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Uncertainty in Life and Medicine

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Weekly Live broadcast replay 20200805

Uncertainty in life and medicine.

Strategies and examples
-Focus on what you can control.
-Accepting uncertainty.
-Focus on your big principles.
-Trusted sources

Also covered a new study showing treatment with canakinumab a il1 blocking medication can possibly help prevent progression of osteoarthritis.
Discussion on how IRAP, PRP, and Bone marrow derived cells can do so as well without medication risks.

Chicago Arthritis and Regenerative Medicine Weekly Live broadcast.
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Discussing relevant issues regarding state of the care for arthritis, tendinitis, injuries, and back pain.
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– Hello, everyone. This is Siddharth Tambar from Chicago Arthritis and Regenerative Medicine. This is our weekly live, live broadcast. Welcome, it is August 5th, 2020. On this broadcast, essentially I’m discussing topics and professional aspects that are relevant and interesting to me. Here at Chicago Arthritis and Regenerative Medicine, we are focused on evaluation and treatment of arthritis, tendonitis, injuries, and back pain with a real focus on utilizing nonsurgical treatments and the most up-to-date and interesting treatments that are currently available to treat not only pain and improve function, but to really treat the root cause of what’s driving these conditions. So there’s two topics I’m talking about today. The bigger one is uncertainty because I think that is just huge right now. But before that, I wanted to briefly go over a recent article that was published in the articles, on the Annals of Internal Medicine yesterday. It’s sort of a hot-off-the-press sort of topic that I think is interesting that I want to give a very brief but relevant commentary on. So essentially the title of the article is Effects of Interleukin-1B Inhibition on Incident Hip and Knee Replacement. It’s a ridiculous name, but it’s being sort of presented as, hey, finally, a medication that will prevent the progression of osteoarthritis and relevant because we have other treatments for things like rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, where medication will actually prevent the progression of those conditions. And we don’t really have a medication for osteoarthritis that can do the same thing. So in this study, they looked at a medication called canakinumab, which specifically blocks a molecule called interleukin-1B, and it’s currently approved for rheumatoid arthritis. Canakinumab is approved for systemic juvenile rheumatoid arthritis or juvenile idiopathic arthritis. And it’s also approved for a very small subset of some other inflammatory conditions called caps CAPS, C-A-P-S. And in this study, they actually looked at patients that in a bigger study, they looked at the patients who have had a history of heart disease and have mildly elevated inflammation levels. And they wanted to know if utilizing this medication would prevent other heart disease. So this followup sort of subset of this study was to look at 1,000 of those patients. And they wanted to see if the patients who are on this medication would actually, it would actually do anything else from a osteoarthritis standpoint. And they found that for patients who are on this medication, as compared to patients who were just taking placebo, they had a much lower rate of progressing to knee replacement surgery or total hip replacement surgery. And so it’s presented as, wow, look at this, finally a medication that is disease-modifying for osteoarthritis. And it’s interesting. It’s very early. There still needs to be much larger studies and more dedicated studies from the osteoarthritis standpoint. And the whole point is that it’s blocking this molecule called interleukin-1. And that’s interesting because here is possibly a biologic way to actually prevent the progression of osteoarthritis. Super interesting. And it’s curious that the medication can do it, but it’s worthwhile understanding that this sort of medication has potential risks, and there may be other treatment options, and I’ll discuss that, that can do the same thing. So the potential risks of this kind of medication are, the main one is infection risk, that it increased the risk of infection. And that’s significant because you need to balance the risk of infection with the possible benefit of what this treatment is trying to do. And you’d have to be careful about suddenly utilizing this in a wide spectrum and like millions of people who’ve had osteoarthritis, especially if there’s some other treatment options that are lower risk. So the options that are lower risk are to utilize your own blood platelets and bone marrow graft stem cells to actually treat osteoarthritis. And the reason why is because those same treatments from your own blood and body and bone marrow do actually block interleukin-1 receptor antagonist protein. So it does the same effect, but because you’re utilizing your own cells, you don’t have that same risk of infection, that same risk of allergic reaction. And anytime you’re measuring risks and benefits, you need to say, what are the potential risks? And can I get the same benefit in a lower-risk fashion? And in this case, you possibly can. Now there’s no head-to-head trials of saying, utilizing your own cells versus this medication. That’s still very early. But it’s worthwhile understanding that while there may be some benefit here to this medication, you can get a similar, if not same effect, in a much lower-risk fashion utilizing your own cells right now. And so my sort of hot-take or initial take is very interesting that there there’s maybe some progress on looking for disease-modifying medications for osteoarthritis. It’s always good to have additional options, but understand that there’s existing options that already work in that same kind of mechanism where we know it’s definitely safer. Okay, so the bigger topic for the day I wanted to discuss is the concept of uncertainty, obviously with a focus on the medical side and a focus on musculoskeletal health and stuff like that. But uncertainty is the topic of the day. It’s just too big of a topic to ignore. I mean, I can’t just talk about joint and tendon issues and not sort of address what are the things everyone’s thinking about, uncertainty, meaning uncertainty with COVID, uncertainty with what are people doing if they want to go back to the gym, uncertainty when it comes to sending your own kid back to school. Obviously, my wife and I are thinking about that a lot in terms of what’s right for our own family and our own child in terms of going back to school, knowing that most schools really don’t, don’t know how to address this. I mean, this is a once-in-every-couple-100-years kind of event. And obviously the modern school system is not exactly made for that once-in-a-several-lifetime event. And there are a number of things that I think about when it comes to uncertainty and obviously seeing patients, and they’re all going through those same issues and thinking about those same concerns. Here’s kind of how I think about it. There’s sort of four different things that I’m going to give examples of of how to address kind of each one of these. But, you need to focus on what you can actually do something about. You need to be able to accept uncertainty, focusing on big principles, and you need to know what are trusted sources. And the examples I’m going to discuss are going to involve COVID-19, in addition, uncertainty in everyday decision-making, as a physician how I look at some of the uncertainty associated with musculoskeletal conditions, whether it’s things like inflammatory arthritis or even routine things like lower-back or knee issues, and how you think about imaging findings as well. Because uncertainty is present in all of these things. So first and foremost, I think it’s so essential to focus on what you can actually control. As an example, so we’re starting to realize that post COVID infection, there’s likely some chronic inflammatory issues that may be present a few months later, and obviously a lot of people are still symptomatic. We’re starting to see some of those patients. And there was a small study that came out of Germany a couple of weeks ago where they found that even two to three months after the initial infection, that a significant number of people in this small study still had evidence of inflammation around the heart, objective inflammation, either lab tests, MRI evidence. And that was regardless of how severe their COVID infection was, whether it was mild, moderate, or severe. So relevant because that same inflammation can be present in other parts of the body as well. And so I’ve had certainly one patient in particular recently who came in with all sorts of pain symptoms and fatigue symptoms after she’d had a COVID infection diagnosed a couple months ago. And it’s challenging because you’re looking for objective evidence of active inflammation that needs to be treated. And in her case, while she has slightly elevated labs, her imaging and exam don’t really show that. And so you’re in that sort of gray zone about, you want to treat this appropriately because this is likely related to her prior COVID infection, meaning the immune system is still revved up. She’s not any longer infected, but her immune system is still revved up and still causing inflammation. And yet how aggressively do you treat this is not clear. In addition, we’re not even sure what the full scope of post-COVID will be, how long does that last, and what’s the right way to handle that. There’s a lot of uncertainty to that. And for that individual that’s dealing with that, that’s super difficult and obviously very challenging when you’re being told that, listen, you have likely something, but we need to be realistic with how we’re going to treat this. And we need to be realistic to understand that there’s a lot of uncertainty here and that there isn’t really definitive guidance as to how to treat this. So let’s focus on what you can control, meaning here’s someone who’s had to pull back in a lot of exercise activity because of symptoms. Well, that will not only perpetuate her pain. It’s obviously affecting her sort of overall emotional and mental wellness as well if she went from doing significant physical activity five days out of the week and now doing none. Well, let’s get back into some physical therapy. Let’s let them start to kind of promote some of that kind of muscle firing, load bearing, get you back into doing some low-impact exercise. They can use some modalities like electrical stimulation, massage, maybe dry needling, just to help with pain as well. Let’s get back into something like that. There’s something that you can do something about. Let’s make sure you’re doing the right stuff from a nutrition standpoint, from a supplement standpoint. Optimize what you can control. It may not be 100% in terms of controlling your symptoms, but let’s at least maximize what we can control on your own without having to resort to medication, stronger treatment options as well. Focus on what you can control. Number two is focusing on big principles. So every single day, right, when I see patients, there’s uncertainty in terms of diagnosis, in terms of treatment options, in terms of what’s the next right step. And a lot of times, you just have to rely on what are your big principle understanding for the overall condition, the way the body works, in order to help make some decisions. So, as an example, inflammatory arthritis, early rheumatoid arthritis, is it really meet the criteria, does it not meet the criteria? You sometimes don’t get exact definitive diagnoses in medicine. And a lot of times, you need to use your best clinical judgment based on what you understand and have seen in the past, based on subtle findings that you might see on exam. For me, utilizing musculoskeletal ultrasound to find some subtle findings to help really push somebody into the right diagnostic criteria, it goes a long way. But a lot of times it is, in times of uncertainty, you still need to find and utilize those big principles, that if somebody has inflammation, their ultrasound findings will tend to look like this as opposed to degenerative arthritis and may look like that. That’s a big principle that helps to guide me in terms of my decision making. And that goes a long way to helping to make a right decision. Another example would be, I mean, knee and lower back degenerative arthritis is endemic. Like 70% of the population will have one of those issues or, if not higher, in their lifetime. And a lot of times people come in with pain symptoms, and their imaging may show a lot of findings. Their X-ray may show advanced arthritis in their knee, or their MRI may show tons of different things. And clinically you realize that not all of that correlates with their pain or their symptoms. And you have to utilize good principles of exam, understanding of the pathology, to really help guide people. As an example, the example I love to give for hips where it can be a little bit confusing is for my own mother. She’d had chronic hip pain for decades, and she’s had some imaging of the hip that actually showed some degree of wear-and-tear arthritis. But after a proper examination and figuring it out, it turned out her pain was really coming more from her SI joint, and her SI joint doesn’t have a ton of imaging findings. But clinically, based on my clinical experience, exam, and even treatment, we figured out that her pain was really coming from the SI joint. And focusing treatment on that has got a humongous way to treating her hip pain. And so even though her imaging may have said one thing, clinical understanding of how pathology works and how a condition presents, those big principles, helped to guide me in terms of making the right kind of medical decision and treatment decision in her case and in other cases as well. I think that same kind of concept applies to big principles in life as well. So, as an example, deciding, you know, what sort of activities do you put your kid back into, you don’t need to make reactive, scared decisions. You do need to make sensible, commonsense ones, things that are based on your own prior experience and principles that you live by. Apply those to the challenges and uncertainty of the day. It’s not going to be 100%, but it’ll at least help guide you to make the right kind of decisions that are going to respect your own beliefs and do the best that you can for your own family. Focus on big principles I think is a huge one in times of uncertainty because that’s how you stay on the right path. The third one is really accepting that uncertainty is, that is what life is. And it’s hard because right now, we went from a world that we were used to. And now there’s a humongous amount of uncertainty about what is happening in the fall for kids’ schooling, uncertainty in terms of what can you do for the normal kind of events in your life, going to weddings, going to the gym, going to restaurants, meeting friends, all that kind of stuff. And yet I think it’s important to understand that as human beings, we’re literally built for this kind of uncertainty. If you go far enough back in anyone’s family lineage, you’ll find people who went through a high degree of chaos, uncertainty, and troubled times. And the reality is that, as hard as right now is, there’ve been times in human history where people, our own family members, have had to go through things that are dramatically worse. We are built for this physically, mentally, emotionally. It’s hard, but we are really built for this, to be hardy and adaptable, to take these kind of things on. And I think that that understanding of uncertainty that that’s what life is, is helpful for not only on an individual level, but understand that even on a macro level, in terms of how science works, how medicine works, that uncertainty is part of the process. And so it’s frustrating for a lot of people to hear the CDC give guidance, one thing, or doctors saying one thing about maybe this medication works, maybe do this, maybe wear masks, don’t wear masks. And then later on, they change it up. But the reality is that’s how science and that’s how medicine works. It works based on understanding to the best of your ability what is going on now, and as more information comes in, to then adapt and change to what the new information is. That’s literally how science works. And while it may be unsettling for people to hear that, the reality is that uncertainty is part of the strength of the system, that it adapts to what the new information is. It considers what it already understands, but then adds on and layers on that new information. And the better people understand that that’s how science works, that’s how medicine works, it’s not static, it’s dynamic, it’s learning, it’s growing and understanding, I think people will feel a little bit better in terms of the advice and guidance that they’re hearing from authorities and their physicians. The last thing is you need to have trusted sources. You need to be really clear what people, organizations, news sources can you trust and that you should rely on. We live in a world where it’s great to have so much information, but there’s just so much noise. It’s overwhelming to hear the discordance in terms of what people are thinking and talking about. You need to be able to judge who you trust so well. That’s no different than how it was pre-COVID. It’s just now there’s so much noise. You really need to be very clear what physician do you trust. What higher authority organizations on a medical level do you trust? What policy organizations and other sources do you trust? Understand that they may not always be right. I think one way that you know you’re dealing with a legitimate organization or person is, are they willing to admit when they’re wrong, and when they’ve made a mistake. When can they admit that my prior belief and understanding was this way, and as information has adapted and changed, now I’m thinking this. That sort of humility is very important. And understand that when it comes to things like science and medicine, you really should trust science, scientists and doctors who are actually experts in their field of study rather than trusting necessarily political sources, other news sources, but actually trusting people who are experts at what they’re doing. So, expertise is helpful, but a sense of being humble and humility when they’re expressing that, and a dynamic process of adjusting that information as things go along because the reality is circumstances change in life. Understanding changes as well, and you know a trusted source is on it when their opinions slowly adjust over time, not someone who’s changing every week or every day what they’re recommending, but somebody who, as they gather more information, can give you more updated, sensible understanding of what you should be thinking and doing. So to me, those are the big things. Uncertainty is difficult at this time, but the same rules apply pre-COVID as they do right now. Understand that there are things that you can focus on, and that’s what you should really be focused on, the things that you can control. Number two, having a big picture understanding of how you approach life and relying on those when times are more difficult. Number three, accepting that uncertainty is part of how life is. And then lastly, making sure you have good trusted sources that can guide you during this process as well. Until next week, I appreciate your time. As a reminder, we do this twice per week, Mondays and Wednesdays. Until the next time, have a good day, be well, live well, bye bye.


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***About this video***
In this video Siddharth Tambar MD from Chicago Arthritis and Regenerative Medicine discusses dealing with uncertainty in life and medicine.

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