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Radiographic Changes (Hand and Wrist) Erosions generic 100 mg zenegra with mastercard does erectile dysfunction cause low sperm count, bony decalcification purchase zenegra 100mg overnight delivery erectile dysfunction high blood pressure, and symmetric joint-space narrowing Duration and Location in the Major Arthritides of Morning Stiffness Rheumatoid Arthritis → PIP, MCP, MTP Joints Duration > 1–2 hours Osteoarthritis (OA) → Distal Interphalangeal Joint (DIP) Duration < 30 minutes Ankylosing Spondylosis → Lumbosacral Spine Duration ~ 3 hours LAB TESTS Although no single test is definitive in diagnosing RA, typical laboratory findings in active disease include: Rheumatoid factor Acute phase reactants: ESR and C-reactive protein CBC: thrombocytosis, hypochromic microcytic anemia, eosinophilia Synovial fluid analysis Synovial Fluid In RA Low viscosity WBC → 1,000–75,000 mm3 > 70% PMNs Transparent - cloudy Hypergammaglobulinemia Hypocomplementemia Rheumatoid Factor (+) 85% of the patients with RA have a (+) Rheumatoid Factor (RF [+]) Associated with severe active disease with increased systemic manifestations (nodules) Serial titers are of no value Can still be RF (−) and have RA because (+) diagnosis needs four to seven diagnostic cri- teria + RF can be seen in other diseases: Rheumatic (SLE, scleroderma, Sjögren’s), viral, para- sitic, bacterial, neoplasms, hyperglobulinemic 84 RHEUMATOLOGY Increased ESR and C Reactive Protein Acute phase reactants Nonspecific, not used in diagnosis RADIOGRAPHIC FINDINGS IN RA Marginal bone erosions (near attachment of joint capsule) (+) Juxta-articular osteopenia (bone wash-out) Predilection of swelling of joints in wrists, MCP, PIP, MTP not DIP Erosion of the ulnar styloid Erosion of the metatarsal head of the MTP joint Disease may be asymmetric at first then progress to symmetric Cervical spine involvement may lead to cervical atlantoaxial (A-A) subluxation (> 2. Morning stiffness → universal feature of synovial inflammation > one hour 2. Structural inflammation → warm swollen tender joints seen superficially 3. Structural damage → cartilage loss and erosion of the periarticular bone Hand and Wrist Deformities Boutonnière Deformity (Calliet, 1982) (Figure 3–1) Mechanism Weakness or rupture of the terminal portion of the extensor hood (tendon or central slip), which holds the lateral bands in place The lateral bands slip downward (or sublux) to the axis of the PIP joint turning them into flexors The PIP then protrudes through the split tendon as if it were a button hole (boutonnière = button hole) The distal phalanx hyperextends RHEUMATOLOGY 85 Result Flexion of the PIP Hyperextension of the DIP Hyperextension of the MCP Note: Positioning of the finger as if you were buttoning a button Orthotic Tripoint finger splint FIGURE 3–1. Boutonnière Deformity Swan Neck Deformity (Calliet, 1982) (Figure 3–2) Mechanism Contracture of the intrinsic and deep flexor muscles and tendons of the fingers Result Flexion contracture of the MCP Hyperextension of the PIP Flexion of the DIP Orthotic Swan neck ring splint FIGURE 3–2. Swan Neck Deformity 86 RHEUMATOLOGY Ulnar Deviation of the Fingers (Calliet, 1982) Mechanism Weakening of the extensor carpi ulnaris (ECU), ulnar and radial collateral ligament Wrist deviates radially Increases the torque of the stronger ulnar finger flexors Flexor/extensor mismatch deviates the fingers in the ulnar direction as the patient tries to extend the joint Result Ulnar deviation is due to the pull of the long finger flexors Orthotic Ulnar deviation splint Tenosynovitis of the Flexor Tendon Sheath One of the most common manifestation of the hands in RA Can be a major cause of hand weakness Result Diffuse swelling of the volar surfaces of the phalanges between the joints with palpable grating of the flexor tendon sheath May be confused with deQuervain’s disease DeQuervain’s disease Tenosynovitis of the extensor pollicis brevis (EPB) and abductor pollicis longus tendon (APL) Thickening of the tendon sheath results in tenosynovitis and inflammation Pain over the tendons on the radial wrist EPB and APL Test: Finkelstein Test (Figure 3–3) Full flexion of the thumb into the palm followed by ulnar deviation of the wrist will produce pain and is diagnostic for deQuervain’s tenosynovitis FIGURE 3–3. Finkelstein’s Test: Full flexion of the thumb into the palm will produce pain when the wrist is deviated in the ulnar direction. Rosemont, Illinois: American Academy of Orthopaedic Surgeons, 1997, with permission. RHEUMATOLOGY 87 Carpal Bones Rotate in Zig-Zag Pattern Mechanism Ligament laxity Radial deviation of the wrist Ulnar styloid rotates dorsally Carpal bones rotate – Proximal row: volarly – Distal row: dorsally Result Zig-zag pattern Floating Ulnar Head (Piano-Key Sign, Think of the Black Keys) Mechanism Proliferating synovium leads to rupture or destruction of the ulnar collateral ligament Result The ulnar head raises up to the dorsal wrist Easily compressible elevated ulnar styloid Ulnar head floats Resorptive Arthropathy Mechanism Digits are shortened and phalanges appear retracted with skin folds Result Telescoping appearance of the digits Most serious arthritic involvement Pseudobenediction Sign Mechanism Stretched radioulnar ligaments allow the ulna to drift upward Extensor tendons of the fourth and fifth digit are subject to abrasion from rubbing on the sharp elevated ulnar styloid Result Extensor tendon rupture Inability to fully extend the fourth and fifth digit Cervical Spine Atlantoaxial Joint Subluxations → Most Common are Anterior Subluxations Instability – Odontoid or Atlas can erode – With flexion, the Atlantoaxial (AA) space should not increase significantly: any space larger than 2. The MCP is thought to be the primary site of RA and inflammation can lead to weakening of joint supporting structures. Insidious Onset Surgical Options Synovectomy Arthroplasty Arthrodesis Tendon repairs TABLE 3–1. Treatment Options for Rheumatoid Arthritis (Verhoeven, 1998) Poor Prognostic Disease Stage Features Treatment Medications 1. Compliance antirheumatic drug (DMARD) Hydroxychloroquine Sulfasalazine Oral gold Moderately (+) 1. Compliance Weekly oral or parental methotrexate May add a second DMARD 3. Corticosteroids PT = Physical Therapy OT = Occupational Therapy NSAID = non-steroidal anti-inflammatory drugs DMARD = disease modifying anti-rheumatic drug RHEUMATOLOGY 93 TABLE 3–2. Drugs Used in Rheumatoid Arthritis and Common Side Effects (Gerber, Hicks, 1995) DMARDs General (Disease Modifying Degree of Anti-rheumatic Drugs) Toxic Profile Toxicity Hydroxychloroquine Macular damage Safer Sulfasalazine Myelosuppression, gastrointestional (GI) distrubances Safer Auranofin GI disturbances, diarrhea, nausea, vomiting, anorexia, rash pruritus, conjunctivitis, stomatitis, anemia, thrombocytopenia, proteinuria, elevated liver enzymes Safer Methotrexate Stomatitis, myelosuppression, hepatic fibrosis, cirrhosis, pulmonary involvement, worsens rheumatoid nodules More toxic Cyclosporine Renal dysfunction, tremor, hirsutism, hypertension, gum dysplasia More toxic Gold, Intramuscular, Myelosuppression, renal → proteinuria Oral Diarrhea (#1, oral), Rash (#1, Intramuscular) More toxic Azathioprine Myelosuppression, hepatotoxicity, lymphoproliferative disorders More toxic D-Penicillamine Oral ulcers, bone marrow suppression induction of autoimmune disease, proteinuria More toxic Chlorambucil Bone marrow suppression, GI disturbances, nausea, vomiting, diarrhea, oral ulceration, central nervous system (CNS) dis- turbances, tremors, confusion, seizures, skin hypersensitivity, pulmonary fibrosis, hepatotoxicity, drug fever peripheral neuropathy, infertility, leukemia and 2˚ malignancies Very toxic Cyclophosphamide Carcinogenesis, impairment of fertility, mutagenesis, GI disturbances, nausea, vomiting, anorexia, alopecia, leukopenia, thrombocytopenia, anemia, cystitis, urinary bladder fibrosis, interstitial pulmonary fibrosis, anaphylactic reaction Very toxic Other Drugs for the Treatment of Rheumatoid Arthritis Toxic Profile ASA, NSAID GI ulceration and bleeding Therapeutic levels for ASA 15 mg/dl–25 mg/dl Toxic > 30 mg/dl Corticosteroids Hyperglycemia, inhibits immune response, osteoporosis, peptic ulcer disease, emotional liability 94 RHEUMATOLOGY OSTEOARTHRITIS (OA) DEFINITION A noninflammatory progressive disorder of the joints leading to deterioration of the articular cartilage and new bone formation at the joint surfaces and margins Disease of the cartilage initially, not bone PREVALENCE Most common form of arthritis and the second most common form of disability in the United States Prevalence increases with age: approximately 70% population > 65 years old have radio- graphic evidence of osteoarthritis (Lane, 1997) Increase in occupations with repetitive trauma Male:female ratio is equal between the ages of 45–55. Because of this, it is suggested that spondyloarthropathies in children include another syndrome, Seronegative Enthesopathy and Arthropathy (SEA) SEA Syndrome – (–) RF – (–) ANA – Enthesitis and either arthritis or arthralgia RHEUMATOLOGY 101 TABLE 3–4. Key Points of Juvenile Arthritides JUVENILE RHEUMATOID ARTHRITIS SYSTEMIC JUVENILE Multisystemic POLYARTICULAR SPONDYLO- Involvement Many joints PAUCIARTICULAR ARTHROPATHIES RF(–) (~98%) RF(–) (90–95%) RF(–) (> 98%) Ankylosing Still’s Disease No extraarticular 1–4 joint involvement Spondylosis (AS) High fever manifestations of Few systemic effects Reiter’s Rheum. Chronic Iridocyclitis: Psoriatic arthritis Lymphadenopathy Gradual onset of: < 6 yrs. RA Both have synovial inflammation that can lead to destruction of articular cartilage and ankylosis of the joint Ankylosing Spondylitis Rheumatoid Arthritis More common in males More common in females Absence of rheumatoid nodules Presence of rheumatoid nodules RF (–) RF (+) in 85% of cases Prespinous calcification RHEUMATOLOGY 105 Clinical Manifestations Skeletal Involvement Sites of Involvement in AS Insidious onset, back pain or tenderness 1→ SI joint in the bilateral SI joint 2→ Lumbar Vertebrae – First site of involvement is SI joint 3→ Thoracic Vertebrae – Initially asymmetric 4→ Cervical Vertebrae Persistent symptoms of at least three months Lumbar morning stiffness that improves with exercise Lumbar lordosis—decreased and thoracic kyphosis—increased Cervical ankylosis develops in 75% of the patients who have AS for 16 years or more Lumbar spine or lower cervical is the most common site of fracture Enthesitis (An inflammatory process ocurring at the site of insertion of muscle. On forward flexion, the line should increase by greater than 5 cm to a total of 20 cm or more (from 15 cm) – Any increase less than 5 cm is consid- ered a restriction Treatment Education FIGURE 3–4 – Good posture – Firm mattress, sleep straight—Supine or prone – Prevent flexion contractures Physical Therapy – Spine mobility—Extension exercises – Swimming is ideal – Joint protection Pulmonary—Maintain chest expansion – Deep breathing exercises – Cessation of smoking Medications – NSAIDs—Indocin Control pain and inflammation Allow for physical therapy RHEUMATOLOGY 107 – Corticosteroids—Tapering dose, PO and Injections – Sulfasalazine Improves peripheral joint symptoms Modify disease process – Methotrexate – Topical corticosteroid drops—Uveitis REITER’S SYNDROME ~ 3%–10% of Reiter’s Triad of Reiter’s Syndrome progress to AS 1. Nongonococcal urethritis Epidemiology Males >> females Organisms → Chlamydia, Campylobacter, Yersinia, Shigella, Salmonella More common in whites Associated with HIV Clinical Manifestations Arthritis Arthritis appears 2 to 4 weeks after initiating infectious event—GU or GI Asymmetric Oligoarticular—average of four joints – LE involvement >> UE – More common in the knees, ankles, and small joints of the feet – Rare hip involvement – UE → Wrist, elbows, and small joints of the hand Sausage digits (dactylitis) – Swollen tender digits with a dusklike blue discoloration – Pain on ROM Enthesopathies—Achilles tendon – Swelling at the insertion of tendons, ligaments, and fascia attachments Low back pain—Sacroilitis Ocular Conjunctivitis, iritis, uveitis, episcleritis, corneal ulceration Genitourinary Urethritis, meatal erythema, edema Balanitis Circinata—small painless ulcers on the glans penis, urethritis Skin and Nails Keratoderma blennorrhagica—hypertrophic skin lesions on palms and soles of feet Reiter’s Nails—thickened and opacified, crumbling, nonpitting Cardiac Conduction defects 108 RHEUMATOLOGY General Weight loss, fever Amyloidosis Lab Findings Synovial fluid—inflammatory changes Reiter’s Syndrome: Synovial Fluid Turbid Poor viscosity WBC 5-50,000-PMN ↑ protein, normal glucose Increased ESR RF (–) and ANA (–) Anemia–normochromic/normocytic (+) HLA B27 Radiographic Findings “Lover’s Heel”—erosion and periosteal changes at the insertion of the plantar fascia and Achilles tendons Ischial tuberosities and greater trochanter Asymmetric sacroiliac joint involvement Syndesmophytes Pencil in cup deformities of the hands and feet—more common in psoriatic arthritis PSORIATIC ARTHRITIS Prevalence ~5% to 7% of persons with psoriasis will develop some form of inflammatory joint disease Affects 0. Seronegative Spondyloarthropathy Fact Sheet The following are all Seronegative Spondyloarthropathies. Arthritis of Inflammatory Bowel Disease Arthritis of All have the following Ankylosing Reiter’s Psoriatic Inflammatory characteristics: Spondyloarthropathy Syndrome Arthropathy Bowel Disease 1. RF (–) RHEUMATOLOGY 111 CTD (CONNECTIVE TISSUE DISORDERS) AND SYSTEMIC ARTHRITIC DISORDERS MCTD: MIXED CONNECTIVE TISSUE DISORDERS Combination 1. Polymyositis SYSTEMIC LUPUS ERYTHEMATOSUS Diagnosis of SLE Multisystemic disease, autoimmune Any 4 of 11 criteria present Females > > > males Serially and simultaneously Criteria—American Rheumatologic Association (ARA) 1. Arthritis—Nonerosive arthritis involving two or more peripheral joints with tender- ness, swelling and effusion 6. Hematologic disorder—Hemolytic anemia, leukopenia, thrombocytopenia, lymphopenia 10. Immunologic—(+)LE cell preparation or Anti-DNA antibody, or Anti-SM, false positive test for syphilis 11. ANA Clinical Fatigue, fever, weight loss, GI complaints Alopecia Vasculitis Arthritis Jaccoud’s Arthritis – Small joints of the hands, wrist, Nonerosive deforming arthritis and knees Ulnar deviations of the fingers and sublux- – Symmetric ations which are reversible early – Migratory, chronic, nonerosive May become fixed – Soft tissue swelling – Subcutaneous nodules – Synovial analysis—ANA (+) – Jaccoud’s arthritis Arthralgias Muscle pain and weakness 112 RHEUMATOLOGY Labs Depressed complement—C3 and C4 Ds-DNA Anti-SM Treatment NSAIDs, corticosteroids, antimalarials, methotrexate, cyclophosphamide, azathioprine, cyclosporine A PROGRESSIVE SYSTEMIC SCLEROSIS (SCLERODERMA) Progressive Chronic Multisystem Disease Classified by the degree of skin thickening Fibrosis-like changes in the skin and epithelial tissues of affected organs Subsets: – Diffuse Cutaneous Scleroderma Heart, lung, GI, kidney ANA(+) Anticentromere Antibody (–) Rapid onset after Raynaud’s phenomenon Variable course—poor prognosis – Limited cutaneous Scleroderma—CREST Syndrome Crest Syndrome Progression after Raynaud’s phenomenon Calcinosis Anticentromere Antibody (+) Raynaud’s phenomenon Good prognosis Esophageal dysmotility – Overlap syndromes Sclerodactyly Combinations of connective tissue disease Telangiectasia – Undefined CTD No clinical or laboratory findings – Localized scleroderma Morphea, linear scleroderma Clinical Skin thickening—face, trunk, neck Symmetric arthritis with involvement of the fingers, hands, arm, legs Initial symptoms—Raynaud’s phenomenon with fatigue, and musculoskeletal complaints Raynaud’s Phenomenon Vasospasm of the muscular digital Causes of Raynaud’s arteries can lead to ischemia, Collagen vascular disease—PSS, ulceration of the fingertips SLE, RA, Dematomyositis/ Triggered by cold and emotional stresses Polymyositis Reversal of episode occurs after Arterial occlusive disease stimulus has ended—and digits rewarmed Pulmonary HTN Present in 90% of patients with scleroderma Neurologic—SCI, CVA Treatment Blood dyscrasia – Education against triggers—cold, smoking Trauma – Rewarming Drugs—ergots, beta blockers, – Calcium channel blockers—nifedipine cisplatin – EMG and biofeedback—self-regulation (Braunwald, et al.

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Lee JL order zenegra 100mg on-line erectile dysfunction operation, Vann WF discount 100 mg zenegra with amex ramipril erectile dysfunction treatment, Sigurdsson A: Management of avulsed perma- Injury rates in football rates have gone from 50% to nent incisors: A decision analysis based on hanging concepts. Phys Sportsmed Compliance can be a problem with mouth guard use— 28:1, 2000. DENTAL MAINTENANCE Trope M: Clinical management of the avulsed tooth: Present strategies and future directions. An initial compre- hensive dental examination should be performed, including chief complaint, health history, intraoral and extraoral examination, and radiographs where appli- cable; then the dentist will recommend a recall sched- 31 INFECTIOUS DISEASE ule as needed dictated by the evaluation. AND THE ATHLETE Oral jewelry has become a recent fad with the youth of this country. Dental professionals are advised to John P Metz, MD give these patients information about the problems that can occur with the jewelry. Dental professionals should also inform patients that INTRODUCTION the jewelry should be removed prior to any contact sporting participation. In a 1989 Runner’s World survey, erosion of the lingual enamel of the teeth, bilateral 60. Neutrophil counts increase with acute intense exer- cise, and several hours later. Long-term moderate IMMUNOLOGY AND EXERCISE exercise seems to elicit an increase in neutrophil activity, but chronic intense exercise seems to sup- The immune system has two parts, the innate and the press it (Woods et al, 1999; Pyne, 1991). The innate, composed of barrier and non- The acquired immune system, mainly T- and B-lym- barrier elements, is nonspecific regarding host phocytes and plasma cell-secreted antibodies, attacks defense. The acquired protects the body against spe- specific foreign particles that invade the body cific infectious agents. Overall lymphocyte counts increase The body’s first lines of defense are physical barriers, with any type of acute exercise. Lymphocyte counts and such as the skin and mucous membranes that can be B-cell function are decreased after intense exercise but impaired by temperature, wind, sun, humidity, and not after moderate exercise (Pedersen and Toft, 2000). Cross-country skiers and cyclists have low base- and mucosal immunoglobulin-A (IgA) activity affect line salivary IgA levels that drop after racing (Eichner, airborne respiratory pathogens (Nieman, 1999). Longitudinal studies of salivary IgA in elite pended until they reach the bronchi and bronchioles swimmers, however, have reported increases where the mucous barrier, rich in IgA, impedes fur- (Bruunsgaard et al, 1997), decreases (Gleeson et al, ther invasion (Shephard and Shek, 1999). Depressed IgA levels have been noted in cross- (Bruunsgaard et al, 1997), male triathletes showed country skiers, cyclists, and swimmers (Eichner, diminished skin test measures of cellular immunity 48 h 1993; Nieman, 1999; Brenner, 1984). There is thus a decreased clearance of infectious peting triathletes and recreational athletes. NK counts (Woods, 1999) and natural killer cell organisms are theoretically more likely to invade the activity (NKCA) (Nieman, 1999) increase immedi- host and cause an infection (Nieman, 1999; Shephard ately after high intensity exercise lasting less than and Shek, 1999; Brenner, 1984; Pedersen et al, 1 h, but fall soon after to below preexercise levels 1996). NKCA is elevated chronically in elite versus untrained athletes (Nieman, 2000), but not with moderate exercise (Woods et al, 1999). Chronic exercise attenuates this Marathon runners have a higher incidence of self- response, but macrophage function is greater than reported upper respiratory tract infections (URI’s) after in nonathletes (Woods et al, 1999). Danish elite orienteers have increased cytokines, like tumor necrosis factor-alpha (TNF- incidence of URI compared to controls (Linde, 1987). High levels of self-reported exercise, occupational, Gleeson (Gleeson et al, 1999) found an inverse corre- and leisure time activities were associated with a lation between pretraining salivary IgA levels and risk 20–30% decrease in the annual incidence of URI of infection in elite swimmers and controls, and pre- in healthy, nonathletic, and middle-aged adults dicted an additional infection for each 10% drop in (Matthews et al, 2002). A similar study of healthy, elderly people noted an infections, however. A follow-up study (Gleeson et al, inverse relationship between the amount of energy 2000) showed no correlation between salivary IgA expended in daily moderate activities and URI levels and infection risk. Runners in short races (5K, 10K, half-marathon) decreased salivary IgA an average of 27. There was a negative correlation found running 16–26 mi a week increased the risk between salivary IgA levels and number of days of ill- of having ≥1 URI compared to running <9 mi a ness and flu symptoms, but not days of cold symptoms. Running 9–16 mi or >26 mi a week con- Studies of immune marker changes with exercise have ferred intermediate risk. Moderate exercise lowers infection risk to below that of being sedentary, while strenuous In premenopausal women, no exercise or a 15-week exercise imposes the highest risk of all (Nieman, walking program made no difference in NK cell 2002).

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