Behcet's disease is a systemic autoimmune vasculopathy that is rare in the United States but has a higher prevalence among certain ethnic groups and in certain geographical locations.The diagnosis of Behcet's disease depends on the recognition of a number of typical clinical presentations and findings, as well as exclusion of other disorders such as Crohn's disease.Significant progress in the understanding and management of Behcet's disease has been made as a result of international efforts.
Fibromyalgia syndrome (FMS) is a chronic pain syndrome, characterized by widespread, idiopathic pain, excessive tenderness to pressure at 11 of 18 tender points, as well as fatigue and poor quality of sleep. Pain research in FMS suggests central nervous system sensitization. Patient education, cognitive behavior therapy and various forms of exercise have been shown to be beneficial. A number of medications have been effective in randomized clinical trials.
Patient education about lupus and its treatment and strategies to prevent vascular complications and bone demineralization are important components of management.Selective use in lupus of established agents has been shown - methotrexate for synovitis; cyclosporin A for membranous nephritis; and mycophenolate mofetil for glomerulonephritis.Promising new agents are in phase I, II, and III trials. These are agents that target B cells, C5a, beta-2 glycoprotein, DNA, IL-10, B lymphocyte stimulators (BLyS), and costimulatory molecules.
Antiphospholipid syndrome is characterized by the presence of venous and/or arterial thrombosis and/or pregnancy morbidity and the presence of antiphospholipid antibodies.Long-term anticoagulation is recommended for antiphospholipid syndrome patients with recurrent vascular events.For antiphospholipid syndrome patients with recurrent pregnancy events, aspirin plus heparin is recommended during pregnacy.
Renal osteodystrophy can be caused by high bone turnover due to secondary hyperparathyroidism or low-bone turnover caused by ingested minerals like aluminum. Arthritis in chronic renal failure may be due to deposition of amyloid in some dialysis-treated patients, sodium urate deposition (gout), or calcium crystal deposition. Vascular calcification can result in ischemic necrosis of skin.
The term "chronic Lyme disease" is being used to categorize patients with chronic nonspecific symptoms and justify long-term antibiotic treatment. The true diagnosis of Lyme disease is made by recognizing certain objective clinical features accompanied by serological evidence of previous infection. There are no controlled studies confirming the benefit of long-term antibiotic treatment in "chronic" Lyme disease.
Obesity is a risk factor for the development and progression of osteoarthritis of the knee. There is information available from controlled studies demonstrating improvement in pain, function, and possible reduction in joint space narrowing in patients with OA if the knee is treated with glucosamine sulfate. There continues to be a concern about the lack of regulatory oversight of dietary supplements, thus there is no certainty about the purity of the products, the dose, or the ingredients present.
The hallmark of systemic lupus erythematosus (SLE) is autoantibody production. Autoantibodies may directly attack organs or cause injury by combining with antigens and inciting inflammation. SLE likely involves a set of unlinked genes that operate to induce SLE. The generation of autoantibodies may occur because of an abnormality in apoptosis and phagocytosis of cell debris allowing nuclear antigens to become antigenic.
The overall goals of physical therapy are to prevent and minimize impairments, functional limitations, and disability resulting from arthritis. Intervention by physical therapists is appropriate at all stages of the care continuum, from primary and secondary prevention through postsurgical rehabilitation. Physical therapists use thermal and electrical agents, exercise, assistive devices, and patient education to achieve patient goals.
Vertebroplasty and kyphoplasty are procedures to treat the pain associated with vertebral compression fracture due to osteoporosis. Vertebroplasty involves injecting polymethylmethacrylate (PMMA) into the involved vertebral body under pressure. Kyphoplasty involves initially inserting an inflatable balloon to expand the vertebral body, then removing it, and injecting PMMA into the cavity.
The most common side effect of self-administered biologics is injection site reaction, but this led to discontinuation of the drug in less than 5% of cases.Serious adverse events due to biologics appear to occur at rates of less than 1 case per 1,000 patient-years.Surveillence should be maintained for serious infections including TB, demyelinating disorders, pancytopenia, congestive heart failure, malignancy including lymphoma, drug-induced lupus, and hepatotoxicity.
The evaluation of a patient with suspected (OA) pain should first include a search for nonarticular sources of pain.Treatment should focus on improving both pain and function through the use of a combination of nonpharmacologic and pharmacologic modalities.Patients with sever advanced disease most often require joint replacement surgery. Delaying surgery for too long may result in a poorer outcome.
Local steroid injections may have lasting benefit when used in one or two involved joints in rheumatoid arthritis, inflammatory oligoarthritis, peripheral joints in ankylosing spondylitis, juvenile rheumatoid arthritis, and crystal-induced arthritis. Local steroid injections have short-term benefit in the involved knee of osteoarthritis, painful shoulder, lateral epicondylitis, and carpal tunnel syndrome. There is no documented benefit from trigger point injections.
Levels of IL-1 and TNF-alpha are increased in RA and allow migration of WBCs into inflammatory sites and the release of MMPs, which increase the inflammation and tissue damage.Etanercept and infliximab - agents that block TNF-alpha - result in clinical improvement in RA and limit bony damage.Anakinra, an IL-1 receptor antagonist, also results in clinical improvement of RA and limits bony damage.
The pathology of GCA is characterized by intimal proliferation and luminal occlusion and giant cell formation. Molecular components associated with intimal proliferation are IFN-gamma, IL- 1beta, PDGF, and VEGF.The systemic inflammatory response is indicated by an elevation of IL- 6, ESR, and C-reactive protein.Treatment with glucocorticoids targets the NF-kappaB transcription factor suppressing Il-1 and IL-6.Acetylsalicylic acid can suppress IFN-gamma, which may augment the effects of glucocorticoids. Other therapeutic targets are PDGF and VEGF.
Skeletal muscles may be involved with inflammation or metabolic abnormalities.The clinical effects of muscle involvement include weakness, fatigue, and muscle cramping.The diagnosis is made by demonstrating muscle weakness, muscle involvement as indicated by an elevation of the CPK, an abnormality on EMG, and the pathology on muscle biopsy.
The most common pathogenesis of septic arthritis is bacteremic seeding. In the evaluation of a patient with acute monoarthritis, think sepsis first. Once septic arthritis is suspected and cultures are performed, antibiotic treatment should begin immediately. The cost-effectiveness of antibiotic prophylaxis to prevent late infections in prosthetic joints is controversial.
The indication for total hip arthroplasty and total knee arthroplasty is disabling pain with X-ray evidence of a damaged joint. Metal-on-polyethylene components are the most commonly used surfaces for arthroplasty today. In well-selected patients, the survival of the hip and knee arthroplasty at 15 years is 90% to 95%.
A variety of drugs can be associated with rheumatic syndromes.Drugs like minocycline, interferon, and anti-TNF agents can induce ANAs and anti-DNAs and, less commonly, clinical lupus syndromes.A number of drugs, including G-CSF and GM-CSF, vaccinations, and leukotriene inhibitors are associated with ANCA-positive vasculitis.
