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My mother the patient.

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CONCISE COMMUNICATIONS
1754
of odors than in previous reports. Third, the deficits were
shown to be differential across the patient population, with
some patients demonstrating marked olfactory deficits and
others performing in the normal range.
James M. Weiffenbach, PhD
Philip C. Fox, DDS
National Institute of Dental Research, NIH
Bethesda, MD
1. Bloch KJ, Buchanan WW, Wohl MJ, Bunin JJ: Sjogren’s syn-
drome: a clinical, pathological, and serological study of sixty-two
cases. Medicine (Baltimore) 44: 187-231, 1965
2. Rasmussen N, Brofeldt S, Manthorpe R: Smell and nasal findings
in patients with primary Sjogren’s syndrome. Scand J Rheumatol
ANOSMIC
I
I
MICRDSMIC
S I T
NORMOSMIC
SCORE
Figure 2. Distribution of scores on the University of Pennsylvania
Smell Identification Test (SIT) in 30 women with Sjogren’s syndrome (4) and 60 unaffected women (a).
abnormal values for IgA. Eleven of 29 patients exhibited
abnormal ESR, and 8 of 29 had elevated serum total protein
levels. Analysis by Fisher’s exact test indicated that none of
these putative markers of disease seventy was significantly
related to impairment of olfactory performance as indexed
by SIT scores below the median of the patient group. Thus,
the most severely affected patients were no more likely than
the less severely affected patients to demonstrate olfactory
impairment.
The smell identification performance of SS patients
and unaffected controls differs significantly. The assessment
procedure by which these differences were documented (the
SIT) samples a broad range of odors. It has been shown to be
sensitive to sex differences (6) and to deficits occurring in
association with aging (7,s). It has also been used to document decreased olfactory performance associated with disease and chemosensory dysfunction (9). The lower average
score of the SS patients on this test documents a significant
depression of olfactory sensitivity. As a group, SS patients
perform odor identification less well than do controls. In
addition, individual SS patients are less likely to perform
perfectly and more likely to be severely impaired. However,
patient self-reports are a poor guide to their sensory performance. Patients with decreased or worsened sense of smell
by self-report were not significantly more impaired by the
objective measure than were those reporting no impairment
in their sense of smell.
The smell deficits that we documented differ in a
number of ways from those previously reported. First, the
olfactory deficits found represent failures to identify odors
that are meaningful in everyday life and that are presented at
concentrations likely to be encountered outside the laboratory. Second, deficits were demonstrated for a wider variety
61~142-145, 1986
3. Henkin RI, Tala1 N, Larson AL, Mattem CTF: Abnormalities of
taste and smell in Sjogren’s syndrome. Ann Intern Med 76:375383, 1972
4. Doty RL, Brugger WE, Jurs PC, Omdo8 MA, Snyder PJ,
Lowry LD: Intranasal trigeminal stimulation from odorous volatiles: psychometric responses from anosmic and normal humans. Physiol Behav 20:175-185, 1978
5. Fox RI, Robinson CA, Curd JC, Kozin F, Howell FV: Sjogren’s
syndrome: proposed criteria for classification. Arthritis Rheum
29577-585, 1986
6. Doty RL, Shaman P, Dann M: Development of the University of
Pennsylvania smell identification test: a standardized microencapsulated test of olfactory function. Physiol Behav 32:489-502,
1984
7. Doty RL, Shaman P, Giberson R, Siksorski L, Rosenberg L:
Smell identification ability: changes with age. Science 226:14411443, 1984
8. Ship JA, Weiffenbach JM: Age, gender, medical treatment, and
medication effects on smell identification. J Gerontol 48:M2&
M32, 1992
9. Deems DA, Doty RL, Settle G, Moore-Gillom V, Shaman P,
Mester AF, Kimmelman CP, Brightman VJ, Snow JB: Smell and
taste disorders, a study of 750 patients from the University of
Pennsylvania smell and taste center. Arch Otolaryngol Head
Neck Surg 117:51%528, 1992
My mother, the patient
Author’s note: I am often asked what I tell patients who
ask about diet for their arthritis. The following is a
transcript of a conversation that might have taken place.
Hello?
Son? It’s your mother.
Hi, Ma. Haven’t talked to you for a while (1). How’rya
doing?
I manage. But your father-he
doctor said he has arthritis.
has problems. Our regular
Ma, did you forget I’m a rheumatologist?
What?
1755
CONCISE COMMUNICATIONS
The kind of doctor specially trained to diagnose and treat
arthritis and other disorders of joints, muscles, and bones
(2). Not everyone recognizes who we are and what we do. In
fact, one of a friend’s patients thinks he’s a “mythologist”!
(3).
It’s not always harmless, Ma. Some people neglect their
illness while trying diets or other things and miss the chance
to benefit from more proper therapy. Unorthodox treatments
are not always harmless-some patients even die from them
(5,6).
Is that better than a rheumatologist? So why didn’t you
study to become one?
Could it ever help?
You told me I’d make a better living as a rheumatologist,
remember? Why didn’t you call sooner about Dad’s arthritis?
Not usually, and not a lot. There may be occasional patients
who get arthritis as a symptom of an allergy to something,
like a food. Like you get hives from strawberries.
But I don’t get arthritis from eating any foods.
Son, it’s not so easy at our age. Besides, we didn’t want to
bother you. After all, it’s not like arthritis is something
serious. It just comes with getting old, doesn’t it?
Ma, there’s about a hundred types of arthritis. Some are
more serious than others, and all can be treated. What kind
did your doctor say Dad has?
Right, Ma, and neither do most people. I think some people
do, but not many, and it’s pretty obvious when it happens.
So, Son, you’re telling me that you don’t think foods cause
arthritis for most patients. And if they did we’d know it.
Right, Ma.
Son, I don’t know. If I did, we wouldn’t have had to go to the
doctor.
Ma, what did he prescribe? The treatments for different
kinds of arthritis are different.
He gave your father medicine, Son, but it made him sick.
And his arthritis still hurts. What diet should I give him? All
our friends tell us that would help. Better, you should come
and examine your father; you don’t visit enough.
Ma, I can’t give you good advice over the phone or without
knowing more about Dad’s condition (4).
Well, what about the cod liver oil we gave you as a child?
Didn’t that prevent you from getting arthritis?
Making me and my sister take that stuff was not nice, Ma.
Anyway, most of us don’t think it’s an important arthritis
therapy.
But many of my friends talk about this. What is it?
It’s a kind of fish oil. Fish oils can reduce some of the
symptoms of arthritis, like aspirin.
So I was right!
Son, I may not remember some things, but I d o know who
sent you to medical school. It’s me you’re talking to. Tell me
about diet for arthritis. Don’t you know something about
that?
Yes, Ma. I doubt that diet will help Dad.
No? Then why do you write so much about this, if it won’t
work?
Not exactly, Ma. These fish oils worked pretty well in
animals and in the research lab. But they didn’t help
that much for patients with arthritis, and they weren’t easy
to take.
Well, what about vitamins, o r minerals, or other dietary
supplements?
No, Ma. There’s no good scientific evidence that any of
these would help.
Ma, it helped me get grants, as I’ve told you (1).
So why do so many people talk about it?
Well, Ma, arthritis usually can’t be cured. It’s sometimes
hard to treat. Like Dad, many patients don’t do well on
medicines. People-and doctors to-would
love to have
something cheap, simple, and safe to use to control symptoms. Like a diet (5,6).
So, it couldn’t hurt, could it?
A special kind of diet? The bookstores always seem to
display something.
No, Ma. We even carried out a very careful experimental
study of a popular diet some years ago. There’s no good
proof that any of these are helpful for arthritis.
It’s not easy to grow old, Son. Or to be sick.
No, Ma. I’m not so young anymore, either, you know. But
there are no simple solutions for arthritis yet.
1756
CONCISE COMMUNICATIONS
It sure would be nice if a diet helped, Son.
So what do we do?
Yes, it would. But it isn’t proven, Ma. There probably are
some patients where food triggers arthritis. But not most.
And fish oils may help the inflammation of arthritis in some
patients. But modestly.
The best we can, Ma. We help our patients as best we can.
And rheumatologists, as arthritis specialists, can help a lot.
So diet isn’t the answer, Son?
I don’t think so, Ma. I rarely encourage patients to experiment with diets.
And not the fish oils either, Son?
No, Ma. I don’t think fish oil is an important arthritis
treatment.
So what did you learn from all your studying this, Son?
Ma, sometimes progress is disappointingly slow. We’ve
learned a lot about diet and arthritis, but it hasn’t changed
the way most of us manage patients.
Tonight’s Friday night, Son. We could have chicken soup, as
usual? (7)
I hope so, Ma. We will too (8). I’d like to talk with you
longer, Ma, but the editors say we’ve gone on too long
already. Try and get Dad to a rheumatologist, and let me
know how he does.
The author appreciates the excellent assistance of Pat
Palma in the preparation of the manuscript; support from the Saint
Barnabas Medical Center Research Foundation; and of course the
understanding, love, and support of his parents and family.
Richard S. Panush, MD
Saint Barnabas Medical Center
and UMDNJ-New Jersey Medical School
Livingston, NJ
It seems like a lot of work for nothing.
Ma, we’ve learned to think about new ideas. We have some
new notions about things that might cause arthritis, how, and
what therapies might and might not work.
Is this important, Son?
Yes, Ma. These insights prepare us for the next scientific
advance. We hope that the next one will lead to a more
important breakthrough.
That’s nice, Son, but it doesn’t help your father.
I know, Ma. But you need to know not only what he has, and
what can be done, but also what can’t be done.
1 . Panush RS: My son, the doctor. Am .
IMed 88:167-168, 1990
2. What Is a Rheumatologist? Atlanta, American College of Rheumatology, 1992
3. Germain BF: Personal communication, August 14, 1992
4. LaPuma .I,
Priest ER: Is there a doctor in the house? An analysis
of the practice of physicians’ treating their own families. JAMA
267:1810-1812, 1992
5. Panush RS: Food for thought, but not for arthritis. Primary Care
Rheum 2:l-5, 1992
6. Panush RS, editor: Is there a role for diet or other questionable
therapies in managing rheumatic diseases? Bull Rheum Dis
42:1-4, 1993
7. Caroline NL, Schwartz H: Chicken soup rebound and relapse
pneumonia: report of a case. Chest 67:215-216, 1975
8. Panush RS: Reflections on unproven remedies. Rheum Dis Clin
North Am 19:201-206, 1993
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