CONTACTS
0201 - Kaiser Permanente
020101 - Dr. Craig M. Boulris, M.D.; Orthopedic Surgeon
020102 - Orthopedic Department
SUBJECTS
Medical, Kaiser
Exam 990910 Knee Treatments
Medical History, Xrays Not Submitted for Meeting
Report Omits Medical History, New Therapies
Report Omits Prescription Glucosamine, Chontroitin
0807 -
0807 - ..
0808 - Summary/Objective
0809 -
080901 - Follow up ref SDS 8 0000, ref SDS 5 0000.
080902 -
080903 - Craig submitted a letter that largely repeats information in his first
080904 - report dated 990925. There is no analysis of possible causes for pain
080905 - in the right knee. New information indicates an MRI may be helpful.
080906 - It appears that medical history and the article on the 8 "new
080907 - therapies" have been reviewed, with minimal comment. Synvisc is the
080908 - only "new" therapy considered for treating my condition. Comments on
080909 - using Glucosamine and Chondroitrin are not clear. Research on the web
080910 - seems to support Craig's idea to use 1.5g per day. ref SDS 0 0546 The
080911 - Medical Letter seems to say Chondroitrin repairs cartilage and
080912 - inhibits enzymes that break down cartilage. ref SDS 0 5933
080913 -
080914 - [On 991018 submitted follow up letter. ref SDS 10 0001]
080915 -
080916 -
080918 - ..
0810 -
0811 -
0812 - Progress
0813 -
081301 - Received email ref DRT 1 0001 from Craig responding to ref DIP 17 0001
081302 - submitted on 991008, ref SDS 8 0001 asking for response to my letter,
081303 - ref DIP 15 0001 submitted on 990927, ref SDS 5 0001, which sets out
081304 - action items from Craig's report, ref DRP 15 0001, reviewed on 990925,
081305 - ref SDS 4 0001, for the meeting on 990910, ref SDS 3 0001
081306 -
081308 - ..
081309 - Medical History Reviewed, Found Not Material to Diagnosis
081310 -
081311 - Craig reports that relevant medical history was considered, that the
081312 - problem is not complicated, and does not require an extensive history
081313 - to make a diagnosis, ref DRT 1 6164, which reflects Richard's view on
081314 - 961222. ref SDS 1 0866
081316 - ..
081317 - This responds in part to record on 990925. ref SDS 4 6734
081319 - ..
081320 - It is always good practice to expressly cite the history reviewed in
081321 - order to establish what was considered.
081322 -
081323 - [On 991028 identified as issue for communication training.
081324 - ref SDS 12 4424]
081325 -
081327 - ..
081328 - Eight (8) New Therapies Reviewed
081329 -
081330 - Follow up ref SDS 4 2303, ref SDS 3 7802.
081331 -
081332 - Craig says cartilage replacement is not an option for my condition.
081333 - ref DRT 1 0161
081334 -
081335 - This may conflict with report on 990910 that pockets of cartilage
081336 - may be missing from the right knee, per below. ref SDS 0 1880
081338 - ..
081339 - Below, Craig proposes Synvisc. ref SDS 0 3942
081341 - ..
081342 - The report on 8 new therapies seems to indicate treatments for
081343 - "implants" and "plugs" which sound like cartilage replacement for
081344 - pockets of wear. ref OF 3 4968
081345 - ..
081346 - He advises that treatments in the article, ref OF 3 0001, that
081347 - he does not comment on are either not treatments for the knee or not
081348 - relevant to the patient's problem. He reports that the article does
081349 - not present anything that has not been known for years. ref DRT 1 0161
081351 - ..
081352 - This responds in part to record on 990925. ref SDS 4 4955
081354 - ..
081355 - It is good practice to expressly cite a therapy and state why it is
081356 - not relevant or will not work, rather make sweeping generalizations.
081357 -
081359 - ..
081360 - Left Knee Has Greater Wear, Why is Pain in Right Knee Comparable?
081361 -
081362 - Follow up ref SDS 4 3088, ref SDS 3 1224.
081363 -
081364 - Craig says the amount of discomfort does not always equate to the
081365 - level of arthritis on an Xrays. Therefore, while your right knee may
081366 - at times or always hurt more than the left, your left knee xray may
081367 - appear to have more arthritic wear. This may be due to the exact
081368 - location of the wear. ref DRT 1 0001
081370 - ..
081371 - This responds to the question on 990925. ref SDS 4 3088
081373 - ..
081374 - Do the diagrams Craig prepared on 990910 explaining "pockets" of
081375 - cartilage damage relate more to the right knee, ref SDS 3 7872, which
081376 - seems to have pain comparable to the left knee. ref SDS 3 1224
081378 - ..
081379 - If that were true, would cartilage replacement be an option?
081381 - ..
081382 - Would an MRI or similar techniques help address this issue? see below
081383 - discussion on Synvisc. ref SDS 0 3942
081384 -
081385 - [On 991018 article indicates MRI might be helpful. ref SDS 10 4620]
081386 -
081387 - [On 991028 doctor says MRI not helpful in this case. ref SDS 12
081388 - 5820]
081389 -
081390 -
081391 -
081392 -
081393 -
0814 -
SUBJECTS
Cortisone
Pain, Swelling Avoidance, Motrin, Tylenol
1004 -
100501 - ..
100502 - Cortisone and Other Pain Relief Treatments
100503 -
100504 - Follow up ref SDS 4 3955, ref SDS 3 5394.
100505 -
100506 - Craig relates national standard methods of initial conservative
100507 - treatments for pain relief, which repeat information in his report on
100508 - 990925. ref SDS 4 4524 He says...
100509 -
100510 - Tylenol and anti-inflamatory pills (motrin, ibuprofen, etc.),
100512 - ..
100513 - Activity modification (avoiding aggravating activities),
100514 - ref DRT 1 0330
100516 - ..
100517 - Craig advises that, if conservative measures fail, e.g., pain relief
100518 - and alternative supplements like Glucosamine, then cortisone injection
100519 - is a viable option because, while it does not cure the problem, it
100520 - decreases swelling and therefore decreases pain. ref DRT 1 3077
100522 - ..
100523 - Craig uses cortisone regularly when conservative measures fail, which
100524 - is noted in my letter on 990927, ref DIP 15 3536, citing the record on
100525 - 990910, ref SDS 3 5394, that the initial aim is to avoid further
100527 - ..
100528 - My letter on 990927, ref SDS 5 0001, recognized these points about
100529 - pain relief, including cortisone, ref DIP 15 3536, and requested
100530 - support for trying Glucosamine treatment, ref DIP 15 7455, in
100531 - accordance with the record on 990925. ref SDS 4 3955 and ref SDS 4
100532 - 3120
100533 -
100534 -
100535 -
100536 -
1006 -
SUBJECTS
Exercise, Weight, Biking, Swimming
Strength Relieves Stress on Knee Joints
Neoprene Brace
1505 -
150601 - ..
150602 - Weight Control and Exercise, Biking and Swimming
150603 -
150604 - Craig says exercise to maintain strength and keep weight down (low
150605 - impact exercises like biking, swimming are preferred), ref DRT 1 0738,
150606 - which reflects information discussed on 990910. ref SDS 3 9633
150608 - ..
150609 - Research on the web today yielded recommendation to use Glucosamine,
150610 - ref SDS 0 0900, and to exercise. ref SDS 0 9066
150612 - ..
150613 - The letter to Craig on 990927, ref DIP 15 2955, reported biking is
150614 - being tried. ref SDS 5 0001]
150616 - ..
150617 - Craig confirms instructions in his report on 990925, ref SDS 4 4524,
150618 - that a neoprene brace can help. ref DRT 1 7304
150619 -
150620 -
150621 -
150622 -
150623 -
1507 -
SUBJECTS
Synvisc Injection Therapy
1603 -
160401 - ..
160402 - Hyaluronic Acid Treatment with Synvisc
160403 - Synvisc Questions Not Addressed by Kaiser
160404 -
160405 - Follow up ref SDS 4 2275, ref SDS 3 7802.
160406 -
160407 - Craig says Synvisc is an option, although the rate of success for this
160408 - treatment has not been as high as he would like to see. ref DRT 1 3079
160410 - ..
160411 - A specific "rate of success" is not presented, e.g., 4 in 10, 50 in
160412 - 80, 5,000 in 7600, which conveys the level of confidence warranted by
160413 - any "rate." Is rate is based on use at Kaiser nation-wide, the Walnut
160414 - Creek hospital, Craig's personal practice, or some source? How do
160415 - rates of success vary according to age, degree and type of arthritic
160416 - condition? Is Craig thinking about both knees, the right or left,
160417 - which he indicates today have different types of problems. ref DRT 1
160418 - 0001
160420 - ..
160421 - Prior questions on Synvisc in the record on 990925, ref SDS 4 2275,
160422 - requested in the letter, ref DIP 15 0001, submitted on 990927,
160423 - ref SDS 5 0001, are not addressed by Craig's letter today.
160424 -
160425 -
160426 -
160427 -
160428 -
1605 -
SUBJECTS
Glucosamine Chondroitin
1703 -
170401 - ..
170402 - Glucosamine May Improve Osteoarthritis, Need Prescribed Usage
170403 -
170404 - Follow up ref SDS 4 3120.
170405 -
170406 - On 990925 Craig's report explained Glucosamine, but not Chrondroitin,
170407 - and did not suggest a treatment plan. ref SDS 4 3120
170409 - ..
170410 - Craig says in his letter today consider Glucosamine 1.5g per day.
170411 - Glucosamine is not a drug, is not regulated by the FDA, does not
170412 - require a prescription to purchase and can be bought in any drug
170413 - store, supermarket, Costco, via mail, etc. ref DRT 1 4118
170414 -
170415 - [On 991026 Don Harms is taking Glucosamine Chondroitin in this
170416 - approximate dosage. ref SDS 11 3392]
170418 - ..
170419 - Below, research on the Internet yielded information that seems to
170420 - align somewhat with 1.5g per day. ref SDS 0 9066 The Medical Letter
170421 - reviews studies where patients take 500 mg three times a day.
170422 - ref SDS 0 6922
170424 - ..
170425 - Craig's letter therefore addresses only part of the request in the
170426 - letter, ref DIP 15 7455, submitted on 990927, ref SDS 5 0001, for
170427 - guidance on using Glucosamine from review of Craig's report on 990925.
170428 - Craig's letter today does not say anything about treatment using
170429 - Glucosamine in combination with Chondroitin which is cited in his
170430 - report on 990925. ref SDS 4 3120 Since research today shows
170431 - Chondroitin is the ingredient that accomplishes repair and deters
170432 - further ware, and since Glucosamine, by itself, is attributed with
170433 - only reducing pain, per below, ref SDS 0 5933, additional comment is
170434 - needed on this issue.
170436 - ..
170437 - Millie and I were at Costco on Saturday, 991009. We looked for
170438 - Glucosamine and Chondroitrin. There is a large section on these
170439 - products offering each separately and in combination. The amounts or
170440 - dosages in each pill seemed to vary, however, print was so small that
170441 - it was difficult to compare everything, since we did not have a
170442 - magnifying glass.
170444 - ..
170445 - Since we did not have instructions from Kaiser on how to proceed, per
170446 - above, ref SDS 0 6534, we bought a combination pill.
170447 -
170448 - [On 991018 sent letter requesting guidance from Kaiser.
170449 - ref SDS 10 0836]
170450 -
170451 - [On 991028 Kaiser does not answer this question. ref SDS 12 4617]
170452 -
170454 - ..
170455 - Vendor:
170456 -
170457 - Shiff Products, Inc.
170458 - Salt Lake City, UT 84104
170459 - 800 526 6251
170460 -
170461 - [On 991026 Don Harms is taking Glucosamine Chondroitin.
170462 - ref SDS 11 3392]
170463 -
170465 - ..
170466 - Glucosamine Complex.......... 500 mg
170467 -
170468 - Glucosamine hydrochrolide
170469 - N-Acetyl D-Glucosamine
170470 - Glucosamine sulfate (potassium salt)
170472 - ..
170473 - Chondroitrin Sulfate..........400 mg
170475 - ..
170476 - Other ingredients:
170477 -
170478 - Cellulose, coating (titanium dioxide, dextrose,
170479 - hyudroxypropyl methelcellulose, polyethelyne glycol,
170480 - sodium carboxymethyl cellulose, mineral oil, sodium
170481 - citrate, polysorbate 80 and dextrin), copolyvidone,
170482 - silicon dioxide, and magnesium stearate.
170483 -
170485 - ..
170486 - Directions say...
170487 -
170488 - As a dietary supplement take one (1) caplet with meals (3) times
170489 - daily.
170490 -
170491 - Question... does
170492 -
170494 - ..
170495 - 3 x 500 mg = 1,500 mg = 1.5g
170496 -
170498 - ..
170499 - Seems like it might, based on review of web site below where a lay
170500 - person, or salesman, proposes dosages. ref SDS 0 9066
170502 - ..
170503 - Aligns with dosage cited in Medical Letter. ref SDS 0 6922
170505 - ..
170506 - Would like to get Craig, or someone responsible with expertise to
170507 - provide guidance on Glucosamine and Chondroitrin in the same way that
170508 - doctors tell patients to take two aspirin twice a day, or 1 aspirin
170509 - every 3 hours for 4 days, etc.
170511 - ..
170512 - Is the stuff we bought the right thing? ref SDS 0 4940 If not, what
170513 - should we buy?
170514 -
170515 - [On 991018 submitted letter to Kaiser on this. ref SDS 10 0001]
170516 -
170517 - [On 991028 Kaiser does not answer this question. ref SDS 12 4617]
170518 -
170520 - ..
170521 - Research on Internet Yielded Information on Usage
170522 -
170523 - Searching for "Glucosamine" found....
170524 -
170525 - http://www.glucosamine-arthritis.org/
170527 - ..
170528 - ...which is an....
170529 -
170530 - Arthritis & Glucosamine Information Center
170531 -
170532 - ....with helpful research and details on medications and treatments,
170533 - and tips for managing pain.
170535 - ..
170536 - This addresses issues raised by the report Doctor Boulris at Kaiser
170537 - submitted on 990925. ref SDS 4 3120
170539 - ..
170540 - Following the research yielded....
170541 -
170542 -
170543 - Cush's Osteoarthritis & G/CS Page
170544 -
170545 -
170546 - ...at following address...
170547 -
170548 - http://pages.prodigy.net/cushman4/index.htm
170550 - ..
170551 - This appears to be information provided by a lay person who reports
170552 - success using Glucosamine and Chondroitrin. ref OF 6 0001
170553 -
170554 - This person was 50 in 1995. His knees ached all the time, and
170555 - exercise caused sharp pains and irritated them a lot. Standing
170556 - and sitting hurt his knees. All night in bed they hurt. There was
170557 - trouble standing up in the morning. Stairs hurt my knees a lot,
170558 - especially going down. ref OF 6 0002
170560 - ..
170561 - Improvement beginning in March 1997 after taking GS in combination
170562 - with shark cartilage was very noticeable within days. Pain from
170563 - hiking up mountains subsided. ref OF 6 9066 and ref OF 6 4899
170565 - ..
170566 - Results should be recognized within at most 60 days. ref OF 6 4971
170568 - ..
170569 - Glucosamine must be taken "forever." ref OF 6 5000
170570 -
170571 - Contra indications list limitations on taking shark cartilage.
170572 - ref OF 6 2099
170573 -
170574 - This patient seems to take a range of other medications, so it
170575 - is difficult to attribute reduced knee pain. ref OF 6 4933
170576 - ..
170577 - Exercise is strongly recommended, ref OF 6 3966, which
170578 - supports Craig's ideas. ref SDS 0 9588
170580 - ..
170581 - Type and level of exercise is suggested. ref OF 6 5152
170583 - ..
170584 - Consult doctor to approve exercise regimen. ref OF 6 4866
170585 -
170587 - ..
170588 - On May 16, 1999 degeneration in knees was completely stopped.
170589 - After getting worse for years, knees started getting gradually
170590 - better after taking Glucosamine Sulfate with Shark cartilage.
170591 - Improvement leveled off, but knees did not get worse. Patient now
170592 - lives with a certain amount of discomfort and soreness in knees,
170593 - that is minor compared to condition prior to taking Glucosamine.
170594 - ref OF 6 5840
170596 - ..
170597 - The age is the same, but the symptoms are more severe than I have
170598 - experienced so far, since my knees only hurt after exercise, as
170599 - reported on 990625. ref SDS 2 4420
170601 - ..
170602 - Dosage based on weight is...
170603 -
170604 - Under 120 lbs: 1,000 mg GS (or GHCL) and 800 mg CS
170605 -
170606 - Bet. 120 and 200 lbs: 1,500 mg GS (or GHCL) and 1,200 mg CS
170607 -
170608 - Seems to align somewhat with Craig's letter received
170609 - today, per above. ref SDS 0 3120
170611 - ..
170612 - Seems to align with research in Medical Letter.
170613 - ref SDS 0 6922
170615 - ..
170616 - [On 991026 Don Harms is taking Glucosamine Chondroitin.
170617 - ref SDS 11 3392]
170619 - ..
170620 - Over 200 lbs: 2,000 mg GS (or GHCL) and 1,600 mg CS
170622 - ..
170623 - ... as shown in frequently asked questions. ref OF 6 7905
170625 - ..
170626 - The author says he is not selling a book on using Glucosamine, however
170627 - the tenor of the narrative supports a conclusion this person has a
170628 - financial interest in promoting a book, Glucosamine and other
170629 - products. This does not mean recommendations are incorrect, but...
170630 -
170631 - ...we need professional opinion on recommendations.
170632 -
170633 -
170635 - ..
170636 - Medical Letter: Glucosamine Might Be Effective for Arthritis
170637 -
170638 - Another web page seems to be a professional medical publication...
170639 -
170640 -
170641 - The Medical Letter
170642 -
170643 -
170644 - ...is described as a highly respected independent, nonprofit,
170645 - peer-reviewed newsletter intended mainly for physicians. (The fact
170646 - that a physician subscribes to it should be regarded as a sign of good
170647 - judgment.), ref OF 8 4620
170648 -
170649 - [On 991125 sent notice to Steve. ref SDS 13 7654]
170651 - ..
170652 - On 970926 The Medical Letter published an article on page 91 - 92 with
170653 - the title...
170654 -
170655 -
170656 - Glucosamine for Osteoarthritis
170657 -
170659 - ..
170660 - ... ref OF 8 0001, the home page for The Medical letter is at...
170661 -
170662 - http://www.medletter.com/
170664 - ..
170665 - However, access to the article from this location is only available to
170666 - annual subscribers.
170668 - ..
170669 - An alternate route to the document is through...
170670 -
170671 - http://www.quackwatch.com/
170672 -
170673 - ...which is described as....
170675 - ..
170676 - Your Guide to Health Fraud, Quackery,
170677 - and Intelligent Decisions
170678 -
170679 - Operated by Stephen Barrett, M.D.
170680 -
170682 - ..
170683 - This site has a listing, which opens the letter on Glucosamine at...
170684 -
170685 -
170686 - http://www.quackwatch.com/01QuackeryRelatedTopics/DSH/glucosamine.htm
170687 -
170689 - ..
170690 - However, we do not seem to be able to open the web page independently.
170692 - ..
170693 - The Medical Letter says...
170694 -
170695 - In vitro, glucosamine stimulates cartilage cells to synthesize
170696 - glycosaminoglycans and proteoglycans [1]. In animal models, oral
170697 - glucosamine sulfate has a beneficial effect on inflammation,
170698 - mechanical arthritis and immunological-reactive arthritis, but
170699 - much less that of indomethacin (Indocin and others), ref OF 8
170700 - 0599
170701 -
170703 - ..
170704 - Pain Relief Comparable to Ibuprofen (Motrin, Others)
170705 - 500 mg 3 times a day = 1.5g per day???
170706 -
170707 - In short-term controlled trials, glucosamine has been reported to
170708 - be effective in relieving pain and increasing range of motion in
170709 - patients with osteoarthritis [3]. One four-week double-blind
170710 - trial in 252 patients with osteoarthritis of the knee found oral
170711 - glucosamine sulfate 500 mg three times a day more effective than
170712 - placebo in relieving symptoms [4]. ref OF 8 0526
170714 - ..
170715 - This seems to be the 1.5g cited by Craig in his letter today.
170716 - ref SDS 0 3120
170718 - ..
170719 - Studies on Glucosamine only report pain relief. There is no
170720 - mention of regenerating depleted cartilage, nor of preventing
170721 - further wear.
170723 - ..
170724 - Chondroitin maintains viscosity in joints, stimulate cartilage
170725 - repair mechanisms and inhibit enzymes that break down cartilage.
170726 - ref OF 8 2058
170727 -
170728 - [On 000124 Doctor Vincent Yamamoto at Kaiser uses Glucosamine
170729 - and Chrondroitin and reports success in treating knee pain,
170730 - but no restoration of cartilage. ref SDS 14 1680]
170732 - ..
170733 - [On 030807 case study shows personal history using liquid
170734 - Glucosamine Chondroiten and clincial research. ref SDS 15
170735 - FN9N
170737 - ..
170738 - [On 040529 0248 report that Glucosamine Chondroitin in liquid
170739 - form relieved knee pain from hiking 3 - 10 miles per day.
170740 - ref SDS 16 MN9P
170742 - ..
170743 - This suggests that Glucosamine must be used with Chodroitin in
170744 - order to achieve the objective set on 990910 of avoiding further
170745 - knee joint deterioriation, ref SDS 3 5394. The objective was
170746 - confirmed in the letter ref DIP 15 3536 submitted to Craig on
170747 - 990927, ref SDS 5 0001, which cites the record on 990925 showing
170748 - patient goal to address cause of knee joint deterioriation,
170749 - ref SDS 4 3955, and sets plan to use Glucosamine with Chondroitin
170750 - based on treatment plan from medical professional. ref SDS 4 3120
170752 - ..
170753 - None of the studies seem to address this issue.
170755 - ..
170756 - Quantities do not seem to be mentioned for Chontroitin used
170757 - with Glucosamine, which is also not prescribed by Craig, per
170758 - above. ref SDS 0 3120
170759 -
170760 - [On 991026 Don Harms is taking Glucosamine Chondroitin.
170761 - ref SDS 11 3392]
170762 -
170763 -
170764 -
170766 - ..
170767 - Glucosamine Generally Well Tolerated
170768 -
170769 - Gastrointestinal discomfort and nausea have been reported, but
170770 - the incidence was no higher than with placebo. One Medical Letter
170771 - consultant in a area where many patients are taking glucosamine
170772 - has not detected any adverse effects. ref OF 8 1764
170774 - ..
170775 - [On 991026 Don Harms is taking Glucosamine Chondroitin.
170776 - ref SDS 11 3392]
170777 -
170778 -
170779 -
170780 -
170781 -
1708 -
SUBJECTS
Debridement, Arthroscopic
Knee Replacement
1904 -
190501 - ..
190502 - Knee Replacement Strong Possibility in Future
190503 - Debridement Interim Alternative to Knee Replacement
190504 -
190505 - Follow up ref SDS 4 2951.
190506 -
190507 - Craig says Arthroscopy and washing out the knee can be performed
190508 - although results are variable in success and usually only temporary.
190509 - Eventually if pain and loss of function get bad enough (can't walk
190510 - five blocks) a total knee replacement can be performed. ref DRT 1 0778
190511 -
190512 -
190513 -
190514 -
190515 -
190516 -
1906 -
Distribution. . . . See "CONTACTS"