By I. Javier. Indiana Wesleyan University. 2017.

Nongonococcal urethritis Epidemiology Males >> females Organisms → Chlamydia generic arava 10 mg online, Campylobacter arava 10mg visa, 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. ANA AND RF ANA RF MCTD + + RA + + SLE + – Scleroderma (PSS) + – Polymyositis + – Sjögren’s + + (+) HLA-B27 A S Reiter’s Psoriatic arthritis Enteropathy arthropathy Pauciarticular JRA RHEUMATOLOGY 115 VASCULITIS POLYARTERITIS NODOSA Systemic necrotizing vasculitis Male:female ratio is 2:1 Also seen in: Small, medium artery involvement R Glomerulonephritis—#1 cause of death SLE Lungs spared Sjögren’s Skin—palpable purpura Mononeuritis multiplex, arthritis GIANT CELL ARTERITIS: ALSO KNOWN AS TEMPORAL ARTERITIS (TA) More common in females > 50 years old Large arteries Tenderness of the scalp and in the muscle of mastication Headaches, abrupt visual loss in 15% of patients Diagnosis: Elevated ESR, temporal artery biopsy Treatment: High dose steroids imperative to prevent permanent visual loss Polymyalgia Rheumatica (PMR) In view of clinical similarities between PMR patients with and without signs of arteritis in a temporal artery biopsy, many authors believe that PMR is an expression of giant cell arteritis Fever, weight loss, malaise Proximal muscles—neck, pelvic Shoulder Morning stiffness—muscle tenderness Abrupt myalgias/arthralgia Diagnosis: ↑ ESR > 50 Treatment: steroids WEGENER’S GRANULOMATOSIS Small artery involvement Male, middle aged Necrotizing granulomatous vasculitis involving – Upper/lower respiratory tract – Focal segmental glomerulonephritis “Saddle-nose” deformity Pulmonary, tracheal, ocular, and cutaneous manifestation 116 RHEUMATOLOGY TAKAYASU Elastic large arteries—Aorta Asian females, 40 years old Erythema nodosum on the legs Pulselessness, arm claudication BEHÇET’S Small vessels Oral and genital skin ulcers 20% experience venous thrombosis GOODPASTURE’S Pulmonary and kidney involvement SJÖGREN’S SYNDROME Autoimmune-mediated disorder of the exocrine glands CLINICAL PRESENTATION: (sicca symptoms) Dry eyes Dry mouth Skin lesions Parotid involvement LABS: ANA (+), RF (+) Classification: Primary and secondary forms Primary—Dry eyes and mouth with ANA (+) , RF (+) Secondary—sicca symptoms – Sjögren’s syndrome plus evidence of SLE, RA, PSS, Polymyositis EXTRAGLANDULAR MANIFESTATIONS Arthralgias Raynaud’s phenomenon RHEUMATOLOGY 117 ARTHRITIS AND INFECTIOUS DISORDERS SEPTIC ARTHRITIS Clinical Picture: Septic Arthritis Rapid onset of moderate to severe joint pain, erythema, and decreased ROM Monoarticular, leukocytosis Knee is the most common joint Risk factors—age, prosthetic joints, comorbidities such as anemia, chronic diseases, hemophilia. Coli) Bone scans 118 RHEUMATOLOGY Treatment Antibiotic coverage Frequent needle aspirations with arthroscopic lavage TABLE 3–7. Joint Fluid Analysis Property Normal Noninflammatory Inflammatory Septic Viscosity High High Low Variable Color Colorless Straw Yellow Turbid-Yellow Clarity Transluscent Transluscent Transluscent Opaque WBC < 200 < 5000 1000–75000 > 100,000 PMN% < 25 < 25 > 50 > 85 Culture Negative Negative Negative Positive Mucin clot Good Good Fair Poor Glucose Equal to blood Equal to blood < 50 mg/dl > 50 mg/dl lower than lower than blood blood OTHER INFECTIOUS CAUSES OF ARTHRITIS Viral Infections—Rubella, infectious hepatitis Fungi—Seen in Immunocompromised adults Mycobacterium—tuberculosis of the spine (Pott’s disease) – Thoracic involvement – TB arthritis—Hips and knees Monoarticular Radiologic findings—Phemister’s triad Juxta-articular osteoporosis Marginal erosions Joint space narrowing Lyme Disease – Tick borne—Borrelia burgdorferi – Classic presentation Erythema migrans—bull’s eye rash Cardiac, neurologic, articular manifestations – Intermittent migratory episodes of polyarthritis – Commonly affects the knee – Synovial fluid—Inflammatory – Diagnosis—ELISA, Western blot analysis – Management—First-line antibiotics: Adults: Doxycycline Children: Amoxicillin – Pattern of Onset: Bite Rash Systemic dz.

Commentary In 1992 purchase arava 10mg with mastercard, Keefe and colleagues expressed widely held hopes that research us- ing larger sample sizes would demonstrate the “active ingredients” of CBT treatment packages; discover how to improve maintenance of treatment gains; and extend CBT to other patient groups generic arava 20mg overnight delivery, such as those with osteo- arthritis, rheumatoid arthritis, and sickle-cell disease. Meanwhile, extensive CBT programs have been subject to cost cutting, thereby reducing the quality and quantity of established treatment facilities. Research has been limited largely to small volunteer studies, making it particularly hard to model change in treatment (and maintenance after treatment) or to carry out stud- ies with sufficient sample size to do justice to the many interacting vari- ables affecting outcome. The questions identified by many clinicians and researchers (Turk, 1990), and to which some anticipate answers from large treatment studies or meta-analyses, are, “Which are the right and wrong patients? Meanwhile, no consistent findings have emerged from many component dismantling trials (see Morley et al. This is not so remarkable given that all investiga- tions are subject to local peculiarities of referral, funding, and acceptance and rejection criteria. We can, however, draw some practical suggestions from mainstream psychology: People with major depressive disorder are unlikely to engage or participate until they have more hope and sense of a tolerable future, so immediate treatment of depression is indicated; pho- 10. PSYCHOLOGICAL INTERVENTIONS AND CHRONIC PAIN 285 bias of groups or health care settings may preclude common methods and settings for delivery. As for “essential ingredients,” the implicit model of component disman- tling studies of additive, independent, and specific component-outcome re- lationships is too far from reality to provide an adequate model for analy- sis. One can no more ask which are the essential ingredients of a cake— butter, sugar, flour, or eggs. The absence of any, or serious compromises of quality, will result in a different and inedible end product; minor variations in one or another or the addition of cocoa or currants does not render it in- edible. The interaction of components (the mixing and cooking process) is crucial, yet team processes and program integration are rarely described. At a risk of stretching the analogy too far, the skills of the cook are also rele- vant, and cost-cutting pressures on programs are likely to reduce efficacy.