Gout and Wine

[TORB]

My conclusions were based on what you wrote Ric - .....

I didn't (and don’t) have any other knowledge of your health problems than that.

Mike,

No argument mate, but that was the point. You don't know the whole picture..... even though I didn't provide it. I agree with your comment about it being not as simple as as seeing a serum level, so I guess we are not really in disagreement.

[Davo]

Oh yes - in the US you would see a cardiologist to prescribe an anti-hypertensive, or a respiratory physician to treat your bronchitis.

Uhm, yes. That is actually quite true - for me anyway. I pay a significant amount of money for health care which includes bypassing what is the equivalent of GPs - called primary care physicians - over here. Having experienced health care in Oz and in the US as well as worked with these folks in my work life for the past 30 years I think I have a fairly good idea of the capabilities of GP/primary care physicians versus medical specialists.

In fact you only have to look at what TORB has written to get a clear idea. He wrote “I have never had gout, but have always had higher than normal uric acid levels. My GP figured that it was only a matter of time before I got it, hence an ounce of prevention.” Normal blood values of uric acid are between 3.0 and 7.0 mg/dL. But a high uric acid level is not the be all and end all of the diagnosis of gout. You can have normal uric acid levels and still get gout, and even with a high uric acid level you can be gout free. Thus there is a good argument that treatment of asymptomatic hyperuricemia is not necessary. To quote one review article

“In the Normative Aging Study, the annual incidence of gout was only 0.1% in people with serum uric acid levels lower than 7.0 mg/dL, rising to 0.5% in people with uric acid levels from 7.0 to 8.9 mg/dL, and to 4.9% with uric acid levels higher than 9.0 mg/dL. Dincer HE, et al, Cleve Clin J Med. 2002 69:594”

So even with significantly high uric acid the chance of developing gout is about 1 in 20. More importantly elevated uric acid can be associated with other medical conditions. Hopefully TORB’s GP is aware of that and made appropriate investigations. Plus a side affect (admittedly uncommon) of Progout include changes in taste sensation!

Even if you have an inflamed joint its still not conclusive that you have gout. The diagnosis is made by taking fluid from the affected joint and finding urate crystals in that fluid (synovial fluid) using polarised light microscopy. This test is necessary because there are other crystals, esp. calcium pyrophosphate crystals, that can deposit in joints. So unless your GP has taken joint fluid and had it examined for urate crystals I'd be looking for a second opinion. And I know which type of doc I would be looking for.

Mike

A certain case of a little knowledge...

Only 30 years of exposure to the literature and a working relationship with those in the forefront of research in rheumatology.

Mike

There's a lot of difference between reading/talking about the war and fighting in it. Same goes for medicine.

So many experts these days

[Daryl Douglas]

The urologist who I've been attending has long experience in his specialisation, charges a very reasonable $80 for a consultation. Some GPs don't charge much less for prescribing antibiotics for a common cold.

[Lee]

Then he charges you $2000 for a 30-40 minute procedure!

[Davo]

The urologist who I've been attending has long experience in his specialistaion, charges a very reasonable $80 for a consultation. Some GPs don't charge much less for prescribing antibiotics for a common cold.

See how good he is when you next have a splitting headache or chest pain

And any GP who prescribes antibiotics for a "common" cold deserves your scorn. Why, you can just go into the chemist and get some very effective vitamins and cough mixes, eh.

[griff]

The urologist who I've been attending has long experience in his specialistaion, charges a very reasonable $80 for a consultation. Some GPs don't charge much less for prescribing antibiotics for a common cold.

See how good he is when you next have a splitting headache or chest pain

And any GP who prescribes antibiotics for a "common" cold deserves your scorn. Why, you can just go into the chemist and get some very effective vitamins and cough mixes, eh.

Leave my cough mixtures out of this eh?

cheers

Carl

[Daryl Douglas]

Come in spinners

[Daryl Douglas]

Then he charges you $2000 for a 30-40 minute procedure!

Well, a fair bit of it to Medicare and the hospital mostly to the private health fund.

[Daryl Douglas]

The urologist who I've been attending has long experience in his specialistaion, charges a very reasonable $80 for a consultation. Some GPs don't charge much less for prescribing antibiotics for a common cold.

See how good he is when you next have a splitting headache or chest pain

And any GP who prescribes antibiotics for a "common" cold deserves your scorn. Why, you can just go into the chemist and get some very effective vitamins and cough mixes, eh.

Headaches? Even a serious hangover rarely results in one of those. Analgesics are generally useless, even those with a boosted/forte codeine content. If I had worrying chest pains I'd get a GP to give me a referral to a cardiologist.

I wasn't disparaging GPs in general but have been prescribed antibiotics for a cold/flu - never bothered to have the prescriptions fillled for the obvious reason, they're not antiviral.

[Davo]

The urologist who I've been attending has long experience in his specialistaion, charges a very reasonable $80 for a consultation. Some GPs don't charge much less for prescribing antibiotics for a common cold.

See how good he is when you next have a splitting headache or chest pain

And any GP who prescribes antibiotics for a "common" cold deserves your scorn. Why, you can just go into the chemist and get some very effective vitamins and cough mixes, eh.

If I had worrying chest pains I'd get a GP to give me a referral to a cardiologist.

Yep, and he'd do a world of good for your pulmonary embolism

[KMP]

A certain case of a little knowledge...

Only 30 years of exposure to the literature and a working relationship with those in the forefront of research in rheumatology.

Mike[/quote]

There's a lot of difference between reading/talking about the war and fighting in it. Same goes for medicine.

So many experts these days [/quote]

How much expertise do you want Davo?

1975-78 Scientific Officer, Sutton Rheumatism Res. Lab., RNS Hospital, St. Leonards, NSW, Australia
1978-82 Graduate Studies, Department of Medicine, University of Sydney, Sydney, Australia
1982-85 Postdoc, Division of Rheumatology Research., Scripps Research Inst., La Jolla, CA
1985-87 Postdoc, Sutton Rheumatism Res. Lab., RNS Hospital, St. Leonards, NSW, Australia
1987-91 Sr. Postdoc., Division of Rheumatology Research, Scripps Research Inst., La Jolla, CA
1992-96 Asst. Professor, Division of Rheumatology Research, Scripps Research Inst., La Jolla, CA
1997-2008: Assoc. Professor of Molecular & Experimental Medicine, Division of Rheumatology Research., Scripps Research Inst., La Jolla, CA

You want more just google "K M Pollard, rheumatology"

Mike

[Lee]

If I had worrying chest pains I'd get a GP to give me a referral to a cardiologist.

This is one good reason why you need GPs - so you aren't self referred incorrectly. There are a lot of causes of "worrying" chest pain, and undifferentiated chest pain is generally an emergency department's role to sort out safely. I wouldn't want to have an infarct in the cardiologists waiting room!

Don't forgot though - for all those who are scorning the GP - you don't HAVE to have a referral to see any specialist - you only need a referral if you would like Medicare to rebate the consultation.....

[Scanlon]

A certain case of a little knowledge...

Only 30 years of exposure to the literature and a working relationship with those in the forefront of research in rheumatology.

Mike

There's a lot of difference between reading/talking about the war and fighting in it. Same goes for medicine.

So many experts these days [/quote]

How much expertise do you want Davo?

1975-78 Scientific Officer, Sutton Rheumatism Res. Lab., RNS Hospital, St. Leonards, NSW, Australia
1978-82 Graduate Studies, Department of Medicine, University of Sydney, Sydney, Australia
1982-85 Postdoc, Division of Rheumatology Research., Scripps Research Inst., La Jolla, CA
1985-87 Postdoc, Sutton Rheumatism Res. Lab., RNS Hospital, St. Leonards, NSW, Australia
1987-91 Sr. Postdoc., Division of Rheumatology Research, Scripps Research Inst., La Jolla, CA
1992-96 Asst. Professor, Division of Rheumatology Research, Scripps Research Inst., La Jolla, CA
1997-2008: Assoc. Professor of Molecular & Experimental Medicine, Division of Rheumatology Research., Scripps Research Inst., La Jolla, CA

You want more just google "K M Pollard, rheumatology"

Mike[/quote]

Flawless victory to KMP!

[griff]

If I had worrying chest pains I'd get a GP to give me a referral to a cardiologist.

This is one good reason why you need GPs - so you aren't self referred incorrectly. There are a lot of causes of "worrying" chest pain, and undifferentiated chest pain is generally an emergency department's role to sort out safely. I wouldn't want to have an infarct in the cardiologists waiting room!

Don't forgot though - for all those who are scorning the GP - you don't HAVE to have a referral to see any specialist - you only need a referral if you would like Medicare to rebate the consultation.....

Reminds me of one occasion when a cardiologist was doing a consult on the ward and we had a cardiac arrest in the same bay. The guy was useless! Give me a medical registrar (just about to sit their physician's exams preferably) any day of the week

cheers

Carl

[Davo]

A certain case of a little knowledge...

Only 30 years of exposure to the literature and a working relationship with those in the forefront of research in rheumatology.

Mike

There's a lot of difference between reading/talking about the war and fighting in it. Same goes for medicine.

So many experts these days

How much expertise do you want Davo?

1975-78 Scientific Officer, Sutton Rheumatism Res. Lab., RNS Hospital, St. Leonards, NSW, Australia
1978-82 Graduate Studies, Department of Medicine, University of Sydney, Sydney, Australia
1982-85 Postdoc, Division of Rheumatology Research., Scripps Research Inst., La Jolla, CA
1985-87 Postdoc, Sutton Rheumatism Res. Lab., RNS Hospital, St. Leonards, NSW, Australia
1987-91 Sr. Postdoc., Division of Rheumatology Research, Scripps Research Inst., La Jolla, CA
1992-96 Asst. Professor, Division of Rheumatology Research, Scripps Research Inst., La Jolla, CA
1997-2008: Assoc. Professor of Molecular & Experimental Medicine, Division of Rheumatology Research., Scripps Research Inst., La Jolla, CA

You want more just google "K M Pollard, rheumatology"

Mike

Excellent research articles. I even read a couple.

And your medical qualifications are...? As I couldn't find any reference to them.

And you last worked as a clinical Rheumatologist when and where ?

Just out of interest, mind, so I know who I am talking to.

[Lee]

Reminds me of one occasion when a cardiologist was doing a consult on the ward and we had a cardiac arrest in the same bay. The guy was useless! Give me a medical registrar (just about to sit their physician's exams preferably) any day of the week

I've seen an orthopedics reg resuscitate a consultant who had an arrest on the way to an arrest - successfully too.... who would have thought!

[Paradox]

A certain case of a little knowledge...

Only 30 years of exposure to the literature and a working relationship with those in the forefront of research in rheumatology.

There's a lot of difference between reading/talking about the war and fighting in it. Same goes for medicine.
So many experts these days

How much expertise do you want Davo?

This is turning into a bit of a pi$$ing contest and it's unpleasant.

I'm a GP. I've aspirated 2 joints in the last week, one with gout and one with CPPD. If you work in South Auckland you will see more gout in a year than in a lifetime in Oxford UK (I've worked in both places). You get pretty good at it. Plus I've worked as a rheumatology registrar as part of my physician training. So I'm probably ok to see about gout. Some GPs may not be so experienced, but in general in Aus/NZ they see enough to be pretty good.

That's probably not the case in the US. If I was living there I'd want to see a rheumatologist because the quality of primary care physicians can be variable. The bottom line is, is you have a problem, you want to see someone who is experienced in dealing with it. I'm not sure it matters what their position/title is. Horses for courses - you're both right. Enough?

Rob

[Wayno]

Hm is this Medics.net forum or Auswine ???

[Davo]

This is turning into a bit of a pi$$ing contest and it's unpleasant.

Rob

No Rob, not a pissing contest. I've just had a gutful of academics and armchair/web surfing experts telling me that as a GP I am useless and that everyone should see a specialist.

I don't go round telling everyone else that they suck at their job/profession. Tell me, why should we in clinical medicine have to put up with this c#*p.

KMP is probably a brilliant research scientist, possibly the best on the planet in the annals of autoimmiune disease. It still doesn't give him the right to suggest I have no idea how to do my job.

[KMP]

This is turning into a bit of a pi$$ing contest and it's unpleasant.

Rob

No Rob, not a pissing contest. I've just had a gutful of academics and armchair/web surfing experts telling me that as a GP I am useless and that everyone should see a specialist.

I don't go round telling everyone else that they suck at their job/profession. Tell me, why should we in clinical medicine have to put up with this c#*p.

KMP is probably a brilliant research scientist, possibly the best on the planet in the annals of autoimmiune disease. It still doesn't give him the right to suggest I have no idea how to do my job.

Davo get a grip. I am not a clinician, have never claimed to be. What I am is a pretty smart guy who has sat through more seminars, symposia, grand rounds etc on rheumatology than I care to remember. Does that give me the right to diagnose and prescribe? No. Does it mean that I know what the gold standard for the diagnosis of gout is? Yes. Does it mean that I know that its simply not recommended to put someone with a high uric acid level onto Allopurinol simply because of a suspicion they may at some future date get gout? Yes.

I stated my opinion that if I had a problem with my joints I’d go to a rheumatologist. How is that a personal affront to you? How does that question your abilities? As Paradox has said “you have a problem, you want to see someone who is experienced in dealing with it”. If you think you have the requisite experience to deal with everything then more power to you.

Mike

[08meltdown]

Davo get a grip. I am not a clinician, have never claimed to be. What I am is a pretty smart guy who has sat through more seminars, symposia, grand rounds etc on rheumatology than I care to remember. Does that give me the right to diagnose and prescribe? No. Does it mean that I know what the gold standard for the diagnosis of gout is? Yes. Does it mean that I know that its simply not recommended to put someone with a high uric acid level onto Allopurinol simply because of a suspicion they may at some future date get gout? Yes.

I stated my opinion that if I had a problem with my joints I’d go to a rheumatologist. How is that a personal affront to you? How does that question your abilities? As Paradox has said “you have a problem, you want to see someone who is experienced in dealing with it”. If you think you have the requisite experience to deal with everything then more power to you.

Mike

I started this post and it's now gone off almost everywhere.

Here's my gout experience.
My first port of call is my GP. Reason is the free Medicare consult. However if I need to pay then I might decide who to see in treating gout. Prior to this forum I have no clue of the role of rheumatologist in treating gout. Researching gout and seeing it consider as part of rheumatism and arthritis, a rheumatologist would be shortlisted.

As stated previously, I was prescribed NSAIDs. The gout is almost gone and I can now wear shoes. In fact I was playing badminton last night with no ill effects.

It so happen that a few days before the gout attack (1st time) I have my annual blood test. I was surprised that my uric acid was within the reference baseline. Now for the past decade except the last 2 years my uric acid level execeded the reference. That's when I learnt that a high uric acid doesn't mean definite gout attack or that low uric acid guarantee no gout attack.

I agree with Mike that medication is not required to bring the uric acid level down just to prevent future occurrence, unless there are frequent attacks. I don't prescribe to the practice of bringing all health readings to "normal" just in case.

[Davo]

Davo get a grip. I am not a clinician,Mike

It may not be your intention, but that is certainly the impression that you have given.

And I stick to my earlier comments. You have no idea what goes on when dealing with patients on a face to face basis in the setting of General Practice and you have no knowledge of the skill set of the average GP in Australia. So be it, but then you said it, you are not a clinician.

I stated my opinion that if I had a problem with my joints I’d go to a rheumatologist. How is that a personal affront to you? How does that question your abilities?Mike

I find your comments an affront to general practice as I know it in Australia, where the average GP is a very capable physician who deals with a wide range of problems on a daily basis, and who usually refers on to specialists only the more complicated and difficult patients, those with difficult to diagnose problems, and those who are already diagnosed but require specialist management because they are not responding to standard and readily available medications, often because the newer medications or diagnostic method is regulated by the Health Act to specialists only, or because, quite rightly, the GP has recognised that the care of the patient is beyond their skill set.

I do take this affront against my profession personally. And even though it may appear as though I am getting a little precious, I am getting bloody sick and tired of the attacks on my profession from every know it all sitting in comfort on the outside and not getting their hands dirty at the coalface.

If you think you have the requisite experience to deal with everything then more power to you.
Mike

I do not have the requisite experience to deal with "everything" and do recognise my limitations and refer to specialists with that area of expertise on a regular basis.

To refer every patient with joint pain to a Rheumatologist, every patient with shortness of breath to a Respiratory Physician, every patient with back pain to a Neurosurgeon, every overweight patient to an Endocrinologist, every patient who cries to a Psychiatrist, every child with a sore throat to a Paediatrician...you get my drift...would rapidly devalue both the specialist and the GP and you would end up rapidly with a system not dissimilar to that in the USA where only the filthy rich can afford any form of medical care.

And on this topic, probably to the pleasure of all, I have said my last.

[dave vino]

I've watched MASH, Marcus Welby, Doogie Howser, ER, Quincy, General Hospital, All Saints, Greys Anatomy, Scrubs and the Young Doctors. If you want to know how to resolve any medical issue in 45mins + ads, I'm your man but I don't bulk bill.

[RogerPike]

I am getting bloody sick and tired of the attacks on my profession from every know it all sitting in comfort on the outside and not getting their hands dirty at the coalface.

So, unless you make wine yourself you should not criticise winemakers?

Roger

[Davo]

I am getting bloody sick and tired of the attacks on my profession from every know it all sitting in comfort on the outside and not getting their hands dirty at the coalface.

So, unless you make wine yourself you should not criticise winemakers?

Roger

Et tu Brute?

I think poorly or misinformed criticism is unwarranted no matter what the profession or job. I'm having enough problem sticking up for my mob, who are about as united as an exploded grenade. You stick up for yours yourself

Oh, and good luck with the vintage. I was just over your way but unfortunately did not have time to catch up. Things looked pretty disastrous in Langhorne Creek and not much better in the Vales.

[RogerPike]

I am getting bloody sick and tired of the attacks on my profession from every know it all sitting in comfort on the outside and not getting their hands dirty at the coalface.

So, unless you make wine yourself you should not criticise winemakers?

Roger

Et tu Brute?

You are a week early Davo.

Roger

[Daryl Douglas]

I've watched MASH, Marcus Welby, Doogie Howser, ER, Quincy, General Hospital, All Saints, Greys Anatomy, Scrubs and the Young Doctors. If you want to know how to resolve any medical issue in 45mins + ads, I'm your man but I don't bulk bill.

At least the general practice I attend bulk bills.

[KMP]

Even with the prospect of Davo going off on another tear this is too good to pass up because it suggests that vitamin C may actually be good for something - gout!. From the Rheumatology Morning Wine (Tues, March 10, 2009).

Increased vitamin C consumption may reduce gout risk, study suggests.

HealthDay (3/9, Preidt) reported, "Consuming more vitamin C may help reduce a man's risk of gout, according to researchers who studied almost 47,000 men over a 20-year span." During the study, which appears in the March 9 edition of the Archives of Internal Medicine, researchers saw that "more than 1,300 of the men developed gout." They found that "for every 500 mg increase in vitamin C intake, the risk for gout fell 17 percent."

The UK's Telegraph (3/10, Smith) notes that the team from the University of British Columbia, in Vancouver, Canada, said that, "compared with men who did not take vitamin C supplements, those who took 1,000 to 1,499 supplemental milligrams per day had a 34 percent lower risk of gout and those who took 1,500 supplemental milligrams per day had a 45 percent lower risk."

They suggest that "vitamin C appears to prevent gout by reducing levels of uric acid in the blood," according to WebMD (3/9, Warner). "Buildup of uric acid can lead to the formation of crystals, which can deposit in the body, leading to the pain, inflammation, and swelling associated with gout."

MedPage Today (3/9, Gever) added that data "showed that uric acid excretion jumped dramatically after single large doses of vitamin C." The researchers explained "the effect probably reflects competition for renal reabsorption of uric acid. Vitamin C may also increase the glomerular filtration rate, further spurring uric acid excretion." Furthermore, "vitamin C may...inhibit gouty inflammation through its antioxidant action, but such a mechanism remains speculative."

Click for ABC Science News

Click for MedPageToday

In the interests of full disclosure. The Rheumatology Morning Wire is prepared exclusively for members of American College of Rheumatology from Newspapers, TV, Radio and Journals.

Mike

[Roscoe]

More reading.
A further word on how much the US health system costs and how little it seems to deliver, from yesterday's New York Times:
http://www.nytimes.com/aponline/2009/03 ... ref=health