Gout: not just for the rich and famous! Everyman's disease

Gout is a painful form of arthritis that affects more than a million Americans annually. Using a case study, a discussion of the clinical onset, signs and symptoms, diagnosis, and treatment of acute and chronic gout is presented. The incidence and etiology of gout is presented, along with current diagnostic criteria and the most common differential diagnoses to consider. The current trends in diagnosing and treating the acute and chronic forms of gout are also addressed as well as some of the controversies and concerns about treatment options. The treatment plan and follow-up for the patient in the case presentation conclude the discussion.     

New daily persistent headache: clinical perspective

New daily persistent headache is a recognized form of primary chronic daily headache. It is unique in its presentation and course. The goal of this article is to discuss the clinical characteristics, triggering factors, possible underlying pathogenesis and treatment options for this unique headache disorder. At present prognosis for new daily persistent headache is considered poor with very few effective treatment options. A new treatment paradigm for new daily persistent headache based on triggering events will be suggested. The current International Classification of Headache Disorders 2 criteria for new daily persistent headache will also be discussed including its apparent inadequacies and revised criteria will be recommended.     

Update on biologicals for treatment of juvenile idiopathic arthritis

Introduction: The development of biologics has markedly changed the treatment of JIA. Complete control of the disease and remission has today become the main goal of treatment preventing long-term damage and disability.

Areas covered: This review gives an overview of the current treatment options using biologics in JIA. The biologic drugs are discussed on the basis of recent clinical trials.

Expert opinion: While JIA is a group of heterogeneous diseases, differences in their biology turned out to influence treatment success with different biologics. TNF inhibitors emerged to be the most commonly used biologics for the treatment of JIA. First they were successful for the treatment of rheumatoid factor positive and negative polyarticular JIA. TNF inhibitors have also been studied in patients with enthesitis-related arthritis, psoriatic arthritis, and extended olioarthritis, and approval of at least etanercept is expected. Second-line biologics are abatacept and tocilizumab. For systemic onset JIA, tocilizumab, and the IL-1 inhibitors anakinra and canakinumab have been successfully studied. In the treatment of JIA, biologics have emerged as potent drugs to control the disease. New advancements will be crucial for further improvement of treatment options in JIA.     

Die Hand im Alter

In this article commonly occurring problems in hands and associated with aging will be presented. The topic will focus on pathologies known to be frequent either from public statistics or the pattern of frequently performed procedures in an orthopedic unit dedicated to hand surgery. Therefore skin aging, radial fractures and malunions, trigger finger, carpal tunnel syndrome and the field of degenerative hand arthritis will be discussed. Therapeutic options for the orthopedic surgeon as to conservative and surgical treatment will be presented.     

Neurophysiology of Arthritis Pain

Arthritis pain is a complex phenomenon involving intricate neurophysiological processing at all levels of the pain pathway. The treatment options available to alleviate joint pain are fairly limited and most arthritis patients report only modest pain relief with current treatments. A better understanding of the neural mechanisms responsible for musculoskeletal pain and the identification of new targets will help in the development of future pharmacological therapies. This article reviews some of the latest research into factors which contribute to joint pain and covers areas such as cannabinoids, proteinase activated receptors, sodium channels, cytokines and transient receptor potential channels. The emerging hypothesis that osteoarthritis may have a neuropathic component is also discussed.     

Gouty arthritis: Understanding the disease state and management options in primary care

Acute gouty arthritis is an inflammatory response triggered by the release of monosodium urate crystal deposits into the joint space. The disease is associated with debilitating clinical symptoms and functional impairments as well as adverse economic and quality-of-life burdens. Because gouty arthritis is typically diagnosed and managed in the primary care setting, clinicians require a thorough knowledge of the presenting clinical features, risk factors, differential diagnoses, and treatment options for appropriate management. Although generally effective, the use of currently available therapies to control gouty arthritis is challenging because many medications used to treat comorbidities can exacerbate gouty arthritis and because current agents are associated with a number of adverse events, contraindications, or both. Based on an understanding of the underlying inflammatory pathogenesis of gouty arthritis, several new agents are being developed that may provide improved efficacy.     

Alternative therapies for arthritis treatment. Part 2

Although modern medicine has been successful in managing infection and saving victims of multiple trauma, healthcare providers have offered little relief to individuals with chronic diseases, such as arthritis. Many patients with arthritis are seeking help with disease management from alternative therapies. When used along with allopathic medicine, these therapies may, in fact, increase quality of life for patients with arthritis. This article, second in a two-part series on alternative therapies, returns to the seven fields of practice identified by the National Institutes of Health (NIH) to explore additional treatment options for individuals with arthritis. Part 1 in this series was published in the September/October 2003 issue of Orthopaedic Nursing.     

Gene therapy for proliferative ocular diseases

Proliferative ocular diseases encompass a wide variety of pathological processes with adverse cellular differentiation, proliferation and migration as common features. Pathologies may involve neovascular responses associated with diabetic retinopathy, retinopathy of prematurity or age-related macular degeneration. These diseases are quite prevalent and account for substantial visual impairment and blindness worldwide. Although treatment strategies are largely surgical, advances in our understanding of the proteins crucial to cell transdifferentiation, proliferation and migration, along with better gene transfer techniques, have greatly increased the potential for biological treatment options. In this report, the most common proliferative ocular vascular diseases and existing therapeutic modalities will be reviewed and an overview of possible gene therapy options will be discussed, along with potential candidate genes.     

Gene therapy for proliferative ocular diseases

Proliferative ocular diseases encompass a wide variety of pathological processes with adverse cellular differentiation, proliferation and migration as common features. Pathologies may involve neovascular responses associated with diabetic retinopathy, retinopathy of prematurity or age-related macular degeneration. These diseases are quite prevalent and account for substantial visual impairment and blindness worldwide. Although treatment strategies are largely surgical, advances in our understanding of the proteins crucial to cell transdifferentiation, proliferation and migration, along with better gene transfer techniques, have greatly increased the potential for biological treatment options. In this report, the most common proliferative ocular vascular diseases and existing therapeutic modalities will be reviewed and an overview of possible gene therapy options will be discussed, along with potential candidate genes.     

Schmerztherapie bei chronischer Pankreatitis und chronisch-entzündlichen Darmerkrankungen

Apart from local inflammation and defects in secretion, central mechanisms are important for pain etiology in chronic pancreatitis. Therefore, centrally acting co-analgetic agents can be used in addition to classical pain medications. Endoscopic interventions are preferred in patients with obvious dilation of the pancreatic duct. Surgical interventions are generally more effective although they are usually reserved for patients with prior failure of conservative treatment. Diverse surgical options with different efficacies and morbidities are used in individual patients. One of the main problems in chronic inflammatory bowel diseases is abdominal pain. Primarily the underlying disease needs to be adequately treated. Symptomatic pain management will most likely include treatment with acetaminophen and tramadol as well as occasionally principles of a multimodal pain regimen. For the treatment of arthralgia as well as enteropathy-associated arthritis the same treatment options are available as for other spondyloarthritic disorders.     

关节镜在诊治急性踝关节痛风性关节炎中的应用

目的提高对单纯踝关节起病的急性痛风性关节炎的诊断认识并加强其早期治疗。方法回顾总结1999年以来,关节镜检查发现的14例踝关节急性痛风性关节炎的诊治经过,经过半年以上的随访,进行疗效观察。结果14例病人术前均误诊,分别诊断为化脓性关节炎、类风湿性关节炎、急性滑膜炎、骨性关节炎。全部病例在踝关节镜检查后发现确诊。并一期行关节镜下清理术,术后配合以系统药物治疗,经过随访观察,近、远期均取得满意疗效。结论单纯以踝关节起病的急性痛风性关节炎少见,且容易误诊,随着关节镜技术的不断提高和广泛应用,其诊断率将会获得提高,同时亦为早期治疗急性痛风性关节炎增加了一个新的方法。关节镜下手术仅是急性痛风性关节炎的一种局部治疗方法,它可以防止晚期骨性关节炎的早期发生,但不能代替排酸、抑酸及饮食控制的治疗。     

Alternative therapies for arthritis treatment. Part 1

Because conventional treatment options focus mostly on pain management, an increasing number of the 43 million people with arthritis are seeking alternative methods of disease management to improve their quality of life. According to a 1998 survey (Eisenberg et al., 1998), those who have used alternative methods to manage their diseases are included in the 50% of Americans who have tried an alternative treatment modality. As the first in a two-part series, this article reviews the historical use of selected alternative therapies and provides current information that will help orthopaedic nurses and other healthcare providers to advise their patients on the use of such treatment modalities.     

Tumour necrosis factor inhibitors in the treatment of psoriatic arthritis: a view on effectiveness,clinical practice and toxicity

Introduction: Psoriatic arthritis is a common and often severe chronic joint disorder associated with the skin disease psoriasis (PsO). Treatment options for psoriatic arthritis patients have changed considerably over the last decade with the widespread use of biological therapies, in particular tumour necrosis factor inhibitors. Current clinical experience based on large registries and careful observations now allows us to understand the true value of these interventions in daily clinical practice.

Areas covered: Literature searches were performed targeting effectiveness, drug survival, toxicity and safety of biological therapies as well as treatment strategies specifically focused on patients with psoriatic arthritis.

Expert opinion: Tumour necrosis factor inhibition is a powerful and effective option for the treatment of severe psoriatic arthritis. The different available drugs have good survival rates and show an excellent balance between effectiveness and toxicity. Switching of inhibitor is feasible, but treatment changes should be carefully considered. Novel biological therapies are introduced into the market and will further provide better perspectives for the patient. New questions are also emerging: How to handle long-term remission, can biological therapies be successfully stopped and are co-morbidities sufficiently managed? These questions should be addressed for optimal long-term management of a severe chronic disease.     

Studies on the pathogenesis and treatment of Lyme arthritis

Lyme arthritis is one of the most common clinical manifestations of Lyme borreliosis. It is caused by an intraarticular infection with Borrelia (B.) burgdorferi. A small number of bacteria are liable to provoke severe arthritis by inducing mechanisms (including the induction of cytokines and chemokines) that amplify the inflammatory response. The cellular immune response against B. burgdorferi is characterised by a predominant T helper cell type 1 (Th1) pattern that appears to be inadequate to overcome the infection. In most cases, Lyme arthritis may be cured by antibiotic therapy. A brief summary of current recommendations for the treatment of Lyme arthritis in adults and children is given in this article. However, about 10% of Lyme arthritis patients do not respond sufficiently to antibiotic treatment. Two not mutually exclusive pathogenetic concepts of these treatment-resistant cases will be discussed in the present study: persistent infection and infection-induced immunopathology.     

Surgical treatment for osteochondritis dessicans of the knee

Osteochondritis dissecans (OCD) of the knee is a disease of the subchondral bone with secondary injury to the overlying articular cartilage. OCD lesions are generally categorized as juvenile—growth plates open—or adult—growth plates closed. This maturity-based classification scheme has a prognostic value in that many juvenile OCD lesions will heal with conservative care while most symptomatic adult OCD lesions need surgical intervention. OCD can result in pain, knee joint effusions, loose body formation, and arthritis. Short-term treatment goals include pain and symptom resolution while the long-term goal is to minimize arthritis. Surgical options include debridement, drilling, microfracture, reduction and fixation, autograft osteochondral transplantation, autologous chondrocyte implantation, and allograft osteochondreal transplantation.     

Trapeziometacarpal joint arthritis

Trapeziometacarpal (TM) joint arthritis is a common cause of radial-sided wrist pain that preferentially affects women. It is diagnosed by a thorough history, physical examination, and radiographic evaluation. While radiographs are used to determine the stage of disease, treatment is dependent on symptom severity. Nonoperative treatment frequently consists of activity modification, non-steroidal anti-inflammatory drugs (NSAIDs), splinting, and corticosteroid injections. After failure of conservative treatment, various surgical options exist depending on the stage of disease. This article reviews the literature supporting the various surgical treatment options. Special consideration is given to the comparison of trapeziectomy with and without tendon interposition and ligament reconstruction.     

Clinical and radiological manifestations of the rheumatoid wrist. A comprehensive review

OBJECTIVE: The intent of this review article is to present the common clinical and radiological features of the rheumatoid wrist as seen in everyday practice. Imaging of the rheumatoid wrist is discussed with emphasis on magnetic resonance imaging (MRI) and its current and future role in the diagnosis and treatment follow-up of the disease. DATA SOURCE: A search of the current medical literature from 1990 to present through PubMed was performed without constraints. Search terms used included: MRI, rheumatoid arthritis, wrist, treatment, diagnosis, radiology, clinical manifestations, and incidence. STUDY SELECTION: The articles included in this review were selected by historical significance, date of publication, pertinent review information, and, most specifically, those articles studying the current uses for imaging the rheumatoid wrist. DATA SYNTHESIS: This review demonstrated an overall agreement between numerous studies that the usefulness of MRI evaluation of the rheumatoid wrist is in its early stages of development. Many of the features of this examination of the wrist are discussed and contrasted with plain film radiographic examination. RESULTS: The role of the clinician in the diagnosis and treatment, including complementary care, as well as the follow-up of rheumatoid arthritis in the wrist is unquestionable. The role of plain film examination as a diagnostic tool is excellent. The current and future role of MRI of rheumatoid arthritis is becoming obvious and will likely become the diagnostic imaging tool of choice in the near future. CONCLUSION: MRI provides more specific information on rheumatoid lesions in the wrist than plain film imaging. This is especially true when intravenous contrast is utilized. The clinician's use of physical examination, laboratory examination, radiography, and MRI will provide for early diagnosis, treatment, and follow-up of RA in the wrist.     

The bright future for total ankle replacements

Total ankle arthroplasty is an evolving method of treatment for end-stage ankle arthritis. Although historic interest did not yield favorable results, new generation total ankle implants have demonstrated comparable results with fusion with short- and intermediate-term follow-up. Comparable outcomes, in the setting of improving surgical technique and implant options, will yield increasingly superior results.     

Canakinumab in gout

Introduction: Gout is a painful inflammatory arthritis with a prevalence of approximately 4% in the United States, affecting an estimated 8.3 million adults. The past 20 years have shown significant increases in the number of patients with gout and its incidence may still be increasing. Current treatment options to control the pain and inflammation of acute gout include nonsteroidal anti-inflammatory drugs, colchicine and corticosteroids, although patients are often unresponsive to, intolerant of, or have contraindications for, these therapies. Additional treatment options are therefore needed for this population with difficult-to-treat gout. Areas covered: Currently available and investigational anti-inflammatory agents for acute and chronic gout will briefly be reviewed. Canakinumab , a fully human monoclonal anti-interleukin (IL)-1β antibody that selectively blocks IL-1β and that is being investigated for the treatment of gout, will be discussed in greater detail. Expert opinion: Canakinumab has been found to be superior to triamcinolone acetonide in acute gout and to colchicine in gout attack prophylaxis in reducing pain and risk of new gout attacks. Canakinumab's long half-life contributes to its prolonged anti-inflammatory effects.