Allergy & Rheumatology Medical Clinic, La Jolla CA
Specialty Expertise + Family Atmosphere
We are a group of specialty physicians that diagnose and treat a broad range of immune and autoimmune diseases, including allergies, asthma, rheumatologic diease, and immunodeficiencies. We often accept referrals from other providers to help with adults or children with complex medical problems. We strive to provide the highest level of medical care in a warm and caring environment.
Scripps Ximed 9850 Genesee Ave, Suite 420
La Jolla, CA 92037
Phone (858) 457-3270
Fax (858) 457-5723
Your Clinic for Allergy, Asthma, Immunology, and Rheumatology Expertise
Here at the Allergy & Rheumatology Medical Clinic (ARMC) we offer:
Longer Appointments
Exemplary care takes time. We offer significantly longer appointments than the industry average.
Specialty Expertise
Our clinic, comprised of multi-specialty physicians, has an unique ability to care for those with difficult-to-treat asthma, immune and rheumatologic diseases.
Family Atmosphere
Established in 1976, many of our patients have been here for decades. We thrive on knowing and treating our patients like family.
Convenience
We offer in-office blood draws* and infusions, walk-in time slots for allergy injections 5 days/week. There is a pharmacy on-site & we are centrally located within the Scripps La Medical Medical campus.
* blood draws are held during Covid-19 pandemic.
Video Visits
We are now offering video visits for all established patients.
Advanced Therapies
Our physicians, with years of experience in clinical care & research, work to provide the latest and best medical therapies.
To provide the highest level of medical care in a warm and caring environment.
Rheumatologic Conditions:
ARMC Rheumatologists are board-certified to treat individuals with arthritis, osteoporosis, and other rheumatologic conditions. Our office offers ultrasound, injection therapies, an in-office infusion suite, wireless internet acces, and laboratory services for your convenience.
These are a group of joint disorders caused by deposits of crystals in joints and the soft tissues around them that lead to joint destruction and soft tissue masses. The most common types are gout and calcium pyrophosphate deposition (CPPD). Over time, crystalline arthropathies can lead to joint damage and occasionally kidney disease.
Connective tissues (e.g. bone, cartilage, and fat) act like the 'cellular glue' that gives your body shape and strength. Connective tissue disease refers to a broad, diverse group of disease that affect the affect the connective tissue. This typically involves the joints, muscles, and skin but may also involve other organs and organ systems, such as the eyes, heart, lungs, kidneys, gastrointestinal track, and blood vessels.
This is a group of disorders characterized by inflammation of the muscles used for movement. The primary sympotoms is typically muscle weakness that develops gradually over weeks to months or years.
This category includes other diseases affecting the bones or connective tissues, but that do not fit well into the other classes listed here. Examples include tendonitis, steoporosis, and hypermobility pain syndrome.
Osteoarthritis is the most common form of arthritis that afflicts millions of people worldwide. It occurs when the flexible tissue at the ends of the bones wears down over time. Osteoarthritis can occur in any joint, but most commonly affects your hands, feet, hips, and spine.
PMR is an inflammatory disorder that causes muscle pain and stiffness around the shoulders and hip in addition to widespread aching, stiffness, and flu-like symptoms. Most people develop PMR after age 50 and it is more common in women than men. Approximately 15% of people with PMR develop a dangerous and sight-threatening condition called giant cell arteritis.
Rheumatoid arthritis is an autoimmune condition where the immune system attacks the lining of the joints and over time can cause damage to the joint, erosions in the bones and deformity. Rheumatoid arthritis can also attack other organs in the body such as the eyes, skin, lungs and heart.
Sarcoidosis is a disease in which tiny collections of inflammatory cells, called "granulomas," form in various parts of your body. Granuloma most commonly grow in the lungs and lymph nodes, but can also affect the eyes, skin, heart and other organs.
Spondyloarthritis is the name for a family of inflammatory rheumatic diseases that cause arthritis. It differs from other types of arthritis because it involves the sites are where ligaments and tendons attach to bones called “entheses.” The most common form is ankylosing spondylitis, and it typically affects the spine causing low back pain and stiffness.
This is a diverse group of disorders is characterized by inflammation of the blood vessels that causes changes in the blood vessel walls, leading them to thicken, narrow, and cut off vital blood supply to tissues and organs. Symptoms include fever, fatigue, weight loss, and muscle and joint pain.
Allergy, Asthma, and Immunology Conditions:
Our Board Certified allergist provides allergy testing and treatment including skin tests, allergy shots, spirometry and medical care. The following is a selection of common conditions we treat:
Allergic rhino (meaning "nose") conjunctivitis (meansing "eyes") is the medical term for nasal and eye allergies.
Angioedema is the medical term for swelling that is deep in the dermis layer of the skin. Common locations for angioedema to occur are the lips, mouth, tongue and the face, but it may also occur at other locations like the hands and feet.
Asthma is chronic inflammation of the small, bronchial airways of the lungs.
Atopic dermatitis, also known as eczema, is a non-contagious inflammatory skin condition that causes dry, red, and typically very itchy skin that may weep or scab when scratched. If left untreated, atopic dermatitis may cause chronic skin changes that includes nodules and a thickened appearance.
Bronchiectasis is a chronic condition of the lungs where the airways become widened, flabby, scarred as the result of injuries caused by infections or noxious agents. Airways affected by bronchiectasis
lose the ability to clear mucus, which builds up and creates an
environment for bacteria to grow, leading to repeated lung infections. If left untreated, bronchiectasis can lead to respiratory failure, atelectasis, and heart failure.
in which damage to the airways causes them to widen and become flabby and scarred. The airways are tubes that carry air in and out of your lungs.
Chronic cough is a cough that lasts more than eight weeks. A chronic cough may be caused by a wide number of causes, such as gastroesophageal reflux disease (GERD), postnasal drip from sinus infections or allergies, or chronic lung conditions such as asthma, chronic obstructive pulmonary disease (COPD), pulmonary fibrosis, and interstitial lung diseases.
A condition in which the cavities around the nasal passages become inflamed. Acute sinusitis can be triggered by a cold or allergies and may resolve on its own. Chronic sinusitis lasts up to eight weeks and may be caused by an infection or growths, known as nasal polyps. Chronic rhinosinusitis (CRS) is typically classified depending on whether or not there are nasal polyps (chronic rhinosinusitis with nasal polyps (CRSwNP) vs. without nasal polyps (CRSsNP)).
Symptoms include headache, facial pain, runny nose, and nasal congestion.
CVID is a medical condition where the
immune system does not make sufficient amounts of antibodies, leaving the body unable to defend itself against bacteria and viruses, and resulting in recurrent and often severe infections primarily affecting the ears, sinuses, and respiratory tract (sinopulmonary infections).
A drug allergy is the body's immunologic reaction to a medication. Drug allergy encompasses a large spectrum of immunologically-mediated hypersensitivity reactions with varying mechanisms and clinical presentations. Drug allergies are the not the same as a drug side effects or drug toxicity.
Desensitization is the process of inducing body tolerance to an agent, whether that agent is an allergen (e.g. pollen), a food, or drug. Typically, tolerance is induced by giving very small amounts of the agent while slowly building up the dose with each subsequent dose.
Previously known as "Churg-Strauss" disease, EGPA is a condition characterized by asthma, high levels of eosinophils, a type of white blood cell that helps fight parasitic infections, and inflammation of small to medium sized blood vessels (vasculitis). The inflamed vessels can affect various organ systems including the lungs, gastrointestinal tract, skin, heart and nervous system.
Eosinophilic esophagitis and gastroenteritis occurs when certain immune blood cells known as eosinophils get into the esophagus and the digestive tract, respectively, and cause damage. Symptoms of eosinophilic esophagitis includes pain or difficulty swallowing, which may cause food to become stuck when swallowing. Symptoms of eosinophilic gastroenteritis may include stomach pain, nausea, vomiting, and the inability to absorb nutrients from food. Sometimes, a blockage in the intestines occurs. In most people, symptoms for both of these conditions may occur from time to time and may go away completely with treatment.
A food allergy is an unpleasant or dangerous immune system reaction after a certain food is eaten. These reactions can vary between individuals but may include hives, swelling of the face, lip, eyes, mouth, tongue, hands, feet or other part of the body, difficulty breathing, and/or digestive issues. Severe reactions can be life-threatening.
Mast cells are allergy cells responsible for acute allergic reactions. They cause allergic symptoms (e.g. hives, angioedema, wheezing, gastrointestinal symptoms, fatigue) by releasing products called “mediators” stored inside them or made by them. There are a diverse array of mast cell disorders with treatments depending on the type and extent of symptoms.
Primary immune deficiency diseases (PIDDs) are rare, genetic disorders that impair the immune system. Without a functional immune response, people with PIDDs may be subject to chronic, debilitating infections.
Vocal cord dysfunction (VCD) or paradoxical vocal fold movement (PVFM) occurs when the vocal cords (voice box) do not open correctly. Vocal cord dysfunction is often confused with asthma.
Our Commitment to Excellence:
Our doctors are personally involved in the care of each of patient, and prefer to communicate and work together closely with your primary care physician and other outside providers to ensure continuity of your care. Our providers maintain an expert knowledge base by writing expert review and research papers, performing regular literature reviews, continuing medical education, training fellows & residents, and conferring with other national experts.
Our Committment to Shared-Decision Making:
Our diagnosis and management recommendations are 100% grounded in best-practice guidelines and evidence-based literature. Yet, we also tailor treatment regimens based on individual needs via shared decision making between physician and patient. I.e. We believe in making decisions based on the best evidence, but value patient autonomy and encourage your involvement in your health & decision-making.
A Unique Clinic for those with Complex Disease:
Our unique partnership of physicians combines multiple specialties that diagnose and treat a broad range of autoimmune and immune disorders. As a result, we are especially good at caring patients with very complex medical conditions, such as those with both immunodeficiencies and autoimmune disease requiring treatment with both antibody replacement therapy and an immune suppression regimens, those with eosinophilic disorders (e.g. eosinophilic granulomatosis with polyangiitis (EGPA) hypereosinophlia syndrome, eosinophilic esophagitis or gastroenteritis), and those with both severe asthma and rheumatologic disease, which may require unique combinations of monoclonal antibody therapy.
Holistic Therapy Recommendations:
We strongly and often recommend additional treatment modalities, such as exercise regimens, sleep regulation, stress management, and other quality of life improvements.
Welcome New Patients
Get a head start on your paperwork. Please print and fill out each of the forms below and bring them with you to your next appointment.
Rheumatology Patients:
Allergy Patients:
Contact Info
Phone: 858.457.3270 Fax: 858.457.5723
Adrian Jaffer, MD
Allergy & Rheumatology
Adrian Jaffer was born in Capetown, South Africa. He attended school at Christian Brother College. His medical school training was at the University of Capetown Medical School, South Africa and his first internship was at Groote Schurn Hospital. In 1969, he immigrated to the United States because of a strong opposition to apartheid.
Dr. Jaffer repeated his internship at Loyola University Hospital in Maywood, Illinois and then a residency in Internal Medicine at Northwestern University, Chicago.
He started his fellowship in Allergy and Immunology at the Beth Israel Hospital at Harvard and came to California to complete it at Scripps Clinic and Research Foundation. In 1976, he went back to Northwestern to add another specialty in Rheumatology and went into practice in 1976 associated with Scripps Memorial Hospital in La Jolla. Dr. Jaffer has practiced in this community since then in the specialties of Rheumatology and Allergy & Immunology. He is a Clinical Professor of Medicine in the departments of Rheumatology, Allergy and Immunology at UCSD and has actively taught the fellows in training for many years and continues to do so.
At Scripps Memorial Hospital, he was Chief of Medicine, then Chief of Staff. Dr. Jaffer has a special interest in bioethics, and headed the Bioethics Committee at Scripps Memorial for nearly 20 years - he continues to be involved in that aspect of healthcare. His personal philosophy is that the humanities are extremely important in the applications of technology to helping the sick and he has tried to maintain this balance through most of his career.
His hobbies include horseback riding, skiing and the usual So Cal compulsive exercising.
Areas of interest:
environmental allergies, food allergies, rheumatoid arthritis, spondyloarthropathies, psoriatic arthritis, sjogren's syndrome, eosinophilic disorders
Janet Kim, MD
Rheumatology
Janet Kim was born in Detroit, Michigan and grew up in the suburb of Birmingham, Michigan. She attended the University of Michigan for her undergraduate studies where she majored in history of art in addition to completing her pre-medical studies and singing in the Arts Chorale. She was a member of Phi Beta Kappa. She stayed on at the University of Michigan for medical school (Go Blue!), serving as Medical Student Council President, and thoroughly enjoyed life in Ann Arbor.
She received her Internal Medicine residency training at the University of Chicago and did her Rheumatology fellowship at the University of Chicago and the University of California, San Diego (UCSD). She then served as Clinical Assistant Professor at UCSD for three years, participating in clinical research trials and seeing patients in clinic.
In 2002, Dr. Kim joined the Allergy & Rheumatology Medical Clinic where she has thoroughly enjoyed working in private practice as a Rheumatologist. She values providing education and understanding to her patients and most enjoys forming long-term relationships with them.
In addition to her role as a physician, Dr. Kim enjoys being mother to two teenage daughters and spending time with family and friends. When she has free time, Dr. Kim loves being out and about in beautiful San Diego, hiking, eating, and traveling.
Areas of Interest:
rheumatoid arthritis, systemic lupus erythematosus, gout, ankylosing spondylitis, psoriatic arthritis, sjogren's syndrome, spondyloarthropathies
Quyen Huynh, MD
Rheumatology
Quyen Huynh is originally from Orange County, California and completed her undergraduate training in Neurobiology at the University of California, Irvine. She was a member of Phi Beta Kappa and was awarded the Honors in Research Program in Neuroscience by the National Institute of Mental Health.
he then pursued her medical school training at Chicago Medical School before coming home to complete her Internal Medicine residency at Scripps Mercy Hospital and her Rheumatology fellowship at the University of California, San Diego.
During her fellowship at UCSD, Dr. Huynh was appointed Chief Fellow of Rheumatology and continued her passion for research in psoriatic arthritis and ultrasonography, for which she has numerous publications.
She remains an active member of the American College of Rheumatologists and GRAPPA (Group for Research and Assessment of Psoriasis and Psoriatic Arthritis). Her dedication to advancing the field is seen in her commitment to teaching Internal Medicine residents at Scripps Mercy Rheumatology clinic along with her involvement in research and clinical trials.
When Dr. Huynh is not hard at work at ARMC, she enjoys taking out her energetic vizsla pup and admittedly spends too much time trying to find her golf game.
Areas of interest:
rheumatoid arthritis, systemic lupus erythematosus, gout, ankylosing spondylitis, psoriatic arthritis, sjogren's syndrome, spondyloarthropathies
Brian Modena, MD MSc
Allergist
Brian Modena, M.D., M.Sc. is originally from a small town southern West Virginia.
He completed undergraduate studies in Mechanical Engineering at Virginia Tech, and medical school at West Virginia University. His completed training in Internal Medicine at Scripps Green Clinic and Hospital, specialty training in both pediatric and adult Allergy, Asthma and Immunology at the University of Pittsburgh Medical Center, and later, a Master's of Science at the Kellogg School of Science & Technology at The Scripps Research Institute. He joined National Jewish Health in 2018 as an NIH-funded researcher in the field of severe asthma before joining the Allergy & Rheumatology Medical Clinic in 2021.
Dr. Modena, along with several his immediate family members, has a lifelong history of severe asthma, in addition to the many atopic diseases that often accompany childhood-onset asthma: allergic rhinitis, food allergies, eczema, and eosinophilic esophagitis. This experience, along with a love for problem solving, has helped shaped and catalyze research interest that aims to uncover the genetic underpinnings and molecular roots of asthma and atopic disease. If you would like to know more about his group's genetic and artificial intelligence research, please feel to email Dr. Modena at brian@torreypines.ai.
His research experience and interest covers a number of fields, including artificial intelligence/machine learning, mRNA gene expression, genetics, microbiome, and the use of IoT devices to deliver personalized and highly-targeted medical care. His clinical expertise includes allergies (drug, environmental, food), asthma, AERD, urticaria, dermatitis, and disorders of the immune system.
In his free time, he enjoys exercising (hiking, running, skiing), summer concerts, and spending time with his wife, daughter, and dog. He is now accepting both pediatric and adult new patients.
Areas of interest:
severe asthma, nasal polyps, AERD, chronic sinusitis, allergic rhinitis, urticaria, drug allergies, disorders of the immune system, food allergy, environmental allergies
Asthma
Chronic inflammation of the small, bronchial airways of the lungs.
Asthma is a chronic lung disease where inflammation in the small airways causes episodes of wheezing, coughing, chest tightness, shortness of breath and sputum production.
Asthma is caused by a combination of your genetic make up (inherited genes) and environmental exposures. You inherit genes from your parents. Thus, having a parent who has asthma, especially if the mother has asthma, increases the risk that a child will develop asthma. But also exposures to various noxious agents, such as cigarette smoke, poor air quality, and occupational hazards, cause and may worsen asthma. Having certain medical conditions, including allergies, obstructive sleep apnea, sinus disease, reflux, and obesity increases the risk and often the severity of asthma.
Asthma affects people of all ages, and sometimes does not develop until adulthood. This type of asthma is called adult-onset or late-onset asthma.
The diagnosis of asthma is based on your clinical symptoms and medical history, and confirmed by breathing tests that test lung function and inflammation within the lungs.
Treatment starts with inhalers that open up the airways and relieve symptoms (rescue medications). If you have symptoms often or daily, you may be prescribed inhalers that reduce inflammation in the airways (corticosteroids) and/or keep the airways open for longer periods of time (long-acting bronchodilators). If you have severe asthma or symptoms despite your regular use of inhalers, you may be prescribed an injectable medication (monoclonal antibody) depending on your 'type' of asthma.
Contact Allergy
An allergic skin reaction due to chemicals, plastics, drugs, metals and other agents.
An abrupt or slow onset of a rash characterized by redness (erythema), small blisters (vesiculation) and itching (pruritis). The most common causes include latex, resings, acrylics, metals (e.g. nickel, cobalt) fragrances, topical antibiotics and steroids, preservatives, glues, plastics rubber, and other chemicals used in various lotions, hair care and make up products.
Workers with high chemical exposure (workers in healthcare & chemical industries, beauticians and hairdressers, construction workers, machinists.
The diagnosis is made based on the appearance and symptoms of the rash, your clinical history (e.g. history of exposure), biopsy results, patch testing results to identify causative agent(s), improvement with avoidance of suspected allergen. We perform patch testing using the North American 80 Comprehensive Patch tests.
Avoidance of the causative agent(s) is the foremost treatment. If needed, the rash may also be treated with a topical anti-inflammatory cream.
Drug Allergy
A drug allergy is an abnormal reaction to a medication.
There are many different types of drug reactions, ranging in severity from mild to more severe, and even life-threatening reactions. In general, there are two broad categories of adverse reactions to drugs: immunological (involving the immune system) vs. non-immunological (not involving the immune system). Historically, immunologic or true 'allergic' drug reactions have been classified into four categories (I to IV) according to the Gell & Coombs System:
Type 1: Immediate onset, caused by IgE and mast cells
Type 2: Delayed onset, caused by antibody-mediated cell destruction
Type 3: Delayed onset, caused by antibody complexes
Type 4: Delayed onset, caused by T cells
The most common medications to cause a drug hypersensitivity (immunological) include antibiotics (e.g. penicillins, 'sulfa' antibiotics), anti-convulsants, NSAIDS (e.g. ibuprofen, aspirin), and chemotherapy agents.
Non-immunological reactions include drug overdosing, expected side effects, indirect effects, drug interactions, worsening of a known medical problem, and poorly understood reactions known as 'idiosyncratic' reactions.
Anyone can develop a drug allergy. Generally speaking, women are at higher risk than men. Those that have required multiple and/or prolonged courses of IV medications, such as antibiotics, are at higher risk of developing drug reactions and developing more severe, life-threatening reactions.
Your report of the reaction, and any new medications taken before the reaction occurred, is typically the most important information needed to make a diagnosis. Having a detailed report of medications started prior to onset of the reaction and a picture of the reaction is very helpful.
Allergy skin testing can be used to determine drug allergies, but it is only accurate when testing for penicillin allergies. We also perform in-office drug 'challenges' in which we give you a medication and watch you closely for an allergic reaction. This is used when the diagnosis is uncertain or to prove safety.
Treatment is stopping the offending drug. Anti-inflammatory medications may also be prescribed as needed.
Environmental Allergy
An environmental allergy is an immune response to something in your environment that's typically otherwise harmless. Although environmental allergies vary from person to person, typical symptoms include red, itchy watery eyes and/or runny nose, nasal congestion, hoarseness, sore throat, and fatigue. Allergies may also cause or worsen asthma in some individuals.
Environmental allergies are very common, and thought to be caused by a combination of your genetic make up (inherited genes) and environmental exposures. Exposure to certain allergens, cigarette smoke, poor air quality, and occupational hazards, may all increase your chances of developing allergies. Allergies also occur more commonly in those with certain other illnesses, like asthma, eczema, food allergies, or chronic sinus infections.
The diagnosis of environmental allegies is based on your clinical symptoms and medical history, and confirmed by allergy skin tests performed in the office.
There are many treatment options for patients with environmental allergies depending on the symptoms you're
experiencing. In general, anti-inflammatory nasal sprays (e.g. fluticasone, budesonide, triamcinolone) are used to improve nasal congestion while anti-histamines are used to relieve itchy, watery eyes and/or runny nose symptoms. If initial therapies are not working or causing side effects, allergy immunotherapy is offered.
Food Allergy
A food allergy is an unpleasant or dangerous immune system reaction after a certain food is eaten. These reactions can vary between individuals but may include hives, swelling of the face, lip, eyes, mouth, tongue, hands, feet or other part of the body, difficulty breathing, and/or digestive issues. Severe reactions can be life-threatening.
In adults, the majority of food allergies are triggered by certain proteins in shellfish (e.g. shrimp, lobster and crab), nuts, or fish. In children, the most common food allergies
are to peanut, tree nuts, eggs, cow's milk, wheat or soy.
The cause of food allergies are unknown, but thought to be caused by a combination of your genetic make up (inherited genes) and potentially environmental exposures. Food allergies if you have a family history of allergies or if you have eczema.
The diagnosis of a food allegy is based on your clinical symptoms, and confirmed by allergy skin tests performed in the office. Often, we will also order blood allergy tests to confirm allergy skin tests or to track levels over time.
Anti-histamines are used to treat mild skin reactions. More severe reactions require injection(s) of epinephrine and emergency room care.
Rheumatoid Arthritis
Rheumatoid arthritis is an autoimmune condition where the immune system attacks the lining of the joints and over time can cause damage to the joint, erosions in the bones and deformity. Rheumatoid arthritis can also attack other organs in the body such as the eyes, skin, lungs and heart.
Rheumatoid arthritis can occur at any age although it is more common in middle age. Women are at slightly higher risk for rheumatoid than men. Other risk for developing rheumatoid arthritis include those with a family history of rheumatoid arthritis, smokers and obesity.
The diagnosis is made by a clinical history and physical exam. Blood tests are ordered to check for inflammatory markers which include an erythrocyte sedimentation rate (ESR) and C-Reactive Protein (CRP). The presence of auto-antibodies are also checked in the blood and they include Rheumatoid Factor (RF) and anti-cyclic citrullinated peptide. These antibodies can be helpful in the diagnosis, but it is important to know that they can also be present in patients without rheumatoid arthritis and some rheumatoid arthritis patients may not have these antibodies. Finally, other imaging tests such as x-rays, ultrasound and MRI may help diagnose the condition.
There are many treatment options for patients with rheumatoid arthritis and it is important to seek treatment early to assure greater success in control of pain, prevention of damage and further disease progression. Many patients are started on non-steroidal anti-inflammatory drugs (NSAIDS) or prednisone initially to help reduce pain and inflammation before selection of a disease modifying anti-rheumatic drug (DMARD). There are also newer biologic agents and medications that have been very helpful in controlling and preventing the disease from further attacking the body.
Osteoarthritis
Osteoarthritis is the most common form of arthritis that afflicts millions of people world wide. It occurs when the cartilage lining in the joints wears down over time. It can occur in any joint although most commonly affects the hands, knees, hips and spine.
Osteoarthritis is mainly a condition of older patients and increases with age. However, there are other medical conditions that may predispose patients to developing osteoarthritis at a younger age such as trauma, metabolic disorders and obesity.
The diagnosis is often made by a simple exam and clinical history. Sometimes X-rays can be done to assist in the diagnosis and assess severity of the condition.
Treatment centers around reduction in pain and improvement in mobility. There is no specific drug treatment that can stop or reverse the changes of osteoarthritis at this time. However, a lot can be done to help manage pain and function. Physical therapy and exercise are very important in the general management of osteoarthritis. When the pain is severe steroid injections can provide temporary relief and occasionally surgery may be an option for some patients.
