every three months for the medical review and snapshot of my current status.

Everything changed for me. My internist reads everything from the other doctors at these appointments, and she answers questions that I have in a cross-disciplinary way that the other specialists can’t. It’s more like a consultation than the usual medical appointment. She looks to see what has been missed by the other doctors, and facilitates communication between the doctors. She has sent me for immediate testing, cut through the red tape so I could get oxygen when I needed it, and makes sure I get the complete text of all testing reports.

I make an appointment with her before I see the specialists to plan for those appointments, and then I see her afterwards to debrief on what happened and to see if anything was missed. When I go to my appointments with the specialists I can talk about test results, my prescriptions, and the symptoms that are concerning me; I have become an informed patient. Because of this I am a better conduit of information between the doctors, and the coordination of care and smooth communication has greatly increased. My doctors and I are now collaborative partners working to manage my disease.

From a collection of 6 doctors I now have a smoothly coordinated team to jointly treat my illness. For me, this is a huge difference! I’m now in much better shape, and I feel more in control of what is happening. I AM the only point in common, so I had to activate my hidden superpower of facilitation and coordination to make it work.

And knit. I had to knit a lot.

Have a good weekend everyone.

Science and the Scleroderma Girl: Hard Choices (Part 2)

Last week I wrote a post about trying to make a good decision about what drug I should be treated with for my systemic sclerosis. My rheumatologist had offered me methotrexate and CellCept; after trying to gather info about the drugs and their symptoms I unhappily picked methotrexate.

Cat
the Mother of Cats chose badly…

The first weeks of the drug seemed okay. I had a couple of hard days after taking my dose on Monday, but then I would feel much better for the rest of the week as the pain and brain fog receded for several days. The crazy thing was, my knees hurt REALLY badly during those two bad days. I checked online and other people had experience a similar phenomenon, so I soldiered on. Then one week the pain was pretty bad in my lower chest and right side and I was having trouble walking and breathing…

IV in arm.
Off to the ER I went where they hunted for lung damage and blood clots… 

It was an inflammation of the cartilage of my ribs, a condition called costochondritis. I called the rheumatologist’s office to see what I should do next, but didn’t hear back for a couple of days. I then emailed, and called again.

Finally the call came back; I was having a rare bone reaction and needed to stop the methotrexate. He was starting me on CellCept immediately.

Oh, that was an adventure. So much stomach pain… scratch that… stomach fire! Not just my stomach… my intestines were on fire too!! I gulped down spoonfuls of coconut oil trying to baby my stomach lining. I added food with the pills. I started vomiting in the middle of the night. It didn’t matter what I did, my stomach was going to be very upset. I stopped the drug and shot off an email to the rheumatologist again.

Hence began the two month battle to get me onto another form of drug in CellCept, which is mycophenolate mofetil. A stomach gentle version called Myfortic did exist, but it was not approved for systemic sclerosis, so the pharmacy refused to fill it. My rheumatologist filed an appeal. It was denied. My rheumatologist doubled down. Another rejection. Eventually I drove down to the Kaiser pharmacy and talked to the pharmacist as calmly as I could. I reminded him that Myfortic as just another salt of the approved drug, I had failed the approved form, my rheumatologist had appealed for this drug, and that I had a letter on file from another doctor in the Kaiser system stating that my gastritis prevented me from taking NSAIDS or anything else that would damage my stomach lining. I must have looked pathetic, because he gave me the pills.

Three years later I have greatly improved because of this drug that we had to fight for. In the meantime I have discovered (by hunting for info on PubMed Health) that while methotrexate helps with symptoms like inflammation and fatigue, the better choice in the long run is the drug that I am now receiving as it is associated with skin, lung, and heart improvements and better survival rates. I do have a higher lymphoma risk with this drug, and infections are a constant concern, but I think that I’m with the best drug available for me right now.

There is a take home lesson here. If you aren’t happy with your treatment, speak up! I should have contacted that doctor about those hurting knees long before I ended up in the ER. It’s easy to take a passive course when you are dealing with busy doctors and unhelpful pharmacists, especially when you aren’t sure if your symptoms are significant, but it is worth the time to shoot off a fast email anyway.

And let’s be honest. There are no easy choices, only hard ones. But even a bad choice can be corrected down the road with some luck,  persistence, and a dash of science.

Rose
I bet you wondered where the rose was, didn’t you. Here it is, a little beat up by the hot weather, but still looking great!

Science and the Scleroderma Girl: Research Results

Yesterday was a good day for me. I ran to the library, went grocery shopping, and had my hair cut. The stylist who cut my hair, however, was having a poor day: she has fibromyalgia and was struggling with the pressure front moving through Colorado. I told her about bananas, and she told me about a new product that she was buying off the internet. As we swapped info she pulled out the bottle of her supplement and I snapped a picture of it with my camera. She gushed about her product: it is just great! It cleans toxins from your liver and pancreas too!

Okay, I just checked out this product  online, and it will need a blog post of its own. It has 19 different ingredients in it that I have to check out, but right now I think that I will need to stay away from it as it has aspirin in it from a willow bark ingredient. I already know that aspirin is something that can hurt my (already struggling) kidneys and put my stomach lining at risk (the gastroenterologist sent me a strongly worded letter on this topic… I’m complying!)  The other ingredients might be okay, however, and I should check them out to see if they are possibilities for me to add to my diet.

So, how do I do this? I do lots of searches with key words like “research”, “evidence”, “inflammation”, “mortality rates”, “efficacy” and the item that I’m searching for. When a friend recommended that I try tart cherry extract to help with inflammation I typed in “does tart cherry reduce inflammation” and discovered that there was an active ingredient in tart cherry that really did reduce inflammation and that it was more gentle on stomach linings than a NSAID. Clinical research projects had been done that showed positive effects by measuring inflammation markers in patient blood. I talked to both my internist and my rheumatologist about it, got their okay with some stipulations, started the supplement with medical monitoring (blood drawn every month), and had to stop 3 months later when my kidney function dropped dramatically. Oops.

There is an important lesson here. Just because something is “natural” doesn’t mean that it is safe. Think like a scientist. Keep a journal of your disease symptoms, diet and interventions. Ask questions and talk to your doctors. Educate yourself as much as you can.

English Rose.
Time for a rose break! Look at what I found in the garden this morning!

Where do I go for information? I could have gotten info from sites linked to the company that markets tart cherry extracts, but that information is somewhat tainted by the simple fact that they want me to buy their product. I look for information from major publications and research funded by the public domain. Some of the best places that I’ve found to go are:

  • The National Center for Biotechnical Information (NCBI) has links to lots of places you can access for information. I used this site a lot as a teacher as students could look at genes and run DNA comparisons. Now I can use it to research tart cherry!
  • Linked to the NCBI home page is a great resource: PubMed. Everything in the medical and biological universe is searchable at this site; you can see the synopsis with a general outline of the research and results,  and there are links to the journals and books along with information on how to access the full text. Some full text articles are free, and there is advice on how to get others.
  • A subset of PubMed that is extremely useful, both for the search engine and information on how to evaluate information you find, is PubMed Health. For me, this is the mother lode.
  • I live in Aurora, Colorado. I am lucky in that the CU School of Medicine is located here, and there is a great library there. I went into the library, talked to them, and got an account that allows me to access articles through their licenses. So far I’ve only had to resort to this option a couple of times, but it is good to have it.

Next to keeping my journal, the info I find using these resources has been extremely helpful and empowering in my battle with these ill-behaved autoimmune conditions.

Knowledge is power!

Science and the Scleroderma Girl: Controlled Experiments

I literally learned about controlled experiments at my mother’s knee; there was a new baby in the house, and she was slowly introducing solid foods into his diet and I was helping to feed him. She carefully added only one new food a week: applesauce, carrots, squash… it was boring and I wanted to give him lots of interesting foods all at once. Nope. She insisted that it was important to keep everything exactly the same EXCEPT for the new food that was being introduced; if the baby got sick then we would know that the new food was the cause. Bam! This is an explanation of controlled experiments that even my five year old self could understand.

Upset cat
The Mother of Cats was raised by a very smart woman…

As a person with a chronic illness I hang out in internet forums and support groups that are awash with lots of confusing and conflicting information. It is a lot to sort through, and I find myself searching for validating information generated by that method I first learned from my mom: results from controlled scientific studies.

This is what I’m looking for when I deep dive into the internet looking for results on medications, alternative medicine treatments, supplements, exercise, possible causes of my illness, whatever.

  • Who did this research? Is it being presented by someone with a financial stake in the results? For example, research showing that cigarettes had no impact on cancer rates funded by the tobacco industry was later shown to not be valid. There was research bias in the tobacco-funded research. I look for bias like that as I collect information.
  • Did this research study have a control group? This means that if a group of patients received a drug, was there another matched group that did not get the drug; the two groups should be compared to see if the drug impacted their illness.
  • How well matched were the two groups? Ideally, they should be as identical as possible. The groups should have patients of the same ages, genders, diagnoses, etc.
  • What was the data that was being collected? I feel that hard data like lung volume, CAT scans, arterial pressure or blood tests are more meaningful than a survey filled out by patients that reports how “bad” they feel.
  • How large were the research groups? A study done with only a dozen patients is not necessarily invalid, but one done with a couple of hundred patients is one whose results I’m more likely to regard as meaningful.
  • The gold standard in research studies is one that assigns one group the drug, and the other group a placebo (an inactive dose) as the control. The patients and the doctors do no know which patients are receiving the drug, and which are getting placebo. This type of study, a double blind, is considered the most reliable as bias has been removed: differences between the two groups is due only to the drug.

This is a lot to keep in mind when looking at research reports, but after a while it gets easier. I used to hunt for newspaper reports of medical research to use with my classes. One of the favorites was this study about a virus that causes obesity…

Mice
Mice used in medical research studies are genetically identical. In the fat virus study animals were kept in identical conditions and one group was infected with the virus, and the other was not. The fat boy got the virus. (okay, this picture was swiped off the internet… I have no idea what actually happened to these two particular mice, but you get the idea…)

I don’t have the article from the Denver Post anymore, but here is the same study described on WebMD. The research, done by Richard Atkinson, M.D., showed that animals infected with the Ad36 virus have a huge weight gain even though they were eating the same amount as the control group. It happened in any animal group exposed to the Ad36 virus: mice, rats, chickens, monkeys. When he checked the blood of humans for antibodies to Ad36, he discovered that 30% of humans had antibodies to the virus, and those people were significantly heavier than people without the antibodies. Here’s the breakdown of the experiment:

  • Virus exposed mice: experimental group
  • Mice not exposed to the virus: control group
  • Conditions kept constant: the students could like several like age, type of mouse, genders, food, cage size, etc.
  • Data collected: weight gain

My students could also come up with the hypothesis and make predictions for further experiments. It was always interesting to me that many students would insist that obesity was just the result of poor diet and lack of exercise and that this data couldn’t be true. That’s bias, I would tell them. You have to follow the data; these results don’t mean that diet and exercise aren’t important, but you can’t just dismiss them out of hand, especially since it was validated using several animal models…

This is the type of thinking that I try to cling to as I hunt for information that might help me handle my chronic condition. Will essential oils help? Which ones? What is this whole AP protocol? Is sugar inflammatory? What about dairy? Is CellCept better than methotrexate in the long run? What is the best treatment for PAH? Should I go to yoga class? What studies have been done, and what does the data say? Learn, learn, learn.

My best survival skill is now the one that I learned at my mother’s knee.

Science and the Scleroderma Girl: Hard Choices

Everything happened really fast when I was first diagnosed with scleroderma  and Sjogren’s Syndrome. I had been referred to the rheumatologist after the results of bloodwork that my PCP ordered up. The rheumatologist did an exam and some tests, told me that I had the form of scleroderma called limited systemic sclerosis, and was evasive when I asked him what this would mean for me in the long term. What would my life be like in five years, I asked. He said he needed to run some more tests and would get back to me. He also told me to stay off the internet.

Well, that was kind of ominous, don’t you think? My first clue that this might be rather serious…

I was given a prescription for a disease modifying drug (DMARD) called Plaquenil, a handful of pamphlets, and referrals for additional testing. Lots of testing. Waiting for my prescriptions to be filled I went to the lab to get blood drawn and then sat down to call to make appointment for the additional testing I needed. It was hard to not feel like the sky was crashing down on me.

Cinco de Mayo rose.
Hey, time for a rose break. Look at what is blooming in my garden this morning! 

After 6 months of the drug Plaquenil I was feeling better, so I was a little shocked when the rheumatologist told me that it was time to add additional drugs and that he was going to give me the choice of methotrexate or CellCept. He handed me information on the drugs, ordered more blood tests to determine the state of my liver, and told me to call back in a week to let him know which drug I was comfortable with.

Of course I went straight to the internet. Hello. Science girl here. How should I make a decision without more information? Time to put all that chemistry and molecular biology to work!!

Ugh. After researching both of these drugs it didn’t look too good to me. Methotrexate is actually a chemo drug, given in a lower dose to rheumatology patients to suppress the immune response.  I would need folic acid to try to minimize hair loss and other side effects, and it would knock me on my butt for a day or two each week. CellCept also suppressed the immune system by another pathway, had fewer side effects, more risk of cancer, and was really hard on the stomach. Both drugs had definite downsides. I would need to stay out of the sun to prevent DNA damage. My risk of serious infections, including  PML, a fatal brain infection, would go up. The side effects of methotrexate seemed to be worse to me, but the CellCept would be awful on my gastritis…

If I chose to remain untreated with either of these drugs my chance of developing a fatal complication from scleroderma went up. I was already in the early stages of interstitial lung disease and pulmonary arterial hypertension, both of which could be fatal, so I really did need to try to slow things down with a drug…

Ugh! I was feeling pretty helpless about making the decision. What should I do when the future was unknown? Everything was a gamble and I didn’t have any really good choices.

I called my rheumatologist and told him I wanted to try methotrexate because I was pretty sure that I wouldn’t be able to handle CellCept. It was done.

Jacob sheep
Science and the Scleroderma Girl will be taking the weekend off because tomorrow I am going to the Estes Park Wool Market with my BKB Deb. Any day in the mountains is a good day, but it will be even better with yarn, peeps, and cute sheep. Woohoo! Fiber festival time!!

This whole process was kind of awful. Just knowing how these drugs worked and their side effects wasn’t enough. I needed more info. I needed to hunt down research studies.

Science time!!

Science and the Scleroderma Girl: The Patient Scientist

It is really annoying to have an illness that just keeps going on and on and on… think of the energizer bunny here. A really annoying scleroderma energizer bunny. I am so over it already. I love my doctors, but they are really focused on slowing down the progression of my bad boy illness, systemic sclerosis, and are kind of dismissive of the pain and dizziness that is coming my way courtesy of the fibromyalgia and Sjogren’s Syndrome.

It isn’t that they don’t care. They just have clearly defined priorities in mind as they treat me. It is kind of like when my mom was going through chemo for her cancer. The doctors were very sympathetic about her struggles with nausea and fatigue, and helped her the best they could, but they did not let up on the chemo schedule. My doctors are also sympathetic, but they still took my immunosuppressant dose up as high as they could when I got into trouble with my lungs two years ago. Oh, you are having trouble sleeping? So sorry. Hang in there. It will get better…

Cat and computer.
Do you see how much help MacKenzie is giving me while writing this? He too is sympathetic. Oh, your legs are hurting today? Here, I’ll sleep on top of them for you…

I had a surge of rebellion about the same time that this was going on and decided that I would consider myself a walking experiment of one and would try to get a better handle of my symptoms; surely there must be correlations between what I was doing in my day and how I felt. If I understood my test results better perhaps I could have better conversations with my doctors. Stop being a victim, I told myself, and become a patient scientist!

Food log.
Today’s entry into my little symptom journal. I started out tracking my daily food intake, and then added in entries about other symptoms.

The food log was perhaps the most important thing that I did. I began to figure out lots of things by focusing on what I was eating and what my symptoms were. I ignored the “universal truths” that I was being told to me by other people and focused on what was happening with me. Bam! Some of the things that I figured out actually changed the diagnosis list on my chart, and I certainly improved the quality of my life. Here is the short list of what I discovered about myself: absolutely NO SALT or other forms of sodium, gluten is fine, fiber is a problem, lactose free dairy with live cultures is a daily must, bananas are boss, and I should eat foods with a low glycemic index. Oh yeah: vitamin D and krill oil supplements are good, but tart cherry supplements will damage my kidneys. Good to know.

What happened when I changed my diet? Muscles pain went way down, I got more energy, my gastritis and other GI symptoms improved greatly, I slept better, and the quality of my life improved. For each of those food choices I used myself as an experimental animal. Just one change was made in my diet, and then I tracked symptoms for a week or two to see what happened. My latest experiment has involved bananas; a banana a day keeps my muscle pain way down. Who knew? Have a headache? Eat raisins!

I began to gather other types of data. I took my blood pressure during times when I was feeling poorly to see what it was doing. That’s how I figured out that my inhaler was making my blood pressure drop. Now that I’m off my blood pressure medicine, my pressure is back up, and I’m using my inhaler safely every day. Today I noticed that I was a little short of breath while doing laundry…

Oxygen monitor
Oh. That blood oxygen level is a little two low. It was in the high 80s when I first checked, and was up to 91% by the time I snapped the picture.
Oxygen monitor
Well look at that! This is what happened a couple of minutes later after using the inhaler. My oxygen level is up to 95% and my heart rate has dropped back down. I really need to use this inhaler every day as it is helping keep my small airway disease under control.

Now that I’m using the inhaler daily my energy level is up in my little notebook. Hmm… I’m not sure if this is completely due to the inhaler as I also added bananas to my diet, but as I keep logging observations I may figure it out.

I also have started collecting all the data that I can get from my routine heart and lung testing. I usually get a phone call from the doctor that tells me how I’m doing, but with the data in hand I can have more meaningful conversations with my doctors.

PFT results.
This is some data from pulmonary function tests that were done 2 years apart.

The data that I have circled in the upper table of data shows that my lung volume didn’t change very much when administered a dose of albuterol during my first pulmonary function test, which was done right after I was diagnosed. Two years later, when I was really struggling with shortness of breath, the data in the lower table showed that I improved 16% in my lung volume after that same drug. The technician told me that this was a big response and that he was sure I would be prescribed a drug to help me; that didn’t happen until I made an appointment with my internist weeks later, told her about my response on the drug, and showed her the specific data that I had picked up from the hospital where the test was done. Bam!! I got the inhaler that day.

By collecting data at home and paying attention to my symptoms I’ve been able to give better information to my doctors who have responded with changes in my drug protocol and treatment focus. Today all of my doctors shoot me a full copy of all of my testing data as soon as they get it. I also can access data through the patient portal at Kaiser. I follow changes in data over time, and then I can have a meaningful discussion with my physicians when I see them.

I’m just one data point out of all of the patients that my doctors treat, but by using myself as a walking experiment of one I’ve been able to figure out management strategies to help myself and how to better communicate with my medical team to work with them as a collaborative partner.

This is good. I will never be in control of my illnesses, but I sure am poking them with the pitchfork.

Err… knitting needles. They have definitely been poked.

It is good to be a science geek.

Science and the Scleroderma Girl: The Nature of Science

Logic clearly dictates…

Spock, Star Trek II: The Wrath of Kahn

Science. Everyone knows what science is, right? I mean, we have all been exposed to courses in science that involved learning lots of stuff about rocks, atoms, moving objects, plants, furry animals and stars. There are all of those books and all those facts, equations, and laws to learn. The vocabulary is ridiculous!

Science is also a way of thinking that allows us to learn new information about the world around us. It is a system of reason and logic that helps us understand what we know, and why we know it. Every year I started the biology course with a little unit called “The Nature of Science”, and this is what it covered:

  • Science is used to explore the natural, physical world around us. The magical and supernatural spheres are definitely off limits. The reason why is…
  • Science requires that we be able to collect data about a phenomenon we are studying: it must be observable with our senses or instruments. Something may be real, but if we can’t observe it we can’t study it using the rules of science.
  •  In science you cannot whip out a miracle to make your model work…
  • The data that is collected should be consistent over time. Think about ghost research; instruments that show the presence of ghosts work on some occasions and not on others. That data isn’t reliable because it isn’t consistent. If I drop a glass it will fall to the floor every time, and it will accelerate towards the floor at the same rate every time I drop it. That data is reliable.
  • It should be possible to make predictions based on observations and prior understandings. We generally call these predictions hypothesis, and they get tested all the time in…
  • Experiments! The way we expand our understanding of the natural world is through experimentation that tests these predictive hypotheses. Observable data is collected during the experiment that allows us to draw some conclusions about whether the hypothesis was correct or false. Either way is fine. The point here is, we should be able to test the hypothesis to see if the prediction was accurate.
  • Here is the best part of science: based on what new understandings are generated our predictive models should be able to be adjusted. NOTHING is forever in science when you are dealing with the big predictive models that we call theories. For example, when I was a child I was told that mountains were formed as the earth cooled and wrinkles formed on the planet “like a raisin”. Ugh! Can you believe I was taught that?! Our current understanding of mountain formation involves the movement of large plates in the earth’s crust (plate tectonics), which actually makes more sense as it also explains earthquakes and volcanoes. Is my heart set on plate tectonics? Nope. If some new information emerges that supports an expanded or new model of mountain formation, I have to follow the data. That’s why theories are said to be “supported” by evidence, but never proven.

Science is about using logic and reason to learn new things about the world. Logical safeguards are in place to help make sure conclusions are valid (you know about some of these… I’m talking about controlled experiments, reproducible results, and peer review of published experimental results). Science is actually a form of applied philosophy; early scientists were called “natural philosophers” and today the degree is still called a Doctor of Philosophy. Yep. That’s what Ph.D. stands for.

Why is this stuff important to me and anyone else with an autoimmune disease? Unhappily, we are out there on the edge of the envelope, falling off the map, and beyond solid scientific understandings. We have diseases that developed via unknown pathways and causes, and they are not completely understood. There is no definitive treatment that will “cure” the disease. We are part of a continuing effort to expand scientific and medical knowledge as we progress through our illnesses using drugs and interventions that are the best predictions for good outcomes. We are all walking hypotheses, and what happens to us helps build the body of evidence on how effective our treatments were. As knowledge expands in labs about the biological pathways and the disease mechanisms, new treatments will be developed, they will also be subjected to this scientific process, and the total body of scientific understandings will grow. Someday it will all be “old stuff” and written in a dusty book.

But today, I’m rocking the edge of the envelope as a walking experiment of one.

I even keep a science notebook on myself.

That’s tomorrow’s post.