SUMMER 2006 Keli’s story: returning from weakness and pain Keli Roberts had achieved everything “By this time, I was working com- moving a little bit. Even though I was she’d aimed for and more. She left pletely for myself,” she said. “The just fussing over a bunch of potted the life of a model and actress in thought of having no income was plants, their growth encouraged me.” Australia and Europe to become a fit- devastating. I didn’t know how I was Keli had already adopted a healthy ness instructor in this country. Her going to get through it.” Keli’s mus- diet: “I was used to eating fresh fruit love of hard physical training and cles responded well to prednisone and vegetables, lean meat and fish, teaching were well received by some and she dreamed of regaining a nor- whole grains and low-fat dairy prod- of Hollywood’s most visible celebri- mal life. “All my clients except one ucts,” she said, “so I just kept that ties. Soon she was lead- were understanding and up.” She took a great many warm ing Nicole Kidman, made temporary arrange- baths, began exercising under water, Beverly Johnson, Lauren ments until I could heal,” and walked, slowly at first, then Hutton and Jennifer Gray she said. Along with increasing the distance and speed. in routines designed for improving her strength, Finally, she began riding her bike. “I strength and agility. prednisone made her slowly came back,” she said. “It was Other celebrities, like dizzy and sick, so she several months, and I didn’t force Cher, Kirsty Alley, avoided the weight gain. anything, but I knew I had to make Jennifer Jason Lee, Susan The medication also spun progress.” Dey and Faye Dunaway, her into a manic episode: Keli’s stature in her profession hired her as their person- “I was in a psych ward was such that she was hired by manu- al trainer. She made a for several days,” she facturers of fitness equipment to train video with Cher and its said. “It may have been a Keli Roberts, DM patient other trainers in the use of new prod- success led to a series of blessing in disguise, as I ucts. This new career focus has sent videos on her own. It seemed like had struggled with highs and lows all her all over the world, and she’s nothing could stop her from living my life.” Once released, shaken by developed many programs to provide the dream she’d had as a young ath- all that had happened to her, she continuing education credits in step lete growing up in Australia. forced herself not to worry so much training, kickboxing, circuit training, and to concentrate on small things She did notice an increasing array sports conditioning, indoor cycling, she could do. of aches and pains. “It seemed pretty dumbbell training, body bar training, normal, given my profession,” Keli “It’s amazing how accomplishing core training, rubber resistance train- recalls. She’d been warned for years one practical thing can make you feel ing and medicine ball training. She’s that her blood tests indicated a great better when you’re sick,” Keli said. written manuals on rubber resistance deal of inflammation but, fueled by “In my case, finding a roommate, training and teaches people with ambition, the sheer love of her cho- though it didn’t solve all my prob- rheumatoid arthritis and fibromyalgia sen field and lots of Aleve, she lems, at least made me feel I was how to use this type of training to worked through the pain. One day in moving towards solutions.” Keli relieve pain and avoid stress on joints 1999, she was no longer able to. “In spent several months recuperating, and muscles. fact, I could hardly move,” she said. finding satisfaction in tiny bits of She’s had to teach herself how to She agreed to the tests her doctor had progress. “I moved as much as I avoid flares. “I still have them,” she been suggesting and, after a biopsy, could, in a gentle way,” she said. A said. “Each time I make a new kick- was diagnosed with polymyositis. small balcony garden flourished boxing video, it seems to trigger a Her symptoms were very severe, under her attention. “I began to take flare.” Then there’s her new sport, including trouble breathing as well as great joy in my gardening efforts,” moving. she said. “At least I was outdoors and See Keli’s story on page 5 Published by: TMA, Inc. TMA advocates for IVIg THE MYOSITIS ASSOCIATION 1233 20th Street, NW, Suite 402 reimbursement, patient registry Washington, DC 20036 Advocacy is a term often used but represented diseases get a dispropor- P: 202-887-0088 little understood. It means being an tionate share of federal research P: 800-821-7356 advocate for your cause and trying to funding and as for those who have F: 202-466-8940 persuade others to your point of myositis “we just want help for peo- Email: [email protected] view. The crisis that has developed ple who desperately need it …. In Web: www.myositis.org for those needing IVIg therapy to the end, it’s about justice and fair- Executive Director: Bob Goldberg treat myositis and other autoimmune ness.” Editors: Theresa Reynolds Curry, Kathryn Spooner diseases has created a great many Through our advocacy efforts and advocates as this crisis has worsened the assistance of persons such as BOARD OF DIRECTORS over the past 18 months. Fabio who can garner media atten- Janet C. Schuler, Chair TMA, along with other autoim- tion, we are working to secure feder- Jay C. Shinn, Vice Chair mune disease organizations, is cur- al funding and create greater aware- Janice Goodell, Vice President rently having a letter circulated in ness of myositis. Richard G. Stevenson Jr., Vice President Congress that would request the Sharon K. Weber, Secretary Secretary of the U. S. Department of Subscribe to IG Living Health and Human Services to Andrea H. Macher, Treasurer IG Living is a magazine for patients declare a public health emergency Sandra Dunphy who use immune globulin products with regard to IVIg reimbursement and their care providers. Keith John Merritt through the Medicare and Medicaid Chester V. Oddis, MD programs. This would restore previ- Regular features include such top- ous rates of reimbursement until ics as product and manufacturer MEDICAL ADVISORY BOARD there was a determination made as to news, resources for healthy living, Richard Barohn, MD, Chair the impact of the reimbursement immune globulin treatment options, reimbursement and clinical trials. 2 Lisa Rider, MD, Vice Chair changes that took place in 2005 and Anthony A. Amato, MD the effects they have had on the IG Living is a community service provided by FFF Enterprises and its Valerie Askanas, MD, PhD availability and distribution of immune globulin products. TMA has specialty pharmacy services division, Walter Bradley, DM, FRCP asked its members to urge their NuFACTOR, free of charge to those Marinos Dalakas, MD Member of Congress to sign onto the living in the United States. Proceeds W. King Engel, MD IVIg “Dear Colleague” letter. For from advertising go to national Michael Harris-Love, PhD further information, contact TMA at patient organizations whose con- Ingrid Lundberg, MD 1-800-821-7356 or stituents receive immune globulin Frederick W. Miller, MD, PhD [email protected]. therapy. Chester V. Oddis, MD TMA is also advocating for fund- To subscribe, visit Lauren Pachman, MD ing from Congress to provide for a www.IGLiving.com; or call 800-843-7477 x1143. Lawrence H. Phillips II, MD myositis patient registry and surveil- lance survey. These will help estab- Ann Marie Reed, MD lish a more accurate picture of the Rup Tandan, MD, FRCP Fabio to speak at Capitol Hill number of those who have myositis, event Victoria P. Werth, MD their demographics, and treatments On September 21, Myositis Robert L. Wortmann, MD being used. Awareness Day, TMA will be hosting STAFF TMA, like many organizations an event on Capitol Hill in Theresa Curry, Communications Manager that represent rare diseases, faces the Washington, DC, to celebrate challenge of getting Congress and Myositis Awareness Day and recog- Bob Goldberg, Executive Director the public to focus on their disease. nize the efforts of those who are Jami Latham, Operations Manager Referencing this challenge, Bob working to increase public knowl- Beverly Posey, Office Assistant Goldberg, TMA’s Executive Director, edge and awareness of the myositis Kathryn Spooner, Programs Manager was quoted in IG Living!, a new pub- at the federal level. A proclamation, lication for those who use IVIg, say- introduced in Congress by MAA Founder: Betty Curry ing that the more common and better See TMA advocates on page 3 ASK THE DOCTOR Rash differs according to skin color TMA often hears from people wanting red-purple or lilac color similar to appears on the face, chest and hands to know why their rash doesn’t look that of the red-purple heliotrope flow- of the Hispanic woman, available free like the photos in the doctor’s office er (a dermatomyositis rash affecting of charge at www.jfponline.com. or the rash of another dermatomyosi- the eyelids is often referred to as the tis patient in their support group. “heliotrope rash”). Sun intensity influences dis- Some members have told us they did- In individuals having racially or ease type n’t even know they had a rash until ethnically determined more heavily Dermatomyositis is more common in their doctor found it. Often, these are pigmented skin such as latitudes with high UV intensity. A patients with darker skin pigments Blacks/African Americans and study led by TMA Medical Advisor that make the rash less visible. We Hispanics/Latinos, the red-purple skin Fred Miller, MD, PhD, analyzed clin- asked Dr. Richard Sontheimer, derma- color of dermato- ical data and, where possible, blood tologist, TMA medical myositis skin inflam- samples from 919 DM and PM advisor and professor mation can be absent patients. Statistical analyses of weath- at the University of altogether or difficult er and patient data spanning more Oklahoma, what the to see by both the than 10 years revealed a very strong typical rash would patient and the doctor. positive correlation between UV look like on an This occurs as a result intensity and the proportion of DM African-American DM of the masking effect patients at a given referral center. In patient. on red color produced fact, the results reveal the strongest by blood vessel correlation ever shown between UV DR. SONTHEIMER: changes in the under- light and any human disease. Among This seemingly lying dermis by the the 15 locales studied, the lowest pro- straightforward ques- higher level of brown portion of myositis patients with DM tion has a complex answer. First of melanin pigment in the overlying epi- was found in Glasgow, Scotland 3 all, the rash of dermatomyositis dermis. When visible, the color (26.7%), and the highest was found in results from changes that come from change of dermatomyositis in more Guatemala City (83.3%). damage to the tiny blood vessels in darkly pigmented individuals is often    the underlying dermal layer of the perceived as a dull red or red-brown skin. An example of these blood ves- color. sel changes can be seen in individuals TMA advocates, having a light complexion by observ- Skin rash in an Hispanic continued from page 2 ing the small blood vessel abnormali- woman: a case study ties that are often visible to the naked In the October 2005 edition of The Representative Steve Israel, to declare eye in the nailfold skin immediately Journal of Family Practice, Jamie September 21 National Myositis surrounding the fingernails. The skin Goodall, MS, and Richard P. Usatine, Awareness Day is expected to be color caused by the degree of ethni- MD, of the Health Science Center at passed this summer. The Capitol Hill cally or racially determined melanin San Antonio, describe a 48-year-old event will honor those in Congress pigment obviously affects the visibili- Hispanic woman who came to their who have assisted with this proclama- ty of the blood vessel changes in clinic as a new patient with a rash tion and the other TMA legislative other areas of skin commonly affect- that appeared on her face three efforts focused on IVIg reimburse- ed by dermatomyositis. months before and had recently ment and increased funding for The degree of darkness of normal spread to her chest and hands. It research related to myositis. Fabio, healthy skin is due to the amount and itched occasionally and seemed to renowned male model and actor, will distribution of melanin pigment in the worsen after exposure to the sun. The be speaking on this occasion to thank overlying epidermal layer of the skin. woman also had been feeling very those who are helping and to encour- In individuals having racially- or eth- weak, with difficulty brushing her age the media to provide more cover- nically- determined lightly pigmented hair, rising from a seated position and age of rare diseases such as myositis. skin, the rash of the dermatomyositis climbing up stairs, and was diagnosed Further information about this resulting from blood vessel changes with dermatomyositis. The authors event will be available in August. in the underlying dermis appears as a publish photographs of the rash as it    How does your doctor diagnose inflammatory myopathy? By Lawrence H. Phillips, II, MD cian is trained to recognize the signs found, it is an important clue that T.R. Johns Professor and Vice-Chair and symptoms of muscle malfunction. something is wrong with muscle. A of Neurology, University of Virginia The main symptom of muscle dis- number of other blood tests may be ease is, of course, weakness. In done to determine whether or not patients with myositis, we have other diseases that may produce sec- If you have read any of the Sherlock learned that not ondary damage Holmes mysteries, you have had a all muscles in the to muscles are glimpse into the way physicians make If you have read any of the body are affected present. diagnoses. Dr. Watson, the narrator of Sherlock Holmes mysteries, equally. For Although few the stories, often expresses awe at the example, certain you have had a glimpse into remember it seeming brilliance of Holmes’ obser- groups of mus- fondly, the elec- vations, but the great detective the way physicians make cles, such as the tromyogram explains frequently that his conclu- ones that we use diagnoses. (EMG) study sions are based on simple observa- to bend our fin- can provide par- tions and deductive reasoning. gers to make a fist, seem to be dispro- ticularly helpful information. This Medical diagnoses are made by portionately weak in inclusion-body study consists of two parts. The first this same process, and it is no coinci- myositis (IBM). Observation of is the nerve conduction study (NCS), dence that Sherlock Holmes weakness in finger flexor muscles is where recordings are made from employed this method. Sir Arthur thus an important clue to the possibil- nerves and muscles while small elec- Conan Doyle, Holmes’ creator, was a ity that a patient may have IBM. The trical shocks are applied to various physician, and he modeled the detec- neuromuscular physician assembles points along a nerve. The NCS is then tive’s character after that of one of his such observations (“findings” in med- followed by the EMG study, where a medical school professors ical speak, “clues” in fine needle electrode is inserted into 4 who was noted for his Holmes’ terms) to make various muscles. Those who have had ability to make bril- a tentative prelimi- this test (myself included) will recall liant diagnoses nary diagnosis. hearing a sound like static on a radio based on simple Once the pre- receiver during this test. There are observations in liminary diagno- patterns of electrical abnormalities in his patients. sis is made, a nerves and muscles that can indicate Physicians search for sup- the presence of an inflammatory dis- who care for porting evi- ease, and the physician who does the patients with dence test is trained to interpret them. myositis use the In recent years, physicians have process of deduc- learned that the appearance of the tive reasoning to muscles on magnetic resonance arrive at their diag- imaging (MRI) scans of a limb noses as well. begins. can provide evidence about mus- Although very few of Such evidence can cle disease. Increasingly, neuro- us are as consistently come from the results of a muscular physicians are perform- brilliant as Sherlock number of tests. Blood tests, in ing MRI scans on patients who are Holmes, the process of making a particular “muscle enzymes,” provide suspected to have myositis. This diagnosis most often begins with the important clues. The muscle enzymes study, too, can provide evidence collection of clues from the history of consist of proteins that exist in high about selective involvement of mus- the illness and observations from the concentrations in muscles. The main cles. physical examination. Although our one is creatine kinase, or CK. When Ultimately, a biopsy of one of the muscles make up a substantial part of muscle is damaged or degenerates, muscles is usually needed to make a our body mass, there are only a limit- muscles leak CK into the blood confident diagnosis. The information ed number of ways in which they can stream. In someone with myositis, the obtained from physical examination, produce symptoms when they mal- CK level in the blood may be elevat- blood tests, EMG, and MRI scans can function. The neuromuscular physi- ed, thus when an elevated CK level is suggest that the most likely diagnosis is a muscle disease, but there are cient to allow a confident diagnosis. Keli’s story, other diseases of the nervous system However the muscle sample is continued from cover that might produce similar abnormali- obtained, it is examined by a physi- ties. Since decisions about treatment cian who has special training in inter- something she truly loves, competi- hinge on having an accurate diagno- pretation of muscle biopsies. The tive cycling. “When I get myself in sis, the neuromuscular physician will muscle sample must be processed and shape for the season, it seems I can usually feel most confident when the stained with various chemical com- do it as long as I build myself up very evidence from a muscle biopsy is pounds before it can be interpreted gradually,” she said. “I am very, very available. under the microscope. The processing careful.” Keli does cyclocross, a com- Although the biopsy procedure can take a week or more, so the final bination of running, jumping and bik- requires removal of a piece of muscle, diagnosis from a muscle biopsy can ing, won the California-Nevada state it is really a rather minimal proce- be delayed. Occasionally, the infor- championship for women over 40, dure. A small piece of muscle is mation obtained on the biopsy is and competes at the national level. obtained by one of two methods. The inconclusive, and a second biopsy is This sport, which is held in the rain, most common one is done through a sometimes necessary. mud and snow, satisfies her competi- tive spirit as well as her desire to small incision (usually an inch or so) The neuromuscular physician will keep learning about herself. She finds in the skin over a muscle in the arm make the most accurate diagnosis the challenges of the rugged courses or leg. This is done through a patch of possible based on information from entertaining and fun. “I may not pace skin that has been numbed by local all of the sources described above. myself on the course, but I do after- anesthetic, so there is little or no dis- The process I have described is used wards,” she said. “I make sure I get comfort. As an alternative to the by neuromuscular physicians to make plenty of rest.” “open” procedure, some physicians diagnoses in other muscle diseases as will use a needle to obtain muscle tis- well, but it is particularly important in Keli Roberts will be at the Annual sue. This has the advantage of only the evaluation of a patient who may Conference in Orlando. For more requiring a small nick in the skin, but have some form of myositis. about Keli’s work, visit her web site the disadvantage is that the amount of at www.keliroberts.com.    muscle obtained is sometimes insuffi-    5 Gardens are therapy for mind and body There’s a story about a young Tibetan it gets a little colder, she advises “Native varieties won’t be as student complaining to his Buddhist moving the bowls to a porch if you stressed and will require a little teacher. No matter how he tried, the expect a night in the mid-20s. less maintenance,” Snyder said. young man couldn’t focus his Stori Snyder, assistant director of  Reap an edible harvest: A tomato thoughts enough to find the mix of the Hilltop Garden and Nature Center plant can grow well in a 5-gallon concentration and detachment neces- at Indiana University Bloomington, bucket. They come in many vari- sary for meditation. “Forget sitting on gives us some guidelines for getting eties, although compact varieties the floor and chanting,” the older started. grow better in containers and monk said: “Tend a garden.”  Prepare the containers: Punch require less staking. Snyder said That’s good advice for everyone. holes at the bottom for drainage cherry and pear tomatoes look Attention to minute detail, working and put in some rocks for the plant delightful in hanging baskets. with nature, and seeing tangible roots to wrap around. “The roots Tomatoes mature at different rates, results from physical labor is a com- don’t want to have wet feet, so to so gardeners might want to select bination that frees the mind and lifts speak,” Snyder said. Containers varieties that ripen at different the spirit now just as it has for cen- should be at least one size larger times or varieties that are indeter- turies. When space, energy, or physi- than the purchased pot size. minate, which means they ripen cal limitations interfere with tradition-  repeatedly until it becomes too al gardening, experts suggest contain- Feed the soil: Grow more plants cold. er gardening, an occupation that Keli in a small space by enriching your  Choose companions: Snyder said Roberts (see page 1) found soothing soil with manure, compost or gardeners should consider as well as just enough movement to humus. Buy a kit to test the researching “companion plants,” keep her flexible during a flare. composition of the soil to see if it needs which grow well together because “July is a great time to start a con- more nitrogen, one plant provides the soil with a tainer garden,” says Andre Viette, phosphorus nutrient the other plant needs host of the popular radio show, “In 6 or potassi- and vice versa. Carrots and the Garden.” “People worry about the um, which tomatoes are companion heat – but many of our annuals and are important plants, Snyder said, as vegetables originally came from nutrients for are roses and garlic. places that are extremely hot. You just plants. Basil and tomatoes are have to make sure your plants get Snyder a dynamic duo with enough water, which is much easier said it’s considerable aesthetic to do if they are in containers.” practically “a appeal. Snyder noted With new varieties of plants avail- given” that soil will that “they smell fan- able at nurseries, gardening has need compost or manure after sub- tastic” and the variety become an all-season hobby, said sequent plantings because plants of colors is interesting – yellow Meg Shelton of Shelton Herb Farm in always remove nitrogen from dirt. tomatoes and purple basil, for North Carolina. She has ideas for car- One way to improve the soil is to example. rying your fall garden over through add a scoop of compost to the hole  Grow your own seasoning: Herbs the winter. She encourages people to where you cover a plant. Feed the are good for container gardening grow their own supply of fresh salad plants again at least once during because compact herbs, such as greens for cutting all winter and well the growing season with a sprin- rosemary, lavender and thyme, can into spring. The trick is knowing what kling of compost or compost tea, grow in small spaces. Sage needs to plant, Shelton said. She chooses a which is compost steeped in water. a lot of space and should be in a lightweight bowl-style plastic pot to  container by itself. Mints, includ- plant in early winter, keeping the con- Buy local: Consider planting native varieties because they han- ing lemon balm, are invasive and tainers small enough so they’re easily dle your region’s climate better. should be planted in the ground or moved if the temperature plummets Local nurseries and county exten- in their own container. into the 20s. At her home near sion services can offer guidance.  Wilmington, she simply sets the Get blooms from your bulbs: Some herbs, such as mints, sage bowls under a table or hides them Bulbs planted in containers should and thyme, are hardier than others from the frost beneath a sheet. Where be brought inside after the green and grow back in the spring. leaves die back and the nutrients are stored in the bulb. They should Wheelchair Semi-Ambulatory Ground be dried and stored in a cool place Height 2-2.5 feet 2.5-3 feet .5-1 feet until next spring. Spring-blooming bulbs planted in yards should be Width (one-sided) 2 feet 2 feet 2 feet planted in the fall, while bulbs that Width (two-sided) 3-4 feet 4 feet 4 feet bloom in the summer can be plant- Diameter (circle) 3-4 feet 4 feet 4 feet ed in the spring.  Cultivate some climbers: Vines, Raised beds are generally 3-4 feet clematis and morning glories make “Products Extras” in the “My TMA” wide and as long as the landscape interesting container plantings and section of www.myositis.org. design allows, but depending on your require trellises or something else strength and endurance, Relf recom- to climb. Fall planting mends limiting the length of the bed Whatever you plant, you’ll need to be to 10 or 20 feet. There’s a wide Late summer is a perfect time to try aware of the plant’s requirements. choice of plants that can be used in out some annuals in your new contain- Plants in containers need to be planters, Relf said. Planters can be ers. Because you can control the shade watered daily during much of the built to be mobile to adjust to avail- and water conditions of your planters summer. Watering during the middle able sun or move out of the way. better than you can in your landscape of the day should be avoided, but border, you can benefit from lower Your containers will need full sun, whether watering in the morning or prices on the droopy, leggy plants now or at least six hours of sun a day. That evening is better is much debated. on sale at nurseries. Stock up on requirement goes up to 8-10 hours of Watering in the evening will avoid reduced-price annuals and perennials, sun if you’re growing vegetables. If scorching the leaves, while watering giving them a little extra care in full sun is not available, choose in the morning will avoid potential planters, and then making the decision shade-tolerant plants such as begonias growth of unwanted fungus on damp whether they will thrive under regular and impatiens. A water source should leaves, said Snyder, who chooses garden conditions. be nearby and the hose should be morning waterings. light and accessible. It may be worth Everyone wants to plant in the People recently disabled who have the investment to install automatic or spring, when nurseries are bulging 7 never gardened can find a new and trickle irrigation systems in perma- with fresh annuals and perennials. rewarding hobby, says Diane Relf, nent planters. Attachments that are an But in many places, fall is the PhD, HTM, veteran Horticulture pro- advantage for any gardener are an longest, most benign season for flow- fessor at Virginia Tech. And with on/off valve at the hose end, exten- er planting. Much of the country some modifications, gardeners who sion nozzles, water breakers, and won’t have a frost until October, so have lost physical ability can continue easy-to-use lever-controlled water even tender annuals like marigolds this valuable activity. Planters, pots faucets. will have many weeks of peak beauty. and raised beds make gardening easi- And perennials put in the ground in Try mulching in larger raised er for disabled and elderly gardeners. the fall will be the size of second-year planters to slow the evaporation of Relf says she’s been a consultant to plants next growing season. Another water from the bed, discourage gardeners who work in a small back- plus: growing fall flowers will add to weeds, and keep the soil cool for the yard, a third floor apartment patio, on the landscaping that shows off the roots. Weed-free organic material is top of a hospital, and on the grounds spectacular color of hardwood trees the best mulching because it enriches of a retirement home. and fall decorations, like pumpkins the soil as it decays, Relf said. Most and cornstalks. She believes the garden area pest control should be done by hand should be as small as possible, so the and without chemicals to avoid the Make sure to check the over- fun of gardening doesn’t change to danger presented by working with crowded roots of your bargain flow- drudgery. All of the raised beds or toxic substances. Relf suggests hand- ers for insects and damage, plant planters should be easily accessible picking pests and quickly removing carefully in well-drained rich soil in a and arranged in a fashion to fit any parts of plants that seem to be clean container, and monitor very together as an attractive landscape disfigured to prevent the spread of carefully for the next couple of unit. “Avoid the tendency to line up disease. weeks, trimming, watering and exam- little garden plots in rows,” she says. ining for bugs. By mid-August, you’ll With a little ingenuity, many TMA She suggests some dimensions for have a spectacular display, ready to members stay in the garden and find planning placement of heavy pots or admire in their container or to trans- it gives them much comfort. To find raised beds: plant to a permanent home. their suggestions, check out TMA’s    New edition of Living with Myositis on sale “Living with Myositis” by Jenny Myositis, Myositis in Children, Fenton has been reprinted and Remission Case Studies, Coping updated, with many new chapters with Relationships, Stress, and case studies added. The new Holidays, and A Laboratory book is called “Myositis: facts Perspective when Diagnosing feelings and future hopes.” All Myositis. the case studies tell the reader Support for the book comes how the real people with myosi- from The Central Middlesex tis introduced in Fenton’s first Hospital Rheumatology book are managing three years Department and the Foreword since we first met them in her was written by consultant original book rheumatologist Dr C. Bernard The book includes chapters Colaco. on diagnosis, treatment, nutri- Jenny was diagnosed with tion, exercise, occupational ther- dermatomyositis in 1998. After apy, feelings, coping, dysphagia, six years of treatment with lung disease and many others, all steroids she is now drug free and written by experts in their fields. in remission. Many new chapters, also profes-    sionally written, have been added, including: The Genetics of

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