Medial plica syndrome and osteoarthritis are different disease entities (不同的毛病)

請不要誤會，我沒有批評呂醫師的 medical practice, 我相信他的 practice (注重預防及好的 physical therapy) 的效果比一般台灣（甚至美國）醫師的好. 我只是不同意他説  退化性關節炎（osteoarthritis—「退化性」已是一個落伍的觀念.  呂醫師的「膝關節軟骨再生促進手術」、這是不負責任的宣傳花樣.

我不是骨科醫師 （orthopedist) 也不是關節炎專家 （rheumatologist), 但是我不同意呂紹睿醫師的説法：

Osteoarthritis 一般叫 degenerative osteoarthritis (退化性關節炎）, 呂醫師說 説「退化性」是一種落伍的觀念。他説 osteoarthritis 是 內側皺襞 （medial plica) 變質硬化引起的。呂醫師還説他是 1995 年做關節鏡（arthroscopy) 無意中發現這個隱藏的原因。其實這個他「無意中發現的病」叫 plica syndrome, 是另一種病, 跟 退化性關節炎（degenerative osteoarthritis) 無關, 也不是 osteoarthritis 的原因。

呂醫師説從來沒有人報告過, 其實關於 plica syndrome 的報告很多.  他説他於 2002 年設立硏究中心.  中正大學機械工程系劉德騏教授說 「世界上就沒有人做這方面的硏究」（很明顯的 劉教授不讀醫學雜志）世界上沒有人説內側皺襞硬化是 osteoarthritis 隐藏的病因倒是真的。

我在4/14/1988 NEJM 看到一篇文章叫「knee injury in sport」其內就有 提到 plica syndrome.

若有膝蓋關節痛或關節炎而做關節鏡 （arthroscopy) 檢查, 發現有 內側皺襞 （medial pelicans) 硬化, 那麼這個病叫 plica syndrome 或 medial plica syndrome, (有各種不同的 plicas, 依其位置而命名, 絕大部分引起毛病的是 medial plica.) 這種情形就不叫 degenerative osteoarthritis. 呂醫師把這兩種不同的疾病混在一起 説 所有的 degenerative osteoarthritis 都是 內側皺襞硬化引起的。所以他才説「退化性」是一種落伍的關念。

呂醫師說 內側皺襞 是胎兒在三個月 關節腔的空腔形成的時候；它沒有完全退開、像衣服一樣皺摺起來叫 plica. 這完全正確。這是胎兒（embryo) 所留下來的 剩餘物 （remnant). 不是每人都有 （為什麼有些人有，有些人沒有；沒人知道。沒有 plica 膝關節功能完全正常。 美國的一個 study 説只有 50% 的人有內側皺襞, 即兩個人就有一個人沒有. 日本的一個報告說 79.9% 的人有內側皺襞。3,563 的病人做了 3,889 關節鏡手術（arthroscopies—-有些人 兩邊都做), 發現20.1% 的人沒有 medial plica.  

根據呂醫師的理論，美國有一半的人 （日本有20% 的人）永遠不會得 osteoarthritis. 因為他説 osteoarthritis 的主因（或惟一的原因) 是 內側皺襞 引起的，那麼沒有 內側皺襞， 不是就不會有 osteoarthritis 了嗎？ 該 YouTube 說每人一出生就有 內側皺襞，那是錯誤的。   

呂醫師的「膝關節軟骨再生促進手術」、這是不負責任的宣傳花樣。如果他真的相信,經他手術後, 軟骨有再生，他應該把他的學術報告公布, 或放在他醫院的網頁。我們都是外行人（yes, including me). 我們沒有能力判斷其 可信度 （merit）。如果在 peer reviewed  的學術性 醫學雜志發表，那至少我們知道他所說的有經過這方面的專家審查通過. 專家辦事，我放心.  呂醫師這個理論已20 多年, 報紙的報導沒有份量（carry no weight). 只有學術上發表的文章才會叫我閉嘴。

（下面那一段來自蘋果日報, 引自聯合報)

「今日出版的《聯合報》報導，呂紹睿指出，膝關節疼痛好發高齡長者，但實際上不少年輕人也有膝關節疼痛問題。他認為，關節疼痛是因關節囊皺襞與關節摩擦導致發炎、變硬，使關節軟骨被破壞而逐漸消失。他建議關節炎輕症患者多休息，嚴重者則以關節鏡手術，清除發炎皺襞及周邊組織。由於不必置換關節，不少患者慕名而來，就算搶到門診號碼牌，首次看診也要等半年後。」

(The following is from UpToDate and other published reports)

 (This report says 79.9% of Japanese have medial plica 內側皺襞)

 (This report shows no cartilage regeneration possible,軟骨不能再生)

Nothing is more absurd than talking about alkaline foods” (鹼性食物）or 鹼性體質

A friend sent me this post about using “強鹼性食品” to cure lung cancer.

這一年來我已經收到了很多關於如何利用食物把我們的身體改變成「鹼性體質」（whatever it means). 所以 you guys can trust me as I consider myself "educated” in this topic.

這種提倡鹼性食物去治療萬病的説法已不是台灣的專利. 連 Tom Brady (Boston Patriots’ 的 quarterback) 也在提倡. 至少 Brady 說的沒有那麼離譜. More to come. 去年九月New York Times 有一篇文章 叫「Tom Brady’s “The TB12 Method” [聽説那本書有三磅重］Is Hefty but Short on Science”.（see attached). NY Times 也會罵人的，比較斯文而已.

這個post 說吃䶨性食物把身體改成䶨性體質可以治癒肺癌。問題在於我不知道什麼是「䶨性體質」。我相信寫這個 post 的人也不知道；因為根本沒有這種東西。

我們的血液確有 pH 値：動脈內的血液其 pH 是維持在 7.36 至 7.44 之間。It is tightly regulated by both kidney and lungs; 分工合作。(靜脈內的血液其pH 値是 0.02 - 0.04 lower). PH 低於 7.36 叫酸中毒 （acidosis); 高於 7.44 叫䶨中毒（alkalosis). 這是很嚴重的疾病導致腎臟跟肺沒有辨法維持正常的 pH 値。也就是說不正常的酸性或鹼性都是疾病，有時會有生命危險。

我們血液的 pH 値一定要在那個narrow range,不酸不鹼；無論是酸性或鹼性都是不正常的。

吃強酸性或強鹼性的食物是不會改變血液的 pH値的。這是由 我們的腎臟跟肺分工合作調整控制的。Our kidney and lungs are very efficient in regulating our PH, it is none of our business, nor can we control it by diet or will.

至於説改成鹼性體質可治癒肺癌；其荒唐（absurd) 的程度，實在不値得浪費筆墨。

這種提倡鹼性食物去治療萬病的説法已不是台灣的專利. 連 Tom Brady (Boston Patriots’ 的 quarterback) 也在提倡. 至少 Brady 說的沒有那麼離譜. More to come. 去年九月New York Times 有一篇文章 叫「Tom Brady’s “The TB12 Method” Is Hefty but Short on Science [聽説那本書有三磅重］”. NY Times 也會罵人的，比較斯文而已.

(from NY Times article)

Tom Brady的 diet 其實是很健康的：No white sugar, no white flour, no dairy, raw olive oil and certain specific greens. 問題出在他說 80% of his calories come from “alkaline foods” (鹼性食物）。他為了要賣書及推銷他的相關企業；利用 pseudoscience; 推銷他的 book, snack bars, apps, and gears. Brady 真是晚節不保（40 歲對一個 football player來説是一個老人的了）。

他的business partner (Alex Guerrero) has been investigated by Federal Trade Commission for falsely presenting himself as a medical doctor, and for promoting bogus nutritional supplements.

Boston Patriots 的教練（Bill Belichick) 禁止 Brady’s business partner (Guerrero) 到 Patriots training camp or football field sideline.

Tom Brady 跟我們嘉義同鄕 陳昭妃博士，都是利用 pseudoscience 而建立一個企業，賺大錢

What’s Epstein-Barr virus got to do with cancer?

I am a history buff, when it comes to medicine; I am naturally fascinated by the history of medicine, having a penchant of wanting to know how things came into being in medicine.

The story of Epstein-Barr virus (EBV) infectious mononucleosis is a good example.  Recently a friend as me about a relationship between mononucleosis and some sort of lymphoma.  I have to tell a story (which is history) to answer this question.

First a few facts:

• Infectious mononucleosis is transmitted by EB virus.
• Burkitt lymphoma is caused by EB virus, mostly in Africa.
• Nasopharyngeal cancer (鼻咽癌）is caused by EB virus, mostly in China,Taiwan
• Some of the stomach cancers are caused by EB virus.
• Mononucleosis may lead to Hodgkin’s lymphoma.

From above facts, one can see EB virus can cause seemingly harmless mononucleosis, but may cause various cancers, including lymphoma.  It should come no surprise that it has been observed that mononucleosis may lead to Hodgkin’s lymphoma.

Dr. Denis Burkitt

The British surgeon (Dr. Denis Burkitt) served in Africa during WWII and he stayed to do missionary medical practice in Uganda after the war.  He observed that many young children were stricken with an aggressive tumor/cancer, and the distribution seemed to be corresponded to the rainy areas with a high year-round temperature.  He suspected it could be caused by some sort of viral infection.  He first reported in the British Journal of Surgery in 1958, the tumor now bears his name.

On March 22, 1961 Dr. Burkitt returned to England and gave a talk about his findings in Africa at a medical school in London, Dr. Michael Anthong Epstein was among the audience.  After the talk Dr. Epstein asked Dr. Burkitt to send him the tumor samples so he could do further research. 

Dr. Michael Anthony Epstein

Dr. Epstein has worked on Rous sarcoma virus.  Dr. Rous was the first one to discover a virus (now bears his name) can cause cancer in chicken, whereas EBV was the first virus known to cause cancer in human.  Dr. Rous was in his 80s when he was awarded a Nobel Prize in 1966, 40 years after his discovery.

Dr. Yvonne Barr joined Dr. Epstein in her PhD study.  There are numerous others, including several distinguished American virologists, made contribution in establishing EBV as the culprit in causing Burkitt lymphoma; an oncogene was also identified.  The intriguing course of discovery is beyond the scope of this writing.

Dr. Yvonne Barr

The virus was christened as Epstein-Barr virus in 1965.  The historical paper was published in Lancet (3/28/1964) with a title of “Virus particles in cultured lymphoblasts from Burkitt Lymphoma”.  Actually, Dr Burt Achong was also the co-author, but, poor Dr Achong, his name was somehow dropped at the naming of the virus and forgotten, except by a history buff like me. Dr Achong was a pathologist, using electron microscope to identify the virus.

There is an article in New England Journal of Medicine (NEJM) with a title of Hodgkin's lymphoma after infectious mononucleosis, in which it states there is casual connection between mononucleosis and Hodgkin’s lymphoma.

The evidence is that 40-50% of the Reed-Sternberg cells (the hallmark of Hodgkin’s lymphoma, 我看連退休或生銹的婦產科醫師都還記得) contain Epstein-Barr virus antigen.  And those patients did have history of mononucleosis.  The median interval between getting mononucleosis and the onset of Hodgkin’s lymphoma is only 4.1 years.

Dr. Burt Achong

Fortunately in this report among the 38,000 patients with mononucleosis, only 29 cases of Hodgkin’s lymphoma discovered.  Still some uncertainty present, as only one third of the adolescents with Hodgkin’s lymphoma with Reed-Sternberg cells containing EBV; so there is still much we don't know.

It is regrettable that none of these four British doctor-scientists was honored with Lasker awards ("American Nobel"), I think this an oversight.

EBV is also implicated in causing chronic fatigue syndrome; that calls for another post.

治療 Alzheimer’s disease 的藥沒有突破

Bapineuzumab 這藥是愛爾蘭的 Elan 藥廠發展的、美國 Wyeth 藥廠投資買了所有權（Wyeth 藥廠後來被 Pfizer 併吞），後來 Johnson & Johnson 也怕吃不到甜頭，也投資於 Alan 藥廠。

Bapineuzumab binds to beta-amyloid, leading to its removal.  這十幾年期間做了好幾個studies/trials. 有時候看來好像有效, 藥廠股價就上漲。如2008年的六月； Wyeth 藥廠股票上升4.83%. (我相信這藥是當年 Pfizer 買 Wyeth 的原因之一；另一個藥是 Prevnar 13; I hope you guy have received Prevnar 13 vaccine).

但是對同一個 study/trial 再仔細分析同一 data, 一個月後 （2008 年七月底）又宣布無效且有很不好的副作用； 當天Wyeth 股價降12%; Alan 降42%。

一個藥有沒有效是一個大學問；在網路上流傳的妙方的問題大都出在這點。這也是兩派無法溝通的主因。因為網路上流傳的文章說有效（我看起來是「有笑」， I mean 「好笑」）。

Katy 的一個高中同學的兒子以前來苉大念了五，六年拿到生物統計的博士；現在在FDA 工作；去年九月我們有去看他；他説像他這樣的人才，FDA有近300 人；當時我們也有去看一個以前在苉城的好友，他們的女婿是FDA 的 statistics 部門的 director; 他是數學博士。Katy 一個朋友的丈夫以前在田那西大學當統計學教授；後來也去New Jersey Roche 藥廠工作。Katy 同學的兒子說，FDA 若增加 統計的人員，藥廠就相對的增加。以毒攻毒。

我沒有辦法告訴你藥有沒有效是怎麼決定的，因為我自己也不知道。但是我知道藥廠及 FDA 是怎麼知道的。

這期間 Eli Lilly 也發展他們自己的藥叫solanezumab (跟 Pfizer 的 bapineuzumab 很類似；其命運也大同小異 （可說是同病相憐）只是一切慢半拍而已. 2012 年Pfizer 心灰意懶開始想放棄時， Eli Lilly 還存一線希望繼續努力，2015 年七月還在說有 break through (突破），直到2016 年的11 月才正式宣布整個 project 泡湯 (went down the drain) 壽終正寢。

Scientific American （July 14, 2014) 有一篇文章叫 “Why Alzheimer’s drugs keep failing”; 因為他們的 editors 沒有在讀網路流傳的文章，不知道有那麼多的妙方。

為什麼會這樣呢？理論（theory) 多如牛毛；但最合乎常理的是：有Alzheimer’s disease 的人在臨床上開始有症狀的幾年甚或幾十年前就已經開始有那些 build up of beta amyloid plaque. 神経細胞可能早已受損害；所以現在把那些 beta amyloid plaque 除去也無濟於事了。 A doctor said “we are 25 years too late.”

幾乎所有專家都同意；腦部開始出現 beta amyloid 很多年後 （甚或幾十年後）才會開始有失智的症狀出現。因為已經証明有些人做那種特殊的 CT-PET scan 時發現有 beta amyloid build up, 但臨床上一切正常。

也是這個原因目前正常的人不應該做那種特殊的 CT-PET scan, 要不然萬一（其或然率是大大超過一萬分之一的）照出了  beta-amyloid plaque 的話, 不病死也會煩惱死了；especially we have nothing to offer, except red wine, 不過要全部靠紅酒可能要先醉死了。

If you still have energy and endurance to read (and you should as some said reading is better than red wine to prevent Alzheimer's disease), this is the link to the post I wrote nearly 4 years ago.)

http://doctorjytsai.blogspot.com/2014/02/what-disappointment-alzheimers.html