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Saturday, March 7th, 2009
The symptoms of rheumatoid arthritis (RA) begin gradually. It may be weeks or months before they are noticeable. Many people experience nonspecific symptoms, such as fatigue, malaise, loss of appetite and low-grade fevers. The joint symptoms begin with morning stiffness that may last an hour or more. Joint pain, stiffness and swelling that occurs symmetrically (same joint on both sides of the body) are also characteristic of RA.
Some people develop rheumatoid nodules, which are painless lumps under the skin that form at pressure points, such as feet, hands and elbows. Some patients have dry eyes and mouth, which in some cases may be overlap symptoms from another autoimmune condition known as Sjogren’s syndrome, or eye inflammations such as uveitis.
RA causes some particular symptoms in each of the joints it affects. Some of the symptoms in specific joints include:
* Hand. Joints in the fingers and hands are usually the first joints affected by RA. They may become red, swollen and tender. Nodules may form that restrict hand movement. Gripping may become more difficult and the thumb may lose mobility. As RA progresses, characteristic problems include the tightening of the tendon on the back of the hand so it becomes prominent and deformities where the fingers shift toward the little finger (ulnar drift).
* Wrist. Carpal tunnel syndrome is a compression of the median nerve in the wrist that causes wrist pain. In early RA, the wrist may not bend back easily. In later stages, inflammation to the joints and tendons in the wrist can make the tendons rupture. Pressure on the median nerve in the wrist may cause carpal tunnel syndrome, a painful wrist condition.
* Elbow. Inflammation and swelling at the elbow can compress nerves and cause numbness or tingling in the fingers.
* Shoulder. In later stages of RA, some inflammation may limit motion and cause shoulder pain, including the condition known as frozen shoulder.
* Foot. The joints in the feet are also among the first affected by RA. There may be tenderness and pain in the joint at the base of the big toe, which may form a bunion. Redness, swelling and heel pain may also occur.
* Ankle. Inflammation in the ankle joint may compress nerves and cause numbness or tingling in the feet.
* Knees. RA may make it difficult to bend the knee and cause swelling. A fluid-filled sac called a Baker’s cyst may form at the back of the knee. Progression of RA degenerates cartilage and weakens the ligaments. This may create the sensation of knee instability.
* Hips. Later stages of RA may inflame the hips, making it painful to walk.
* Neck (cervical spine). Most people with RA in the neck have had tAnatomy of the spine includes the cervical spine, thoracic spine, lumbar spine and sacral region.he disease for 10 years or more. Inflammation can cause a stiff neck and inability to bend or turn the head. Later inflammation in the neck can cause serious pressure on the spinal cord, which may result in arm pain, loss of coordination and loss of bowel and bladder function.
* Windpipe. Nearly one-third of people with RA have inflammation of the cricoarytenoid joint in the neck near the windpipe (trachea), which can cause difficulty breathing and hoarseness.
If RA moves to other body systems, it may cause the following symptoms:
* Lungs. Inflammation of the lung lining (pleuritis) may cause chest pain with deep breathing or coughing.
* Cardiovascular system. Nearly all RA patients have anemia, a lowered level of red blood cells, which can cause fatigue. RA in the heart may cause chest pain when leaning forward or lying down, although this is rare. Inflammation in blood vessels (vasculitis) can slow blood supply to tissues. This may produce symptoms in different locations, depending on the affected blood vessels. It may first be visible as leg ulcers and black areas around the nail beds.
* Nervous system. RA in any part of the nervous system may cause numbness, weakness or tingling.
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Thursday, March 5th, 2009
The specific cause of rheumatoid arthritis (RA) is unknown. Although the immune system attacks the tissue in the joints, no one knows what triggers such an autoimmune attack, or why it first attacks only a few joints. Some researchers think that some outside factor or a combination of factors trigger the initial inflammation.
Risk factors are elements that may increase a person’s likelihood of developing a disease or condition. For RA, risk factors may be divided into two groups. Susceptibility factors may indicate a person is susceptible to the disease. Initiating factors are those that may occur with the susceptibility factor and trigger RA. The presence of a risk factor does not mean a person will develop the condition, and the absence of a risk factor does not mean the condition will not occur.
Susceptibility risk factors for RA include:
* Sex. Like many other autoimmune diseases, RA is much more common in women. Women make up about 70 percent of the RA cases in the United States, according to the Arthritis Foundation (AF).
* Age. RA can occur at any age but usually begins between the ages of 30 and 50.
* Family history and genetics. Having immediate family members with RA (parents, siblings or children)Lupus is a chronic autoimmune disease that can cause joint pain and inflammation (arthritis). increases the likelihood of developing the disease. One of the genes associated with RA is HLA-DR4. This gene is present in some percentage of the entire population, but they may not develop RA. However, about two-thirds of Caucasian RA patients have this gene, according to the AF. Presence of another autoimmune disease. People with an autoimmune disorder, such as Sjogren’s syndrome, type 1 diabetes or lupus, are at greater risk for developing others.
Birth weight might also affect susceptibility. Women in the U.S. Nurses’ Health Study were twice as likely to develop RA if they weighed more than 10 pounds at birth.
Known or suspected initiating risk factors for RA include:
* Smoking. People who smoke have a higher risk of developing RA. Smoking may also be a factor that initiates inflammation.
* Infection. A previous infection with bacteria or a virus may help initiate RA. The link is suspected, but there is no evidence yet to support it.
* Lifestyle factors. Stress and diet may also be factors that can initiate RA inflammation, but no studies have proven this as of yet.
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Wednesday, March 4th, 2009
Rheumatoid arthritis (RA) is one of the most debilitating types of arthritis. It can cause the joints to swell and eventually become deformed, making it difficult to perform routine tasks.
RA begins in the joints, where two or more bones meet. There are several types of joints. Arthritis occurs mostly in synovial joints, which can move, such as those in the hands, wrists, ankles, knees and feet. For each synovial joint, a space enclosed by the ligaments and adjoining bones forms a cavity called the joint capsule. The outer layer of the capsule is formed by a fibrous membrane. The inside of the capsule is lined with a membrane called the synovium. This membrane secretes synovial fluid, which fills the joint capsule and provides lubrication. The ends of the bones encased in the capsule are cushioned in soft cartilage. The cartilage and synovial fluid permit the bones to move without rubbing against each other.
People with RA experience inflammation in the joint capsules, which affects the movement of the joint and causes pain. RA is an autoimmune condition, which means people with RA have an abnormal immune response. Normally, the immune system protects the body from outside invaders, such as germs. Immune cells (e.g., white blood cells) attack these invaders and flush them out or make them inactive. Part of this process normally produces some inflammation in tissue.
For someone with autoimmune response, the immune system misidentifies regular body tissue as an outside invader. It attacks the tissue and tries to destroy it. In RA, certain types of white blood cells attack parts of the synovium, causing the inflammation that characterizes RA. The process by which this occurs is not well understood. The synovium thickens, which causes the joint to swell. The synovium can form a body called a pannus, which has granular tissue that covers the bone and cartilage. The pannus tissue reacts with enzymes and erodes the bone surface.
RA usually begins in the smaller joints of the fingers or feet. It frequently occurs in the same joints on both sides of the body. It eventually may move to involve more joints, including the wrists, ankles, elbows and knees.
RA is a chronic condition, but attacks may vary. There are periods of severe inflammation called flare-ups, and RA can go into remission for long periods of time. A few people may experience one flare-up followed by remission. However, RA is generally a progressive (worsening) illness. It may start in a few small joints and eventually spread to other joints and tissues, such as cartilage, bones and ligaments. Some RA patients eventually have substantial functional disability that prevents them from working.
RA is a systemic disease, meaning it can involve other body systems. RA can affect the linings of the heart, lungs and blood vessels, and increases the risk of heart disease and heart failure. It can also affect the eyes and the nerves. Inflammation of the blood vessels (vasculitis) can be life-threatening, causing skin ulcerations and infections, bleeding ulcers, hemorrhage and nerve problems.
Rheumatologists classify the status of RA patients based on their ability to function:
* Class I. Completely able to perform usual activities of daily living.
* Class II. Able to perform usual self-care and work activities, but limited in other activities (i.e., sports or chores).
* Class III. Able to perform self-care activities but limited in work and other activities.
*Class IV. Limited in ability to perform usual self-care, work and other activities.
RA can occur at any age and in all races and ethnic groups. It generally begins between the ages of 30 and 50. Although adults are primarily affected, there is also a disease called juvenile rheumatoid arthritis that can affect children.
Women are more commonly affected by RA than men. Of the 1.3 million Americans with RA, at least two-thirds are women, according to the Centers for Disease Control and Prevention (CDC). Women with RA tend to experience remission of symptoms during pregnancy and flare-ups after giving birth or while breastfeeding.
RA is not the same as osteoarthritis (OA), the degenerative form of arthritis most common among elderly people. Although both forms of arthritis cause joint pain, there are several major differences:
* OA involves degeneration of joint cartilage. RA involves inflammation of the membranes lining joints, caused by immune dysfunction.
* RA usually occurs symmetrically, such as in both hands or both knees. OA may occur on one side (e.g., in one knee).
* OA affects only the joints. RA can affect other systems in the body, including the lungs, nerves or heart.
* OA usually affects people over age 50. RA affects people between 20 to 60 years of age.
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Tuesday, March 3rd, 2009
Also called: RA, Systemic Rheumatic Disease, Rheumatoid Disease, Rheumatic Joint Disease, Subacute Rheumatic Arthritis, Acute Rheumatic Arthritis
Osteoarthritis is the most common type of arthritis and is caused by joint cartilage deterioration. Rheumatoid arthritis (RA) is an autoimmune condition that involves joint inflammation and pain. Although less common than osteoarthritis, RA is more debilitating and usually starts earlier, between the ages of 30 and 50.
About 1.3 million Americans, at least two-thirds of them women, have RA, according to the Centers for Disease Control and Prevention (CDC).
The cause of RA is not entirely understood. It begins with an altered immune response, in which immune cells attack normal cells in the joints. This causes inflammation and pain in the joints, frequently in the same joint on both sides of the body. RA can also affect the eyes, heart and other organs.
RA may begin as pain, swelling or stiffness in a few joints. The progress of the disease varies. It may remain the same for many years or progress to other joints and systems in the body. The swelling can deform the bones and tendons in the joints, which may make the joints difficult to use. Some people eventually lose the ability to work or perform daily tasks.
Physicians may use multiple blood tests and a physical examination to diagnose RA. Guidelines to classify the disease include joint pain or swelling in multiple joints for more than six weeks.
There is no known cure for RA. Treatment concentrates on pain relief and slowing the progression of the disease.
Great strides have been made in recent years with drugs that can slow RA’s progress. Drug treatment may include basic pain relievers such as acetaminophen or anti-inflammatory drugs. Other drugs modify the disease’s progress or work on parts of the immune system that malfunction to trigger RA. The course of RA is different for each patient and different drug combinations may provide relief. No drugs can reverse damage inflicted on the joints.
Some surgical procedures can remove parts of damaged joints or even replace a joint (arthroplasty).
Research into the causes and progress of RA continues. Scientists are studying genetics and the biochemistry of the immune system. Other studies focus on potential new drugs, drug combinations or other treatment methods.
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Monday, March 2nd, 2009
Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about gout:
1. If I have hyperuricemia, does it mean I will get gout?
2. Am I at risk of developing gout?
3. Will eating a high-protein diet put me at risk for gout?
4. Are there specific foods I should avoid?
5. What test for gout might I undergo, and what do these tests involve?
6. What are my treatment options for gout?
7. How long will my treatment last?
8. Are there any side effects associated with my therapy for gout?
9. What things should I avoid while undergoing treatment for gout?
10. Is there any way I can prevent gout?
11. Do high levels of uric acid increase my risk of heart disease or other conditions in addition to gout?
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Thursday, February 26th, 2009
Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about rheumatoid arthritis (RA):
1. How do you know I have RA and not some other form of arthritis?
2. Will RA spread to other joints in my body?
3. What tests will confirm my condition? Will I need to take them again to monitor the disease?
4. What drugs can help my condition? Do I need to take them all the time or only when I have pain
5. Should I watch for symptoms in body areas or systems other than my joints?
6. Do the different types of drugs have the same effects?
7. What changes should I make in my diet to help RA?
8. Will exercise improve or worsen my pain?
9. How do I know when I should exercise and when I should rest?
10. Can physical therapy, occupational therapy, heat therapy, cold therapy, water therapy, biofeedback or other such treatments help me?
11. Is it possible my RA may require surgical treatment? If so, what type of surgery is recommended, and what is the prognosis?
12. How likely is my RA to cause heart disease or other complications? How often should I get my cholesterol, blood pressure and other cardiac risk factors checked? Do I need any treatment for this?
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Wednesday, February 18th, 2009
In general, keeping uric acid within a normal range (under 7 milligrams/deciliter) is the long-term key to preventing buildup of uric acid, which may lead to gout and/or bouts of acute gouty arthritis (episodes of severe joint pain and swelling) in people diagnosed with the disease. This can be achieved by:
* Maintaining a healthy body weight. Patients can achieve and maintain a healthy body weight by eating a balanced diet and exercising regularly.
* Avoiding excessive consumption of foods rich in purines. It should be noted that all meat, fish and poultry contain moderate amounts of purines. However, some are more rich in these substances than others, such as:
- Seafood (e.g., anchovies, sardines, fish roes, haddock, salmon, smelt, herring, mackerel, trout, mussels, scallops)
- Organ meats (e.g., liver, hearts, kidneys, sweetbreads)
- Bacon
- Poultry (e.g., grouse, turkey, partridge, goose, pheasant)
- Other meats (e.g., mutton, veal)
- Yeast
- Legumes and vegetables (e.g., beans, peas, mushrooms, cauliflower, spinach)
* Limiting or avoiding alcohol. Drinking excessive amounts of alcohol, especially beer, can inhibit the elimination of uric acid and cause dehydration, which in turn may lead to gout. Also, if a patient is experiencing a gout attack, it is best to abstain from alcohol to prevent worsening of symptoms.
* Drinking plenty of fluids (at least 68 ounces or 2 liters a day). Fluids help dilute uric acid in the blood and urine. It is especially important for gout patients to avoid dehydration during hot and humid weather.
* Avoiding use of the inflamed joint during an acute attack until pain and inflammation disappear.
Limited research has suggested that eating cherries might help prevent or relieve gout. Additional studies would be needed to establish this connection. The U.S. Food and Drug Administration (FDA) has warned companies not to market juice and other cherry products as a treatment or preventive measure for gout, other forms of arthritis or other diseases.
When gout is properly treated, the prognosis is excellent, and many patients experience relief from their symptoms and live productive lives.
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Tuesday, February 17th, 2009
Rheumatologists will often be involved in the treatment of gout because they specialize in managing this and other forms of arthritis.
A number of medications may be recommended to reduce joint pain and inflammation. To avoid any interactions, patients must advise their physicians if they are taking other drugs.
Medications to treat gout include:
* Nonsteroidal anti-inflammatory drugs (NSAIDs). High doses of NSAIDs such as indomethacin or ibuprofen are the most common treatment for acute gouty arthritis. However, aspirin should not be used for this condition because it can elevate levels of uric acid in the blood. Patients who have a history of ulcers or kidney problems, or those taking anticoagulant medication, may be treated with another type of anti-inflammatory medication, or other medications may be used in conjunction with NSAIDs to protect against unwanted side effects.
* Corticosteroids. These medications are strong anti-inflammatory hormones, which may be given to patients who cannot use NSAIDs. Corticosteroids may be given in pill form (in high doses) or via injections into the swollen joint. Patients usually begin to improve within a few hours of treatment, and the attack often completely Osteoporosis involves the bones becoming thin, brittle and more prone to fracture, causing pain.subsides within a week or so. When used long term, however, these medications may produce side effects, such as weight gain, osteoporosis (bone thinning), cataracts, glaucoma and diabetes, and may contribute to hardening of the arteries (atherosclerosis).
* Colchicine. This alkaloid drug is often prescribed when NSAIDs or corticosteroids do not control symptoms. However, it is most effective when taken within the first 12 hours of an episode of acute gouty arthritis. Physicians may prescribe it as often as every hour until joint pain and inflammation begin to improve. When taken orally, side effects may include nausea, vomiting, abdominal cramps or diarrhea.
In addition, colchicine may also be prescribed in low doses to prevent further attacks. When taken in low doses, side effects are less likely to occur. Even though the chronic use of colchicine can reduce or prevent attacks of gout, it does not prevent the accumulation of uric acid crystals that can cause joint damage even without attacks of hot, swollen joints.
Colchicine may also be administered intravenously (I.V.), but this form of therapy should be performed only by a physician experienced in it. When done improperly, I.V. colchicine therapy can have severe side effects, including bone marrow toxicity, kidney failure and, in some cases, even death.
Once the acute gouty arthritis is under control, treatment for gout focuses on preventing recurrent attacks and decreasing the levels of uric acid in the blood.
Therapy to lower blood levels of uric acid, which may lead to the formation of uric acid crystals in the tissues and joints of the body, may include:
* Uricosurics. These medications help the kidneys eliminate excess uric acid in the urine. Uricosurics should be taken with plenty of fluid (at least 68 ounces or 2 liters a day) to prevent the formation of uric acid kidney stones. These drugs are usually prescribed when gout is caused by under-excretion of uric acid, which occurs in most cases. However, uricosurics should not be used by patients with reduced kidney function or those with tophaceous gout.
* Xanthine oxidase inhibitors. These drugs, including allopurinol, decrease the body’s production of uric acid and are the most reliable way to lower levels of uric acid in the blood. Common side effects include stomach pain, headache, diarrhea and rashes. In very rare cases, some people can develop an extremely severe allergic reaction that can lead to kidney and liver toxicity as well as become life-threatening. Patients who develop a rash or a fever after use of a xanthin oxidase inhibitor should seek immediate medical care.
To be effective, medications to reduce uric acid in the blood must be taken regularly and long-term. Stopping the medications often results in recurrence of gout later.
In addition, medications to treat hyperuricemia (high blood levels of uric acid) should not be administered during an episode of acute gouty arthritis because they may intensify and/or prolong the attack. They should be administered only after symptoms (e.g., joint pain and inflammation) subside.
In instances of medication-induced hyperuricemia, switching medications under a physician’s supervision is often the only course of action necessary.
Surgery is rarely needed for Knee replacement surgery involves replacing part of the knee joint with metal and synthetic pieces.gout unless significant joint damage has occurred from lack of effective and timely treatment. Sometimes surgery may be performed to remove large tophi that are draining (oozing), infected or interfere with normal joint movement. In very severe cases, patients may have to undergo joint replacement surgery (arthroplasty).
Treatment for gout should begin early to prevent long-term complications, such as chronic tophaceous gout, the formation of kidney stones and kidney damage. In secondary gout, treatment of the primary condition causing gout may control the disease.
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Monday, February 16th, 2009
Diagnosis of gout usually begins with a physical examination and questions about personal and family medical history. A physician may suspect gout if a patient has had a history of acute arthritis, especially in big toe, that has been followed by a period when symptoms have disappeared.
To confirm gout as well as rule out other diseases with similar symptoms (e.g., pseudogout, septic arthritis, rheumatoid arthritis), a physician may perform an arthrocentesis. This procedure uses a needle to withdraw (aspirate) fluid from a joint so the sample can be examined for uric acid crystals. Gout crystals are needle-shaped and are negatively birefringent (unable to split a ray of light in two) under a polarized light microscope, as compared to pseudogout, where crystals are positively birefringent. During an acute attack, the crystals are often present inside white blood cells.
Large deposits of uric acid crystals (tophi) may be removed from beneath the skin in a biopsy to diagnose an advanced stage of gout called chronic tophaceous gout, though this procedure is not commonly performed for diagnosis.
Other tests may include:
* Urinalysis. Laboratory analysis of urine samples to measure the amount of uric acid being eliminated by the kidneys. This test is also performed to detect kidney stones.
* Blood tests. Laboratory analysis of blood samples to measure uric acid in the blood and detect hyperuricemia, which is present in most cases of gout. Hyperuricemia is defined as more than 7 milligrams of uric acid per deciliter of blood. However, some patients with gout may have normal levels of uric acid, so hyperuricemia is not used to definitively diagnose gout. Blood tests are also used to rule out other arthritic conditions.
* X-ray. This imaging test is primarily used to assess joint damage, especially in patients who have had multiple episodes of acute gouty arthritis.
Once a diagnosis has been made, treatment should be started immediately to avoid long-term complications of untreated gout, such as chronic tophaceous gout, kidney stones and kidney damage. Sometimes it becomes difficult to diagnose gout clinically, especially if it affects an atypical joint in the beginning and the person has normal values of uric acid.
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Sunday, February 15th, 2009
Generally, gout progresses through four stages. During the first stage, a patient has elevated levels of uric acid in the blood (hyperuricemia) but no other signs or symptoms. At this stage, called asymptomatic hyperuricemia, patients seldom require treatment. In addition, not all people with hyperuricemia go on to develop gout.
The second stage of gout is called acute gouty arthritis. It occurs when the patient suddenly experiences a hot, red, swollen joint, caused by the formation of uric acid crystals between the joints. In most cases, the big toe (a condition once known as podagra) or the knee is affected.
The attack often occurs at night and in a single joint, with the pain becoming more severe. When a single joint is involved, the condition is called monoarticular gout. The pain may grow so intense that even a bed sheet on the joint can cause pain. Chills and a mild fever along with a general feeling of malaise may also accompany the severe pain and inflammation.
Monoarticular gout occurs more often in middle-aged patients and usually involves one joint in the lower limbs, especially the big toe (hallux).
Even without treatment, the first episode often disappears spontaneously within three to 10 days, but prompt treatment can abort the attack in a few hours. Although the pain and swelling disappear, gouty arthritis almost always returns in the same joint or in another one.
A patient is usually symptom-free for a period of time. During this third stage, called interval or intercritical gout, a patient does not have any symptoms and has normal function of the joints. The next attack usually occurs within two years, followed by additional attacks thereafter.
If left untreated, the interval between attacks may shorten and they may become increasingly severe and prolonged. Over time, the attacks can begin to involve multiple joints at once – called polyarticular gout – and may be accompanied by a joint infection (e.g., septic arthritis). Polyarticular gout occurs more often in elderly patients and usually involves the joints in the upper extremities, especially the fingers.
In addition, episodes of acute gouty arthritis can be triggered by circumstances that affect blood levels of uric acid, such as certain chronic illnesses (e.g., diabetes, high blood pressure), injury, surgery, fasting, drinking alcohol, overeating (especially foods rich in purines, such as liver) and taking certain medications (e.g., diuretics, aspirin, immunosuppressives).
People who experience sudden, intense joint pain with fever should see their physician as soon as possible. If gout is left untreated, it can lead to worsening of the pain and permanent joint damage.
When gout goes untreated for several years, it can progress to a condition called chronic tophaceous gout. During this last phase, patients experience chronic pain and inflammation and there is permanent joint damage due to the formation of large masses of uric acid crystals, which also collect in bone and cartilage, such as in the ears. These masses or nodules of crystals are called tophi. They can form near the knuckles and small joints of the fingers and can cause disfigurement. These large masses or lumps may drain and ooze a chalky substance.
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