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Inflammation (transcript)
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Major funding for "Second Opinion" is provided by the Blue Cross and Blue Shield Association.  An association of independent locally owned and community based Blue Cross Blue Shield plans committed to better knowledge for healthier lives. 

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(Peter Salgo) 
Welcome to "Second Opinion", where each week we solve a real medical mystery.  When we close this file in a half an hour from now, you will not only know the outcome of this week's case, but you will be better able to take charge of your own healthcare.  I am your host Dr. Peter Salgo. And you have already met our special guests who are joining our cast of regulars, Primary Care Physician Dr. Lou Papa, and Bio-ethicist Dr. Glenn McGee.  Now no one on the team has seen the case.  And we are going to get right to work.  Our case today concerns Theresa.  Theresa is sixty-two years old.  And she is on her way to the emergency room because her husband made her go. 

(Lou)
Wow! That's very interesting!!!

(Peter)
This is in contradistinction to many of our cases with a wife who is pushing the husband to the emergency room.  She finally went because she has had chest pains.  She has had it for about four days, although she has been describing it as heart burn.  She is also short of breath.  Good call here Lou by the husband?

(Dr. Lou Papa) 
Oh absolutely.  I mean she has had chest pain for four days.  Women can sometimes present in A-typical matters, especially with that shortness of breath, her age.  We get more information about her risk factors that may make it even wiser.  And I think - yes I think that is a sharp call.

(Peter) 
Joseph, does this sound familiar to you?

(Joseph Mercogliano) 
Yes.  I had a similar situation where I was experiencing chest pain over a weekend working around the house.  And on a Monday my wife urged me to go to the ER.  So I did.

(Peter) 
What are you worried about Lou?  If you are in the emergency room you are there.

(Lou) 
Well the biggest thing, whenever you have chest pain and you know is this a life threatening situation?

(Peter) 
Does every heart attack present with chest pain?

(Lou) 
No.

(Peter) 
No?

(Lou) 
No.

(Peter) 
No, why not?

(Lou) 
Because it can do what it wants?  It can present in a various number of ways.  There are some heart attacks that present with no symptoms at all.

(Peter Salgo) 
Theresa was in pretty good health up until about 10 years ago.  At that time she suddenly developed a very high fever.  I don't actually have the number here.  And an enormous papular rash which covered virtually all of her body.  Really red, really nasty.  On physical exam her doctor also noticed a few joint pain, generalized edema everywhere.  That is body swelling, everywhere.  Her liver and kidney tests were abnormal.  I have a creatinine of about one-and-a-half.  A BUN of forty.  And her ASTE and ALT were about twice normal.  Just to paint kind of a dim gloom picture here. 

(Dr. Mark Hyman)
Bad liver..

(Peter)
So back then what do you think the doctors were thinking could have been going on?

(Dr. R. John Looney) 
Sounds like she has a multi-system disease.  I mean she ...

(Peter) 
Multi-system disease meaning what?

(John) 
She has got involvement of her skin, her joints, her kidneys, liver.  Multiple areas of the body are being influenced by inflammation.

(Peter) 
Now that is the first time we have heard that word inflammation.  Can you define it for me?

(John)
Inflammation is the body's response to injury usually, or it is their response to external stimuli that might cause injury.  And the body is going to try and prevent that.

(Peter) 
This looked like a pretty severe something.  And I say something because it is vague in the chart.  They were perplexed.

(Lou)
Rightly so.

(Peter) 
So they did when doctors are perplexed what doctors always do.

(Mark) Lots of tests.

(Peter) 
They ordered tons of tests.  And I can give you without belaboring this, a whole bunch of them.  They did a test for Lupus.  They did a rheumatoid arthritis test.  They were both negative.  Let's see what else they did.  Her white blood cell count though was elevated.  And her CRP was three ten.

(Mark) 
That is very high.

(Peter Salgo) 
So now what is wrong?

(John) 
When you have a very high CRP the first thing I think about is infection, as you said.  And this could be the clinical presentation of a - as an infection.

(Peter) 
Well her doctors cultured everything in sight.  And some things they couldn't see.  And that includes blood and other body fluids, and they came up empty. So what they did was that over the next year, they treated her symptomatically.  They gave her some NSAIDs.  Like non-specific ...

(Dr. Mark Hyman) 
Anti-inflammatory.

(Peter) 
Anti-inflammatory drugs.  And despite this therapy, although she seemed to get better, her joints got worse over the next ensuing months.  And her joints always hurt.  Now, did they treat her correctly given what I have told you?  Would you have done something different, this ten years ago?

(Mark) 
I think when someone presents with inflammation, it is very important to ask the question why?  Not just how do we shut off the inflammation with a drug, but why is this happening?  Is it infection?  Maybe we have to go hunting.  Is it an allergen?  Is it something you are eating in the environment that we need to find out.  Is it a toxin in their system?  Does your diet create inflammation?  Does it have lots of trans fats and sugar which promote inflammation?  Are they under a lot of stress?  So what are those factors that we have to navigate to, to find out why?  And that is what they didn't do.

(Peter) 
But is it fair to say that it is unusual for someone to have a cube of sugar and break out in a rash from head to toe?

(Mark) 
That is unusual.  But it ...

(Dr. Lou Papa) 
The problem is you are - you are trying to treat something that doesn't have a diagnosis. 

(Mark) 
But she has some type of audio immune disease.  Let's say we can all agree on that?

(Lou) 
Which is a big basket.

(Mark) 
Right.  But does it matter what we call it?

(John) 
Before we focus on what she might have, I guess we really need to hear a little bit more about her major manifestation now, which is the joint pain.

(Peter) 
All that we have here is that there is edema.  Lots of joints were involved.  And they sent her home on a NSAID.  Is that what you would have done, given admittedly an incomplete picture?

(John) 
If she had an impressive rash, I would have biopsied the rash right at the beginning.  That is an easy place to get some information that might ...

(Peter Salgo) 
I don't have the result of any biopsy.  They probably didn't.

(Lou) 
I will bite the bullet.  I think that was a reasonable thing to start with.

(Peter) 
Well that is what they did.

(Lou) 
At least for some symptom control.

(Peter) 
Okay, I will tell you the one thing that they did, which I think everybody here is going to like.  They followed her.  They brought her back.  They continued to get some blood tests.  And I can give you the results of some of those blood tests, because some of them began to evolve.  She had a negative ANA, elevated HFCRP, elevated SED rate, a positive rheumatoid factor.  All right.  Does that give you enough information to zone in on the diagnosis here?  What did it all mean?

(John) 
It sounds like Rheumatoid arthritis at this point.

(Peter)
Well that is what her doctors thought.  Her doctors said she has rheumatoid arthritis.

(Dr. Mark Hyman) 
I just have to say something.  We're always focused on trying to get to the diagnosis.  And particularly in autoimmune disease, and there I twenty-four million Americans with autoimmune disease.  And you lump them altogether, it is a phenomenon.  And why is it happening?  And does it really matter always what we call it?  Because the treatment ends up being the same for the most part.

(John) 
Well ... Wait a second.

(Peter) 
Before we call it anything.  And I will let you jump.  You used a word that we  have not used before.  What is an autoimmune disease?  I know we defined inflammation.  But now what is an autoimmune disease?

(John) 
So an autoimmune disease is a disease that is driven by a response against your own tissue.  An autoimmune response.  So you know, responses against organisms outside the body that can cause a disease is a good thing.  But you don't want to respond to a lot of other things.  You don't want to respond to your food.  You don't want to respond to the things that you inhale.  You don't want to respond to your own tissue.  You don't want to respond to bugs that aren't doing any harm.

(Lou) 
Collateral damage.

(Mark) 
Immunity is your body attacking itself.

(Lou) 
Right.

(Peter) 
That is the problem.

(Glenn McGee) 
It's a symptom that is the problem right now.  And we are kind of trapped in the diagnostic imperative.

(Dr. R. John Looney) 
The problem is that there are some autoimmune diseases where you need to know what to expect down the road.  And you want to be able to prevent those things from happening.  And Rheumatoid arthritis is one of those diseases, where you can get damage that is going to be permanent if you don't treat it properly.

(Peter)
Again, autoimmune is the immune system senses something in you as foreign, when it is really not foreign.  And then goes ahead and marshals the troops and attacks it.  And in this case, it looks like it is her joints that are still having pain a year after whatever that initial insult is.  And by the way, as long as I have got that on my mind, what was the initial insult, do we know?

(John) 
I don't really know.  I don't know.

(Peter Salgo) 
Is it common to have something like that?

(John) 
Well, you know we don't know what triggers a lot of autoimmune diseases.  Sometimes it is some outside stimulus that induces an immune response, and then you get cross reactivity.  So maybe that was what was going on.  We don't really know.

(Peter) 
Let me ask another question, which goes back a year.  I know you wanted this biopsy.  Her doctors didn't get it.  Now her tests are for the first time, turning positive for rheumatoid arthritis.  Why just now?  Did her doctors miss it a year ago?  Or does it take a year to make the diagnosis?

(John) 
That is a great question.  You know we are - we often see this happening where we aren't really sure what is going on initially with the inflammatory arthritis.  And then over time, the auto-antibodies which the rheumatoid factor is begin to turn positive.

(Peter) 
You Joseph, had trouble coming to a diagnosis too, didn't you?

(Joseph) 
Yes.  Because after my visit in the emergency room when I was admitted, my heart turned out to be fine.  But my lymph nodes were all swollen.  And the pain was radiating through my chest.  They had done all series of tests, the stress tests and so forth.  Heart was ruled out.  So my next step was to go to an oncologist.  And then I had a biopsy.  And then I waited for over three weeks.  And they said that I had lymphoma.  And then they retracted that and said that I did not.

(Peter) 
So what did they - when did they finally tell you you had autoimmune, or did they tell you you had autoimmune? 

(Joseph) 
No they did not tell me that I had an autoimmune.  I found - I went to a number of doctors.  Because from the oncologists, then I went to a rheumatologist.
 
(Peter) 
Do you have a diagnosis now?  Let's just cut to the chase.

(Joseph) 
Well I actually - it took two years.

(Peter) 
My goodness.

(John)
Wow.

(Peter) 
What did they finally tell you?

(Joseph Mercogliano) 
Well my current doctor told me I had Celiac disease.

(Peter Salgo) 
Does that fall under the umbrella of an autoimmune disease?

(Dr. Lou Papa) 
Yes.

(Peter) 
I want to stop for just a moment.  Because it's been confusing. This is a complicated case.  One of the more complicated cases that we have discussed.  That is because the immune system, which is the body's defense system is complicated.  It defends us against infection.  It defends us against disease.  It defends us against invaders.  Autoimmune disease develops when this system attacks us, healthy cells in the joints, the nerves, the connective tissue.  It mistakes us for them.  I think that is a fair way to put it.  There is a little more to learn about her history.  Over the next few years after that initial visit, ten years ago, and then the diagnosis being applied to her sometime thereafter.  Her joint pain, and now joint deformity got worse.  What would her doctors be doing during this period of time?  Assuming it is rheumatoid arthritis, what kind of joint deformity are we talking about, and what do you do about it?

(John) 
Well with rheumatoid arthritis you get deformity for two reasons.  One is the hard tissue in the joints.  The cartilage in the bone actually gets destroyed.  And therefore you don't - things cannot be lined up correctly.  And the second thing is also you get damage to the soft tissue.  The tendons, the ligaments, things like that.  So things don't move correctly either.  So for both of those reasons, you get deformities.  And so what is very important, and you know there has been huge advances in the last decade, is to begin treatment early.

(Peter) 
Sort this through for me, somebody.  What does inflammation have to do with rheumatoid arthritis?  Where does the immune system come in?  And why should anti-inflammatory drugs work?

(Dr. R. John Looney) 
Well we don't have good ways of getting rid of your immune response to a specific thing right now.  We - what we are stuck with is treating inflammation for the most part.  We have for good medicines, at least good comparatively in a historical sense.  Medicines now that can cut down on the inflammation and cut down on the damage.  But we don't have a good way to get rid of the autoimmunity.

(Peter) 
Tell me, what kind of treatment did you get for your autoimmune disease?

(Joseph) 
I had to change my diet.  I was supposed to go on some medication and food.  Food and nutrition.

(Peter) 
What was the diet change that you undertook?

(Joseph) 
Well, I had to stay away any - gluten-free.    Gluten-free products, stay away.  Anything that contains gluten, and gluten is in a lot of products.  Breads, flours, and so forth.  I also had an intolerance for dairy.  And I cut out the dairy.

(Peter Salgo) 
All right.

(John) 
Celiac disease is a very peculiar autoimmune disease, as I am sure you know.  Because here you have a something that is outside the body, a gluten which seems to be the trigger.  Most other autoimmune diseases are not like that.  We don't really have that nice specificity.  And you can't just eliminate gluten or something like that to get rid of the autoimmune disease.

(Mark ) 
You know maybe though.  But it may be a clue to how other autoimmune diseases work.  Because maybe there are infections or toxins, or other allergens that were reacting to it.  We just haven't identified them like we have the gluten.  But that by addressing those the body can stop overreacting.  Because the thing that is there is gone.

(Peter)
We have been, if you will permit me, demonizing the inflammatory response. Let's look at the trouble its causing, its caused a rash, it's caused his trouble, it's caused joint disease... the inflammatory response is there for a reason, right?

(John) 
Right.  It is absolutely critical.  I mean the people who don't get an inflammatory response get into tremendous problems with infections and can die of infections.  And that is one of the major problems with a lot of the medicines we use to treat autoimmune diseases now, is that they do predispose people to infections.  They do compromise the immune system.

(Peter) 
We haven't asked about your ticker.  That is one of the reasons I think you are sitting there.  Can this inflammatory process damage the heart if it has gone awry?

(Dr. Ajit Raisinghani) 
Oh yes absolutely.  It - patients with autoimmune diseases have a host of cardiac manifestations.  You can start off with just inflammation of the heart itself.  Inflammation of the sack around the heart.  And you can have valvular heart disease.  And then most importantly you can  have - I think the studies have shown the increased incidence of coronary artery disease.

(Peter) 
In case you were wondering why we were spending so much time on Theresa's past medical history, lest you forget, she is in the emergency room with what?  With chest pain.  Here she is, her doctors have this history. Ten years after the onset of her symptoms.  And her doctors check her vital signs in the emergency room.  We are in the present day, right now.  And they give her a cardiogram right now.  And guess what?  One of her cardiologists comes over and says, you have got an MI in evolution.  What is that?
 
(Ajit) 
MI is Myocardial Infarction, which is obviously a heart attack.

(Peter) 
So she has gone from rash, fever, rheumatoid arthritis, probably a ten-year history.  Now she is having a heart attack.  How unusual is that?

(Lou) 
It is known that autoimmune disease have a higher risk for coronary artery disease.  So it is definitely ...

(Ajit) 
I think that - I mean the data on autoimmune disease and heart disease is somewhat limited because we don't have that many patients.  But I think there is one study that looked at rheumatoid arthritis patients, they looked at - it was part of a larger trial that looked at nurses, which were healthy population.  And they isolated the group that had a history of rheumatoid arthritis, and have found that the ladies with rheumatoid arthritis had about a three-fold increase risk of coronary artery disease

(Dr. Mark Hyman)
That's a lot

(Ajit)
as compared to people without rheumatoid arthritis.

(Peter) 
So that is big time.

(Ajit)
 Yes.

(Peter Salgo) 
Not only did they do an electrocardiogram on Theresa.  They got their echocardiogram machine.  And sure enough, they found evidence of a heart attack in evolution right now.  But two others that looked old.

(Dr. Ajit Raisinghani)
Well....

(Peter) 
That she'd had previously.

(Ajit) 
You know let me just - I think that - I don't have an ECG in front of me.  But first of all, if you look at an ECG or an electrocardiogram and you think that she is having what we call an ST elevation MI, then they shouldn't be wasting their time doing an echocardiogram.  If they have a cardiac cath lab, they need to be moving - rushing her to there and getting that artery opened, rather than making more diagnostic tests.

(Peter) 
Well they did it.  But she did apparently have two other parts of her heart wall that were not moving, which were not in the area of the cardiogram today which looks like it is having a heart attack.  Could she have had two other heart attacks that she never knew, she never felt them?

(Ajit)
Sure...Silent heart disease is common.  It is possible that it may have been her heart.  It is possible that it may be hibernating myocardium.  Myocardium that is not dead.

(Peter) 
Well Theresa gets admitted.  I am sure you would agree with that. And by the way, I would agree with you.  I would take her to the cath lab.  And I am not sure I would have echoed her, but it is what they did.  She is admitted with a diagnosis of a heart attack.

(Ajit) 
Yes.

(Peter) 
She also carried a diagnosis along the way a pulmonary interstitial disease and pericarditis.   What is going on?

(John) 
All of this is very consistent with her having had rheumatoid arthritis.  Certainly both lung disease and pericarditis can occur with rheumatoid arthritis.  You can also get pericarditis when you have a myocardial infarction as well.  So it is - we don't know - you would really like to know, what for example, what medicine she has been on for this rheumatoid arthritis because some of those medicines can also be associated with pulmonary fibrosis. 

(Peter) 
But let me see if I can sum up a little bit of this discussion.  I think the basics are pretty clear.  Inflammation can be a life saving response of the body's defense system.  But sometimes when inflammation goes awry, bad things can happen all over the body.  Wherever the blood goes, and immune cells which are going AWOL, wherever they go, they can cause disease.  So it can be in the brain.  It can be in the heart.  It can be in the pericardium.  It could be in the kidneys, the liver, the joints.  How am I doing?

(John) 
Sounds good.

(Peter Salgo) 
I listen.  Let me tell you a little bit more.  Let's go forward.  I can tell you that Theresa's condition did not improve after being treated for her heart attack.  To the point where she could return  home and go through whatever rehab she needed.  The cardiac rehab, and the rehab for her joint disease.  So she was admitted to a long-term care center.  And she is currently there now.  And she is receiving intensive rehab, as much as she can tolerate, which is about twenty to thirty minutes at a time, and no more.  Because her joints hurt too much and she gets short of breath.  She is in - she is not in great shape.  She is severely, severely debilitated at this point.  Now, we know that inflammation plays a role in autoimmune disease.  And there is some research out there I know that connects aging and inflammation as well as heart disease and cancer as we age.  All of this is going on.  And it may be a consequence of aging.  Do we need to monitor our immune system?  Do we need to monitor our inflammation almost yearly?  Would you do it, and how would you do it?  Anybody want to help me here?

(Lou)
 I would not.

(Peter) 
You would not.

(Lou)
I would not.

(Mark) 
I absolutely would.  But I will tell you about that later.

(Lou)
 Well I would not. 

(Peter)
Do it now!

(Lou)
And part of that ...Part of that is right now, I am not sure what to do with that inflammation.  It is one thing to say that you can identify this risk factor, which some studies has been variable in its impact.  And what do you measure?  And then what do you tell a patient?  Sure, you tell them to eat right. Wait, wait a second.  So my question is, down the road, okay, where is the data that says if you make this number go down, if you improve this number you live longer, and you have less heart attacks and you live better?  That is the weak point.

(Mark) 
Well we know that if you lower your blood sugar, if you reduce your cholesterol, if you lower your blood pressure and all those things, you get a reduced risk of death.  And in the same way, I think we can connect an inflammatory life style with all those problems.  High blood pressure is an inflammatory problem.

(Lou) 
But the key...

(Dr. Mark Hyman) 
One second.  Diabetes is an inflammatory problem.  Heart disease is an inflammatory problem.  And we know what influences inflammation. 

(Lou) 
Can you tell me definitively that if you do these things, you have the data that says you have less heart attacks, you live longer?

(Mark) 
Yes.  If you reduce ...

(Lou) 
No the data.  Not what you think, but the data.

(Mark)
No.  No.  If you look - I mean what do you mean?  A long-term thirty-year randomized control trial?

(Lou) 
Absolutely.

(Mark) 
You are never going to see that.  You are going to have to look at the data we have and make your best estimate.  And I don't want to wait and tell somebody to lose weight and to lower their cholesterol until we have enough data.

(Lou)
 But that is contradictory.  You just said we need to get to the root.

(Dr. Ajit Raisinghani) 
Well I think you know - I think the way you have to approach this is that first, let's do something that is simple.  Then the simple things in which have clearly been defined are the traditional risk factors which are you know - and I am talking about heart disease, which are you know obviously smoking, hypertension, diabetes, lack of exercise.  And let's get a handle on those.  And then as a next step, maybe talk about inflammation.  And I agree with you.  The problem with inflammation is that one, what do you measure to see if somebody has inflammation?  And two, how do you treat it?  And we have no evidence to say that treating it - and we don't even know how to treat it.  And if you treat it, whether it is going to work.

(John) 
I would agree with Ajit.  I would look for cardiac risk factors, and eliminate them as you can.  And I would agree with Mark that you have to live a healthy lifestyle.

(Peter) 
How are you going to reduce an elevated CRP?

(Dr. R. John Looney) 
I am going to go after the risk factors.  And ...

(Peter) 
And it doesn't change.  Now what do you do?

(John) 
It doesn't matter.  I am not interested in the CRP per se.  I am interested in whether the patient is going to live longer, live healthier.  And right now I agree.  We don't really know that the goal should be to lower the CRP.  The goal now should be to try and make these changes in lifestyle, and try and reduce risk factors.

(Glenn McGee) 
Well on the patient, no matter how you frame it, the patient is confused.  Right.  I mean we have presented an incredible amount of information.  Just - I wouldn't want to be a patient in this room.  And now tell me right, you have heard so much about so many possibilities about which there is some data or a lot of data.  And we don't know how we'll act on the data.  And maybe I will have a heart attack and die.  We can agree that a healthy lifestyle will prevent among other things, inflammation and perhaps have some role in autoimmune disease.  The question that is being asked through really is, how is it going to help me now because I am hurting?

(Mark) 
It will make you feel better now, not just in the future.  That is the critical question.

(Peter) 
Well let me ask a couple of very quick questions. 

(Mark)
Joe, did you feel better when you got on that new program?

(Peter) 
That was one of my questions, you stole it.  How are you feeling Joseph?

(Mark) 
Diet and ...

(Joseph) 
It was a hundred and eighty degree turn.  The supplements, it just - the food - I was told to stay away from high fructose corn syrup.  A lot of trans fats.  Anything that is hydrogenated, partially hydrogenated, and to use these supplements. 
 
(Dr. Mark Hyman) 
Things like what, Acidophilus, fish oil.

(Joseph Mercogliano) 
Correct.

(Glenn) 
You were disciplined, and it is impressive.  But I - we are a nation that eats very poorly.  And those changes are very difficult.  And this amount of diagnostics is an incredible amount of money.  We have spent a million dollars easily in however many minutes we have been here.  So these changes are hard.  The amount of money involved is a lot.  It is not a small matter.

(Peter Salgo) 
All right.  Let's stop for a second and sum some stuff up shall we?  There are things that you can do to reduce chronic inflammation.  The right medication sometimes, diet and exercise, all of them are important.  It is talking about global body health.  I don't want to go without pointing out something really interesting here, which is we have a bunch of physicians from various different specialties, all of which are converging on this one syndrome, which is inflammation which is out of whack, the immune system which is out of whack.  This is one of the very few times where you see docs come together and scratch their heads in the same spot.  Is this the future of medicine?  Is it interdisciplinary cooperation?  Is this where we are all going eventually?  And is inflammation leading the way?

(Mark) 
I would say absolutely.  I mean inflammation is sort of the spear head of a whole new movement in medicine that looks at all the underlying biological systems in the body, and how those influences ease, whether it is free radicals, state of stress, or inflammation, or trouble with energy production ourselves, or detoxification or digestive function.  This is what we call functional medicine.

(John)
For me the really important thing is that when we come together and we discuss this, we start generating data.

(Dr. Lou Papa) 
The real future of medicine is the question.  As long as we continue to ask the question.

(Mark) 
That is right, the question.

(Lou) 
That is the future.

(Peter) 
If everything depends on the correct question, here is the correct question.  Joe, how are you feeling?

(Joseph) 
Now I feel great.
 
(Peter) 
You're a study of one!

(Joseph) 
My energy level came back to when I was the age of twenty-five.  I feel that good.

(Peter) 
I'm thrilled that your better .  We are glad you joined us.
 
(Joseph) 
Thanks for having me.

(Peter) 
This has been a wide ranging discussion.  This is the cutting edge of medicine.  But there are things we can say about it.  Let's see if we can sum some of this up.  We covered a lot of ground today.  There were some very key things to remember.  The immune system is the body's defense system against infection and against disease.  Autoimmune disease develops when the system attacks healthy cells.  It makes a mistake.  These cells can be in the joints, in the nerves, in the connection tissue.  Inflammation can be a lifesaving response of our body's defense system.  But sometimes inflammation can go awry.  Bad things can happen when normal tissue becomes inflamed incorrectly.  There are things that you can do to reduce chronic inflammation.  The right medication, the right diet, exercise, all of which can be important.  And the final message is this.  Taking charge of your health means being informed, and having quality communication with your doctor.  I am Dr. Peter Salgo, and I will see you next time for another "Second Opinion.


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