Cassandra Kicks AS

Cassandra Kicks AS is moving

2009-09-30T14:40:00.000-04:00

Cassandra Kicks AS is still an active website but has moved to the following address:

http://web.me.com/cmkoits/Cassandra_Kicks_AS/Home_Page/Home_Page.html

Starting Simponi in September

2009-08-20T22:37:00.000-04:00

I saw my Rheumatologist last week, and we agreed that I would try the new biologic therapy, Simponi. Although Humira has proven effective at reducing my inflammation, stiffness, and fatigue, the pain of injecting the medication is too much to bear--the medication stings like battery acid as I inject it under my skin. Getting lemon juice in the eye could be comparable. I just injected my second-to-last dose of Humira. One more painful dose to go.

New Race Goals

2009-05-30T11:51:00.000-04:00

I've been feeling antsy. Despite taking up two new sports--golf and tennis--I feel as if something is missing from my life. It took me a while to come to terms with the fact that I was missing running. I had literally stopped running since the Goofy Challenge in January, touting the need to start running for fun rather than to be race-ready, to regain my core passion for the sport. The sad thing was that I was not running for fun as I thought I would; I would not consider running 5K once or twice within four months a commitment to running for pleasure.

I am now seeing a sports nutritionist to get my eating on track for racing in the Scotiabank Half Marathon in September of this year. My goal is to surpass my last personal best by 11 minutes. Today is day three on my nutritional plan; so far, so good.

My experience taking Humira

2009-05-20T23:03:00.031-04:00

Humira works incredibly well at controlling my stiffness, fatigue, inflammation, and night sweats. I inject myself every two weeks. Occasionally, I forget to take the medication or I postpone the injection because the solution stings. Consistently, within a few hours of my scheduled administration time, I start feeling the pangs of stiffness developing, my SI joints start to crack, and my mobility is markedly reduced. If I don't receive Humira within 48 hours of my scheduled time, I begin to experience night sweats, worsening mobility, and increasing fatigue. If Humira did not sting, I would likely not "forget" to take it as often.

Health Canada approves Simponi for AS

2009-05-20T00:02:00.000-04:00

Health Canada approves new medication for treatment of rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis

(Posted April 29, 2009)

Centocor Ortho Biotech Inc. and Schering-Plough Corporation recently announced that Health Canada has granted approval of Simponi (TM) (golimumab) as a once-monthly, subcutaneous therapy for the treatment of moderately to severely active rheumatoid arthritis (RA), active psoriatic arthritis (PsA) and active ankylosing spondylitis (AS).

With this approval in Canada, Simponi, in combination with methotrexate (MTX), is indicated for reducing the signs and symptoms in adult patients with moderately to severely active RA; reducing signs and symptoms in adult patients with moderately to severely active PsA, alone or in combination with MTX; and reducing signs and symptoms in adult patients with active AS who have had an inadequate response to conventional therapies. According to a company release, this medication is the first biologic therapy to be approved concurrently in three distinct rheumatologic diseases. Schering-Plough anticipates that the medication will become available in Canada in the second half of 2009.

"This first approval marks a major milestone in the clinical development program for Simponi," said Jerome A. Boscia, M.D., senior vice president, Clinical R&D, Centocor Research & Development, Inc. "More importantly, the approval of Simponi expands the therapeutic options for physicians and offers patients an effective new medication that can be self-administered once monthly."

"This is the first approval for Simponi, one of the five stars in our late-stage pipeline," said Thomas P. Koestler, Ph.D., executive vice president, Schering-Plough Corporation and president, Schering-Plough Research Institute. "Offering once-monthly subcutaneous dosing, Simponi will provide an important and convenient new treatment option to rheumatologists and their patients. Simponi expands our leading immunology franchise in meeting the needs of the rheumatology community."

Centocor Ortho Biotech Inc. developed and discovered Simponi and has exclusive marketing rights to the product in the United States. Following regulatory approvals, Schering-Plough will assume exclusive marketing rights in Canada and other countries (except for a few) outside the United States. The approval of this medication in Canada is based on data from five pivotal clinical trials: GO-BEFORE, GO-FORWARD, GO-AFTER, GO-REVEAL and GO-RAISE. Each trial found the medication to be effective in reducing the signs and symptoms of RA, PsA and AS.

Simponi is a human monoclonal antibody that targets and neutralizes excess TNF-alpha, a protein that when overproduced in the body due to chronic inflammatory diseases can cause inflammation and damage to bones, cartilage and tissue. The first once-monthly subcutaneous anti-TNF-alpha therapy, this medication is available either through the Simponi SmartJect auto injector or a prefilled syringe. It's also being studied as an intravenous infusion therapy for the treatment of rheumatoid arthritis.

(Source: PR Newswire - Centocor and Schering-Plough)

Goofy Challenge--I did it!!!!!!!

2009-01-18T00:03:00.039-05:00

I can't believe I accomplished my third dream running goal: to complete the Walt Disney World Goofy Challenge. I can't describe how proud I feel!!

HALF MARATHON
I went to bed early and awoke at 3am to start fuelling and hydrating. I was on the bus at 4am for the 6am start. Two hours of waiting around in the cold temperatures for the start of the race did not impress me--I could not see the logic in the wait. For extra cash paid ahead of time, a heated tent with additional luxuries, such as private toilets and a full post-race meal, was provided.

I decided weeks ago that I would pace myself for the half-marathon component of the Goofy Challenge. It was very difficult to not pick up the pace when I experienced sudden bursts of energy. The race took me through Epcot and the Magic Kingdom, where Disney characters lined the streets for photos with racers, and to provide moral support. As I ran through the castle in the Magic Kingdom, horns trumpeted as I emerged on the other side, and hundreds of spectators cheered us on.

FULL MARATHON

My body was slightly sore on Sunday, and my IT band was tender on both legs, however, the vision of the finish line and an accomplished dream goal caused me much excited anticipation. I went to sleep early on Saturday night, but I felt exhausted when I awoke at 3am to start the hydrating and fuelling process. I knew the challenge that lay ahead, but I tried not to think too deeply about it and redirected my thoughts to the present moment of preparing for the eve

nt. The morning routine mimicked yesterday's, including the early morning boarding of the bus to go and wait at Epcot until the 6am start. I continued to hydrate and fuel as I huddled in a tent with others trying to keep our muscles warm.

The race took us through all the theme parks. There were points in the race I was hurting terribly (sore muscles, particularly both IT bands that felt they would tear at any time) and needed to walk to stretch out my tight muscles. I gratefully accepted Advil and blue gooey muscle rub at the Aid Stations along the route. Occasionally, a few choice four letter words would slip past my lips as I would semi-run, semi-limp along...words the would mingle among sentences of self-encouragement and visionary motivation. The runners with the blue wrist bands stood out--we were the Goofy runners--and we supported each other along the way with pats on the back and pep talks; anything to distract from the pain was welcome.

The finish line, finally a distant memory, awarded me three large gold medals: Mickey, Donald, and Goofy. They were heavy weapons of achievement, and I wore them proudly that day.

Goofy

2009-01-02T06:58:00.003-05:00

The Goofy Challenge is just around the corner. Just a few more days before I jet-set to sunny Florida to fulfill my dream goal of running in this particular group of races. I plan on running nice and easy for both the half and full marathons, primarily because I have succumbed to a terrible virus that has left me with severe laryngitis, mild fevers, night sweats, and frequent uncontrollable dry coughing fits. Not very sexy at all. As a result, I can focus on enjoying the scenery, the spectators' cheers of support, the live bands, and the experience of all that is Walt Disney World.

First day on Humira

2008-12-24T15:34:00.001-05:00

My package of Humira arrived on December 22nd, perfectly timed with my return from hitting the sloped in Mont Tremblant, Quebec. A Registered Nurse from VON was expected to arrive on Christmas Eve to show me how to administer the medication properly, and to answer any questions I had. I prepared my list of questions in anticipation and waited with bated breath.

I was not impressed with the nurse's skills, I'm afraid. I never told her that we were members of the same registered body, and I almost wished I had: the basic skill of proper hand hygiene was sorely lacking. Despite the nurse telling me that I should wash my hands before injecting myself, she failed to do so and then proceeded to manipulate the area on my abdomen that I had carefully swabbed with alcohol. I swabbed a second time the now-contaminated site, and she once again manipulated the area and then quickly injected me the with medication. I was warned by the pharmacy that the formula was very acidic and burned, but I was not prepared for the intensity with which it stung. Reflexively, I tensed my muscles tightly; the pain was unwavering. The nurse told me, as I watched drops of medicated fluid spill down my stomach (I counted the hundreds of dollars being wasted with every dribble), that my abdominal muscles were creating resistance and pushing the needle out of my body. I was not sure if that was the true cause for the wastage of my precious medication, or if she was not as competent as her professional title implied. I am sorry to be so harsh, but if you been there listening to her...watching her...you would have been shaking your head and wondering if she had ever given a subcutaneous injection before. When I asked her about the side effects, she told me to read the pamphlet that came with the drug; which is all well and good given my nursing background, but she did not know of my clinical expertise and should have explained the side effects instead of directing me to small-printed clinical-trial jargon. She also directed me to do searches on the internet. Geez...why didn't I think of that (sarcasm dripping down the screen so thick you can barely read my blog anymore).

On a more positive note, Progress contacted me to find out if the nurse had shown up to provide the instruction and to learn of my experience. I was not brutally honest about my experience with respect to providing all of the details, but I did share my disappointment with the lack of hand washing. Progress committed to following up with VON to have another nurse come on January 6th to provide my second dose and answer any outstanding questions. At this point, I am extremely impressed with the comprehensive case management of Progress; it has certainly eased any anxieties I had starting a new biologic.

Seven days hitting Whistler Blackcomb

2008-12-13T21:23:00.003-05:00

It was time, finally, to hit the slopes: eleven days of ripping up powder in Whistler and Mont Tremblant. On December 7th, I ventured out to Whistler, British Columbia for seven days with four close friends. We arrived in Vancouver before 10am and drove the scenic Sea-to-Sky Highway to the Whistler Blackcomb resort. I spotted at least ten spectacular bald eagles resting on tree tops and soaring the bluebird sky as we made our way through Squamish.

Little did we know, but we would be present for the grand opening of the Peak to Peak Gondola that spans the 4.4km distance between the peaks of Whistler and Blackcomb mountains. The Guinness Book of World Records, along with hoards of media, descended on Whistler Village during the week prior to the Gondola's opening on December 12th--mainly because over three world records had been broken by this impressive engineering masterpiece.

I boarded on Blackcomb for two days and hit Whistler for three this week. Unfortunately, tearing up the snow for six hours every day took a toll on my lower back. I started flaring on my second night with terrible night sweats, stiffness, and back pain. I tried to suck it up and stick it out, but the stiffness worsened each day after that. By Thursday December 11th, I could barely stand up after strapping myself on my board. I had a noticeable difficult time walking...lifting each leg to propel me forward was met with significant stiffness and pain (the SI joint being the pivot point). Extra-strength Motrin took the edge off the pain a bit, but my mobility became progressively hindered. Needless to say, it's impossible for me to bend forward (friends help me don my socks and shoes/boots), and most mobilization requires some creative movements if I don't have friends nearby to assist. After five straight days of exploring the terrain on both mountains, I decided to give my body a break during my last two days here and enjoy the activities the Village offered: shopping, restaurants, apres, soaking in the hot-tub with friends and beer, and night life fun. I wanted to allow my body time to recover before leaving for Mont Tremblant on December 18th. With all of the snow Tremblant has experienced so far, I anticipated taking in some hardcore powder during my four day stay there.

The weather has been a bit wonky this week, with spring-like conditions at the base of the mountains, and a light foundation at the peak, resulting in the limited access to trails and runs on both summits and forcing every level of alpinist to share the track. There was a frustrating disorganized convergence of people from novice toddlers to professional racers. Everyone became either a target or an obstacle to avoid; I even overheard the mountain guides and safety patrol comment on the chaos. I was guilty of taking out a few people, and suffered the forceful impacts of others' uncontrolled speed. We relished the light dusting of snow on the peak on Tuesday and delighted on Friday when we awoke to the first snow gracing the Village (which meant that the peaks would have enough snow to conceal the icy 57cm snowbase for the morning crowd). Today was -25 degrees Celsius at the peak (with 57km/hr winds) and -12 degrees in the valley. The winds howled through the Village too. I was still struggling to mobilize my legs which forced me to walk slower than normal and endure the bone-chilling temperature. I was glad I was not on the peaks today. Instead, I spent the day shopping for snow-sport clothing, and the evening celebrating friendships over internationally-acclaimed fine dining at Araxi Restaurant and Lounge.

I'm LOVING the apres!!!

Humira Welcome Package Arrives

2008-11-19T15:43:00.002-05:00

In Canada, support services are provided by the Progress Program for Canadian patients with Rheumatoid Arthritis, Psoriatic Arthritis, Psoriasis, Ankylosing Spondylitis, or Crohn's taking Humira. They have nurses available around the clock to answer any questions, as well as cost reimbursement specialist to assist patients in optimizing reimbursement of Humira.

My Humira Starter Kit arrived today by FedEx from my Support Specialist at the Progress Program. Inside was a 2-compartment bag containing a journal, Humira Treatment Guide, 5 Steps card, an information booklet, a magnetic compliance device, a Medical Alert card, a Progress magnet, a DVD, Welcome card, demo auto-injector pen, a cooler bag, a reusable ice pack, and a Sharps disposable container.

I am now awaiting their pharmacy to deliver the medication to my home, and a home-care nurse to visit and walk me through using Humira. I have been reading about others' experience switching to Humira from Enbrel. The pattern has been that Enbrel initially relieves the disabling symptoms, but the relief wears off. Noticeable improvement occurs for most after switching to Humira. This is not to say that the same thing won't happen with Humira, or any other biologic; perhaps the beneficial effects are time limited. Unfortunately, we are the guinea pigs for long-term studies on this group of medications.

Still waiting

2008-11-17T17:20:00.002-05:00

Well, I'm still waiting for the Humira to arrive. A community agency representative contacted me today to confirm that my private health benefits will cover 90% of the cost of the medication. She indicated Humira costs approximately $1600 each month (that's only two injections), so any reprieve from the full expense is a blessing.

I found a Canadian health advisory for Humira that I thought may interest readers:

HEALTH CANADA ADVISORY

January 13, 2006

Health Canada has issued new warnings concerning the use of Humira(adalimumab). To read the full Health Canada Advisory, visit Health Canada's web site at: http://www.hc-sc.gc.ca.

Before you begin using a medication, be sure to inform your doctor of any medical conditions or allergies you may have, any medications you are taking, whether you are pregnant or breast-feeding, and any other significant facts about your health. These factors may affect how you should use this medication.

Allergic reactions: In rare cases, some people may develop an allergic reaction to this medication. Signs of an allergic reaction include a severe rash, hives, swollen face or throat, or difficulty breathing. If these occur, contact your doctor immediately. The needle cover on the pre-filled syringe contains dry natural rubber. Before you start injections, tell your doctor if you have an allergy to rubber or latex.

Blood disorders: Rarely, people taking this medication have become deficient in certain types of blood cells. If you notice signs of infection (such as fever, shaking or chills, fast heartbeat, or quick breathing) or bleeding (such as easy bruising, blood in the stools, black tarry stools, or vomiting blood or material that looks like coffee grounds), seek immediate medical attention.

Cancer: Compared to the general population, people taking adalimumab have a slightly greater risk of developing a cancer of the immune system (known as lymphoma). However, the risk is still small. In general, people with severe rheumatoid arthritis who take medications that suppress the immune system over long periods of time may also have a higher risk of developing lymphoma, even if they don't take adalimumab. If you experience any of the following or other unusual symptoms, contact your doctor immediately:

chills
decreased appetite
fever
night sweats
one or more enlarged lymph node
unusual fatigue
weight loss

Signs and symptoms of lymphoma can vary depending on the extent of the disease and the parts of the body involved (e.g., chest, abdomen or bowel).

Heart failure: Adalimumab may cause congestive heart failure (CHF) or worsen existing CHF. People with CHF should be monitored closely by their doctors. Symptoms to watch out for include swelling of the feet and ankles and shortness of breath. If you notice these symptoms, contact your doctor immediately.

Infections: This medication, or other TNF blockers, can increase the risk of developing infections such as tuberculosis and those caused by bacteria and fungi. If you notice signs of an infection such as fever, chills, pain, swelling, or pus, contact your doctor as soon as possible. Tell your doctor if you have a history of infections that keep coming back, or other conditions that might increase your risk of infections, including fungal infections. This medication should not be used in combination with anakinra, as this can increase the risk of severe infections.

Immune system disorders: Some people who take this medication have developed lupus-like syndrome, an autoimmune disease (a condition where the body is attacked by its own immune system). Symptoms of lupus-like syndrome include chest pain, joint pain, difficulty breathing, and a skin rash (usually on the cheeks and arms) that is sensitive to the sun. If you develop these symptoms, contact your doctor as soon as possible.

Liver problems: Very rarely, people taking adalimumab may experience liver problems. Symptoms of liver problems include:

abdominal pain
dark urine
fatigue
loss of appetite
yellow eyes or skin

If you notice these symptoms, contact your doctor immediately. People infected with hepatitis B (an infection that can damage the liver) may have a relapse of their condition while taking this medication. If you are at risk for hepatitis B, your doctor may want to test you for this infection before starting treatment with adalimumab, and will follow your condition closely while you are taking the medication. If you notice symptoms of a liver problem (see above), contact your doctor immediately.

Nervous system diseases: Rare cases of disorders that affect the nervous system have been reported by people taking adalimumab or other TNF blockers. If you are experiencing numbness and tingling, vision problems, weakness in your legs, and dizziness, contact your doctor immediately.

Pregnancy: This medication is not recommended for use during pregnancy. This medication should not be used during pregnancy unless the benefits outweigh the risks.

Breast-feeding: It is not known if adalimumab passes into breast milk. If you are a breast-feeding mother and are taking this medication, it may affect your baby. Talk to your doctor about whether you should continue breast-feeding.

Children: The safety and effectiveness of using this medication has not been established for children.

Switching from Enbrel to Humira

2008-11-07T14:14:00.002-05:00

I went and saw my Rheumatologist on Monday. My mobility was reassessed, and although my lateral range of motion has improved over the years, my forward range of motion has worsened. I suspected this was the case because it's been getting harder to don my socks and shoes bending forward. I've also been awoken by lower back pain every night. My Rheumatologist recommended trying Humira to see if my AS is more responsive to that medication.

Within two days, a Registered Nurse Case Manager responsible for my Rheumatologist's Humira's patients, contacted me at home, explained her role and what to expect: a call from a Reimbursement Specialist, a welcome kit in the mail that includes a sharps container, and to be connected with their pharmacy who will deliver Humira to either my home or workplace. I felt reassured to know that I had a local Case Manager whom I could contact with any questions or issues. Anyone who contacted me regarding my experience with Enbrel was always from the United States. I am uncertain of Humira's cost, but my Case Manager indicated that it was comparable to Enbrel.

Run for the Toad 50K - October 4th, 2008

2008-10-06T21:48:00.007-04:00

First 50K trail race...
7 hour and 11 minutes...
Tears almost shed in the 3rd leg of the race...
Accomplishing my 2nd dream running goal injury-free...

PRICELESS!!!!!

I did it! I am so proud!

I recall my first running clinic at the Pickering Running Room; it was a 10K Clinic. On the first day the instructor asked his group of eager students to think of one short-term, long-term, and dream running goal. The dream goal was to be something very challenging--something we could not fathom accomplishing at that point in time, but was attainable. My dream goal was to run a full marathon. I never thought I would ever strive for a distance longer than 21K, but I was confident I could attain it because other's had paved that road of possibility. On December 10th, 2006, I achieved my dream goal running the Honolulu Marathon in Oahu. In January of 2007, I set my sights on two other dream goals that had crossed my mind a few times over the last three years: a distance beyond a full-marathon (preferably off-road) and Walt Disney World's Goofy Challenge. I was fortunate enough to sign up early enough for each before registration was closed. With one of the goals finally achieved, I can now look forward to maintaining my base training for Goofy in January 2009.

It feels surreal to be thinking about Goofy so quickly after The Toad. It was during the 3rd leg I recall saying out loud that I never wanted to see my running shoes again. I was trying to maintain my sense of humour on the route; I spoke to anyone, cracking jokes and sharing motivational quips. A few runners within my proximity would chuckle in agreement with my idea of banning our running shoes from sight after the race. We all knew we would never have the balls to do such a terrible thing; it was just the hypoglycemia talking.

The first two legs of the race felt great. I was conservative with my pacing because I was new to this distance. I could not tell if the other runners sprinting by were doing the 25K or were competitive athletes with their own goals to beat doing the 50K. Only 100 of the 1100 people started the race with the objective of finishing the 50K. Eleven of those never finished the race. I was so proud that I was not one of them. The thought of quitting, I admit, entered my mind only in the context that it was possible, but not in the context of being something I would ever do. I ran the first 12.5K leg with an incredible woman from Hamilton who suffered from Multiple Sclerosis. We shared our experiences of running and its beneficial effect on each of our autoimmune diseases. I was so distracted by her inspirational stories that the first leg seemed to fly by. The third leg was the most challenging because I was not taking in as much fuel as I should have been. I risked gastrointestinal issues by agreeing to drink some flat Coke and ingesting two spoonfuls of Hammer Gel at the third aid station (products I had never ingested during training). I felt re-energized enough once my body greedily and desperately soaked up the carbohydrates, and I knew I had to keep downing Coke and gels at each aid station to pull me through. Gummies, pretzels, Gatorade of any colour...I was stomaching what I could...trusting that my body would be fuelled enough without getting gastrointestinal distress. I was lucky; I tend to have a stomach of lead and experienced no discomfort. My only suffering came each time I planted my foot on the ground. I swore I would see blood when I removed my shoes due to the pounding, but that didn't happen. I did feel a toenail bend backward when I kicked a tree root that ran across my path, so I anticipate it falling off in a few weeks, but for now, it's look quite pretty covered in pink nail polish from my pre-race pedicure.

Recovery has consisted of mentally resting and hydrating. I did some slow cycling on my recumbent bicycle on Sunday while playing a strategy game on the Playstation 3. It was relaxing allowing myself that time to do nothing, when normally I would be reading or gardening. I'm only sore at the hips today; my colleagues are ribbing me with implications as to the cause for my waddling gait. My lower back feels great (I injected Enbrel the night before the race), and I have not experienced any symptoms indicating an impending flare. I recognize that 50K was very strenuous on my body. I will be carefully considering distances beyond a half marathon once Goofy is over; I think my body needs a rest from intense training for a few months. In the interim, I'll just bask in this warm glow.

Scotiabank Half-Marathon - Sept 28, 2008

2008-09-28T13:39:00.000-04:00

The weather was perfect: 17 degrees celsius and slightly overcast. A gentle breeze escorted the runners and wakers from the start, along Toronto's Lakeshore Blvd, to past the finish line. I took it easy today; reminded myself at each kilometer banner not to push too hard...to save my muscles for the 50K in six days. I focused on keeping my head clear of all thoughts; I paid attention to only the music on my iPod and the faces of the runners on the other side of the street who were that much closer to the finish line than I. As I looked into those faces, I wondered how many had Ankylosing Spondylitis; how many of them had any type of disease...illness...affliction that impacted the quality of their life; that made them grateful for being able to get out of bed and face the beautiful day. At every race, the reality of my ability to run, while many others with arthritis cannot, is glaring. Part of me feels very accomplished; part of me wonders when my body will eventually say "enough!" Until that time comes, I'll just keep on running.

Travelling the Confederation Trail in PEI

2008-09-10T11:02:00.001-04:00

This is my first trip to Prince Edward Island. All I envisioned during the planning phase of my trip was running the Confederation Trail and eating as much shellfish as possible. It's unfortunate that my return to Ontario is during the start of PEI's International Shellfish Festival; I could have easily indulged for another week on this beautiful island. I suppose 10 days will have to suffice; I need to accumulate vacation time for my January trip to Disney World to run the Goofy Challenge.

During my second day on the Island, as it is affectionately called by locals, I went for an 11K jaunt around the capital of Charlottetown, the birthplace of Canadian Confederation, to tour the historic city by foot. I learned quickly that cars rarely stop for pedestrians, and you're lucky if they stop for the flashing lights at the crosswalk. In fact, leaving the airport on my day of arrival, I almost got T-boned by a car running a red light, despite their light being red for a while. I was cautioned by friends that my experience is quite common. I ran along the waterfront boardwalk, past the Lieutenant Governor's Residence, along Water Street, through Confederation Landing park,towards Founder's Hall. I returned home via Sydney Street to soak in the atmosphere of quaint restaurants, cafe's, and shops. The roads throughout Charlottetown are very flat and make for an enjoyable mental escape as you take in the scenery.

After spending time with friends, I ventured out for a 35K run on the Confederation Trail, starting once again in Charlottetown. From Churchill, I took Euston Street across the middle of town to the 9K Charlottetown branch of the Confederation Trail. From tip to tip, the trail totals 270K, but offers 400K of rolled stone dust surface for use when the branch trails into popular towns are accounted for. The offshoot of flat granular stone lead me to the main Royalty Junction trail, where I proceeded West (at least I think I went that way) until the town of Loyalist on Rte 256. That was 19K according to my Garmin, so I headed back the same way. I told my friends of my planned route, and advised them to come and find me if I was not back by a certain time, so I stuck to the route even though thoughts of exploring ventured into my mind. The trail was simply spectacular and well-travelled by many cyclists and runners.

I'm sporting a fever and sore throat this morning, so I'm curling up with a good book until the boys return from golfing--then it's off for some shellfish. All bi-valves should beware!

Fatigue

2008-09-01T15:11:00.003-04:00

I've been in a funk since completing the ITT race on August 16th. Immediately following the race, I suffered a short-term flare; however, some anti-inflammatories and lots of sleep brought on a speedy recovery with only minor discomfort. Since then, I have been hit with the forceful blow of energy-sucking general fatigue. Today was my first time running since the ITT, and I made it 2K before I returned home - mainly because of the 26 degree temperature, but also because my legs felt like lead from the start. It was terribly discouraging. In some semblance of a rebuttal, I have been hitting the gym frequently since August 16th to build strength and change up my training with the intent of moving past Boredom Boulevard back to Passionate Parkway. Alas! This fatigue has been plaguing me far too long, and it's hard to treat these lazy days as "recovery" from an internal injury when my personal critic ceases to silence her persistent drone: Is this laziness or fatigue? Am I just unmotivated? Give yourself a break; it's not like many healthy people are doing what you're trying to achieve! But is this laziness or fatigue?

I am perpetually trying to understand the tug-of-war between mental and physical exhaustion. I am curious as to the validity of this so-called lethargy that makes thinking seem like a strain. I feel as if I am constantly fighting my body's drive to sleep, which makes remaining awake all the more a chore. I planned to run 36K this weekend, but sleep got the better of me each day, and by the time I awoke, the heat of this glorious weekend was in full bloom - as if to remind us to not renounce its existence given the rainy summer. I would retire to the gym instead for five sets of varied exercises that would challenge my muscles and provide the satisfaction I miss from running. The workouts were two hours each and I could get lost in the variety of my training plan. Within 10 minutes of exertion with weights, I predictably begin my customary yawning routine - long drawn out reflexes spaced 5-10 minutes apart, acting as nagging reminders of how tired I feel.

"But I NEED to run!" quips a critical voice.

Is this what most ambitious sufferers of AS endure? Is it common to engage in a daily cognitive battle, not sure of whether the determined "what I want to do" side or the opposing realistic "how I feel" position will be victorious. It's tiresome to be party to, much less read about.

32K Iroquois Trail Test (ITT)

2008-08-18T21:42:00.005-04:00

Large moss-covered slippery fieldstone. Mud. Steep rocky terrain. Two river crossings. Bouldering over a sheer vertical rock wall. Perfect weather. 32K of this for some pretty cool bragging rights in the beautiful town of Kilbride, Ontario. I started counting how many times I rolled my ankle, stubbed my toes, and stumbled and slipped over large stones down muddy embankments, but I lost track. I was proud to not have fallen on my face, unlike one of my old running buddies. Another one of my running partners got lost 4K into the race and ran approximately 26K, but not on the race route. To top it off, she sustained some nasty injuries as a result of the unstable terrain. She found her way back to the starting point in surprisingly good spirits; I admired her positivity and perseverance. Participants followed the white and blue blazes of the Bruce Trail, and a few people ended up running more than 5K in the wrong direction. Of the 97 participants, only 90 people finished the race.

I loved the challenge of the technical elements, and the rocks beautifully broke up the routine of running flats or rolling hills through the trail. I was happy with my time up to 21K, but the

second part of the race--the most technical aspect--was met with severe cramping of my left calf and some nagging IT issues in my left leg. I chose not to risk injury on an already risky running surface, so I was considerably more conservative with my pace in the final leg of the race. It was not worth it to get injured at this point in the racing season.

Should I enter the ITT in the future, I will pick up my pace in the first leg to conserve energy for the final technical sections, and finish injury-free.

The Natural History of Ankylosing Spondylitis as Defined by Radiological Progression

2008-08-10T17:54:00.003-04:00

The Natural History of Ankylosing Spondylitis as Defined by Radiological Progression

SINEAD BROPHY, KIRSTEN MACKAY, AHMED AL-SAIDI, GORDON TAYLOR, and ANDREI CALIN

(J Rheumatol 2002;29:1236-43)

Radiological status is an important objective endpoint in the assessment of ankylosing spondylitis (AS). This study investigated the disease development of AS using radiological change.

Existing radiographs (n = 2284) of 571 AS patients attending the Royal National Hospital for Rheumatic Diseases were scored retrospectively using the Bath Ankylosing Spondylitis Radiology Index.

Progression of disease was initially examined cross sectionally. Factors associated with joint involvement were examined.
Progression of disease was then examined longitudinally for patients with films at time of symptom onset.
Rate of progression of radiological change was calculated using longitudinal data of 2 sets of radiographs taken 10 years apart (patient number = 54). The results from this were used to extrapolate backwards to age at first radiological change.

The results of the study demonstrated the following:

Progression to cervical spine disease was a function of: disease duration, severity of hip and lumbar involvement, and a history of iritis. Lumbar (lower back) involvement was associated with disease duration, age now, and severity of cervical and hip involvement. Hip involvement was a marker for cervical disease and associated with disease duration.
Longitudinal analysis revealed marked variation among patients with a slow general rate of progression.
The progression of AS over any 10 year period is linear [first 10 years = 30% (SD 0.3) of potential change, 10-20 yrs = 40% (SD 0.3) change, 20-30 yrs = 35% (SD 0.4) change (p = 0.5)]. Backward extrapolation suggests that the approximate time of first radiological change is at the age of 8 years.

The researchers concluded the following:

AS is a linearly progressive disease with about 35% change every 10 years. Spinal involvement is largely an expression of disease duration while the hips become involved in about 25% of individuals and may predict a more severe outcome for the cervical spine.
Backward extrapolation shows that the disease process may start as young as 8 years of age. However, the time interval between the disease trigger and radiological change remains unknown.

Tired

2008-08-10T17:15:00.002-04:00

I ran 25K yesterday through the towns of Ajax and Pickering. The weather could not have been better; the last 9K was run in the rain, but I never mind the rain as the moisture helps keep my asthma at bay. My stomach was cramping around 14K and continued to do so throughout the run; I was hesitant drinking my liquid fuel because it did not feel that it was getting quickly absorbed. After drinking any fuel, my stomach still felt heavy with liquid sloshing around even after 15 minutes had elapsed.

Today, I am feeling physically fatigued. I was supposed to run 30K, but given my energy level, I will likely weight train at the gym and throw in some plyometric exercises to train my nervous system. I am growing suspicious that my body has unspecified physical limits, which if pushed beyond, will result in an arthritic flare and immediate symptoms of fatigue. It's just an assumption right now, but a recent email from a US physician describing his AS symptoms leads me to believe that this assumption may not be far from reality.

It honestly disappoints me to think that no matter how hard I push myself physically, I am servant to the limits imposed by my arthritis. Not knowing those limits is frustrating; worse yet, who knows if those limits vary daily or under certain conditions. I realize I should feel grateful that I am still physically able to engage in strenuous activity (remember my mental curse of invincibility); however, as a perfectionist who wants to challenge her performance beyond any comfort zone, I hate feeling defeated by intrinsic forces (which I foolishly tell myself I should be able to control). If this sounds like the afflictions of a Type A personality, you're correct; not an easy burden to bear in the least.

Toad in Training

2008-07-26T16:25:00.003-04:00

I bought a new pair of road and trail shoes yesterday: my second pair of Asiics Foundation Gel and a pair of bright lime green Brooks Cascadia 3 pure trail shoes. I wore the Brooks to run 25K at the Toad in Training day held at Pinehurst Lake Conservation Area. I used the training day to not only experience the route I'd be racing October 4th, but to break my shoes in while having access to my Salomen XA Pro 3D trail shoes at the end of each 12.5K loop. I mourned the transition over to Brooks--leaving behind my Kevlar lazy-lace system of the Salomen's--until I ran 25K in the Brook's. What a light, breathable shoe! I still miss my lazy-lace system.

I ran the first 12.5K with Terry, an elderly gentleman I met on the course who was recovering from a recurrent running injury. We chatted non-stop, which made the first loop seem shorter. The weather was very humid with anticipated thunderstorms looming overhead, and pounding central-east Ontario. I was fortunate to avoid most of the rain, but was graced with a few sprinkles during the last 5K of the second loop. The mosquitoes were fierce; I'm not sure how much energy I exerted swishing them away. What I do know is that when you're tired and hot, any mosquito is intolerable.

The "terrible hill" that people seem to fear during this event was not as terrible as I thought. It was pure grass, intentionally clipped and free of roots and rocks. Steep, especially for tired legs, and appearing steeper with each reintroduction as the loops were conquered. The hill is approximately 1K from the finish/transition point. It's been recommended to save one's energy and walk the hill, as it's not going to make that much of a difference in timing.

Peggy and George, the hosts of the Toad events, generously stocked the transition area with treats: various soft drinks, 8 freshly cut watermelons, chips, lollipops, veggies and dip, among other savouries. They did an exception job of marking the route with 500 orange flags and signage; the volunteers were all welcoming and encouraging; and the transition area did not wrap up until the last runner returned.

After the run, I soaked my legs in spring-fed Kettle Lake to leach the lactic acid from my body. It certainly did the trick. I need to remember to bring a beach towel in October so I can soak the rest of me. Next race: the Iroquois Trail Test on August 16th in Kilbride.

Watch out: Toad in Training

2008-07-02T20:18:00.003-04:00

It's been a while since my last post. I'm incorporating more balance into my training by engaging in a social life with all of my dear friends. I'm not sure weather it's because I finally have a more balanced personal and professional life, but I have only had one significant flare of my arthritis this year, which is more than I could have hoped for.

As preparation for my 50K trail race, I am participating in the Toad in Training 25K run in July at Pinehurst Lake Conservation Area, which also incorporates trail racing technical discussion and delicious snacks. This is the same location as the 50K race, and will be a great introduction to the course I've heard that there is an infamous "killer" hill near the end of the route, so I am eagerly anticipating seeing this grassy mound.

I've also signed up for the 21st annual Iroquois 32K Trail Test in Kilbride. This race is part of the Ontario Ultra Series, an arduous 12-race series involving a variety of running routes across the province. I've been told that if I can conquer Iroquois, the Toad will be easy. Sounded like a perfect challenge. I was the 17th person to register for this event.

My running partner and I plan on treating ourselves to pampering at a spa after the Iroquois race, and then meeting some friends downtown for dinner and drinks to close the evening. I've always made plans for pampering after achieving milestones, but I've never followed through and indulged. And why not? I'm sure my body is screaming for professional hands kneading tired muscles, or gnarled toes begging for peppermint soaks, submersion in parafin baths, and an adornment of colour. I better take heed before my body goes on strike.

Cape Hatteras

2008-05-04T14:30:00.003-04:00

Ahh...vacation. As I type this entry, I watch my friends surfing in the Atlantic Ocean. I would join them but I just returned from a challenging 18K run along the Outer Banks of North Carolina. It had rained earlier this morning in Frisco and I thought a run towards Avon after the thunderstorm would be enjoyable. I had not counted on the humidity that would follow. The route was mostly flat along the spit with long grades that kept my quads engaged. The road was nestled between the Atlantic and Pamlico Sound, and a gentle breeze blew occasionally across my path. The heat rose from the asphalt and my skin cooked in the sun. I drank my mixture of GU2O and Carbo-Pro frequently to remain well hydrated and energized. At times, all I could think of was the heat and envisioned returning to our house on the beach and diving into the pool, or running straight into the cool Atlantic Ocean, shoes and all.

Feeling strong

2008-04-27T18:11:00.002-04:00

I had a wonderful 16k run this morning along the Ajax waterfront into Pickering and back again. Just one month left before I run alongside my two running partners as support on their way to achieving their Personal Best (PB) at the Ottawa Half Marathon. This will be my first time participating in a race for the sole purpose of helping others achieve their goals. It has certainly removed a significant amount of self-imposed pressure to achieve my time goals and refocused my attention on motivational coaching.

Thanks to Bob at the Running Free store in Markham, I have discovered Carbo-Pro, which has become my new liquid fuel of choice, replacing my once-hailed GU gel. Carbo-Pro offered me sustained energy without the rollarcoaster highs and lows to which I am accustomed when ingesting gels. It's flavourless and I mix it with GU2O so that I get my carbohydrates, fluids, and electrolytes with every sip.

Flare

2008-04-15T12:03:00.002-04:00

The last two days have been physically challenging; my AS started to flare on the evening of Sunday April 13th. My assumption is that it was likely triggered be two significant stressors experienced during the previous week: a legal matter as well as a very touching, though inspiring, memorial service. I required assistance turning in bed to get comfortable, getting in and out of bed, going to the washroom, and getting dressed. There is something very humbling about requiring assistance for accomplishing tasks that seem so simple...that are typically very routine for an able-bodied individual. Pride has no place here; when you need help, you accept it. I'll admit that I try to do as much as I can independently before seeking assistance from others. It allows to me to determine my physical limits in my current state. I am not fond of being fussed over, so I usually mask the extent of my pain with a smile and a "I'm okay" attitude. Those who know me well are intuitive enough to see clearly through my facade, and in the end I am always thankful that I have friends thoughtful enough to willingly try to ease some of my suffering. Stubbornly, I insisted on going to work; after all, I consider myself to still be functional and capable of putting in a good 8 hours despite the objections and concerns of colleagues as they observed my visible discomfort as I walked hunched over and shuffling from one meeting to the next. The Indomethacin taken that evening failed to fulfill promises of easing the inflammation in my lower back. My body rebelled against the activity I forced it to endure during the day and I awoke with more stiffness and pain the morning of Tuesday April 15th. Standing is quite painful now. Sitting feels even worse. Every rotation of my body as I try to move around results in very audible cracks and snaps. I finally submitted to the pain and decided that I would work from home today. So here I sit clothed in comfortable pyjamas attached to a TENS machine, sipping on warm herbal tea, taking my Indomethacin on prescribed cue, and engaging in frequent stretching breaks and warm showers in an attempt to recover enough to venture into work tomorrow. I feel hopeful, but I am a stubborn one.

Started Enbrel 50mg today

2008-03-08T15:51:00.002-05:00

After months in the absence of any anti-inflammatory pharmaceuticals for my AS (thanks primarily to a lack of health benefits), I am now able to resume my regime. I was reassessed by my rheumatologist and prescribed Enbrel 50mg once a week via the SureClick auto-injector. She warned me that her patients reported increased pain during the injection, which she attributes to the medication's chemical composition.

I decided the site of the first injection would be the middle of my right thigh. The instructions indicated that I would not have to pinch my skin or angle the syringe at 45 degrees to keep the needle in the subcutaneous tissue; direct placement on the skin at a 90 degree angle was the new process. I took off the protective cap, pressed the auto-injector firmly against my thigh at the required angle, and pressed the purple button until I heard a click. Not too bad, I thought after I felt the needle pierce my skin...until I felt the sharp burning sensation of the medication being pushed into my tissues. The instructions warned that I was not to pull the auto-injector away until I heard a second click, which felt like it would never come. I can only describe the pain as if someone pinched a tender piece of your flesh between their fingernails, and continuously increased the intense pressure of their pinch until you could no longer bear it...worse than sharp pins pricking through fleshy epidermal layers...worse than a papercut in the web of your individual phlanges. I am not sure how I long I will continue with this dosage if the pain is this intense; multiple injections a week may provide less discomfort.

Blood test can predict severe ankylosing spondylitis

2008-01-07T14:01:00.000-05:00

Measuring blood levels of a protein called matrix metalloproteinase 3 (MMP3) may help predict which people with ankylosing spondylitis will develop severe joint damage, particularly among people with pre-existing damage visible on X-ray, according to new findings presented at the American College of Rheumatology Annual Scientific Meeting in Washington, DC.

Ankylosing spondylitis (AS) is an inflammatory form of the disease which causes a breakdown of bone and cartilage, primarily in the spine and large joints. It can lead to inflammation of the eyes, lungs and heart valves. AS typically develops in men between the ages of 20 and 40. Until now there has been no way to predict which patients will go on to develop more severe forms of the disease.

Researchers analyzed blood samples for numerous protein biomarkers that indicate cartilage breakdown and are associated with deformities in other related diseases in 100 people with AS. Of all the proteins assessed, MMP3 proved to be most strongly associated with progressive joint and bone damage at two years, particularly in those patients with pre-existing damage visible on X-rays. In fact, MMP3 levels correctly identified two-thirds of patients who progressed.
"Being able to predict disease activity and damage in AS in patients can lead to more aggressive treatment when the disease is active and (hence) more aggressive." says lead researcher Walter P. Maksymowych, MD, Professor of Medicine, university of Alberta, Edmonton, Alberta, Canada.

Reference:
"Blood test can predict severe ankylosing spondylitis." Health News 13.2 (Feb 2007): 4(1).

Ankylosing spondylitis patients miss effective Tx due to lack of referrals; primary care docs 'a major barrier'

2008-01-07T13:28:00.000-05:00

Primary care physicians have proved to be one of the biggest obstacles to getting the new highly effective therapies for ankylosing spondylitis to affected patients, Dr. Christopher T. Ritchlin said at a symposium sponsored by the American College of Rheumatology. Tumor necrosis factor (TNF) inhibitors constitute a major therapeutic advance in ankylosing spondylitis. But rheumatologists have had a tough time getting out word of this new therapeutic option to the huge number of disaffected patients who were lost to follow up during the era of less-satisfactory treatment.

"We've had all these patients who've come to us, usually young very active males or females who had early ankylosing spondylitis (AS) and may have had minor radiographic changes, [to whom] we gave NSAIDs and exercises to do. We'd say, 'OK, come back in 6 months.' And we've just never seen them again," explained Dr. Ritchlin, director of the clinical immunology research center at the University of Rochester (N.Y.). With varying degrees of success, these patients have adapted to the limitations imposed by their disease. Upon learning about the new treatment options, some patients simply aren't interested; many others with more severe disease who have come in to the office have been helped enormously by anti-TNF therapy, he said.

Meanwhile, large numbers of patients with early AS continue to be misdiagnosed or diagnosed late and undertreated by primary care physicians, according to the rheumatologist. Dr. Ritchlin has mounted an aggressive local effort aimed at educating patients and clinicians about the new therapy for AS. The Arthritis Foundation has been a big help in making contact with new and former patients. Efforts to reach out to primary care physicians and get them to consider AS in the differential diagnosis of chronic back pain in young patients have been less successful.

"The primary care physicians have been a major barrier for us. They really haven't looked for or found ankylosing spondylitis. The referrals we get are mostly from a big orthopedics group that does a lot of joint injections. We need to become more active in helping primary care physicians diagnose the disorder], especially in women, where it's a much harder diagnosis to make," Dr. Ritchlin continued.

In women with AS, axial spinal involvement is often milder than in men. Affected women have more cervical spine and peripheral disease. Their higher self-rated pain scores and impairment of daily activities indicate a generally less favorable long-term course. Until anti-TNF therapy came along, standard treatment involved a gradual escalation from NSAIDs and physical therapy to off-label use of methotrexate and other disease-modifying antirheumatic drugs. But at best the older DMARDs controlled signs and symptoms without altering progression of ankylosis, a key factor in the disease's substantial disability.
TNF inhibitors offer much faster onset of action and substantially greater improvements in symptoms, quality of life, and function.

Clinical measures such as chest expansion and occiput-to-wall distance have shown significant gains. Toxicity is substantially less than with older DMARDs, too, at least out to about 1 year (the length of studies to date). Whether TNF inhibitors are truly disease modifying hasn't been settled, although MRI studies are encouraging, Dr. Ritchlin said. Etanercept is the only TNF inhibitor with FDA approval for AS. Infliximab is approved in Europe, and a phase III U.S. randomized trial is close to completion.

Reference:
Jancin, B. "Ankylosing spondylitis patients miss effective Tx due to lack of referrals; primary care docs 'a major barrier'." Family Practice News 34.8 (April 15, 2004): 44(1).

Juvenile-onset spondylitis does damage to hips

2008-01-07T13:23:00.000-05:00

Patients with juvenile-onset ankylosing spondylitis have functional outcomes similar to adult-onset disease, but more often have less severe lumbar degeneration and more hip involvement requiring total hip arthroplasty, Ms. Lianne S. Gensler said in a poster session at the annual meeting of the American College of Rheumatology.

Ms. Gensler and her associates compared the disease characteristics of a cohort of 53 patients with juvenile-onset ankylosing spondylitis (JoAS) and 349 patients with adult-onset AS (AoAS) in a multicenter, cross-sectional study.

Compared with AoAS patients, JoAS patients were significantly younger (average 50 vs. 56 years), had significantly longer duration of AS (37 vs. 31 years), and included significantly more women (40% vs. 23%), said Ms. Gensler of the University of California, San Francisco.
Although each group had similar functional outcomes, JoAS patients were 45% less likely to have severe lumbar disease than were AoAS patients. The comparison was adjusted for disease duration, gender, white race, having ever been a smoker, family history of AS, and occupational activity. But JoAS patients were more than twice as likely as AoAS patients to need total hip arthroplasty.

Reference:
Evans, J. "Juvenile-onset spondylitis does damage to hips." Family Practice News 37.8 (April 15, 2007): 38(1).

Disease with a funny name

2008-01-07T13:19:00.000-05:00

AS is not a new disease. The spines of 4,000-year-old mummies excavated from Egyptian tombs show conclusive evidence of the affliction. Yet today, because of the lack of proper diagnosis, no one knows exactly how many people are affected. At present, 500,000 people are reported to have AS in this country and studies strongly indicate it may be much more.
AS is extremely difficult to diagnose in its early stages. Studies show the average spondylitis victim endures many years of misdiagnosis before their condition is correctly identified, even though it is the third most common form of chronic arthritis in the United States. AS is not restricted to humans either. Primate studies indicate gorillas also suffer from a form of AS.

Reference:
Winston, C. "The mysterious back disease." AFAA's American Fitness 7.n2 (March-April 1989): 6

Ottawa Half Training Starts Today

2008-01-02T15:03:00.000-05:00

I am excited to start training today for the ING Ottawa Half Marathon. My running partners and I have extended base training to allow our bodies to adjust to winter running. Today, we're running a mere 3K after work. Easy enough.

Farewell 2007. Hello 2008!

2007-12-24T10:09:00.001-05:00

Merry Christmas and Happy Holidays!

2007 proved to be a very intense year full of adjustments, personal challenges, and many changes for me. I would even say that I finally found myself in 2007 after a few jarring awakenings; however, I believe that everything happens for a reason and there is often a lesson to be learned during the journey. What we glean from each challenge is very personal, and what we do with the learnings truly depends on where they fall in our hierarchy of priorities.

I am ending 2007 in a very positive space. It's a marvellous feeling...a novel sense of clarity and a comfort in my skin. I am going to be good to myself moving forward: increased self-acceptance while calming my perfectionistic voice, a focus on engaging in a defined circle of recreational activities instead of spreading myself thin, an increased concentration on friends, family, and fun. With the latest purchase of my djembe and a Canon 40D camera, I plan on exploring anew my musical and visual fecundity. Three road races and one trail ultra-marathon have already been formalized with my new running companions. With snowboarding and mountain biking as a means of cross-training, I can take a break from the gym, and perform all physical activities in the crisp fresh air of the great Canadian outdoors.

I will not miss 2007 very much, despite the priceless learnings. But I can't wait for 2008!!!

Run for the Toad

2007-11-20T19:03:00.000-05:00

Well, the year is not quite over and I have already identified my next four races: ING Ottawa Half-Marathon (May, 2008), Run for the Toad 50K trail race (Oct 4, 2008) and the Goofy's Race and a Half Challenge (Jan, 2009), a race in San Francisco (2009). The Toad and the Goofy are exceptionally challenging and will be my ultimate running achievement.

I signed up for the Run for the Toad tonight (Registration for the 2009 WALT DISNEY WORLD® Marathon Weekend opens January 14, 2008). The Toad is situated in the heart of Tent City in Cambridge, Ontario. I have only run a 5K and 10K trail race. It would have been logical to move up to the 25K distance, but I thought a longer distance would be more satisfying given that I plan to train for the Disney Goofy run within the same timeframe. I suspect it is realistic to train for both of these events consecutively, especially since not all training is necessary to do on trail when preparing for the Toad. The course offers very few flat sections, and at the same time very few extended climbs. The course is very rolling and the longest climb shouldn’t take you much longer than 90 seconds. The exciting part of the course is what didn’t seem like a hill on loop one or two become mountains on loop 3 and 4! About 60% of the course is shaded and there are some exposed sections in the grassy meadows. Weather has come in all forms at the Run for the Toad from snow and hail to gorgeous 70F sun.

My next task is to determine when training for each event starts, and to ensure that I am physically fit to engage in the intensive training required to tackle these races. I am quite excited about the whole thing. I am fortunate to now work in an environment filled with running enthusiasts; even my manager is a competitive marathoner. I will not lack the opportunity to pair up with runners for a lunch-time adrenaline rush in the spring. I plan on using winter training for Ottawa's half-marathon as my base for the Toad ultra-marathon (which is my real focus in 2008). The Toad would have prepared me for the Goofy, so the timing could not be better.

Mission Accomplished

2007-10-14T16:07:00.001-04:00

As I started to write today's entry, I automatically wanted to announce my finishing time; however, I won't. Rather, I will say that today I ran the Toronto Half Marathon stronger and faster than I anticipated.

I need to thank a few people for supporting me during this race. Firstly, I would like to that inner voice of negativity for keeping quiet the entire route (definitely a first). My sister's never-ending support receives great gratitude: she travels over 3 hours to attend each of my events and cheers me on along the route. When I finally made my way on to University Avenue from Wellington, there she was arms waving high in the air with cheers of encouragement and excitement. Her energy displaced my fatigue and I powered forward towards Queen's Park. Enormous thanks to Steve for offering to be my paparazzo with my pup, Iniko, in tow. And finally, a huge thank you goes to Dave (bib 6744), a solitary stranger met whilst running along Rosedale, for the engaging conversation that made reaching the finish line seem effortless.

I was in great spirits for this race. Familiar faces of former running partners cheered me on along the route (Rob, Neil, Richard, Joanna) or ran beside me for brief chats before continuing on with their pace (Maureen).

The week leading up to the race entailed lots of carbs, a few light runs, and lots of water. This was the first time I ever carb loaded and hydrated throughly for a race. The day before the race, I accompanied friends downtown for a casual walk-about: we picked up fresh pasta and filet mignon at St. Lawrence's Market for that evening's dinner before collecting my race kit at the Sheraton Hotel. We ended the day with a leisurely stroll through Kensington Market before meeting my sister at the bus station and heading back to Clarington. I took my Enbrel injection before bed, set aside my Singulair, Flovent, and Indomethacin anti-inflammatory medication for the morning, and stuck a sticky note to the fridge to remind me of the peanut butter and honey slathered bagel. I had slight pre-race jitters and could not settle into bed until 11pm, but the excitement I had when I awoke fueled me through a spectacular day. Stay tuned for pictures.

Mitochondrial Dilution

2007-10-06T12:46:00.000-04:00

Throughout my years training for races, I have tried to maintain my strength training routine in the gym. Achieving this balance has been very difficult as time spent in one area detracts from improving performance in the other. I used to run with people who avoided weight training stating that dense muscle would add speed-limiting weight to their body. Other running partners would engage in light weight training every morning to improve muscle strength. I am perpetually trying to find a balance between challenging the strength of my muscles and improve my endurance performance.

Below is an excerpt from Stephen Seiler's (PhD) website, the MAPP, dedicated to examining and explaining the physiology and training methods of the endurance athlete. In this excerpt, Seiler discussed strength training and endurance performance:

"When a bodybuilder trains, the goal is to make each muscle fiber as big as possible. Muscle fibers have contractile protein, mitochondrial protein, and other components. Increasing the relative proportion of one component (like more contractile protein) means that you have relatively less of everything else in the same fiber (like mitochondria). From an endurance standpoint this is not a good adaptation. We even give it a name in sports physiology circles, mitochondrial dilution. The bodybuilder's muscles may actually become more easily fatigued as they get bigger, because their mitochondrial density is not increasing at the same rate. The bodybuilder accepts that because the name of the game is size, not endurance.

It is possible for the endurance athlete to gain some muscle size and maintain mitochondrial density, but it requires that the volume of endurance training be maintained. If you are a runner and you decide to get stronger in the weight room by really doing a lot of strength training 3 days a week for an hour, you will probably drop some of your running volume to fit it in. After 6 months you have gained 5-10 pounds of muscle, you look really good, and you are running 2 minutes slower for 10k! Why? Well besides having to carry around 5-10 more pounds of muscle that you can't use when you are running, you have probably lost endurance capacity in those bigger stronger quads. So, you have a lower lactate threshold due to the detraining of your leg muscles, plus you are less efficient due to the increased bodyweight (and decreased training volume). The concept that just making muscles bigger and stronger will automatically translate to faster endurance performance is Wrong! "

Toronto Half-Marathon Point in Time

2007-10-02T18:31:00.000-04:00

I am anticipating a pace of 6:10/km for the Toronto Half-Marathon, which will place me at the finish line around 10:10 am. Hard to say how realistic that is, but it's worth aiming for. I've already run the route, I know my markers to anticipate how close I am to the finish line, and I have a fabulous support team geared with two Canon 40D cameras to record what will likely be my last race for a while.

I am eager to complete this race upright and smiling, as they say. I am not very focused on my speed, but I have that naging anxiety that is concerned with not performing a personal best. I question why I can't just run the race to enjoy the race...why the journey is diminished with the resulting numbers that allow one to judge their competence at a sport. I am not an elite athlete, so why do I place such ridiculous pressure on exceeding my own expectations? It's silly, really. Obviously, I am competitive with myself...always trying to outperform my last performance. But where is the tipping point? Everyone has a limit to their performance. Where is mine? I don't feel I have reached it with respect to running. I feel I could do better, but whether I really want to is another question.

Training for a full marathon this year proved not be as important as other things that occured over the last 365 days...things requiring more attention and time. Things like refocusing attention on emotional, spiritual, and psychological well-being, which had taken a back seat to my attempt to perfect my physical strength with countless hours in the gym. A critical turning point early in the year, and an accumulated stack of life's challenges, forced me to rethink everything that was important to me. Sometimes, one's life is tossed around as a test of inner strength, resilience, and perseverence; afterall, a great mariner is not made on calm seas. Now that the storms have passed, I have emerged more confident in implementing strategies to care for myself and assert my needs.

This may appear as the rant of an anxious runner, but it ties into the psychological strategies I will use during my run to push me through the difficult parts of the race. Mentally preparing oneself for a race is similar to moving through the challenges of life, except the course is more predictable. We all want to get to the finish line, preferably upright and smiling, despite the taxing journey. How we perceive and respond to those challenges is what matters the most, and will contribute to the energy exerted to defy tests against our character. As I race the Toronto Half-Marathon on October 14th, I will be thinking about all of the hardships I have overcome in life, the person I have developed into, the intensity and courage required to develop into that individual, and how my performance (regardless of time) is not an indicator of who I am.

Components of Training

2007-09-20T20:55:00.000-04:00

The following components are critical in developing a solid training program:

Building aerobic base
Developing endurance-speed-strength
Developing anaerobic strength and endurance
Speed endurance
Developing strength thru tempo runs
Long runs to increase stamina and running economy
Short intervals - lactic acid tolerance workouts
Long Intervals - lactic acid tolerance sustain workouts
Short recovery - long recovery
Race pace workouts
Running pace - training at different velocities
Periodization - planning for the performance at the right time
Racing

Training for Toronto's Half Marathon on Oct 14

2007-09-10T10:55:00.000-04:00

Despite my disappointment to not race Wineglass, having eliminated the inherent pressure of the marathon training schedule has been revitalizing. I can't say that I have been able to fulfill 100% (mainly the frequency of the runs) of the half-marathon training schedule, but I have the distance beat. The frequency of my running has been appaling, to say the least, and I suffer for it during my tempo runs; however, I feel very strong on my long Sunday runs (likely because speed is not encouraged). With approximately one month to go before the big day, my focus will be on getting those tempo runs in.

I had a splendid 17km run late last night--a little too late resulting in terrible insomnia and a 3 hour book review of growing culinary herbs at 3am, followed by a snack of shaved turkey with horseradish mayo. Nothing like turkey to help one count sheep. I experimented with my fuel for last night's run, substituting my fruit punch flavoured Accelerade for Tango Mango GU2O electrolyte replacement. I used 3/4 of a Chocolate Outrage GU (my favourite flavour) for instant carb replenishment. The GU2O had a hint of mango flavour and went down as easy as plain water. I did not experience any cramping, feelings of dehydration, or other ill effects, and I never felt sluggish during the run. The primary ingredients are malodextrin and fructose. I may have to retire the Accelerade for my mountain biking adventures if the Gu2O works this well.

Farewell to Wineglass

2007-08-28T13:55:00.000-04:00

It was a personally tough decision. For months I ruminated about the thought of going through with it, dreading following through with the decision I knew would be in my best interest. And last night I did it. I decided not to participate in the 2007 Wineglass Marathon in Corning, New York on Sept 30th. I am not satisfied with my training over the summer, and don't feel prepared to take on such a rigourous distance and risk physical injury. I can't recall the last time I ever quit something I committed to; however, the thought of racing a distance I was unprepared for would not offer me the confidence of achieving a personal best.

So I set my sights on training for Toronto's 2007 Half Marathon on October 14th. I was already ahead of the training schedule with respect to distance as I had previously run 22km, so now I was actually scaling back my distance to adhere to a sensible and achievable training schedule that fit into my busy summer plans. The stress had instantly lifted as the pressure to catch up with missed marathon runs was eliminated. I love half marathons--they are achievable without much preparation required. My race strategy was to start slowly and end strong. Prior to the race, I plan on running the route a few times to have a good visual of the course. I break down the distance into 5 or 10km segments, and psychologically pat myself on the back every time I complete a segment: "Alright! Your made it X km. Now only X more to go. You can do that. You've done it before." A mantra that I repeat in my head during intense moments was one I saw during my first Toronto Half Marathon many years ago: "Pain is inevitable; suffering is optional." Embracing the pain rather than distracting mysef from it, knowing that every runner out there with me is probably experiencing some sort of discomfort and is still pushing through it, helps me keep going kilometer after kilometer, on foot planted in front of the other, inching my way closer to the finish line and the streets lined with cheering, supportive spectators, family, and friends. Rounding the corner to see the numbers of people near that end point encouraging you with the sweet sounds of shouting and clapping gives me a shot of adrenaline that propels me towards the the finish...battered but never beaten.

Struck Dumbfounded

2007-07-05T17:22:00.000-04:00

It was 9:30pm on July 4th, 2007 when I decided to go for a 10km tempo run with my 13 month pup, Iniko. I was less than half-way into my run along the sidewalk of Harwood Avenue in Ajax when a passenger, in a passing red minivan heading the opposite direction, threw an empty glass juice bottle at me. I felt the bottle breeze past my face, only to smash into pieces as it hit my left shoulder. I stopped dead in my tracks. I was stunned in disbelief that someone would actually throw a hard object at another person, an object that barely missed my face and could have caused significant injury had it impacted my head. I watched as the minivan sped up and made the first available left turn into a residential neighbourhood. I was not able to make out the license plate, so I didn't bother reporting the incident to the police. I was tempted to run in the direction of the minivan to track down the assailants, but I didn't. I didn't think I would be able to find the vehicle. There were no witnesses...just a man walking with his head down on the other side of the street. His lack of reaction indicated he had not seen the incident.

This was an emotional experience. I was disturbed that people could be so desensitized to inflicting harm on others, and so ignorant as to gain pleasure from causing such harm.

The new opiate of the middle-class masses

2007-07-05T16:58:00.000-04:00

Saturday, October 14, 2006
Anne Marie Owens
National Post

When the enthusiasts make their way through the streets of Toronto or alongside the shores of Prince Edward Island this weekend, when they fill the downtown in Chicago and Washington, D.C., after that, it is unlikely they will be pelted with derisive epithets or rotten apples.
There was a time, not so long ago, when practitioners of long-distance running were the subject of societal ridicule for an extreme athletic pursuit that was regarded as freakish. These days, however, marathon running is the quintessence of mainstream. It has become so common among the ranks of upwardly mobile professionals that participating in such a race is almost expected -- the ancient event has been transformed into a thoroughly modern status symbol that singlehandedly conveys fitness, financial success, work-life balance and an unerring ability to do it all.

"If you look at a cross-section of marathoners in a big race, it would be almost identical to a cross-section of the urban middle class," says Ian Ritchie, a sociologist who studies sport and is a marathoner himself. "The event reinforces the values which are important to that class: individual ability, merit as a reward system, self-discipline, hard work, organization, constantly striving for self-improvement." Between 400,000 and 500,000 people across North America run marathons in a single year, with October the busiest month of all.

In just a couple of decades, a predominantly solitary pursuit has become a group-bonding activity; a male-dominated sport is being gradually overtaken by high-powered, multi-tasking women; and what was once an elite event is increasingly being propelled by the middle-class masses. Prof. Ritchie, who teaches in the physical education department of Ontario's Brock University, says that until recently people who undertook such extreme physical exertion were widely regarded as societal freaks, and even in the 1970s, "passers-by would regularly yell and throw objects at runners, considering them deviant."

He says the image of the long-distance runner has been overhauled and remade in the image of modern society, "Sport has often been used to reinforce notions of class, of gender, of society ... This has now come to reinforce status as a person who is successful and who can do it all. There is a lot of positive status in our society to being the kind of person who can hold down a job, be physically active, raise a family, and find the time to run this kind of distance."
He also points out that most of the marathoners participating in these events are the opposite of those who dominate the prize-winning - where the medal holders still often hail from the traditions of the great black long-distance runners from small African villages. The majority of participants these days are white, middle-aged, urban professionals.

John Stanton has witnessed the cultural revolution in running firsthand, and benefited greatly from it. The Edmonton-based founder of the Running Room, a chain of stores that offers a one-stop service and supply centre for all manner of runners, began running marathons in the mid-1980s when the sport fit into an era where crush-your-opponent racquetball prevailed, Wall Street's Gordon Gekko crushed the financial competition onscreen and the credo of all runners, he says, "was go hard, or go home."

Back then, his competitors in marathons were 80% male, and the competition was hard-driving: When he and a friend were clocking in for three-hour, 20-minute marathons, their times were often regarded as not even worth showing up. These days, three hours, 20 minutes is beyond a respectable time, it is deemed downright competitive in most races. The average time for all runners in marathons in the U.S. last year was four hours, 45 minutes. The mean finishing time in the Ottawa marathon in 1984 was about three-and-a-half hours; this year, the mean finishing time was four hours, 20 minutes, says Mr. Stanton. So what has changed? The number of participants, for one thing. Events that were once sparsely attended now draw people in the thousands. An Ottawa marathon, for example, drew 25,000 participants this year. In 1984, there were only 2,500. There has also been a huge gender shift. In the Okanagan marathon in British Columbia recently, 60% of the competitors were women.

Mr. Stanton says that where the first boom in marathon running was characterized by odd, loner-type runners involved in a solitary pursuit, this latest boom has been fuelled by the social potential of running as a community of enthusiasts, a supportive network.
His company realized the possibility early on when it began offering group runs in the late 1980s. There are now 90 Running Rooms across North America and this group approach is now the dominant training model for marathoners. "Running has brought a sense of community at a time when we really need it," says Mr. Stanton. "It allows us to disconnect briefly from technology and it allows us to interact with people."

For Trish Murphy, a 52-year-old Calgary resident who shuttles between her native Dublin, her Canadian home and various exotic locales, the only constant in her peripatetic life is her long-distance running. She took it up as a stay-at-home mother in a new city with no friends or community, where the long runs provided the regularity and discipline she desired.
"Running is not competitive, it is community," insists Ms. Murphy, who has competed in five marathons, the most recent, the legendary one in Boston. "You compete against yourself, your time, your desires to do another one ... We lead such hectic lives, running long distances gives a structure to your day, to your life really. It gives you that sense that you can do anything."
aowens@nationalpost.com

NIPPLES
The constant friction and chafing that results from clothing rubbing against tender skin leaves many long-distance runners with raw, painful and even bloody nipples. The common problem among men, always fodder for much discussion in any runner's chatroom, is usually remedied by wearing lighter fabrics or smearing on anti-chafing products prior to a run. Some runners wear Band-Aids.

BONES
As a high-impact activity, running may maintain or increase bone density and help offset osteoporosis. However, it can also put more stress on the joints than lower-impact activities such as walking and cycling. Runners can get stress fractures as a result of overuse and repeated stress to a bone, where broken surfaces are held together only by surface tension and surrounding tissues. These fractures are usually diagnosed by what is called "crescendo pain," which as the name suggests, begins at the onset of running, increases in intensity during the run and only ceases when the runner stops.

LIBIDO
Are runners better lovers? A survey that correlated sex habits and finishing times of long-distance runners in England found that runners who had sex the night before a marathon ran faster than those who did not. While half of those questioned said their sex life had been unaffected by running, 30% said the sport had improved their performance in bed.

MUSCLES
There are two different kinds of fibres in muscles, fast twitch and slow twitch, which are largely determined by genetics. Slow-twitch fibres, which contract slowly and can keep going for a long time, are the key to successful marathon running, while fast-twitch fibres, which contract quickly but are rapidly worn out, benefit sprinting. Long-distance running is an aerobic activity, utilizing oxygen, and requires a great deal of muscular endurance.

LUNGS AND RESPIRATORY SYSTEM
In order to run, the body needs to keep muscles supplied with enough oxygen to make the energy required. A key physiological attribute of a good distance runner is the body's capacity for oxygen consumption, known as VO2 max. Any kind of running, from slow jog to endurance race to all-out sprint, improves the lungs.

HEART
When a runner starts to breathe quickly and more deeply, the heart beats faster to provide more oxygen for the muscles. The arterioles, the small terminal branches of an artery, also widen to stop blood pressure getting too high. The increased cardiovascular capacity that comes from living at high altitudes is thought to be part of the key to the success of Kenya's world-famous runners.

SHINS
The repeated smacking of foot on ground puts stress on lower leg muscles and can cause a condition called shin splints. These sharp pains on impact are caused by small tears in the muscles where they attach to the tibia bone. Many novice runners develop shin splints because they wear worn-out or improper shoes, or because they run too much too soon. Rest is required to allow the tears to heal.

BOWELS
Running is good for maintaining regular bowel movements and has been linked to a decreased incidence of colon cancer. The downside of such regularity is the frequency of what are known as "runner's trots," which afflict 20% to 50% of distance runners, with symptoms ranging from cramping and nausea to bouts of flatulence and diarrhea. The problem is so common that running clubs and online chatrooms devote considerable attention to prevention tactics, such as avoiding warm fluids before a race.

KNEE
One of the most common injuries to plague runners is the softening, wearing away and cracking of cartilage under the kneecap, or patella, that is known as runner's knee. The cartilage-against-cartilage induced swelling is caused by over-pronation, which is when the feet rotate too far inward on impact, causing the kneecap to twist sideways.

FEET
A force three- to five-times body weight can be absorbed with each step. The constant pounding is so intense during a long-distance run that it results in a temporary loss of height - surprising evidence suggests that marathon runners finish a race two centimetres shorter than they were at the outset, due largely to the impact of feet hitting ground. Many runners lose toenails and most develop hard calluses where their feet rub their shoes.

Marathon Training and Performance Strategies Based on New Research

2007-06-20T17:12:00.000-04:00

NEW ORLEANS - June 1, 2007/PRNewswire-USNewswire/

Two studies presented at the American College of Sports Medicine's (ACSM) 54th Annual Meeting in New Orleans examined marathoners and marathon performance, giving further insight into what makes a great runner. The first study looked at physical and training characteristics of all, not just elite, marathon runners and how these characteristics affected race outcomes.

Gender, body size and training miles were the greatest predictors of race success. In general, male runners had faster race times than female runners, due to men's greater aerobic capacity and ability to pump more blood through the heart than women. Successful marathoners of either gender were very light in proportion to height. Another key factor to race success was training mileage per week. Although a high per-week mileage was not necessary to merely finish the race, greater mileage increases aerobic fitness and usually leads to faster race times. Surprisingly, years of running experience did not play a significant role in race success. This was probably due to having many experienced marathoners who were not fast runners, and many fast novice marathoners who have not yet learned the most effective strategies for running their best race. Non-serious past injuries and physical symptoms during the race, such as nausea, also had no significant bearing on outcome compared to the other variables studied. "Basically, 'legs and lungs' are the major body parts that marathoners need to run a successful race," said James Pivarnik, Ph.D., FACSM, one of the lead authors on the study. A related study examined weather conditions for optimal marathon performance, and found that the fastest marathon times were run in cool conditions of approximately 50 degrees Fahrenheit. Although the study did not examine why this was true, lead study author Matthew Ely believes that cooler temperatures allow for sufficient dissipation of metabolic heat and therefore maintenance of thermal equilibrium during a race. Since weather during a marathon can be unpredictable, Ely recommends that marathoners be prepared to run in all weather conditions. "The last four years of the Boston Marathon have been hot, warm, cool and cold," he said.Ely can relate his research to personal experience. He recently finished 79th of all male competitors in the Boston Marathon, and placed third in ACSM's five-kilometer Gisolfi Fun Run in 2004. The Fun Run is held yearly at ACSM's Annual Meeting.The American College of Sports Medicine is the largest sports medicine and exercise science organization in the world. More than 20,000 international, national, and regional members are dedicated to advancing and integrating scientific research to provide educational and practical applications of exercise science and sports medicine.The conclusions outlined in this news release are those of the researchers only, and should not be construed as an official statement of the American College of Sports Medicine. American College of Sports Medicine

Marathon Training Update

2007-06-12T13:14:00.000-04:00

Now that my corneal ulcer is healing, I am able to resume marathon training. I was starting to feel like a slug. I reviewed and adjusted my training plan to incorporate cross training in a manner that would not cause me to over-train (which I have historically done).

I have allotted Friday as a rest day. The rest of the week is devoted to running, weights, and cycling. Monday's are devoted to one hour of either yoga or spinning. Tuesdays, Thursdays, and Saturdays are short runs of no more than 10km, so I bring Iniko with me. Eventually, I plan on trail running on one of those days to give my knees a break from the pavement, and to utilize my muscles differently on unpredicatble terrain. My long runs are spent focusing on my endurance, and refining my form.

My nutrition has been on track. I ensure my meals are heavy in carbs in the morning and increasing in protein and decreasing in carbs as the day progresses. My goal is to drink lots of water. I have a tendency to not feel very thirsty, and so I tend to be dehydrated on every run. I have been aiming for 3 glasses of water a day (I can easily not drink for three days...not healthy), and this realistic goal has been achieveable so far. A little CrystalLight helps make water more palateable.

Over the years I have noticed that my sweat smells like ammonia after a run. This has puzzled me for years. I finally did some literature research out of curiosity....I also wanted to know what I could do to stop smelling like a cat litter box (okay...so it's not THAT bad). I was told that this is an indicator of dehydration. Other causes are a high protein intake or not eating enough carbs before exercise (I'm definitely guilty). Liver expels the excess protein in the form of nitrogen, which cells convert into ammonia and pass through sweat and urine. Another cause is that during prolonged, exhaustive exercise, skeletal muscle generates ammonia from oxidation of branch chain amino acids (BCAAs) to make adenosine triphosphate (ATP). In the process, the amino group is removed from the BCAA, producing ammonia.

Elevated ammonia within the skeletal muscle and blood negatively affect performance. Neuromuscular function is impaired by ammonia, leading to local muscle fatigue. Ammonia can cross the blood-brain barrier. So it accumulates in the brain when blood levels are high. The brain's capacity to get rid of ammonia is adequate for short-term maximal exercise, but it is overwhelmed during prolonged, exhaustive exercise. Abnormally high levels of ammonia in the brain can disrupt normal neurotransmitter function. Ammonia depletes the excitatory neurotransmitters, glutamate and its precursor, gamma-amino butyrate, leading to central fatigue. Training and diet affect the production of ammonia during exercise. Endurance training decreases the amount of ammonia produced in skeletal muscle, thereby lowering blood and sweat ammonia concentrations. Depletion of muscle glycogen following a low carbohydrate diet increases the blood ammonia response to exercise due to increased use of BCAAs for energy. Carbohydrate consumption during prolonged, submaximal exercise reduces muscle ammonia production from BCAA degradation.

Looks like I need to drink more water throughout the day, and certainly eat more carbs prior to exercising. I'll post on the outcome later.

Corneal Ulcer Follow-Up

2007-06-05T14:21:00.000-04:00

Today was my third follow-up appointment with the ophthalmology resident at Sunnybrook Health Sciences Centre. I arrived at 9am and was seen quickly. He performed a visual acuity test at which I performed poorly related to blurry vision. My acuity appeared worse than before, but he did not seem concerned. After examination he stated that the epithelial defect in my cornea was improving. He contacted the lab to get the results of my cultures (results that he was supposed to have two days ago). My cultures were positive for Staphylococcus, a bacteria that is sensitive to vancomycin. The ophthalmology resident stated that I could now instill my drops every four hours, and recommended a fourth follow up appointment on June 8th. He eluded to continuing me on Vancomycin drops, discontinuing my other prescription, and adding on another antibiotic that would be "less toxic" on my eyes.

I decided to head to work after my visit at Sunnybrook. I thought I would attempt my routine work activities using my prescription shades; however, once there, I was encouraged to return home until my eye had healed further. A friend was gracious enough to drive me back to Ajax. This will be difficult because I am not fond of staying home if I am not ill.

Corneal Ulcer Follow-Up

2007-06-04T21:37:00.000-04:00

On June 1st at 9am, I attended my ophthalmology appointment at Sunnybrook, where I was examined and discharged within one hour. Impressively timely, I thought. I was seen by a resident with the worst communication skills and demeanor I have ever experienced in a sub-specialty physician. He diagnosed a bacterial corneal ulcer after careful examination using a slit lamp microscope. Special types of eye drops containing dye, such as fluorescein, were instilled to highlight the ulcer, making it easier to detect. The corneal ulcer was vigorously cultured via three separate scrapings, and smears were obtained using a metal instrument sterilized each instance over a Bic lighter. Dropping the instrument on the ground prior to the first scraping, coupled with his poor bedside manner, did not instill the greatest of confidence.

The staff ophthalmologist (Dr. C. Birt) came in to examine my eyes briefly, and stated that I had corneal scarring on my left eye, and that I would likely have corneal scarring on my right eye after the ulcer healed. She instructed me not to go swimming over the next few weeks and explained that typical corneal ulceration begins with pain (aggravated by blinking), followed by increased tearing. Eventually, central corneal ulceration produces pronounced visual blurring. This explained why I had difficulty seeing objects clearly over the past few weeks. A hypopyon (accumulation of white cells or pus in the anterior chamber) may produce cloudiness or color change. She stated that corneal ulcers may heal with treatment, but they may leave a cloudy scar that impairs vision. Other complications may include deep-seated infection, perforation of the cornea, displacement of the iris, and destruction of the eye.

The examining resident made no effort to explain the diagnosis, prognosis, or treatment of a corneal ulcer, and every question I asked was responded to in a hasty manner, as if I interrupted some critical thought pattern. After prescribing me two strong ophthalmic broad-spectrum antibiotics ([1]tobramycin mixed with gentamicin; and [2] fortified vancomycin) to instill every 30 minutes (even throughout the night), he then instructed me to return two days later for follow up. I was reminded that corneal ulcers are an emergency and that I needed to be treated immediately with frequent follow up.

I returned June 3rd at 10am for my second specialist appointment. Apparently, he told all of his other patients to return at the same time. I was not seen until after 2pm. It was apparent that he was incompetent at scheduling his patients as well. The waiting area was awash with complaints as result of his scheduling-handicap. I was relieved at my chance to wait in the examining room. There, I observed patient records ripped in half and tossed in the garbage (an obvious breech of privacy). On the back of the door hung another resident's lab coat with his Sunnybrook identification tag attached (an obvious disregard for internal security). Lucky for them, I was an honest girl; however, I was tempted to take the ripped patient report and the resident identification and mail them to the hospital CEO with a note attached voicing my concerns about the accesibility of these two articles to the public. When the ophthalmology resident did see me in the examining room, he had misplaced my chart, and had not followed up on my culture results. He assured me that he would phone me with the results (which has not happened yet). He examined my eye and assured me that it had improved. I feel like I have glass shards under my eye lid, and I can barely open my right eye related to the photophobia; a note of improvement was a good sign. Fortunately, I can now instill my eye drops every 2 hours during the day and every 4 hours at night. He also requested I return for follow up on June 5th.

My first corneal ulcer

2007-05-31T18:31:00.000-04:00

Approximately six weeks ago I started feeling symptoms of iritis in my right eye. I assumed it was iritis and used my Voltaran eye drops previously prescribed at my first diagnosis. I noticed that many symptoms were different than previous flares of iritis. Photophobia and blurred vision were intermittent this time; my daily symptoms consisted of watery eyes, eye pain, redness, and burning. Sometimes the Voltaran would alleviate the symptoms, but not always. Weeks elapsed, and I finally went into the emergency department at Women's College Hospital in Toronto for an investigation.

I was triaged quickly and spent from 12:35 until 4pm in the Emergency Department. I waited in the ER's ophthalomogy room after the nurse performed a visual acuity test. My vision was very blurry in both eyes. I didn't see the doctor until 3:35pm. I explained my history of ankylosing spondylitis and prior episodes of iritis originating back to September 2006. He appeared familiar with AS, but didn't know what Enbrel was. He assessed my eyes, performed a fluorescein stain of my cornea (to differentiate from a simple abrasion), and diagnosed me with a right corneal ulcer, which he impressed upon me was an ocular emergency requiring an emergency referral to an ophthalmologist. His medical notes indicated a white patch on my upper cornea. He said that he did not think corneal ulcers were associated with AS or Enbrel, and got me an appointment for June 1st (tomorrow) with an ophthalmologist at Sunnybrook for 9am.

Of course, once I got home, I did my own research on corneal ulcers. The literature states that corneal ulcers are most commonly caused by an infection with bacteria, viruses, fungi or amoebae. However, other causes are abrasions (scratches) or foreign bodies, inadequate eyelid closure, severely dry eyes, severe allergic eye disease, and various inflammatory disorders. This means that there is a possibility that my AS may have contributed to my corneal ulcer. Risk factors are dry eyes, severe allergies, history of inflammatory disorders, contact lens wear, immunosuppression, trauma, and generalized infection. Treatment is an emergency referral to an ophthalmologist. Untreated, a corneal ulcer or infection can permanently damage the cornea. Untreated corneal ulcers may also perforate the eye (cause holes), resulting in spread of the infection inside, increasing the risk of permanent visual problems.

Yoga

2007-05-28T09:05:00.000-04:00

Every Monday, at 7pm, I do yoga to encourage a good stretch of my muscles after my Sunday endurance runs. Outside India, Yoga has become primarily associated with the practice of asanas (postures) of Hatha Yoga, although it has influenced the entire dharmic religions family and other spiritual practices throughout the world. The Zen Buddhist school of meditation has its roots in yogic practices. Certain essential elements of Yoga are important both for Buddhism in general and for Zen in particular.

Eight Limbs of yoga practice are:
(1) Yama (The five "abstentions"): violence, lying, theft, (illicit) sex, and possessions
(2) Niyama (The five "observances"): purity, contentment, austerities, study, and surrender to god
(3) Asana: Literally means "seat", and in Patanjali's Sutras refers to seated positions used for meditation. Later, with the rise of Hatha yoga, asana came to refer to all the "postures"
(4) Pranayama ("Life Force Control"): Control of prāna, life force, or vital energy
(5) Pratyahara ("Abstraction"): Reversal of the sense organs
(6) Dharana ("Concentration"): Fixing the attention on a single object
(7) Dhyana ("Meditation"): Intense contemplation of the true nature of reality
(8) Samadhi ("Liberation"): Super-conscious state of enlightenment

While Yoga evolved as a spiritual practice, in the West it has grown popular as a form of purely physical exercise. Some Western practice has little or nothing to do with Hinduism or spirituality, but is simply a way of keeping fit and healthy. This differs from the traditional Eastern view of yoga. For people with back problems, studies have shown yoga helps physically with strength, flexibility and endurance. Yoga also helps create relaxation through the breathing and meditation techniques employed, which has been shown to help people better proactively manage a chronic pain problem like back pain. There is much debate whether the term Hatha Yoga properly describes yoga as exercise, since the traditional Hatha Yoga system originated as, and still is, a spiritual path in its own right.

Run with Spirit offers Yoga classes tailored to runners. Sheree Nicholson is a Certified/ Registered Yoga Teacher (R.Y.T. 200) she is currently studying towards her R.Y.T. 500. She has been practicing yoga for 10 years and brings this experience to her teaching. She uses humor blended with spirituality to make her classes enjoyable and to make students feel comfortable on their mats. She has been running for 10 years and has been an instructor at the Running Room in Pickering.

Let the training commence!

2007-05-28T08:55:00.001-04:00

May 27th was the start of my intensive training for the Wineglass Marathon in Corning, New York on Sept 30th, 2007. In the morning, I ate my usual Sunday breakfast comprised of two whole eggs and 1/3 cup of oatmeal. I checked the weather: rain was scheduled, but not for a few more hours. Perfect. Iniko and I ran 11km with Steve and Chris following on their MTBs. I would not say it was an enjoyable run...I could not find a comfortable candence until 9km. I could not establish a rhythm. Iniko was a marvelous running companion, and remained at heel despite tantalizing visual distractions beckoning a curious puppy.

It was a good first day. I was pleased with getting out there and enjoying the fresh--albeit humid--air. Later Sunday evening, around 9pm, Shaneel and I rode our MTBs around the Nottingham neighbourhood for an hour with Chris and Steve on their rollarblades. I had not been on my MTB in a long time, and I look forward to cross-training with the bike more this summer.

The Wineglass Marathon will be my second full marathon. The point-to-point Wineglass Marathon course starts at Philips Lighting, just north of Bath, NY. If your adrenaline and an 40 ft. drop over the first mile doesn't get me started on the right foot, then the cheering crowds in downtown Bath will push me through those first few miles.

Miles 2-4 are absolutely flat, and will give each runner a chance to get into a rhythm. At about 4.75 miles there is a 40 ft. uphill that finishes at mile 5. For the next 4 miles, the course passes through the countryside, with two more smaller hills, but an overall elevation drop of 90 ft. until you reach Savona (the first Team Relay exchange zone). Savona is an excellent viewing opportunity as it is conveniently located just off Rt. which parallels much of the marathon course, and offers easy access from start to finish.

Out of Savona, runners continue through the countryside while continuing on a slightly downhill trend 40 ft. over the next 4 miles). The halfway point is in Campbell (home of Polly-O String Cheese), where again the crowds turn out to cheer runners ahead… back into the country again. Runners ascend about 30 ft. just beyond mile 14, before gradually losing 80 ft. in elevation as they reach Coopers Plains (Mile 18.2). Team Relay exchange #2 is in Coopers Plains, so again, the activity and spectator level is high, just as the runners need an additional moral boost.
From Coopers Plains to Painted Post is only a couple miles. There runners enter a park (after the last, brief climb of 25 ft.), and tour a residential neighborhood. They then exit onto a bike path, that takes them through the village of Riverside and into Corning. Once the runners enter the bike path (mile 22.5), it is a flat trek to the finish. In Corning, runners are greeted by many spectators as they proceed through several neighborhoods, before hitting the downtown area.

All runners in the marathon and relay will receive a Wineglass Marathon long sleeve shirt, a commemorative glass finishers medal, PLEASANT VALLEY NYS Brut Champagne with a commemorative silk-screen Wineglass Marathon logo and race date, and a finisher certificate in the mail.

Training update

2007-05-25T13:37:00.000-04:00

Marathon training officially commences May 27th, 2007, followed by 16 weeks of intensive running and cross-training. My destination is the Wineglass Marathon in Corning, New York on September 30th, 2007.

Yesterday I took my four-legged canine companion for her first off-leash run. She ran 11km perfectly at heel (beside my left leg). She stopped appropriately at traffic lights before crossing the street, and she did not alter her course in the presence of distractions i.e cyclists, other runners, children, or other animals. She has developed into a true running partner.

15K along the Ajax Waterfront

2007-05-15T13:22:00.000-04:00

Congrats to all of my friends who raced in the Mississauga Marathon this past Sunday. I thought of them fondly during my 15K run along Ajax's beautiful waterfront. Cardinals, Canadian geese, rabbits, dogs leashed to their owners, cyclists, and other runners were plentiful along my route from north Ajax to the wind turbine at Pickering's Nuclear Plant. A persistant head wind challenged my endurance, but a raspberry HammerGel helped me achieve the upperhand.

SportingLife 10K Personal Best

2007-05-06T20:25:00.000-04:00

A glorious personal best of 56:52.9! What can I say? I am thrilled!

The morning started off chilly at approximately 7 degrees with a gentle breeze. The sun was brilliant and I anticipated a good run. I ate oatmeal with brown sugar and peanut butter for breakfast an hour before the race started. I'm lucky...I can eat anything prior to a run without it affecting my stomach. The starting line presented approximately 9000 smiling faces eager to achieve their personal goals set for that race. I confidently positioned myself in the first third of the pack. I had been running enough over the last few weeks to accurately assess my pace. My previous 10K PB was 58 minutes during a training run. I wanted to try to achieve that in a race. I kept a steady pace along the rolling hills of Yonge Street, trying not to twist an ankle in the potholes or on the uneven road surface. I did not stop for water--that's my time to overtake my competition. I had to stop and walk three times when my heart rate ran over 180bpm...which makes me that much more proud of my finishing time. I think of what could have been had I not walked. Ah well...I am very happy.

What's interesting is that as soon as I stopped running, I started sneezing and have not stopped all day. I am hoping this Neo-Citrin I am sipping will help. To top the rest of the day off, I went for an amazing group ride on my motorcycle to Port Perry, followed by a savoury BBQ get-together with friends where my 11-month old pup got to romp with a 14 week old black lab.

It's been a marvelous weekend.

Today's media articles

2007-04-25T12:17:00.000-04:00

Ground-breaking Initiative: Canadian Arthritis Network Surveys Public on Future Arthritis Research Priorities (CCNMatthews) VANCOUVER, BRITISH COLUMBIA and TORONTO, ONTARIO--(CCNMatthews - April 25, 2007) - The Canadian Arthritis Network (CAN) and Arthritis Consumer Experts (ACE) are calling on people with arthritis and the public to tell them what areas of research are of greatest importance to them by launching...

Glorious Weekend

2007-04-23T20:08:00.000-04:00

Oh glorious weekend! Can't dispute it. I had several fabulous runs over the weekend, and took the SV650S out for a romp around Toronto Friday night (High Park and Yorkville to be precise).

I experienced a little stiffness after the long rides--mainly my traps and lower back were affected; however, a hot shower offered pleasing relief.

It feels great to ease into training this year. I feel as if a lot of pressure has been lifted. I would like to try and find some routes leaving from Queen's Park that are scenic and enjoyable. Not finding much luck.

My Personal AS Update

2007-04-14T11:33:00.000-04:00

Today is another Enbrel day (thank goodness). As you can see from the pictures to the left, I still experience site reactions. This reaction occured after my friend injected me in my upper left arm. The bumps visible in the photo only arise once the site become itchy (not sure of the cause). I have had back pain for the last few days, and yesterday experienced restricted mobility after bending forward to stroke my puppy for approximately 10-15 minutes. I was also very stiff last night, but still managed to get a great night of rest.

This week has been quite stressful. I have been working considerably late in the office on a huge project, in preparation for a presentation to the Premier of Ontario yesterday at 3:30pm. Although I consider this all positive stress, my body does not know the difference and responds in kind. Taking time off of running to allow my right foot to properly heal has been personally stressful, and attending the gym does not satisfy me to the same degree as a challenging run outdoors. I suspect I am tiring of the gym scene.

This weekend I have lots to do: taking my pup (Iniko) to the leash-free park, completing household chores (groceries, planning this week's meals, cleaning), reading up on material for work, a Sunday's Raptor's game (my first basketball game), going for a run, weights at the gym, etc. My priority over the next two days is to spend time with Iniko and read. She is now proud to add paw-shaking to her list of skills, and is eager to perform her new skill for treats. She is such a joy in my life.

Q&As

2007-04-08T12:49:00.000-04:00

Here are some medical questions and responses found on the website of The Arthritis Society:

Question: I am 43 and have had ankylosing spondylitis (AS) for over 20 years. I usually get iritis once every 4 years, mostly the same eye. What are your thoughts about having laser surgery for corrective vision? I have heard that if you have arthritis, they do not like to perform this type of eye surgery. Is it best to not consider this type of surgery due to iritis and my AS?
Answer: I agree that it is not a good idea to have laser surgery to correct visual acuity because of the AS and the history of iritis. With autoimmune diseases, the risk of complications is increased and proper healing may not occur. If corticosteroid drops are needed for a flare-up of the iritis right after the procedure, the cornea might not heal properly. Corticosteroid drops could also alter the cornea and negate the benefit of the surgery.

Question: I have been diagnosed with ankylosing spondylitis and sternocostoclavicular hyperostosis. I am also morbidly obese. Would it be a practical step to have the fat surgically removed to prevent further damage?
Answer: There are no studies regarding the acceleration of damage in ankylosing spondylitis and sternocostoclavicular hyperostosis by obesity. However, obesity could further compromise the restricted chest wall expansion in ankylosing spondylitis leading to clinically significant underventillation of the lungs. By increasing pressure on weight bearing joints such as knees, hips and low back, obesity could worsen already damaged joints or hasten the onset of osteoarthritis in previously healthy joints. Obesity may restrict your mobility further and contribute to many other health problems. Weight loss is important. You should consult an expert in obesity for a weight reduction program and on the advisability of including the surgical removal of fat as part of such a program. There are anaesthetic risks as well.

Question: I have ankylosing spondylitis. I am currently 5 months pregnant and can barely walk. I have not taken any medication (I usually take Mobicox) since I began trying to conceive. I am in agony. I try to keep active by walking and have been using heat and cold to help relieve some discomfort. Is there anything else I can do?
Answer: Several of the non-steroidal anti-inflammatory drugs (NSAID’s) are safe to take during the first 6 months of pregnancy, for example, naproxen, ibuprofen, diclofenac, indomethacin and ketoprofen. However, they should be stopped in the last 6 to 8 weeks of pregnancy as they may delay labour, affect a vascular duct in the baby’s heart and prolong bleeding in the mother and baby. They can be resumed during breast–feeding since only trace amounts of these drugs appear in the breast milk. During the last trimester of pregnancy, when NSAID’s should be avoided, low doses of prednisone (a type of cortisone), 5 to 10 mg per day, could be used. The mother’s blood pressure and blood sugar occasionally rise due to the prednisone. These low doses of prednisone are also compatible with breast-feeding. It is unlikely that other measures would help apart from trying the new biologic agents like infliximab and etanercept, but experience with them during pregnancy is limited.

Question: I am a 42-year-old female with active ankylosing spondylitis (AS). My mother and maternal grandfather both died from aortic aneurysms at 56 and 49 years of age. There are several others on my father's side that have AS. Should I request to see a cardiologist given that AS occasionally damages the aorta?
Answer: Ankylosing spondylitis can lead to inflammation of the origin of the aorta where it exits from the heart. As a result, the root of the aorta can become dilated causing the aortic valve to leak (aortic insufficiency). However, aortic aneurysms are not usually associated with ankylosing spondylitis. Aortic aneurysms, in general, can run in families. Rare inherited conditions such as Marfan’s syndrome and Ehler-Danlos are associated with aneurysms. Atherosclerosis is the commonest cause of abdominal aneurysms. Risk factors for atherosclerosis are usually present: smoking, age, high blood pressure, elevated cholesterol levels. There is a family clustering of abdominal aortic aneurysms in 20% of cases. Aortic aneurysms can be associated with such congenital conditions as bicuspid aortic valve and coarctation of the aorta). Inflammation of the wall of the aorta due to infections (e.g. syphilis and other bacteria) or rheumatic diseases (e.g. Takayasu’s arteritis and giant cell arteritis) is also associated with aortic aneurysms. It appears that you inherited ankylosing spondylitis from the paternal side of your family and that aortic aneurysms run in your family on the maternal side. Because ankylosing spondylitis can cause insufficiency of the aortic valve and because there is a family history of aortic aneurysms, you should be evaluated by a cardiologist.

Question: I am 60 years old and was diagnosed 7 years ago with ankylosing spondylitis (AS). Two of my three children (36 and 37 years of age) were also diagnosed with AS. My other child does not carry the gene. I understand that today the laser beam can be extremely fine and work well on very, very minute jobs, e.g. eyes. Can keyhole laser work on the spine - gently, very gently chipping away at the calcified extra bone, thus freeing the spine?
Answer: LASER stands for Light Amplification by Stimulated Emission of Radiation. Photons (units of light energy) are emitted in a narrow beam. The light consists of a single wavelength or hue. The energy range of low level laser light lies between 1 and 500 mW (milliwatts), while for surgical lasers the energy range lies between 3000 and 10000 mW. Low-level laser therapy is the external application of red and near infrared light over injuries or wounds to improve soft tissue healing and to relieve pain and inflammation. The therapy is safe. Light is transmitted through the skin and fat under the skin. However, light waves in the near infrared ranges penetrate the deepest of all light waves in the visible spectrum--up to 30 mm (a little over one inch). There is one article in the Russian literature suggesting that external irradiation of the spine and joints in people with ankylosing spondylitis using an He-Ne laser (20 sessions) was comparable to taking indomethacin at a daily dose of 75 mg. As far as I know, surgical lasers have been used to treat mild degenerative disc disease but not ankylosing spondylitis. The process in ankylosing spondylitis is so diffuse that it would be technically impossible to insert the surgical laser into all the places involved and chip away at the extra bone. I have not heard of anyone even trying this with ordinary orthopedic surgical instruments.

Question: I have had ankylosing spondylitis (AS) for two years and have been able to slowly reduce my medication through daily exercise. Last year, I had surgery on my prostate and have been having trouble with bladder retention. I am being treated for a problem dysfunctional bladder which they are telling me could be related to my spinal cord function. Is there a relationship between AS and bladder retention?
Answer: The “cauda equina syndrome” may develop rarely after many years or decades of ankylosing spondylitis (AS). The cauda equina is the bundle of spinal nerve roots (resembling a horse's tail) that run through the lower part of the spinal canal below the first lumbar vertebra where the spinal cord ends. These nerve fibres innervate the legs, buttocks, rectal area and bladder. In AS, these fibres can be enmeshed in inflammatory scar tissue so that nerve transmission is blocked. As a result, the following symptoms can occur: the gradual onset of pain, muscle weakness and altered sensation in the legs and buttocks, and bowel and bladder dysfunction. The diagnosis is made by MRI scanning of the lower spine.

Question: I am 26-year-old male, that has had ankylosing spondylitis (AS) for 13 years but do not have B27 gene. What other genes are involved in AS? I do not respond well to NSAIDs and I have taken Pamidronate IV and received some benefit (which is gone now). I have read some medical articles regarding K. pnemoniae and mycoplasma. Are there are studies of AS patients taking antibiotics?
Answer: Antibiotics have been used in the past in Reiter’s disease which can lead to ankylosis of the spine. They are not part of the modern day arsenal for AS. Has your physician considered a biologic? You could see if it applies to your case.

Question: I was diagnosed with ankylosing spondylitis in 2002. I am 25 now and still trying to find a prescription that works for me. I am currently taking Naproxen (two 325mg) before bed, but am still waking up in the night with low back pain. My SI joint was fused the last time I went to the doctor in September 2006 and I am worried that it will start going up my spine. Is there anything I can try that will slow down the fusing in my bones?
Answer: Have you seen a rheumatologist? If not, perhaps you should ask your family physician to see one. They could jointly work to control the pain and the inflammation with non pharmaceutical and pharmaceutical therapies. Do you have an exercise program for instance? Have you stopped smoking? Do you have a weight problem? Naproxen may be given at a higher dosage and, eventually, biologics are now available for ankylosing spondylitis that does not respond to traditional measures. Do get help.

Question: I have had ankylosing spondylitis (AS) for over 25 years and it is quite severe. My rheumatologist is suggesting we try an I.V. drug called pamidronate. Are you aware of it's success rate, if any. Is it safer than other treatments for AS? How long has it been around?
Answer: Dr. Walter Maksymowych, a University of Edmonton rheumatologist who is doing research in this area, has helped me with the answer to this question. Pamidronate has been used to treat Paget’s disease of bone, osteoporosis, high calcium levels, cancer metastases to bone and multiple myeloma for about 20-25 years. Dr. Maksymowych would expect this treatment to lead to a good response in about 40% of AS patients and a partial response in perhaps an additional 20%. It is important to note that responses are usually delayed for 3-6 months. It has an excellent safety record, likely superior to currently available therapies. The commonest side-effects are transient low grade fever, fatigue, aching and nausea.

Question: I am a 29-year-old female with ankylosing spondylitis. In the last four years I have tried just about every medication (NSAID, DMARD, etc) with no success. Prednisone (moderate doses) is the only thing that has helped, but the long term use is giving me very bad side effects. I am now quite disabled and would do anything to try one of the new anti-TNF drugs. Is there any sort of Canadian drug program that would help desperate people like myself afford such new drugs?
Answer: Biologic agents, such as infliximab and etanercept, improve pain, stiffness, function and well-being in patients with ankylosing spondylitis. However, it is not known whether they can stop the long term damage in the spine or improve its range of movement. To read more about the biologics in ankylosing spondylitis, go to: http://www.arthritis.ca/look%20at%20research/cochrane%20reviews/ankylosing/biologics/longversion/default.asp?s=1
Each province in Canada has a different set of rules for funding drugs. Many will pay for theses drugs but only for certain indications e.g. for rheumatoid arthritis but not for ankylosing spondylitis. Both you and your rheumatologist should get in touch with the ministry of health in your province. The ministry should be apprised of the positive results of studies using these agents in ankylosing spondylitis. Some private extended health plans will pay for these drugs. You and your rheumatologist could plead with the drug company to release one of these drugs on compassionate grounds. A local charity or benefactor might sponsor your request. If there is a clinical study on the use of these agents in ankylosing spondylitis in an area near you, you might be eligible to enter the study. You should consider joining an advocacy group to push for government funding of these drugs for ankylosing spondylitis. You should check out groups like The Arthritis Society, the Canadian Arthritis Patient Alliance and Arthritis Consumer Experts.

Question: I was diagnosed with ankylosing spondylitis about three years ago. I was taking Bextra for the past two and a half years and it was working great when I suddenly began developing painful cankers - lots of them. After three months and after having exhausted other avenues, I stopped taking the Bextra and they went away immediately. I was then prescribed meloxicam and again, the cankers came back immediately. I am at my wits end! I have been off all medication now for a week and the cankers show no signs of leaving me. Is there anything out there I can take for my AS that won't give me cankers? Or am I having to suffer with them in order to stop the pain of the AS? My doctor just keeps changing the prescription to a different NSAID.
Answer: It should be determined that the canker sores are truly due to the NSAID’s. Canker sores can also be caused by diseases associated with ankylosing spondylitis such as Crohn’s disease, ulcerative colitis and Behcet’s disease. Other drugs, allergies (e.g. certain nuts, spices, chocolate and tomatoes) and gluten sensitive bowel disease can also cause canker sores. An allergist may help to sort this out. If the cankers are due to the NSAID’s, then they should be stopped and consideration should be given to using biological agents like infliximab or etanercept to treat the ankylosing spondylitis. You would have to consult a rheumatologist.

Question: I am a 32 year-old woman who has pain in my si joint, lower back, deep within my left buttock, and my left shoulder & neck. I am seeing a chiropractor and massage therapist right now. I run 50 miles a week and lift weights and have a very strong upper body. I stretch my back constantly, but always have tightness and pain in these locations. Sometimes, for example, I cannot lie or sit without pain. Could I have ankylosing spondylitis? Both my massage therapist and chiropractor are unsure, and my doctor usually rushes me out before I can bring it up.
Answer: You could have ankylosing spondylitis. A simple X-ray of your sacroiliac joints would show the typical changes of ankylosing spondylitis and you would feel a lot better after taking regular doses of an anti-inflammatory drug for a few days if you had ankylosing spondylitis.

Spondyloarthritis Research Consortium of Canada (SPARCC)

2007-04-08T12:32:00.000-04:00

Principal Investigators (left to right):
Dr. Proton Rahman - Memorial University

Dr. Walter Maksymowych - University of Alberta

Dr. Robert Inman - University of Toronto

Dr. Dafna Gladman - University of Toronto

Award: In February 2006, The Arthritis Society announced a $2.5 million grant over 5 years to SPARCC to research underlying causes of and treatments for Ankylosing Spondylitis and Psoriatic Arthritis.

Project Details:
The current initiative focuses on a major form of arthritis which until recently has been under-recognized and under-studied in Canada. Spondyloarthritis (SpA), of which the major clinical subsets are ankylosing spondylitis and psoriatic arthritis, has a significant prevalence and high burden of illness in the Canadian population, approximately 1 in 100; it is characterized by chronic inflammation of the spine and is frequently accompanied by arthritis in a number of other joints.

The present study proposes a national research program which extends from genetics through to clinical epidemiology. The studies seek to address the biological basis of these types of arthritis and the impact of the disease on individuals and society, and will do so through a multidisciplinary approach which draws expertise across the spectrum of health research. The primary goal of the research program is designed to improve both the diagnosis and management of Canadians with SpA. With the major advances in new treatments for arthritis in the past 5 years, we are optimistic that we can achieve better results in quality of life and function for these patients.

Investigators on this team have already been involved in breakthrough research pioneering the use of MRI for arthritis, in genetic discovery, and in the use of ground-breaking biological therapies for patients with inflammatory arthritis. We plan to adopt a new interactive model of research in which patients become active participants in the design and execution of the research plan. Our aim is to set a new benchmark for research into chronic diseases in Canada.
This project will include an assessment of SpA patients from across Canada and will help the team develop a better understanding of the genetic basis of expressions of the disease, juvenile aspects of SpA, regional and cultural differences and how it impacts native Canadians. From this data we will be better able to predict, and therefore manage, treatment programs including drug therapies.The research will also evaluate the significance of early diagnoses and treatment.
Because SpA involves the spine and is often slow to develop, and takes patients an average of eight years to receive a proper diagnosis.

Helping Hands Forum

2007-04-08T12:11:00.000-04:00

Date: Saturday May 5th and Sunday May 6th, 2007
Registration: 9:30am
Location: Renaissance Toronto Hotel, 1 Blue Jays Way (416-341-7100)
Time: 9:30am until 1:30pm
RSVP: 416-663-1500 x 226 or rsvp@stimulushealth.com

Saturday's Agenda
0930: Registration
1000: Dr. Robert Inman-->New Developments in Ankylosing Spondylitis
1045: AS Patient speaks
1100: Break and refreshments
1130: Dr. Edward Ng-->Rheumatoid Arthritis:Beyond the Copper Bracelet
1230: Open Discussion/Q&A

Sunday's Agenda
0930: Registration
1000: Dr. Dafna Gladman-->Psoriatic Arthritis: Not Just Skin & Joints
1045: AS Patient speaks
1100: Break and refreshments
1130: Dr. Jerry Tenenbaum-->Understanding Your Osteoarthritis: Management Strategies
1230: Open Discussion/Q&A

I will be attending the Saturday forum to hear Dr. Inman speak.

Harry's Run

2007-04-08T11:26:00.000-04:00

What a beautiful day for a race. The sun was shining. It was cold and breezy (not my preference for a run of any sort--I'm a warm weather gal). My pup was there to view her first race. And my right foot felt fine prior to the event.

I did a gentle run prior to warm up my muscles and elevate my heart rate. I set my Garmin305 to run 8K in 48 minutes. This would be a reasonable pace post recovery from Around the Bay. My goal was to keep a steady pace and not reinjure my foot. The course had rolling hills which I tackled confidently. The last hill just before the finish line had a steep incline and was lengthy. I could hear the runners' laboured breathing around me, despite my iPod's wonderfully distracting rhythms. It was here that I could feel the weight of my legs as I lifted them with a drill-like cadence. I finished in 48:39.7. I was pretty much on target and was happy with my performance.

It was wonderful seeing running partners (hey Joanne B, Neil, Chuck) gathered at the finish line with a sense of accomplishment on their faces. Good memories of past training days...of our Second Cup lattes after those 8:30am long runs every Sunday...of speed work with Ken at the track. I loved those times.

Remicade & Humira Increase Cancer & Infection Risk

2007-04-06T14:08:00.000-04:00

A Mayo Clinic study indicates that arthritis drugs Humira and Remicade triple the risk of many types of cancer and double the risk of serious infections . While the overall risk of developing cancer from these drugs remains small, the risk can vary widely by patient. The findings of this new study can be found in the May 17, 2006 issue of the Journal of the American Medical Association. It has been known for years that these treatments increase the risk of certain types of cancer or infection (such as lymphoma and tuberculosis). While even rarer than these previously-known (but uncommon) problems, there appears to be a slightly increased risk for a broader set of cancers and infections in patients undergoing anti-TNF treatment.

This is not the first time studies have indicated an increased risk of cancer and infection associated with these arthritis drugs. However, this study is the first to quantify these risks and discover additional types of cancer linked to Humira and Remicade. Previous evidence suggested that these drugs might increase the risk of lymphoma , a cancer of the lymph nodes. Past research also found that the risk of tuberculosis and pneumonia was greater for patients taking Humira or Remicade.

The study, led by investigators at Mayo Clinic, used "meta-analysis" to combine and assess the results from a large set of clinical studies already in the literature. With the large number of patients and years of treatment represented by these combined studies, less common events associated with treatment can be detected. Overall, the study suggests that the increased risk of cancer (lymphoma, skin, gastrointestinal, breast and lung) or serious infection may be three-fold and two-fold, respectively. These serious side effect risks appear to be greatest when higher doses are used. The risk appears to be mainly in patients receiving high dose treatment (more than 6 mg/kg every 8 weeks; or adalimumab, 40 mg every other week). Researchers also noted that older sicker patients who have taken this medication for an extended time are at the greatest risk for these arthritis drug side effects.

While medical researchers at the Mayo Clinic noted the benefits of Humira and Remicade-including increased range of motion, flexibility, and life expectancy and a reduction in pain-they caution patients and medical providers to be aware of these risks and their symptoms.
Patients taking these medications should seek medical attention at the first sign of infection , such as a fever, cough, or related symptoms. Some patients may wish to consider cancer screenings; those which are recommended to the general public.

Abbott Laboratories and Centocor, the makers of Humira and Remicade, respectively, have criticized the Mayo Clinic's study, claiming that this new evidence does not prove that these arthritis drugs cause cancer and infection. Other experts have raised questions as to whether the increased risk of cancer is actually attributable to the drugs or the disease itself. The exact reason for these increased risks remains unclear.

An additional drug, Enbrel , was not included in this study, as it differs at the molecular level. Researchers say a study on this arthritis drug is in the works.

Q1 2007 at a glance

2007-04-06T13:18:00.000-04:00

What a happy existance:

The pain no longer exists in my right foot from the Around the Bay race. I have not run since I promised myself I would treat this as a recovery week to allow my foot to heal.

My career is skyrocketing. I have recently been delegated the lead on two major strategic programs (paediatric and cardiac surgery), and the sole expert on cardiology within my organization. Surgical quality and hospital /LHIN allocations are also part of my portfolio. As a former paediatric cardiac nurse practicing in one of Ontario's five busy academic hospitals specializing in this population, I have the clinical expertise and front-line experience to ensure patients are kept at the forefront of policy decisions. Given all the work to be done, I am spending this long Easter weekend working at home--so much data analysis needs to get done before I head to the spa overnight on Sunday for a little "me" time.

I am getting used to my Enbrel routine. I am not sure if it's having a therapeutic effect as of yet (it took 3 months of injections before taking effect the last time I was prescribed the drug). I have not had any night sweats since starting the medication; however, I still have stiffness and pain in my lower back. My fatigue has subsided which is fabulous. I did experience one new side effect during the early stages of resuming Enbrel: a bilateral rash on the top of my hands that did not disappear for two weeks. That side effect--which I read was experienced by some clinical trial patients--has resolved. I try to inject my stomach the most as it is the least painful location, and my thighs the least as this is the most painful location. Last Wednesday, I had to inject my left thigh (must rotate sites): it was incredibly painful inserting and withdrawing the needle. The lump on my thigh was the size of a plum, and it was red, itchy, and hot to touch. Mind you, compared to the side effects of other medications taken by people with more critical diseases or illnesses, this is bearable.

On a sad note, my grandmother has been admitted to the same hospital in which my grandfather recently died. She has bacterial pneumonia. She also required several pints of blood over several days. I spoke to her in the nursing home and she sounded very tired. Her private nurses are by her side 24 hours a day, along with support from the hospital staff. I hope she is able to return to health soon.

Tomorrow is another race. I can't say I am feeling very prepared for it, given my week off from running. My nutrition has been out of whack for one month now: too many damn JellyBelly jellybeans and nightly outings to restaurants. I've been too indulgent, and it's been sooooo tasty.

Ah well. I am trying not to be too rigid this year with my training, while still being disciplined to follow my training plan. It's all about balance for me this year. I would like to have more fun with friends this year, something I have put aside for years while I focus on training. My friends have been incredibly patient with me...most are convinced I have fallen off the planet (Carlos...Denise...Sam...Jason B...Deanah...Rene...Ainka...Rox...Jason E...Adedoyin: you guys have been tolerant and understanding).

I now have a new training parter who will be following the same training plan as myself with regards to running, nutrition, and weight training. Given that we also both mountain bike and scuba dive, I suspect that my life will be more balanced with social activities than previously. Camping excursions with my dog and a scuba trip to Mexico have already been booked for this year. I am eagerly anticipating the fun.

Harry's Spring Run Off Toronto 8k

2007-04-01T12:09:00.000-04:00

The second annual Harry's Spring Run-Off 8k & 5k to Fight Prostate Cancer in Toronto will take place on April 7, 2007 at High Park, a month after Harry's Spring Run-Off 8K to Fight Prostate Cancer unfolds on March 11, 2007 in Vancouver's Stanley Park.

Prostate cancer is the most common cancer threat to Canadian men. It will afflict one out of six men in their lifetime – approximately 20,500 men this year alone. Men over the age of 45 are urged to speak to their doctors about testing. Once again, proceeds in Toronto will be donated to the Princess Margaret Hospital Foundation, while in Vancouver, proceeds will be donated to the Prostate Centre at Vancouver General Hospital.

This will be my first time participating in this race--I have signed up for the 8K, where I plan on achieving a Personal Best (PB). Given the state of my right foot, I am hesitant to say that I will achieve this goal, but I will try to while minimizing my risk of injury. The last thing I want is to cause are more serious injury which may prevent me from training for several weeks.

Bruised but not Broken

2007-04-01T11:26:00.000-04:00

Well the good news is that the lateral aspect of my right foot is not broken. The attending physician ordered an Xray to determine if I had a stress fracture--I tried to tell him that Xrays don't determine acute stress fractures until the 3rd week after healing has started to occur. MRIs, CT scans, and 3-image bone scans are more successful in identifying early-stage stress fractures. I was not surprised when the radiology report suggested no abnormal findings. The attending physician then sent me on my way without investigating my pain and bruising further; however, he suggested I could attend the sports therapy clinic in the hospital if I wanted to pursue a diagnosis more aggressively. Naturally, I would pursue this avenue--the pain still exists despite a finding of no fracture and I would like to determine the cause so that I may treat it appropriately without risking injuring myself by ignoring it (this is where I get really frustrated with physicians).

After doing my own research into the matter (until I access the sports therapy clinic to get the opinion of an expert) I suspect possible cuboid subluxation. Cuboid syndrome is somewhat obscure and poorly defined in the literature. When conditions are poorly defined in the literature, this usually means that there is a lack of consensus among doctors as to the etiology (reason for the condition) and the treatment. Cuboid syndrome is a common cause of lateral foot pain in the athletic population and is often misdiagnosed or mistreated. Occasionally the symptoms of cuboid syndrome occur without an obvious injury. The symptoms of cuboid syndrome are very similar to the symptoms of a sprain. Pain is significant when weight is first applied to the foot. Pain increases with the toe off phase of gait as the weight of the body and load from the calf muscle are delivered to the lateral (outside) column of the foot. An athlete with a cuboid subluxation will complain of lateral foot pain and weakness in push-off. Rest, ice, and anti-inflammatory medication (I am taking the Indomethacin I use during my arthritis flares) have been helping. I still can't walk flat on my feet, so I bear all my weight on the ball of my right foot. I would use crutches if I had any because hobbling on the ball of my foot puts too much weight on my left leg which is recovering from shin spints.

One of the fun things about running is that it gives one the opportunity to learn, and it seems as if this never stops. No matter how experienced you are there is always something more to learn. This observation is made relevant by several investigations into overuse injuries in runners. These studies show that experienced runners have about the same rate of overuse injuries as beginners. It is not that experienced runners never learn. Certainly some do not and constantly run, and rerun, into the same injury pattern. However, it is likely that a larger percentage cure one injury then develop and improve until they stumble into the next. This is probably because as one area gets stronger the stress load is subsequently re-applied elsewhere. Injuries, thus, tend to march along what is referred to as the “kinetic chain”. Each runner, however, tends to march to the beat of a different drummer. The specific location for an overuse injury is determined by a multitude of factors (e.g., genetics, previous injuries, training factors, etc.). This means that there is not an etched-in-stone-overuse-injury-sequence through which all runners progress (Feet first, then ankles, then shins, then knees, then … ). Thus, it is a good idea for runners to become aware of regions of the body that may become affected and learn a little about the specifics in each region. Knowledge and early warning are a runner’s best friends.

I am thrilled that I don't have a fracture. I am taking the rest of the week off of running so that I may push myself for my next race on Saturday April 7th. Instead, I am attending the gym and adhering to my nutritional plan with planned cheat-days during the week. Fridays are my cheat day. I enjoyed last Friday with friends for a night of drinks, chocolate, Thai food, and Trivial Pursuit. My evenings have been filled with the company of friends--a great distraction during my down-time from training.

References

Stone DA, Kamenski R, Shaw J, Nachazel KMJ, Conti SF, Fu FH. Sports Injuries, Mechanics, Prevention, Treatment-Second Edition. Philadelphia, Lippincott Williams and Wilkin; 2001. pp381-397.2.

Leerar, PJ. Differential Diagnosis of Tarsal Coalition versus Cuboid Syndrome In An Adolescent Athlete. J Orthop Sports Phys Ther 2001; 31(12)3.

Marshall P, Hamilton WG. Cuboid Subluxation In Ballet Dancers. Am J Sport Med 1992; 20(2).4. Mooney M, Maffey-Ward

L. Cuboid Plantar And Dorsal Subluxations: Assesment And Treatment. J Ortho Sports Phys Ther 1994; 20(4).

Stress Fracture?

2007-03-28T21:53:00.000-04:00

For two days after the race I could barely walk. My quads were especially tight, and I could feel a sharp pain along the lateral side of my right foot that I could not identify. By the end of Monday I was very frustrated with my inability to lift my feet off the floor and my shuffling gait; I made a one-hour appointment at Sutherland-Chan's massage therapy clinic located at Bay/Dundas for the following day. I took a taxi down to Atrium on the Bay and had a fabulous lower body deep tissue massage which produced a noticable improvement in my gait. What an amazing feeling to be able to walk normally again without the previous stiffness.

Today most muscular pain had disappeared, except for some soreness along my left shin. The pain along the lateral side of my right foot had worsened and I was starting to suspect a stress fracture. It was managable during the day; however, towards the end of my 6k run around Queen's Park with a colleague, the pain became unbearable. It was too late to see my family physician for a diagnostic referral; however, my goal is to have my foot assessed at Women's College Hospital tomorrow. I hope nothing is broken; it would hinder my performance at my next race in 2 weeks where I intended to really push myself.

Was it worth it? Hell yeah!

2007-03-26T13:21:00.001-04:00

Hooray! It's over. I am so happy to report that I accomplished my goal of completing the Around the Bay 30K race with a chip time better than anticipated: 3:17:38.8. I was hoping to achieve 3:15, but anticipated between 3:15 and 3:30 as my race time.

The day truly started the night before. I went to Barbarian's Steak House at 7:30pm after mapping the course on my GPS during a day trip to Hamilton, and ordered a delicious bottle of French bordeaux, oysters to whet my appetite, followed by an entree of 10 oz filet mignon with lobster (tail and claw), baked potato (with sour cream, bacon, and feta cheese), topped off with blueberry cheesecake, 3 glasses of water (for hydration of course), and a teapot of loose-leaf chamomile tea to end the meal.

I organized my race gear before heading to bed. I didn't get to sleep as early as I wanted, and once in bed, I was too excited to sleep. I am sure I dozed briefly; it was hard to sway my mind to think of anything other than my strategy for tackling the Hamilton course. My goal was to take it slow in the beginning to warm up (after all, it's been a long time since I did any "real" running/training), kick up my speed in the midst of the race, and then drop it down a bit to conquor the rolling hills for the last 10K of the route. I did not want to focus on time at all for this event; I wanted to see if I could endure 30K in a decent time after a hiatus from routine running.

I awoke on the Sunday at 0630, got dressed, and ate my typical pre-race meal of three eggs (two if I'm doing 21K or less), large-flaked oatmeal, and water (sometimes green tea). I was out the door and in Hamilton by 0830. My Garmin was set and ready to go. I ran into several past running partners--how wonderful it is to reunite at a race. The weather never passed 4 degrees Celcius, although a low of 5 and high of 11 was anticipated. The air was thick with fog on the drive in (at least I think it was fog; it is Hamilton after all). I placed myself behind the 3:10 pace bunny, and made certain I never saw the 3:30 pace bunny pass me (a sure signal I was slowing down). As I passed the start line, I went over on my left ankle thanks to a pothole--luckily no injury; however, the first 5km I was plagued with terrible shin splints. Worried that this had the potential to hamper my performance, I stuck to a slow pace (6:15) and tried to avoid the potholes in the road. The first 10K of the route was through a very run down area that made downtown Detroit look like Forest Hill. Just before the 10K marker, as a group of us waited at a rail crossing for the train to pass (just our luck), a stench resembling that from a bathroom at a cheese convention for lactose-intolerants wafted heavily in the air. It was sickening, but was incentive enough to pick up the pace slightly. My shins felt better and I was feeling great at this point, and kept up my pace (5:45-6:00) until 19K. Now it was time to bear down and take those 10K of hills, keeping a slower but steady pace, anticipating the final steep hill around the 24K/25K marker. My IT band was aching a bit and forced me to walk half of one small hill for 2 minutes. By that time, I had recovered enough to keep going. I followed the tradition of high-fiving the midget playing Queen's "We are the Champions" on a huge stereo system around the 24K/25K mark prior to literally talking myself up the final incline, which felt similar to running up a ladder. Once at the top, I patted myself on the back, and ran at a pace I thought was quicker--but was not given my legs of lead--towards the finish line 4K away in Copps Collisium. I felt the urge to throw up for that entire stretch. It subsided somewhat when I was greeted by a tall fellow in the middle of York Blvd dressed as the Grim Reaper. He was standing near the cemetary along the road and asking passing runners if they were "ready to die yet." In my head I yelled, "No" and pushed my way into Copps to the sound of cheers. What a fabulous feeling!!!!

The day ended with a fabulous post-race meal: a large mojito to accompany a savory 10 oz sirloin, mashed garlic/idaho-sweet potato with vegetables, and mango passionfruit creme brule.

Now that I know I can manage a base of 30K, the rest of this year's training will be cake. I already have my schedule set. Mind you, I shuffle like a penguin and I cannot drive my car (it's a stick-shift). Thanks Steve for driving me to and from work today. Everyone's been calling me Happy Feet--mind you my mental spirits are the happiest of all!

Around the Bay: March 25, '07

2007-03-23T21:59:00.000-04:00

For the first time I am nervous prior to a race. On March 25th, 2007, I will be running my first 30K race--Around the Bay in Hamilton, Ontario. I visited Hamilton last Sunday to drive the race route, which starts at the intersection of York Blvd and Caroline Street. The first 20k of the Around the Bay Road Race is an exciting, scenic, and fast route. The route was relatively flat until 10.5km, where the first small incline of a bridge was encountered. The remaining hills didn't surface again until around 18k: strips of continuous rolling hills lined by beautiful estates (at least I'll have interesting architecture to distract me from fatigue or aching muscles). The last 10k includes rolling hills through scenic North Shore Blvd. The final "hill' is a steep embankment along Valley Inn Road (starting at 26km). It's this hill that causes me the greatest anxiety of this whole race, likely because I have only run five times since the start of the year. Basically, the start of my 2007 training will be begining with Around the Bay (crazy, I know). I look forward to my grand finish into Copps Coliseum at York Blvd. and Bay Sts.

Live Results! for all runners will be available during the Around the Bay race this Sunday. Follow a Runner! You will also be able to select the runners you would like to follow and watch their times as they cross the Start, 10K, 15K, 20K and Finish Mats. My bib# is 2884.

Enbrel: Day 3 - In the leg

2007-03-15T17:22:00.000-04:00

Last night I administered my Enbrel in my right thigh - a site I consider quite painful. As I inserted the needle the first time, the pain was so much I had to withdraw the needle from my leg. The second attempt was much better, but the site reaction was intense. The area became quite red, swollen, itchy, and hot to touch, with approximately 12 small bumps emerging around the injection site. Almost 24 hours later, the area is still visibly red, hot, and swollen.

Iritis...possibly

2007-03-14T21:20:00.000-04:00

Guess who has iritis again? ^(&#$!@*(#&(*@^!

Feverish

2007-03-12T13:44:00.000-04:00

I had a great 10K run last night with my new running partner. The weather was beautiful, if not a bit chilly. I felt great. Upon returning home, I became quite feverish and chilled. I could not regulate my temperature. Externally I was hot, but I was shivering. I was also so nauseous that the smell of my steak dinner was unbearable; I could not eat. All I could do was sleep.

I am not certain if this is related to starting the Enbrel, or the side of a flare I've never previously experienced.

Use of a low starch diet in the treatment of AS

2007-03-10T14:04:00.000-05:00

The majority of ankylosing spondylitis (AS) patients not only possess HLA-B27, but during active phases of the disease have elevated levels of total serum IgA, suggesting that a microbe from the bowel flora is acting across the gut mucosa. Biochemical studies have revealed that Klebsiella bacteria, not only possess 2 molecules carrying sequences resembling HLA-B27. Furthermore AS patients from 10 different countries have been found to have elevated levels of specific antibodies against Klebsiella bacteria. It has been suggested that these Klebsiella microbes, found in the bowel flora, might be the trigger factors in this disease and therefore reduction in the size of the bowel flora could be of benefit in the treatment of AS patients. Microbes from the bowel flora depend on dietary starch for their growth and therefore a reduction in starch intake might be beneficial in AS patients. A "low starch diet" involving a reduced intake of "bread, potatoes, cakes and pasta" has been devised and tested in healthy control subjects and AS patients. The "low starch diet" leads to a reduction of total serum IgA in both healthy controls as well as patients, and furthermore to a decrease in inflammation and symptoms in the AS patients. The role of a "low starch diet" in the management of AS requires further evaluation.

Famous sufferers of AS

2007-03-10T13:51:00.003-05:00

Mötley Crüe guitarist, Mick Mars: AILING ROCKER MARS CAN'T MOVE HIS HEAD
Ramses II
Former England cricket captain, Mike Atherton;
Former Australian cricketer, Michael Slater;
Scottish poet, William Soutar was bed-ridden for the last 13 years of his life due to AS
British comedian, Lee Hurst;
Canadian radio personality, Mike Stafford;
Norwegian Prime Minister, Jens Stoltenberg;
World Chess Champion, Vladimir Kramnik;
Former author and "Saturday Review" editor, Norman Cousins;
Scottish former snooker player, Chris Small;
Ed Sullivan, the Ed Sullivan Show, US
Leonard Trask, "The Wonderful Invalid"
Canadian musician, actor, and writer, Chris Michaud
The Phillies' first baseman, Rico Brogna had a successful nine-year career in American Major League baseball. Ankylosing Spondylitis forced his early retirement, at 31, in 2001.

Enbrel Treatment: Day 1

2007-03-10T13:04:00.001-05:00

I have chosen Wednesdays and Saturdays to have my Enbrel treatment. Tonight was my first treatment since February 2006. Below I have documented the procedure:

A package of Enbrel (below): Four of these come in each box and last 2 weeks. Note: alcohol swabs no longer come in the package and must be ordered seperately.

Solution prep: I previously instilled the diluent in the vial of powdered medication, allowed it to dissolve, and I am now drawing back the preparation into the syringe.

Site prep (below): Preparing the site properly is critical to minimize risk of infection. I am swabbing my chosen site (left lower quadrant of abdomen) with an alcohol swab.

Safety precautions (below): The far left photo shows my aspirating (pulling back on the plunger) before injecting the solution (right photo).

Injecting (below): The medication must be injected subcutaneously. To do this, pinch the skin and insert the needle at a 45 degree angle.

Complications: Site reactions are common after injecting Enbrel. This site reaction occured within 2 minutes of injecting Enbrel. The site became red, warm to the touch, and itchy, with small welts emerging. You can see a small bump above and to the right of the bloody insertion point. Beneath the site reaction I could feel the bleb of fluid beneath my skin, like a round pebble.

Three Cheers!!!

2007-03-06T23:10:00.000-05:00

It was a bitterly cold day, but I didn't care. Today was the day I strolled across to Women's College Hospital's pharmacy, with a slight spring in my step, and picked up my prescription for Enbrel. I could not be happier. Two boxes, enough to last me a month, with each box containing four Enbrel dose trays of 25mg vials of etanercept, one diluent syringe, one 27-gauge needle, one vial adapter, and one plunger--all waiting for assembly and usage. Given that I need to inject Enbrel subcutaneously twice weekly, I need to pick days that are convenient. I am thinking Wednesdays and Saturdays would be suitable: I could inject my abdomen at work on Wednesdays and find someone to inject my arm on the weekend. Saturdays are great because it would preload my body before my long runs on Sundays, which tend to cause my body to experience a systemic inflammatory process (aka flare) that lasts well beyond the day.

Tomorrow I will post photographs of myself preparing the medication and injecting it. This would allow those contemplating taking this medication some insight as to the process that must be carried out twice weekly. For people who have difficulty preparing the medication, it also comes in 50mg pre-filled syringes for once weekly injection. Stay tuned.

New Running Goals for 2007

2007-03-04T14:38:00.000-05:00

After much deliberation, I have decided to focus on distance, rather than speed, for 2007. I love my long runs: hours of solitude along stretches of road or trail, focusing on planting one foot in front of the other, getting closer to my destination. I have resolved not to place too much emphasis on time goals for Around the Bay, and to use the subsequent two races to concentrate on speed.

Training update

2007-02-26T21:47:00.000-05:00

I started my new training program today, comprised of a nutritional plan to help reduce my carb intake, and an exercise routine that balances cross training with running. This 12 week program will provide me with the base I need before I increase the intensity of my training in the spring.

The nutritional plan has me eating a combination of select lean protein and healthy carbohydrates every three hours to speed up fat loss and maintain stable energy levels. If I get hungry again in about three hours, my food portion sizes are correct. If I am hungry sooner, I didn’t eat enough. Still feeling full four or five hours later? I ate too much.

Our bodies work better with a balance of carbohydrates and protein. Not only is protein essential for building healthy muscle and maintaining a strong immune system, it stabilizes insulin levels, which leads to steady energy throughout the day. One more benefit: eating protein has been shown to reduce your appetite. Portion size is important to weight management. I employ a common sense approach, such as using the palm of my hand or a clenched fist for gauging the portion sizes of food. I need to focus on fixing my meals in advance and freezing them. I also need to plan grocery shopping at least once a week. I find that when I run out of nutritious food I become tempted to select unhealthy food choices.

My exercise plan is to weight train intensely, three times per week on alternating days with cardio exercise three times per week. My routine involves selecting one exercise and conducting five sets with it, starting with a set of 12 reps, then increasing the weight and doing 10 reps, adding more weight and doing 8 reps, adding more weight for 6 reps. Then reducing the weight and doing 12 reps. Immediately after, I perform another set of 12 reps for that muscle group using a second selected exercise. For each muscle group, I rest for one minute between the first four sets. I then complete the final two sets with no rest in between, wait two minutes before moving on to my next muscle group, and complete this pattern five times for the upper body training experience and four times for the lower body training experience.

Although my schedule called for an upper body workout today and cardio tomorrow, I switched my schedule to accomodate my attendance at a concert tomorrow night. Given that my gym is open until midnight, I plan to do weight training after the concert concludes. I decided to run tonight. I ran 7k at a 5:58min/km pace in snow while using my YakTraks for the first time. This was my first run in approximately 4 weeks or more, and it felt great. I took my time because I am still getting over the flu; the crisp air felt refreshing, and I was pleased with my performance.

At work I announced that I planned on starting up a lunchtime run/walk club. When I trained for the Ottawa Half-Marathon in 2004, I found running 5-6k at lunch four days per week very refreshing; if I was not tired by the day's end, I would then hit the gym for 2 hours of aerobics and weight training. Given that there are a few recreational runners in my branch at Queen's Park, I thought it would be a welcomed initiative. The feedback was incredibly positive. Looks like I'll have a few more running partners.

New Blog

2007-02-23T16:22:00.000-05:00

Hi everyone,
I am creating a new blog discussing my personal philosophies.
If you click the link "View my complete profile," and scroll to the bottom of the page, you will see the link to "Beautiful Spirit" or you can enter the url http://chi-spirit.blogspot.com/
This blog will be more personal, as I discuss my beliefs and thoughts on what really matters. It's a chance for me to share my ideas, and expose the personality behind the blogger.
I hope you enjoy.

Life Update

2007-02-21T21:26:00.000-05:00

Well, the stress continues to take a toll. I had another bout of night sweats last night; however, the severity was considerably less in relation to those I've experienced over the past week. I did need to change my night clothes at one point and grab a towel to sleep on something dry. The emails of support continue to pour in, offering reassurance that I am not alone in my experiences. Thanks everyone. The downfall of AS being such a hidden disease--and a very uncommon one as well--it's very difficult to connect with other people who share these personally-challenging experiences. It is very isolating when you envision that people don't understand when you talk about feeling tired, being in pain, or not being able to emerge from your bed. I'm sure this probably sounds like whinning; being in the midst of a flare that seems neverending can really alter one's mood. I have been trying to stay positive and upbeat, but I am so emotionally and physically exhausted by the end of the day, and that's when I tend to update my blog.

Today I switched my prescriptions from my local pharmacy to Women's College Hospital pharmacy. The pharmacist assured me that Enbrel is eligible for reimbursement under my new health benefits with Manulife Insurance. I am counting down the days until I can pick up my first box of Enbrel. I will need to find a few select people who would be willing and able to inject the medication into the subcutaneous tissue over my triceps (it's not an easy area to reach on your own). The photo to the right shows subcutaneous sites where Enbrel can be injected safely. Rotation of sites is recommended to minimize complications. When I rotate sites, I tend to prefer self-injecting into my abdomen as I find my thigh an extremely painful site. To inject elsewhere, I need to request assistance.

One of my concerns with starting Enbrel, particularly now that my primary mode of transportation to work is public transit, is the resulting suppression of my natural immunity to infections. People taking Enbrel are especially susceptible to respiratory infections. Taking public transit is like attending daycare during flu season. I currently have some bug at the moment: over the last week I have presented with a very sore throat (it feels like I am swallowing razor blades) and a low-grade fever. I'll have to determine if I should start Enbrel while experiencing these symptoms or if I should wait until my health has returned to baseline.

Life Update

2007-02-20T20:00:00.000-05:00

Today I learned my health benefit plan is effective March 1st, 2007. I receive 100% of eligible prescription expenses, and only pay a single-time deductible of $10. This is great news. However, to take advantage of direct billing to the insurance company, I am restricted to filling my prescriptions at the hospital pharmacy of either Sunnybrook Hospital or Women's College Hospital. Transfering my prescriptions out of my local community pharmacy would be a small price to pay for access to affordable biologics.

3rd straight night of nocturnal sweats

2007-02-20T17:56:00.000-05:00

Another night of awakening soaked in a cold sweat from head to toe. Grrr.

I would like to express my sincere appreciation for the numerous emails I have recently received from friends and strangers concerned for my wellbeing during this personally difficult time as I struggle with my health.

Literature on the subject of night sweats is scarce. Night sweats has been defined as drenching sweats that require the patient to change bedclothes. Tuberculosis and lymphoma are diseases in which night sweats are a dominant symptom, but these are infrequently found to be the cause of night sweats in modern practice. Any disease that results in autonomic overactivity (e.g., ankylosing spondylitis) may result in night sweats.

Mechanics of Temperature Regulation and Elevation
Normal human body temperature displays a circadian rhythm, and is generally lowest in the predawn hours at 36.1° C before rising to 37.4° C or higher in the afternoon (Young, 1988; Boulant, 1991, Dinarello and Bunn, 1997), so the fever/sweating events are probably linked with this daily cycle. There are three phases to fever. In the initiation phase, cutaneous vasoconstriction promotes heat retention and shivering generates additional heat. When the new (elevated) set point is reached, heat production balances heat loss and shivering stops. With lowering of the set point to normal, cutaneous vasodilatation promotes heat loss to the environment in the form of sweating (Young, 1988; Boulant, 1991, Dinarello and Bunn, 1997; Cleary, 1998).

Potential Causes of Night Sweats
When night sweats are due to an infection, the sweating usually occurs as the body temperature drops suddenly after running a fever. Non-infectious illnesses can cause night sweats as well. The first that comes to mind is a malignancy. The most common symptoms of lymphoma, a tumor of the lymphatic system, are swollen lymph nodes, often in the neck. In addition, some people also have fever, night sweats and weight loss. Several other malignancies and other diseases can lead to night sweats as well.

Tumour necrosis factor alpha (TNF-α)
Tumour necrosis factor alpha (TNF-α) is one of the peptide signalling molecules implicated in triggering night sweats in AS. Monocytes (a type of white blood cell) are a significant source of TNF-α. It is possible to reduce TNF-α levels. For example, thalidomide suppresses TNF-α production and helps to moderate the characteristic symptoms and signs of tuberculosis. However, care has to be taken when manipulating TNF-α levels to avoid reducing the person’s natural immunity. For example, it has been shown that when an antibody against TNF-α (Infliximab) is given in the treatment of rheumatoid arthritis, the patients have an increased risk of developing previously latent tuberculosis (Keane et al, 2001).

Night Sweats

2007-02-20T00:39:00.000-05:00

Last night I experienced my worst case of night sweats. My bed was completely soaked. I would awaken drenched and chilled, and would move to the nearest dry spot only to awaken drenched again. I was so frustrated. I don't understand what causes night sweats, but a rheumatologist confirmed that it was related to my AS. Perhaps as a result of the inflammatory process, I thought. I will investigate existing research and provide you with an update.

Below are the comments of others with AS on night sweats:

"My rheumatologist told me that my night sweats are a result of the pain... That was actually the first symptom I saw improve after I started taking Enbrel. I used to wake up completely drenched and freezing and have to change pjs and find other sleeping locations - the couch, the recliner, the other side of the bed. Then I started thinking about it and got some good silkweight capilene thermal underwear - they're designed for a little bit of insulation, but mostly to wick moisture away from your body. That helped a lot. They're kind of expensive, but Patagonia and Helly-Hansen make good ones. My guess is that any good exercise clothes designed to wick sweat away would work, too. ."

"I get night sweats as well. They seems to happen for several nights in a row and then start up again. I can go months without having them and then all the sudden have them for seveal nights. I am not sure what causes them, but it is listed as one of the common symptoms. Many people with AS get low grade fevers which could be one of the reasons. As far as what to do about I have no idea. I just have learned to live with it."

"Night sweats here, too. Always, when flaring, and sometimes just out of the blue. It can range from a bit sticky to completely drenched. Mornings when I wake up in the latter state, I know I am going to have a really bad day."

"I only get night sweats after I've gone through a bad flare. I always thought it was due to stopping pain medication, narcotics, too abruptly. Mine goes away within a few days and is not too bothersome."

"Hey guys!I also experience these night sweats. Usually I will get the chills before I go to sleep and wake up in the middle of the night or early morning all wet and shaking with chills real bad. That's when they are the worst. When I wake up and have to go change my all my clothes, not just like my shirt. Sometimes the sheets get wet a bit too. Once I get changed I usually just try to get warm, stop shaking and fall back asleep hopefully. Other times I might get the chills and wake up with a semi wet shirt and have to get up and change just my shirt. I do think it is from the A.S. inflammation personally, but since I don't run a high sedrate so far it's not something I could prove. I also know that my pain does increase after a night sweat. My body feels like it is more "sick" and the pain stems out from the spine more to all over. Oh and I would say I feel stiffer after. I used to take my temperature before I was diagnosed and for some time after but I don't really do that anymore. I did find that I often ran a low grade fever at night. But sometimes when I take it now it's below normal but that's when I take it after the night sweat when I wake up wet and cold. Also, it doesn't seem to matter the time of year or time of month. I haven't been able to correlate it with anything except the pain increasing. Hope this helps. Great topic by the way!!! "

"I have had the 'night sweats' for almost all the years I've had AS (about 20?) and the only thing that works for me is sleeping with a fan blowing right on me, hard, all night. When it's single digits outside, I still have the window open at least 4", and another fan bringing in air from there to 'intersect' with the path of the fan that's blowing on me. In the summer, I have an 8000btu A/C running on pretty much max, 24/7, and I rarely use any kind of blanket, other than a comforter that I roll up as a body pillow, and occasionally snuggle under 'a bit', in case the room gets extra cold. It's either this or wake up soaking wet from head to toe, freezing my ass of in the morning, and having to change the sheets every darn day. If it's not COLD in my room, I just can't sleep worth a damn. "

Update to "I'm so tired" post

2007-02-18T11:40:00.000-05:00

After writing my post titled "I'm so tired," I called my Nutritionist and voiced my frustrations.

To provide some context for why I sought his support: he is a dedicated runner and my occasional running partner, he has been privy to the disabling symptoms of my AS, and he's truly the only person who has insight of my private emotions, thought processes, and personal characteristics. He's obviously somebody I trust, and he's provided me with invaluable support during times of poor coping.

Our midnight conversation centred around my irritation with having frequent night sweats, eating too many refined foods composed of simple sugars, not having the motivation nor energy to exercise, and my feeling of general malaise. I spoke of how isolated I was feeling because I did not have the energy or desire to leave my home. Even the simplest of tasks, such as getting out of bed or answering the phone, felt like a chore. So I would curl up in bed under my blankets and wish the day would pass faster. I even spoke of my desire to not awaken at all (likely my annoyance expressing surrender).

Beneath it all, I feel guilty: guilty for not being able to muster the mental and physical strength to overcome the symptoms. I know I have not accepted that I have a disease that can limit my functional ability. It makes it more difficult to accept when you can perform certain tasks one day and not be able to function with minor tasks the next. Sometimes the thoughts and feelings of guilt are worse than the physical expressions of AS:

What does it feel like to have the energy of a "normal" person?

Why can't I just get out of bed? What's holding me back?

Just snap out of it!

Am I really symptomatic or am I just being lazy?

All I want to do is sleep.

I don't want to talk to anyone. It's hard for others to understand.

We spoke until 1am. He listened and validated my impatience. It was all I needed. I was worried that having slept all day that I would be unable to sleep now. However, I tried to sleep at 1:30am and slept soundly until 9am. My body obviously needed this rest over the last 24 hours. I awoke feeling refreshed (despite the night sweat) and told myself that it was a new day, which I started off with a healthy protein shake in a water base with some frozen fruit. I then made a list of my plans for the remainder of today.

It's not an easy road for many afflicted with AS. We all cope differently at different stages of the disease. I cope better during the physical pain, but poorly during symptoms of fatigue, which has a mentally draining component. My coping is also poor when I am not able to exercise; being physically active is an integral part of my life, and to be prevented from engaging in that lifestyle wrecks havoc on my mental wellbeing. I have always been a harsh self-critic always striving for my personal best, and peripheral restrictions are the most difficult to personally tolerate.

Lesson learned today: We can't control what we feel, but we can control how we act on those feelings. If I feel guilty, frustrated, or tired, then I need to learn to accept those feelings and let them express themselves. What I can control is the blame I self-impose for those feelings. I must also learn to accept that I have a real diagnosis (this is the hardest part for me because it involves accepting having external limitations imposed on my functional ability, and I don't like to feel as if I don't have full control over my body). However, every day is a fresh start; now I need to take it one day at a time.

Training update

2007-02-18T10:59:00.000-05:00

Sitting before you on the blogging pulpit, my Penitent begins by saying “Bless me Father for I have sinned, it has been 4 weeks since my last run."

Unlike many of my running colleagues, I have a very difficult time running in the cold. My asthma does not help. I find it painful and most miserable, actually. Every year I ensure I have all winter-ready running apparel in hopes that of realizing that I have no excuse to stay indoors; yet, I feel that blustery wind and my motivation takes a nosedive. The cold is not the real deterrent: it's that bone-chilling wind. I confessed to a friend that I had not been running, despite still aiming to participate in the Around the Bay 30K race next month. Here was his response:

"Have you run the ATB before? It's certainly a challenging run with the last 10km being very hilling. This will be my fourth ATB race. I really like this run. If you're not running outside I would be running on the treadmill for sure!!! I know it is boring, I don't really like it either but I run at least 5 miles a day during the week on the treadmill and then depending on the weather I will run between 10 and 21km on Saturday and Sunday. I don't run any longer than an hour on the treadmill at any one time. I took a week off after Hawaii and have been running at least 5 days a week since. I also do a core and weight program as well. The spinning class will help but there is nothing like running!!!"

With this knowledge and guilt in tow, I arranged for my nutritionist to help me get back on track, I renewed my gym membership for another year, and I plan on running today (however, it may involve a treadmill).

AS Experiences

2007-02-18T10:45:00.000-05:00

I would like to post the disease experiences of others with AS on my blog with hopes that this collective understanding would diminish our isolative perceptions and would contribute insight into the disease itself.

If you would like to share any aspect of your experience with AS, please email me at gymjunkie247@rogers.com If you prefer to share your experience with me but not have it published, please indicate that. Confidentiality will be respected.

I'm so tired

2007-02-17T20:39:00.000-05:00

8pm: that is the time I got out of bed today.

Since Jan 21 I have been subjected to inhumane amounts of personal stress. It all ended last night; however, as a result of cummulative events, I am grieving the loss of my dear friend, Matthew--a mentor I have admired and respected since 2002.

The emotional and mental stressors took their toll physically: despite awakening at 9am, the general malaise I felt was overwhelming. I did not have the energy to stand upright for long, and had to remain in bed all day. I tried reading to feel somewhat productive, but I could not concentrate. I could not even keep my eyes open for long. So I slept.

It's now 11pm and I still feel so lethargic, as if wearing a heavy lead apron, the kind worn when having an X-ray. I'm frustrated with this cyclical process: stressor-->flare-->stressed-->flare. I am frustrated with the effect this has had on my motivation to run, my ability to concentrate, and my nutritional habits. The cold weather has not helped either. I'm not usually one to complain about anything, but I am so tired of this disease.

Ironman Canada update from an AS Athlete

2007-02-11T10:43:00.000-05:00

Ironman Canada Race Report by Rob Williams
Sunday, August 29, 2006

The day began early. My first alarm rang at 4:01 am, but I was ready. I hopped right out of bed without needing the second ring or the second alarm set for 4:05 am. I had been getting to bed between 8:30 and 9:30 pm most nights recently, and combined with about ¼ of my normal exercise load for the past 2 weeks I was ready to get on with the day.

I threw on the race shorts that would adorn me for approximately the next 14 hours, then sweats and on to breakfast. We had made a boatload of waffles the previous day so I toasted one of those and had my standard race day (actually any day) breakfast: uncooked oatmeal mixed with yogurt and fruit overnight. The goal was to be finished with breakfast as close as possible to 3 hours before the race, and since the start was planned for 7:00 am, I was on target.

The previous day I had checked in my bike, my swim to bike transition bag and my bike to run transition bag, so all I needed to carry was my post race bag (consisting of the clothes I was currently wearing) and the special needs bags containing extra nutrition that I would pick up approximately half way through the bike and the run. I threw on a warm fleece cap as I walked out the door since the sun was not yet up and though it was summer in the Okanagen (the desert wine country on the east side of the Cascade mountains), it is still cold in the morning in the desert.

I was curious what the weather would be like. It had been getting warmer and warmer each day we came, and if there was no wind or a south wind the valley would fill with the smoke from the forest fires burning to the south. I did not spend too much time obsessing about the weather because there was nothing I could do and it would affect us all the same. While walking down to the transition area it was calm and the stars above foretold a clear day. The wind would be a mystery, but the swells on the lake from a couple days before were likely gone.

I took a page out of Erica’s book by getting to the transition area early. By 5:00 am I was in the transition area already having been body marked (had my race number applied) and dropped off my special needs bags. There was almost no one there and the quite calm was relaxing. After checking my bike I went for an easy 15 minute jog and felt like a salmon running against the stream of athletes walking towards transition area. I had plenty of time to stretch, make a couple trips to the port-a-johns, then with an hour before race time I drank the espresso I had picked up the night before.

No matter how much time you have before a race, there is always a rush that happens near the start, but despite the magnitude of this race it was not that bad. I found myself just before 6:45 am with my toes in the water of Lake Okanagen waiting for the cannon to signal the start for the pros. As I looked around I had to catch my breath and force myself to relax. There were over 2,200 people crammed into a small beach area and I was worried about getting clobbered on the head and having to fight my way around the swim course. After the pros started we had about 10 minutes for warm-up and the feel of the water gliding over my wetsuit helped restore that calm. I decided that I had nothing to loose by getting on the front row, so that was where I started at 7:00 am as the cannon sounded for the second time that morning.

After the first 500 meters I was quite surprised to find myself swimming smoothly in open water. Not only that, I was doing a three count bi-lateral breathing sequence that meant I was pretty relaxed. I did not feel the need to do much sighting in the first few hundred meters since the mass of people would probably generally be headed in the right direction. As I finally popped my head out to get a better perspective I was shocked to find myself in the front group of approximately 15-20 swimmers breathing relatively easily. I continued here for about 2/3rds of the first leg out when I either eased off, lost my focus, or drifted a bit off course without sighting properly. Despite the reason I lost the good draft I had and though I felt strong in the water, never really regained it. When I came to the swim finish my time was 1:01:38. It was a bit disappointing because I had set 1 hour as my goal time and was secretly hoping to break that by a couple minutes, but I was certainly in the ball game.

I ran up the chute, pealed my wetsuit off the top of my body and flopped down at the feet of two volunteer “wetsuit strippers” who grabbed the rest off of me quite efficiently. It was a bit more of a production to get my swim to bike bag, but then it was into the changing tent. For some reason I thought they would have towels in the tent, but luckily the guy to my left was kind enough to lead me his. I did a quick towel off of the feat, pulled on my socks, snapped on my helmet, put on sunglasses, and zipped up my bike jersey. (I wear a full jersey to cover my shoulders because they always get fried by the sun and I’m convinced that zaps energy, also I only have one bottle cage on my bike because there is no space on the aero down tube; therefore I just my bike jersey as my second nutrition bottle and an aero bottle on my handlebars just for water which I fill at every aid station.

As I mounted the bike I was not prepared for the crowd up main street – I had never experienced anything like it. Granted the Alp d’Huez crowd stretches on for miles, but this crowd was a similar boisterous tunnel that ushered you out of town. I knew that with the exception of one moderate hill, the first 40 miles were relatively flat. Though anyone can hammer down that stretch, the key is to be able to keep yourself in enough control for the hills the followed and the remaining 72 miles. I had therefore changed my bike computer to only give me the elapsed time (so I could take my nutrition and water every 20 minutes) and my heart rate. I had told myself to keep my heart rate under 150, but even at that rate I felt like I was thundering though people too quickly, so I reduced that upper limit to 145 and settled in for the long haul.

The first 40 miles were relatively uneventful, except for the aid station in Oliver where a guy went down HARD right in front of me (there is an unmistakable sound of carbon hitting asphault). I had one hand on my handlebars and the other taking a water bottle from a volunteer but miraculously made it around the tangle of athlete and bicycle on the ground. I was just marveling how I had made it when the guy behind me said, “Man, how did you get around that guy, I almost bought it and I was behind you.” I figured that with two rather serious bike crashes earlier this year my time on the pavement had passed for a bit.

When I got to the Husky station and the 90 degree right turn that basically marked the beginning of the first substantial climb, Richter Pass, I did a quick check of my average speed and was happy to see that I was over 24 mph which boded well for my overall average goal of 21.5. Now my goal for the bike was basically a three part strategy: 1) keep it under control for the first 40 miles, 2) spin the hills in control and waste no excess energy, 3) charge the downhills. Now that I found myself at Richter a few people blew past me, but for the most part I felt like I was holding my own and spinning in a controlled fashion. I was very glad that I had borrowed the 11-25 cassette from a friend instead of the 11-23 because those couple extra teeth were making all the difference. Even if I was not using the, just knowing I had a couple easier gears was a nice feeling.

After Richter I forgot how hilly it was. I had ridden the course the year before, but not as hard as I was at the moment, and last year was a whole year ago. Needless tot say I pushed on and found myself gaining on the people in front of me with no one riding through. Either I was riding well, or all the fast people were already ahead of me, or both.

When I got to the special needs bag I took it and stopped. Having just seen a guy go down in front of me at an aid station and a couple others with some tell tale road rash, I decided that I could spare the 30 seconds to take my two nutrition bottles out of the bag and drop off my other bottles. Somewhere around this point, I honestly can’t remember if it was before this point or after but I was hitting that lull that is inevitable somewhere between 70 and 85 miles. I found myself thinking, “What am I doing? Do I really have to run a marathon after this….and am I seriously thinking about doing this all again in October?” Then as quickly as it came the sentiment was gone and I was approaching the next major climb of the course….Yellow Lake.

Again I was greeted with a mini Tour de France crowd that could not have been more encouraging. I had a bit of a cramp in my left hamstring, but as I focused on a smooth pedal stroke the tension passed and I was at the top before I knew it. The rest of the ride was mostly uneventful and punctuated by more wind and hills than I had expected in the last section. I was especially chagrined to find that the first start of Main Street on the way into Penticton was slightly up hill, and no hill felt slight at this point. Since I had a goal of 5:15 for the bike I was pushing this section and was happy to cross the “bike in” mat at 5:13.

As I was running with my bike one of the volunteers was cautioning “no running….walk please.” I was tempted to turn to him and say, “Is this a parade, or is this a race?” but it certainly did not matter and I knew negative thoughts did nothing but chew up energy, so I focused on finding my transition bag and getting into the changing tent.

As I sat in the chair something did not feel right. I was not quite sure what it was, but I just knew something felt different. I was in auto pilot now, however, so I switched my top, changed my shoes, threw on my running hat and started moving again. I stopped to get sprayed with sunscreen and took a water from the aid station, but as I began running, something definitely felt wrong. While on the bike I had a few tense spots, but a tightness quickly developed in the left lower section of my back and then felt like a string ran up my back and connected to my front ribs and I was either going to give birth to some alien baby out of my solar plexus or my rib cage might just collapse.

A lot of thoughts started running through my head and I put most of them out of my mind just to see if over the next mile or so that I could relax and make it go away. It did not take long before the primary though kept surfacing, “You have 26 miles of this?” Though it was not easy to walk away from the course in the middle of putting together a decent race, it ultimately did not feel like my day.

I remember in the past hearing about people dropping out of races and thinking, “That’s a mistake, you want to finish what you started,” or “You don’t want to quit a race because that sets a bad psychological precedent and it will be easier to abandon in the future.” It is clear to say that I no longer feel that way having a bit more relevant experience. Going into this race I was already having trouble justifying a trip to Kona this year both in terms of work (having already been away for a few weeks in Australia) and finances with an impending house purchase. The thought that Erica and I might attempt to qualify together was another sentiment that rose to the surface as I walked back to the transition area. I also immediately thought of a few local races that I could still do this season because I did not beat myself up with 26 miles of running.

So I walked back to the transition area, stretched, had a nice conversation with a couple volunteers, got some more water and Gatorade, walked back to the house where I was staying and showered, stretched, ate, and iced. I then walked back to the race venue and wondered into the massage tent. After explaining my situation the therapist indicated that I had come at a good time since he had seen on one yet and there was no line behind me. Because I had stretched, iced and warmed up again he said, “Let’s get to work.” He spent over an hour working on me, gently and but persistently doing muscle release. He explained the entire muscle compensation mechanism that had caused me trouble and was a byproduct of my past accident. The irony was that I had been getting active release therapy on my left proneus (sorry if my spelling and anatomy and spelling is less than perfect – just say it’s the muscles running down the outside of my left leg) which was likely related to the car accident and though I had some back issues they had not affected my racing to date. I specifically told to doctor that I wanted to leave them alone until after Ironman Canada because I was afraid of stirring up some trouble….oh well. Now I guess I can get on with that treatment. Though it has been a difficult road of dealing with a variety of issues I am happy to feel like I am well down the path toward recovery.

I know that in the Ironman arena a swim and bike split really does not mean anything until it is all put together with a good marathon. I also know that my run training this year has been hampered by injury so I look forward to another effort in the future once I have a bit more running base. I also know that I am looking forward to taking a year off of Ironman training and focusing on having more fun in shorter distance races and focusing on some other priorities. Kona is still a calling and one that I do not think I will be able to ignore, but for now I will put it on hold.

Life update

2007-02-05T23:48:00.000-05:00

It has been suggested that I try to personalize my blog a bit more--"too technical" was one of the terms used. I agree that my blog does contain some medical jargon, but it's my attempt to educate the populace about a disease that can be very confusing to even those of us who must cope with the symptoms every day. The more we know, the better equiped we are to ask the most appropriate questions of our family physician or rheumatologist, and the more empowered we are to self-manage the disease. Knowledge is power, is it not?

On the other side, I want to also appeal to my audience, so I will try to soften the posts a bit without detracting from my overall intention: to educate using subjective and objective material.
So...something more personal....Hmmm.

Well, today I got great news: I received a long-awaited phone call indicating acceptance into an intermediate position in my organization. It's a new role at a new location in the heart of Toronto. I will be working with an amazing team of health analysts--one of whom I graduated with in 2006. He was thoughtful enough to send me the posting for this single position, so it looks like I'm taking him out for drinks. I felt quite confident during the interview, and he had indicated that the members of the interview panel were very impressed with my performance. One of the perks to this position is that it comes with health benefits, which means that I can return to taking Enbrel.

Lack of health benefits has been stressful. Blue Cross--the only insurance company that would provide the converage needed to afford monthly Enbrel--recently declined my coverage citing a diagnosis of AS as the reason for my ineligibility. I sent a letter and email challenging their decision, but they stood firm. What a blow! Pre-exisiting illnesses, even if you're asymptomatic, preclude people from acquiring access to needed medical insurance. From a financial standpoint I can understand their stance, but without assessing each applicant individually, I find it insane that your circumstances can be generalized--despite age, gender, severity of symptoms, and prognosis--and your eligibility is automatically determined. I am investigating further to learn of available options. Stay posted.

Pain

2007-01-31T23:58:00.000-05:00

A healthy spine is able to move in many directions, which is why you can bend, turn, and twist. The spinal bones are joined together by flexible ligaments and are separated by cushiony discs, which allow a lot of movement. Movement can become impossible if the ligaments calcify and the bones fuse together. This is why AS can be disabling in its advanced stages.

Often the first sign of AS is inflammation of the sacroiliac (SI) joints. The SI joints are the two joints that connect the lower spine to the pelvis. You can feel these joints about two inches to either side of the spine in the low back. It is the inflammation which causes the symtom of pain. Inflammation eventually moves to the spine. Long-term inflammation of the spinal joints starts a process of damage to the bone where the body continually tries to repair the damage with scar tissue and new bone tissue. As the process continues, the bone becomes weaker and weaker. When the inflammation finally "burns out" and begins to disappear, the body attempts to heal the bone by producing calcium deposits around the area of the damage. For some unclear reason, as the bone heals itself, the calcium deposits spread to the ligaments and discs between the vertebrae. This leads to a fusion of the spine, sometimes referred to as bony ankylosis.

Symptoms

Like other forms of arthritis, the symptoms of AS are from the effects of inflammation. Initially the symptoms may come and go for weeks or months at a time.

The first sign of AS is usually sacroiliitis (inflammation in the SI joints). This condition causes pain in the low back and buttock areas. There is often severe low back pain, along with buttock, hip, and thigh pain on one or both sides. It usually comes on gradually and gets worse with time. Stiffness and low back pain commonly occur in the morning and ease with activity over the course of the day. Prolonged rest, such as lying down or sitting for any length of time, worsens the symptoms of AS, which is different from some other forms of low back pain that are eased with rest.

Spine flexibility is reduced with AS, which can affect your ability to bend forward and backward. In the mid back, AS can affect the joints where the ribs connect to the vertebrae. These are called the costotransverse and costovertebral joints. Inflammation in these joints can cause pain in the chest wall and into the abdomen. Symptoms in the neck include stiffness, pain, and limited neck motion. Because AS attacks the joints of the body, synovitis can occur. Synovitis is a term used to describe inflammation of the synovial membrane (lining of the joints). Symptoms of synovitis include pain, stiffness, and swelling in any joint in the body.

Breathing can be affected as AS progresses. The disease can make the mid back round forward, a deformity called kyphosis. When this occurs, it can compress the lungs and make it increasingly difficult to take a breath. Also, when the disease affects the joints between the ribs and spine, the chest loses its ability to expand enough to take a full breath. Inflammation of the lungs can also occur with AS, making it even harder to breathe.

The eyes can be affected by AS. About 25 percent of AS patients develop iritis, a condition that is caused by inflammation of the iris. The iris is the colored part of your eye around the pupil. There may be pain and redness in the eye, but usually vision is not impaired.

The spine bones may eventually grow together, fusing into one continuous column of bone. This is due to calcification of the ligaments and discs between each vertebra. If the vertebrae fuse together, the spine is robbed of mobility, leaving the vertebrae brittle and vulnerable to fractures. When the spine becomes completely fused together, the pain in the spinal area usually goes away. This does not signal a remission of the disease. However, patients are left with no spinal mobility and brittle bones that are more likely to fracture. If pain suddenly reappears in the back after a long period of no pain, there may be a fractured vertebra.

Treatment
The goal of treatment is to relieve pain and stiffness, and prevent or delay complications and spinal deformity. Treatment of ankylosing spondylitis is most successful early, before it causes irreversible damage to your joints, such as fusion, especially in positions that limit your function.

Medications
Your doctor may recommend that you take one or more of the following medications:

Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs — such as naproxen (Naprosyn) and indomethacin (Indocin) — are the medications doctors most commonly use to treat ankylosing spondylitis. They can relieve your inflammation, pain and stiffness.
Disease-modifying antirheumatic drugs (DMARDs). Your doctor may prescribe a DMARD, such as sulfasalazine (Azulfidine) or methotrexate (Rheumatrex), to treat inflamed joints and other tissues.
Corticosteroids. These medications, such as prednisone, may suppress inflammation and slow joint damage in severe cases of ankylosing spondylitis. You usually take them orally, ideally for a limited period of time because of their side effects. Occasionally, corticosteroids are injected directly into a painful joint.
Tumor necrosis factor (TNF) blockers. Doctors originally used TNF blockers to treat rheumatoid arthritis. TNF is a cytokine, or cell protein, that acts as an inflammatory agent in rheumatoid arthritis. TNF blockers target or block this protein and can help reduce pain, stiffness, and tender or swollen joints. These medications, such as etanercept (Enbrel) and infliximab (Remicade), may decrease inflammation and improve pain and stiffness for people with ankylosing spondylitis.

Physical therapy
Physical therapy can provide a number of benefits, from pain relief to improved physical strength and flexibility. Safe movement can improve spine mobility and posture. Physical therapy assists in pain control and prevention of deformities from AS. Patients are advised against prolonged sitting and best rest and encouraged to keep their spine straight, walk erect, and avoid stooping over for long periods.

The goals of physical therapy are to help you:

Learn correct posture and body movements to counteract rounding of the upper back (kyphosis)
Use appropriate sleep positions upon a firm mattress and thin pillow
Maintain appropriate activity levels
Implement daily stretching and strengthening exercises
Learn ways to manage your condition

As your condition worsens, your upper body may begin to stoop forward. Proper sleep and walking positions and abdominal and back exercises can help maintain your upright posture. Though you may develop spine stiffness despite your treatment, proper posture can help to ensure that your spine is fused in a fixed upright position.

Surgery
Most people with ankylosing spondylitis don't need surgery. Surgery may help if you have severe pain or joint damage. You may need surgery if a nonspinal joint needs to be replaced. However, doctors don't usually recommend back surgery.

Impact of pregnancy on health related quality of life

2007-01-30T13:33:00.000-05:00

A Swiss research study (i) investigated patient experiences of the disease course and health related quality of life during and after pregnancy in 10 women with rheumatoid arthritis (RA) and 10 women with ankylosing spondylitis (AS). Twenty-nine age-matched healthy pregnant controls were evaluated by the medical outcomes study short form 36 (SF-36) health survey once at each trimester and at 6, 12, and 24 weeks postpartum. A group of non-pregnant age-matched female patients (40 RA, 16 AS) was studied for comparison.

Impaired physical dimensions as well as increased bodily pain was observed in healthy women in late pregnancy. Patients with rheumatoid arthritis showed improved physical functioning scores in the second trimester and reduced pain in the third trimester. Among pregnant patients, those with ankylosing spondylitis suffered the greatest impairment of health related quality of life during pregnancy. In all patient groups the physical impairment in the third trimester was less pronounced than in healthy controls. Mental health scores remained stable even with persisting active disease during pregnancy, or with a postpartum flare. Pregnancy reduced physical functioning in healthy women and patients, but had no impact on mental and emotional health, even at times of disease aggravation.

Another Swiss study (ii) demonstrated that most patients with RA showed sustained or increased improvement of disease activity during pregnancy. Higher disease activity scores were found in the patients with AS with a frequent increase of disease activity in the second trimester and mitigation of symptoms in the third trimester. Analysis specifically for the patient's assessment of pain showed continuously higher pain scores in the patients with AS than in those with RA. Rank correlation showed good to moderate correlation between most clinical measurements and RA Disease Activity Index (RADAI) or Bath Ankylosing Spondylitis Activity Index (BASDAI), respectively. Functional indices were confounded by physiological changes of late pregnancy..RA can be monitored during and after pregnancy by the swollen joint count and RADAI without interference from pregnancy related symptoms, whereas usual measures of disease activity are not always applicable in pregnant patients with AS.

References:

(i) Forger, F., Ostensen, M., Schumacher, A., and Villiger, P.M. (2005, Oct). Impact of pregnancy on health related quality of life evaluated prospectively in pregnant women with rheumatic diseases by the SF-36 health survey. Ann Rheum Dis. 64(10):1494-9.

(ii) Ostensen, M., Fuhrer, L., Mathieu, R., Seitz, M., and Villiger, P.M. (2004, Oct). A prospective study of pregnant patients with rheumatoid arthritis and ankylosing spondylitis using validated clinical instruments. Ann Rheum Dis. 63(10):1212-7.

AS Athlete: The Road to Kona

2007-01-29T11:55:00.000-05:00

Rob Williams was diagnosed with ankylosing spondylitis in 1991 and was told by his doctor that he would never be able to run again. Despite this, Rob pushed himself toward a lifelong dream: To compete in the Ironman World Championship.
Visit his online training journal that will document his quest for the ultimate goal in triathlon. Rob will be sharing his thoughts and experiences with us while he attempts to qualify for the 2006 Ironman Championship in Kona, Hawaii.

If you wish to email Rob a question or a comment, you can do so by emailing him here: rideoutas@hotmail.com

The Road to Kona 2006 - The Beginning by Rob Williams

How many defining moments do you remember in your life? I have a few, but one came while sitting alone on my parents' bed watching television in 1982. The TV was an old machine that seemed to take 20 minutes to warm up, but once it did it was in color that was vaguely representative of the real world so I was excited. On this particular day I was watching ABC's Wide World of Sports and saw, for the first time, something called a triathlon - an Ironman triathlon no less (2.4 miles of swimming, 112 miles of cycling, and a marathon - 26.2 miles of running). Like thousands of people across the country I was moved by the sight of Julie Moss valiantly crawling towards the finish line in utter exhaustion having just missed a first place finish by a mere couple hundred yards. Like many, I watched that effort and thought, "I am going to do that someday."

If you fast forward 9 years I was given news that this would "never be possible." I found myself in my first year at Wesleyan University in Middletown Connecticut. I was recruited to play goalie on the soccer field and attack for lacrosse, but I was developing an insidious pain in my lower back that crept down the sciatic nerve in my right leg. Coach Jackson told me to take that first soccer season off to rehab and get ready for where he really wanted me, on the lacrosse field. I never made it back.

Despite my best efforts at a variety of therapies the pain would not diminish. Since it was an acute nerve pain it was not a matter of "playing through the pain" as my body would physically be unable to move at times. There was more than one occasion when my friends would have to carry me into the dorm shower in the morning to help warm me up enough to get moving. Needless to say my career on the field and my identity as an athlete was gone. By the spring of 1991 I saw a rheumatologist who diagnosed me with a strangely named disease and told me that I would be unable to run again.

Ankylosing Spondylitis - I had enough trouble pronouncing and spelling this arthritic condition, much less understanding what it was. Questions, anger, depression seemed to swarm about me constantly, and the Hawaiian lava fields of Kailua-Kona were not even a glimmer in my eye.

If you fast forward a few more years I was pursuing a Masters degree at Oregon State University. I decided in 1999 to try my first triathlon, a sprint distance event (500 yard swim - 12.4 mile bike - 3.1 mile run) called the Beaver Freezer. From there I tested my limits and improved my results. Over the years I worked my way up to mid-pack performances at the USA Triathlon Age Group National Championships, completed my first Ironman distance triathlon (Ultramax) in 2002, won my first bike race in 2003, and qualified as a representative for the US National Team by winning the USA Triathlon Pacific Northwest Regional Championships in 2004.

This is the beginning of a new and remarkable chapter in my life that I hope ends on Alii Drive at the Ironman World Championships in Kona, Hawaii; but first I have to qualify at Ironman Canada in Pentiction, British Columbia on August 27, 2006. This is the first of weekly entries into a training journal that will document my quest for the ultimate goal in triathlon.
In addition to following my training, this on-line journal will occasionally look back at past competitive events, watershed moments, and a cross-country cycling trip on a tandem bicycle to raise money and awareness for the Spondylitis Association of America.

History of AS: Bernard O'Connor

2007-01-28T23:28:00.000-05:00

Three hundred years ago, on 30 October 1698, a young Irish doctor died in London from fever, possibly malaria, at the age of 32 years.

Bernard O'Connor was born in Kerry in 1666. At the age of 20 he went to France to study medicine, first at Montpelier and then at Rheims, graduating Doctor of Physic in 1693. He set up in practice in Paris but before long he was asked to accompany the sons of the chancellor of Poland on their journey home. They travelled through Italy, Germany and Austria, visiting leading medical centres on the way. Arriving in Warsaw early in 1694, O'Connor was introduced to the royal court and was invited to become personal physician to the king.

King John III Sobieski was one of the heroes of Poland and of Europe in the late 17th century. In 1673 he had defeated the invading Turks at Khotin. In 1683, allied to Austria, he again overwhelmed the Turks at Vienna, thus ending the threat of a successful Turkish occupation of Eastern Europe.

After nearly a year in Warsaw, O'Connor was on the move again. The King appointed him to escort his daughter to Brussels for her wedding with the Elector of Bavaria. While in the Low Countries he visited more medical centres before travelling to England. He set up practice in London, soon gaining a reputation as a teacher, and anglicising his name to Connor. He gave a course of lectures on medicine and natural philosophy at the University of Oxford in 1695 and was invited to lecture in Cambridge the following year. The Archbishop of Canterbury allowed Connor the use of his library for experiments.

The main interest of orthopaedic surgeons and of rheumatologists in Bernard O'Connor is that he was the first to describe Ankylosing spondylitis, although he did not give it a name. In a letter in French, published in Paris in 1693 he describes the appearance of part of a skeleton ; pelvis,lumbar and dorsal spine and ribs up to the mid thoracic level. An English translation of parts of the letter was published in Philosophical Transactions in 1695, and a Latin version was included in Connor's book "Dissertationes Medico-Physicae" published in Oxford in 1695.

"All of these Bones ...... were so straightly and intimately joyned, their Ligaments perfectly Bony and their articulations so effaced, that they really made but one continuous Bone.... The Figure of this Trunk was crooked, making part of a Circle...... If the other Vertebrae of the back and neck had been preserved, and had bent in the same Curve, they would have made near the half of a Circle...."

In London Connor published "Evangelium Medici" in 1697. This latter book was very controversial, some people claiming that Connor suggested natural explanations for some of the miracles in the Gospel. Connor had to defend himself against charges of heresy and wrote a long letter to his benefactor,the Archbishop of Canterbury. He also wrote to a friend: "I am resolv'd not to meddle any more with Matters of this kind, but to apply myself entirely to the Practice of Physick". Not the first, nor last, doctor to get "a belt of a crozier"!

Connor was elected a fellow of the Royal Society, a fellow of the Royal College of Physicians and Membre de l'Academie Francaise, remarkable achievements in such a short time. He became ill in October 1698 and died within a couple of weeks.

Further cases of ankylosing spondylitis with clinical descriptions were later published - Delpeche in 1828 and Strumpell in 1884. Pierre Marie gave a very full description in 1898, giving it the name "Ankylosis rhizomelique". The name "ankylosing spondylitis" was first used by C.W.Buckley in 1935.

My Health Update

2007-01-28T22:02:00.000-05:00

I have been under an enormous amount of stress lately. Curious, I completed the Life Event Stress Scale which accounts for major life events that have taken place in ones life over a 12 month period. The scale shows the kind of life pressure being faced. Depending on ones coping skills or lack thereof, this scale can predict the likelihood of falling victim to a stress-related illness. A score of 300 or more indicates a high susceptibility to stress related illness, 150-299 is a medium susceptibility, and 0-149 is a low susceptibility. My score was 619. Some of my stressors over the last 12 months (score is in brackets) have included:

Death of my Grandfather (63)
Training for, and completing, my first marathon (?)
Finishing my Masters (26)
Divorce (73)
Change to a different line of work (36)
The sudden end of a contract due to department closure (?)
Outstanding personal and professional achievement (28)
Change in financial status (38)
Change in the health of three family members (44x3)

The cumulation of these took their toll this weekend. I could not get out of bed until after 4pm as a result of extreme fatigue and mild stiffness. I am still suffering with iritis in my left eye. I have not felt such fatigue in a long time. My mind was alert and thinking of all the things I wanted to do, but my body felt like lead. Everything was an effort. I was planning to run 21K this morning in the 3rd annual Las Vegas North Half Marathon. By 2am last night, I knew it was not going to happen, and that caused me some anxiety (I hate not fulfilling a commitment).

I pride myself on my optimism; it shapes my perception of stressors and allows me to cope in healthy ways. I am confident that my flares are more managable as a result. Overall, I manage quite well and truly believe that everything happens for a reason; personally, I see every circumstance as an opportunity to learn or demonstrate something. I have often said that it is during the most difficult times that I learn the most about myself. One thing is for sure: I am very resilient. As with other things, I know I will bounce back from this flare.

The real face of AS

2007-01-26T13:39:00.000-05:00

Etanercept 50 mg once weekly vs 25 mg twice weekly

2007-01-26T13:18:00.000-05:00

According to research based out of the Netherlands, patients with ankylosing spondylitis can expect a comparable significant improvement in clinical outcomes with similar safety when treated with etanercept 50 mg once weekly or with 25 mg twice weekly. Significant improvement (p<0.05) was seen in measures of disease activity, back pain, morning stiffness and C reactive protein levels as early as 2 weeks. Incidence of treatment-emergent adverse events, including infections, was similar and no unexpected safety issues were identified.

References:

van der Heijde, D., et al. Etanercept 50 mg once weekly is as effective as 25 mg twice weekly in patients with ankylosing spondylitis. Ann Rheum Dis. 2006 Dec;65(12):1572-7. University Hospital Maastricht, Maastricht, The Netherlands.

Anti-Tumour Necrosis Factor

2007-01-26T13:08:00.000-05:00

In ankylosing spondylitis (AS), there has been consistent benefit with the use of anti-TNF therapy, shown initially in pilot studies, open follow up studies, and, most importantly, in several randomised controlled trials. The cytokine, tumour necrosis factor-alpha (TNF-alpha) plays a key role in the pathogenesis of many chronic inflammatory and rheumatic diseases, in particular, Crohn's disease, rheumatoid arthritis (RA), AS, and psoriatic arthritis. Controlled trials have shown that the TNF inhibitors significantly reduce symptoms and signs, improve function and quality of life, and reduce radiologically evident damage in patients with rheumatoid diseases. The antitumor necrosis factor-alpha agents currently available, infliximab (Remicade), etanercept (Enbrel), and adalimumab (Humira), are approved for the treatment of RA in North America and partly in Europe.

The situation in spondyloarthritis is different from that of rheumatoid arthritis because there is an unmet medical need, especially in ankylosing spondylitis: no therapies with disease-modifying antirheumatic drugs are available for severely affected patients, especially with spinal disease. Thus, tumor necrosis factor blockers may even be considered a first-line treatment in a patient with active ankylosing spondylitis and psoriatic arthritis whose condition is not sufficiently controlled with nonsteroidal antiinflammatory drugs in the case of axial disease, and sulfasalazine or methotrexate in the case of peripheral arthritis. Results of the available clinical trials provide strong evidence of the clinical effectiveness of infliximab and etanercept, and are supported by continuation data of up to one year. Currently there is no other known disease controlling antirheumatic treatment for AS. This is in sharp contrast with RA, where many DMARDs are known to be effective.

For reasons that are not entirely clear, etanercept does not work in Crohn's disease. Infliximab was very recently approved for AS in Europe. The efficacy of etanercept was first demonstrated in psoriatic arthritis, and it is now approved for this indication. Injection site and intravenous reactions and increased risk of infection (in particular, reactivation of tuberculosis) are associated with the use of these agents. Guidelines are currently needed to ensure appropriate selection of patients suitable for anti-TNF therapy, which can lead to harm, with rare, but possible, side effects, such as increased risk of lymphoproliferative disease, the development of lupus-like syndromes and demyelination, including optic neuritis and reactivation of multiple sclerosis. The TNF inhibitors are expensive and in some patients need to be given continuously to maintain benefit, even in the presence of other immunosuppressive therapy.

There is hope that ankylosis may be preventable, but it remains to be shown whether patients benefit from long-term antitumor necrosis factor therapy and whether radiologic progression and ankylosis can be stopped. Rheumatologists consider both disease activity and severity to be determinants of starting TNF blockers. Severe adverse events have remained rare. Complicated infections including tuberculosis have been reported. These can be largely prevented by appropriate screening. There is need to identify patients with AS with active disease who are at increased risk of severe disease, with deterioration of functional capacities, and who therefore are the best candidates, as they have the most to gain from the use of anti-TNF treatment. As it stands now, the benefits of antitumor necrosis factor therapy in ankylosing spondylitis seem to outweigh these shortcomings.

The current long term experience with TNF blocker therapy in AS is now about five years. More data on long term treatment beyond two years are currently being collected. There is no evidence that the long term use of these agents must be discouraged, there is just a need for more data. Evidence for the consecutive use of different agents is limited. Therefore, successive use of different TNF blocker drugs cannot be recommended at the present time. As further data become available, these will be used to guide decision making.

The following recommendations were developed by a review of published reports in combination with expert opinion, including a Delphi exercise, and a consensus meeting of the ASsessments in AS (ASAS) Working Group

The final international consensus comprises the following requirements for the use of anti-tumour necrosis factor (anti-TNF) for treating patients with ankylosing spondylitis (AS):

For the initiation of anti-TNF therapy: (a) a diagnosis of definitive AS; (b) presence of active disease for at least four weeks as defined by both a sustained Bath AS Disease Activity Index (BASDAI) of at least 4 and an expert opinion based on clinical features, acute phase reactants, and imaging modalities; (c) presence of refractory disease defined by failure of at least two non-steroidal anti-inflammatory drugs during a single three month period, failure of intra-articular steroids if indicated, and failure of sulfasalazine in patients with peripheral arthritis; (d) application and implementation of the usual precautions and contraindications for biological therapy.
For the monitoring of anti-TNF therapy: both the BASDAI and the ASAS core set for clinical practice should be followed regularly.
For the discontinuation of anti-TNF therapy: in non-responders, consideration should be made after 6–12 weeks’ treatment. Response is defined as improvement of (a) at least 50% or 2 units (on a 0–10 scale) of the BASDAI, (b) expert opinion that treatment should be continued.

Infliximab

Infliximab is a monoclonal chimeric human anti-TNF antibody that binds with high affinity to TNF. It is currently licensed for the treatment of RA to reduce signs and symptoms of RA in patients with active disease, to improve the physical function of patients, and to reduce the rate of progression of joint damage. Infliximab is approved for combination therapy with methotrexate in RA in a dose of 3 mg/kg given every eight weeks after the usual initial saturation phase, where infliximab is given at weeks 0, 2, and 6. Furthermore, infliximab is approved for acute and maintenance treatment of Crohn’s disease in a dose of 5 mg/kg. Infliximab is given as an intravenous infusion usually over 1–2 hours.

Etanercept

Etanercept is a recombinant 75 kDa TNF p75 receptor fusion protein that acts competitively to inhibit the cell surface receptor binding of TNF. It is licensed for the treatment of active RA when the response to DMARDs, including methotrexate, has been inadequate. Etanercept is administered by subcutaneous injection at a dose of 25 mg twice weekly or 50 mg once a week.

Adalimumab

Adalimumab is a monoclonal, fully human, anti-TNF antibody that binds with high affinity to TNF. It is approved for the treatment of active RA in the USA. It is given by subcutaneous injection at a dose of 40 mg every two weeks or weekly.

References:

Maksymowych WP, Inman RD, Gladman D, Thomson G, Stone M, Karsh J, et al. Canadian Rheumatology Association Consensus on the use of anti-TNF--directed therapies in the treatment of spondylarthritis. J Rheumatol 2003;30:1356–63.

T Pham, D van der Heijde, A Calin, M A Khan, Sj van der Linden, N Bellamy, and M Dougados. Initiation of biological agents in patients with ankylosing spondylitis: results of a Delphi study by the ASAS Group. Ann Rheum Dis 2003 62: 812-816.

van den Bosch F, Kruithof E, Baeten D, Herssens A, de Keyser F, Mielants H, et al. Randomized double-blind comparison of chimeric monoclonal antibody to tumor necrosis factor (infliximab) versus placebo in active spondylarthropathy. Arthritis Rheum 2002;46:755–65

van der Linden SM, Valkenburg HA, de Jongh BM, Cats A. The risk of developing ankylosing spondylitis in HLA-B27 positive individuals. A comparison of relatives of spondylitis patients with the general population. Arthritis Rheum 1984;27:241–9

van der Linden SM, Valkenburg HA, Cats A. Evaluation of diagnostic criteria for ankylosing spondylitis: a proposal for modification of the New York criteria. Arthritis Rheum 1984;27:361–8

Cardiac complications in AS

2007-01-26T13:03:00.000-05:00

The HLA-B27-related spondyloarthopathies are associated with cardiovascular disease in 2% to 10% of cases. Cardiovascular mortality is increased in patients with ankylosing spondylitis. A possible explanation might be a more prevalent atherogenic lipid profile in patients with ankylosing spondylitis than in the general population. It has been postulated that inflammation deteriorates the lipid profile, thereby increasing cardiovascular risk. An increase in disease activity has been associated with decreases in lipid levels. Inflammation and sclerosis of the aortic root and ventricular septum have been linked to the development of isolated aortic regurgitation and conduction abnormalities. It is suggested that clinicians consider the possibility of HLA-B27-associated cardiovascular disease in patients who have aortic and coronary aneurysms.

A recent review of data from patients enrolled an "integrated outcomes database" have shown that "cardiovascular diseases and their risk factors were more common in patients with rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis," than in those without these diseases.

A small number of people with spondylitis will display signs of chronic inflammation in the base of the heart - around the aortic valve and origin of the aorta (i.e. that vessel which takes all blood from the heart to be distributed throughout the body). Years of chronic and silent inflammation at these sites can eventually lead to heart block and valve leakage, sometimes requiring surgical treatment. Although recognized, these cardiac lesions probably are seen in fewer than two percent of all patients with spondylitis, and nearly always in males. The lesions are readily detectable by the physician's examination and when necessary, cardiac testing.

Also, adults with spondylitis often have chest pain that mimics the heavy chest pain of cardiac angina or pleurisy (the pain with deep breathing that occurs when the outer lining of the lung is inflamed). Anyone experiencing symptoms should seek medical attention to rule out a more serious condition. What often happens, over time, is that the joints between the ribs and spine, and where the ribs meet the breastbone in front of the chest, develop decreased chest expansion because of long-term inflammation and scarring of the tissues. If the pain is found to be spondylitis-related, it is important to practice critical deep breathing exercises to help maintain chest expansion.

References:

Chenglong Han et al. (2006, Sept 15). Cardiovascular Disease and Risk Factors in Patients with Rheumatoid Arthritis, Psoriatic Arthritis, and Ankylosing Spondylitis. J Rheumatol 2006;33:2167-72

Norton, H. (2006, January / February ) The Heart in Spondylitis. Spondylitis Plus

OPSer Calls Herself a “Chronic Volunteer”

2007-01-26T01:07:00.000-05:00

OPSer Calls Herself a “Chronic Volunteer”
Topical Stories (Jan 2007)

Jan. 30, 2007 – Cassandra Williams, an Ontario Public Service (OPS) employee, is a chronic volunteer.

Williams admitted her addiction to volunteering when she spoke at the OPS Spirit campaign launch event recently held in Toronto.

Currently a program and policy analyst with the Ministry of Health and Long-Term Care’s Primary Health Care Transition Fund Unit, she was bitten with the volunteer bug when she was a young girl growing up in Trinidad.

Her birth country’s successful campaign to steer young people away from drugs, guns and crime inspired her to contribute her own efforts at making a difference in the lives of young people.

A slogan used in Trinidad to combat youth violence – “ The future of youth is in their schoolbags” – has always influenced her interaction with young people.

As a volunteer with youth, her mission is to encourage them to remain connected to their goals and to teach them the benefits of staying focused on school and strategies to cope with difficult times.

With a pediatric nursing background, she loves being with young people and has the ability to quickly develop a rapport with them.

Williams has worked on health promotion activities as far north as Webequie, Ontario where she helped a First Nations community implement youth suicide prevention initiatives. She has also traveled to the exotic wilds of Tanzania, Africa to work with children of the Masai tribe who are afflicted with disease and famine.

In Toronto, Williams works with YOUTHLINK and organization that supports vulnerable youth in making positive choices and meeting its commitment to at-risk and homeless youth. She also serves as Director on YOUTHLINK’s Board.

“Volunteering with youth is intense and emotionally challenging but it is also very satisfying for me. Helping young people discover the goodness within themselves and the beauty of life is the best feeling in the world,” said Williams.

She has also raised thousands of dollars for The Arthritis Society and donates her time as a foster parent with the Toronto Humane Society.

Value of Volunteering

2007-01-24T17:08:00.000-05:00

The Ontario Public Service’ Spirit 2007 Campaign was kicked off Tuesday with the help of a moving speech delivered by a self-described “chronic volunteer”.

“I was raised in an environment where the village raises the child. I truly appreciate the work of volunteers,” Cassandra Williams, a program/policy analyst with the Ministry of Health and Long-Term Care, told a gathering of about 100 people in the St. Lawrence Lounge of the MacDonald Block.

Williams, who was raised in Trinidad, said the mentors of her youth, who helped her navigate a safe path to adulthood, inspired her to embrace volunteerism as she grew up. “I have volunteered medical services in Tanzania for three months living with the Massai, in Trinidad for three months caring for end-stage palliative patients and for 3 months in a Northern Aboriginal community of 611 people, where youth suicide had become a serious issue."
“I am a foster parent for the sickest animals at the Toronto Humane Society, and I am involved as a board member with YOUTHLINK, a United-Way funded agency, which supports vulnerable youth in making positive life choices,” Williams said.

Cassandra Williams, a self-professed chronic volunteer, helped launch the OPS Spirit 2007 Campaign.

Williams, who was among a group of OPS employees recognized in December with a Volunteer Recognition Certificate for their tremendous volunteer efforts, urged her colleagues to look in their own communities for the umpteen ways they can volunteer and make a difference.

Marc Lalonde of the MOHLTC, who was announced as 2007 Chair of the Spirit Corporate Team, said Williams and many more like her throughout the OPS represent a powerful force for change for the betterment of communities across Ontario. Each year the Spirit Corporate Team, made up of ministry Spirit Leads, chooses a signature campaign to promote throughout the OPS. This year’s campaign of Developing Our Youth—Building Our Future is an especially compelling theme Lalonde said. “Helping youth, truly is about building the future,” Lalonde said. “The kids in the world today, in the province, in the GTA, they need help, they need mentors, they need guidance.”

A number of community organizations serving youth, set up displays and passed along information during the launch, including the Boys and Girls Club of East Scarborough, Big Brothers, Big Sisters, Future Possibilities, Tropicana Community Services, Voices for Children, Youth Assisting Youth, Kids Grow Ontario, 7th Generation Project, YOUTHLINK and the Toronto Public Library.

Although youth is the focus of this year’s campaign, Lalonde said he would encourage OPS members to get out in their communities and volunteer for any organization of their choosing. “We’re about promoting volunteering period,” Lalonde said. “There are so many reasons to volunteer.” Lalonde said he was excited and looking forward to an exciting and eventful year as campaign chair.

A number of other speakers also shared their thoughts with the crowd on youth issues as well as volunteering, including Michelle DiEmanuele, Deputy Minister of the Ministry of Government Services and Associate Secretary of the Cabinet, Trinela Cane, Assistant Deputy Minister of the Business Planning and Corporate Services Division in the Ministries of Children and Youth Services and Community Services and Angela Coke Assistant Deputy Minister, Modernization Division, Ministry of Government Services. Dr. Avis Glaze, Ontario’s Chief Student Achievement Officer and CEO of the Literacy and Numeracy Secretariat was the guest speaker of the well attended event, which ran from 10 a.m. to 2 p.m.

Photo credit: Allen Paul

After my presentation, I was approached by a journalist for TOPICAL--a government newszine that promotes accomplishments/best practices/examples of change in the Ontario Public Service (OPS)--who was interested in writing an article about me, my work with youth, and my inspiration for volunteering. The article should be posted the week of January 29th.

I was also approached by a Coordinator for the Deputy Minister of Community Safety and Correctional Services. She invited me to present at a conference in May, which I graciously accepted.

I was also personally invited to join TOPS, a forum of new professionals in the OPS that have been identified as a key partner in the internal delivery of the Youth and New Professional Strategy as well as a conduit for identifying and implementing suitable learning and development opportunities. TOPS is an organization that was created by young professionals from across the OPS, with the aim of providing networking, mentoring and learning opportunities, and to harness the energy and ideas of a dynamic OPS workforce.

Iritis again

2007-01-11T21:44:00.000-05:00

For the last two weeks I felt a burning sensation in both eyes (worse in the left eye) upon awakening. I would mention this to one of my colleagues over morning tea. I also experienced mild light sensitivity. Today it became worse while I was at work and I grappled with the idea of remaining at work until dusk (because of the photophobia) or leaving for home before my symptoms worsened. I decided the smartest thing to do would be to head home.

On my way home the symptoms worsened significantly within ten minutes of being exposed to the bright sunshine. Both eyes began to weep and I had to drive while squinting because the light was painful. I could not keep my left eye open for long, and eventually I was driving with my head tipped back against my headrest to afford me some view of the road through my 3/4 closed right eye. I acknowledge that this was dangerous to do. I thought of pulling over to the side of the road, but I had no cell phone and would not have been able to arrange a lift. I ensured that I took every safety precaution: driving within the speed limit in the slow lane, not changing lanes, and frequently checking all mirrors.

I am really frustrated that this is now my third episode of iritis that I have experienced: Sept 9th, 2006, October 7th, and now Jan 10th, 2007.

Upon reaching home, I instilled Voltaran eye drops that had been prescribed. I then slept for five hours and reinstilled them upon awakening. So it's back to two drops three times per day. I would be interested in hearing about others' experiences with this AS complication; please email/comment your experiences to gymjunkie247@rogers.com

More Books on AS

2007-01-06T21:15:00.000-05:00

Ankylosing Spondylitis: The Facts
Muhammad Khan, Professor of Medicine, Case Western UniversityOxford University Press, 206 pagesPublication date: August 2002

Ankylosing Spondilitis: The Facts provides clear and accessible information on treatment, diagnosis, genetic counselling, and daily life with the illness. Professor Khan is one of the leading experts in the world on AS, while also having it himself. This combination of scientific knowledge and personal experience of a debilitating disorder results in a unique book which will prove invaluable for readers wishing to know more about their condition, and those that share their lives.

Your Guide To Living With Ankylosing Spondylitis
Spondylitis Association of America, Sherman Oaks, CaliforniaBook (32 pages) 2000

This guide provides information on common symptoms, causes of pain, fatigue, genetics, treatment and management, psychological challenges, exercises and frequently asked questions. Includes a disclaimer that advises consultation with a health professional prior to beginning any activities or exercises.

Ankylosing Spondylitis - A Medical Dictionary, Bibliography, and Annotated Research Guide to Internet

This is a 3-in-1 reference book. It gives a complete medical dictionary covering hundreds of terms and expressions relating to ankylosing spondylitis. It also gives extensive lists of bibliographic citations. Finally, it provides information to users on how to update their knowledge using various Internet resources. The book is designed for physicians, medical students preparing for Board examinations, medical researchers, and patients who want to become familiar with research dedicated to ankylosing spondylitis.If your time is valuable, this book is for you. First, you will not waste time searching the Internet while missing a lot of relevant information. Second, the book also saves you time indexing and defining entries. Finally, you will not waste time and money printing hundreds of web pages.

Car Driving With Ankylosing Spondylitis
The National Anklyosing Spondylitis Society (NASS) East Sussex, Great BritainBooklet 28 pg 1998

This booklet addresses some of the special considerations related to car driving when one has ankylosing spondylitis. There is an emphasis on car driving safety in general, seat belts, neck restraints and air bags. Written by researcher Dr. Jon Erlendsson of Denmark with assistance from the Volvo Car Corporation.

Straight Talk On Spondylitis (Second Edition)
Robert L. SwezeySpondylitis Association of America, California, USA, 1992Book (58 pages) 1992

This guide is the result of information gathered from patients and rheumatology professionals. The nature of spondylitis and what patients can do to help themselves in conjunction with treatment are discussed. The following topics are covered: understanding the disease; spondylitis in women; medications; exercise; posture; sports and recreation; stress reduction and relaxation; sex; sleep; and employment.

Guidebook For Patients: A Positive Response To Ankylosing Spondylitis
National Ankylosing Spondylitis SocietyEast Sussex, UK

This booklet, produced by the National Ankylosing Spondylitis Society of the United Kingdom, provides answers to frequently asked questions and includes useful exercises.

Ontario Spondylitis Association

2007-01-06T21:04:00.000-05:00

In October of 1984, physicians in Toronto invited their ankylosing spondylitis (AS) patients to attend a public forum on current research and new developments in the treatment for the various forms of spondylitis. Dr. Hugh Little, Rheumatologist at Sunnybrook Hospital in Toronto and Russ Morrison, Executive Vice President from The Arthritis Society, Ontario Division, were instrumental in organizing this forum to see if there was sufficient interest amongst the patients to form a spondylitis association in Ontario. Similar groups have been successfully formed in Europe and they felt that a similar group was needed in Canada. A small group volunteered to join a steering committee and on May 1, 1985 the Ontario Spondylitis Association was formed at its first general meeting.

Over the last 20 years the OSA has provided support for its members through public forums, educational materials, support groups and quarterly newsletters while raising over $100,000 for AS research. Dedicated volunteers, including medical and physiotherapy advisors, working under the support and auspices of The Arthritis Society, Ontario Division have been instrumental in keeping the Association active for this past 20 years.

To celebrate our 20th Anniversary, the OSA and The Arthritis Society, Ontario Division, planned a series of special forums in Ontario communities (Cambridge, Ottawa, Peterborough and Toronto). Our aim continues to reach out to AS patients and their families to provide an opportunity for education and discussion on living with AS and related diseases. Please visit our What's Happening and Events sections for updates on public forums and events being held by OSA this year.

Membership 1. Jan. 2006: 298 paying members, including 206 AS sufferers

For further information about the OSA, please contact us at mailto:info@spondylitis.caor by calling 1.800.321.1433.

Canadian Arthritis Health and Research Centres

2007-01-03T17:09:00.000-05:00

Arthritis and Autoimmunity Research Centre (AARC) Foundation--2004-2005 Annual Report. The goal of AARC researchers is to achieve significant advances in the understanding and treatment of arthritis and related disorders.
University Hospital Network has a Rheumatology Outpatient Clinic at Toronto Western Hospital, which also houses the Centre for Prognosis Studies which conducts clinical trials in Lupus and Psoriatic Arthritis.
Southlake Regional Health Centre in Newmarket, ON hosts The Arthritis Program (TAP)which delivers effective assessment, treatment and education to individuals of all ages who are diagnosed with inflammatory joint diseases (rheumatoid arthritis, systemic lupus erythematosus, and juvenile joint disease) degenerative joint disease, including erosive and nodal osteoarthritis, osteoporosis and fibromyalgia.
St. Joseph's Hospital in London, ON hosts the Arthritis Institute, which is a collection of 4 centres and the associated inpatient orthopaedic/plastics unit that are focused in the care of musculoskeletal conditions and injuries such as fractures, replants, rheumatoid arthritis and osteoporosis. In collaboration with the Arthritis Society, their Rheumatology Centre provides outreach services to patients, physicians and allied health professionals outside the London/Middlesex area.

Cassandra Kicks AS

Cassandra Kicks AS is moving

Starting Simponi in September

New Race Goals

My experience taking Humira

Health Canada approves Simponi for AS

Goofy Challenge--I did it!!!!!!!

Goofy

First day on Humira

Seven days hitting Whistler Blackcomb

Humira Welcome Package Arrives

Still waiting

HEALTH CANADA ADVISORY

January 13, 2006

Switching from Enbrel to Humira

Run for the Toad 50K - October 4th, 2008

Scotiabank Half-Marathon - Sept 28, 2008

Travelling the Confederation Trail in PEI

Fatigue

32K Iroquois Trail Test (ITT)

The Natural History of Ankylosing Spondylitis as Defined by Radiological Progression

Tired

Toad in Training

Watch out: Toad in Training

Cape Hatteras

Feeling strong

Flare

Started Enbrel 50mg today

Blood test can predict severe ankylosing spondylitis

Ankylosing spondylitis patients miss effective Tx due to lack of referrals; primary care docs 'a major barrier'

Juvenile-onset spondylitis does damage to hips

Disease with a funny name

Ottawa Half Training Starts Today

Farewell 2007. Hello 2008!

Run for the Toad

Mission Accomplished

Mitochondrial Dilution

Toronto Half-Marathon Point in Time

Components of Training

Training for Toronto's Half Marathon on Oct 14

Farewell to Wineglass

Struck Dumbfounded

The new opiate of the middle-class masses

Marathon Training and Performance Strategies Based on New Research

Marathon Training Update

Corneal Ulcer Follow-Up

Corneal Ulcer Follow-Up

My first corneal ulcer

Yoga

Let the training commence!

Training update

15K along the Ajax Waterfront

SportingLife 10K Personal Best

Today's media articles

Glorious Weekend

My Personal AS Update

Q&As

Spondyloarthritis Research Consortium of Canada (SPARCC)

Helping Hands Forum

Harry's Run

Remicade & Humira Increase Cancer & Infection Risk

Q1 2007 at a glance

Harry's Spring Run Off Toronto 8k

Bruised but not Broken

Stress Fracture?

Was it worth it? Hell yeah!

Around the Bay: March 25, '07

Enbrel: Day 3 - In the leg

Iritis...possibly

Feverish

Use of a low starch diet in the treatment of AS

Famous sufferers of AS

Enbrel Treatment: Day 1

Three Cheers!!!

New Running Goals for 2007

Training update

New Blog

Life Update

Life Update

More questions answered about AS