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Old and new drugs used in rheumatoid arthritis: a historical perspective. Part 1: the older drugs.

Rheumatoid arthritis is the paradigmatic immune-mediated inflammatory arthropathy and may be of comparatively recent, New World origin. Apart from the symptom-relieving nonsteroidal anti-inflammatory drugs, whose natural congeners have been in use since antiquity for musculoskeletal pain and inflammation, only a dozen drugs or drug classes--the disease-modifying antirheumatic drugs--are currently in common use in rheumatoid arthritis. Development of these drugs has been a notable achievement of the 20th century. Some were developed serendipitously (glucocorticoids, antimalarials), some were the product of faulty reasoning (gold, D-penicillamine), and others were applied for plausible reasons but whose mechanism remains unproven (sulfasalazine, methotrexate, minocycline). A minority were originally applied on the basis of actions that remain germane to the pathophysiology of rheumatoid arthritis as currently understood (azathioprine, cyclosporine, leflunomide, infliximab, etanercept). Among the latter are the more recently introduced and effective agents. The practical use of these drugs is determined by efficacy-toxicity considerations, which have also driven the recent development of the cyclooxygenase-2-selective nonsteroidal anti-inflammatory drugs.

Anti-Inflammatory Agents, Non-Steroidal↗

Refractory torticollis after a fall.

Though multiple medical and psychiatric causes of torticollis have been described, cervical dystonias resulting from distant somatic dysfunctions have not. This article describes the treatment of a 62-year-old woman in whom refractory retrotorticollis of surmised pelvic etiology developed after a fall. Structurally, cervical dystonias have been addressed as problems that originate in the head and neck, but this limited view of the musculoskeletal component of torticollis may prevent physicians from directing osteopathic manipulative treatment to the underlying problem.

Accidental Falls↗

[Clinical aspects of epileptic ion channel disorders].

OBJECTIVE: One of the recent findings in the investigation of epileptogenesis is the localization of new gene situses and mutations of the ion channels. The pathology of these ion channel disorders is responsible for a considerable number of disorders affecting the central nervous and musculoskeletal systems. Their clinical expression is often paroxystic. Mutations cause inactivation of the channel, which depending of the degree, conditions the phenotype of the disorder. DEVELOPMENT: We studied the main ion channel disorders related to simply inherited idiopathic epileptic syndromes in which four genes have been codified to date: benign familial neonatal convulsions, generalized epilepsy with febrile seizures plus and autosomal dominant nocturnal frontal lobe epilepsy. CONCLUSIONS: The ion channels, both voltage dependent and receptor channels, are involved in the genesis of idiopathic epileptics syndromes. Their importance is due to their contribution to the understanding of epileptogenesis and its application to the investigation of drugs which modify the initial cause of the seizure. At present, it may be affirmed that the idiopathic epilepsies, or at least some of them, seem to form a family of ion channel disorders.

Epilepsy↗

[Systemic inflammatory reactions and extracutaneous manifestations of acne vulgaris].

166 patients suffering from acne of different severity were examined with regard to associated systemic manifestations. 74 of the patients showed acne conglobata, 12 acne tetrade, 11 acne fulminans, and 69 acne papulopustulosa. Subjective symptoms like weakness, fever, and arthralgia, as well as unspecific serological inflammatory parameters and internal symptoms were taken into consideration. Acne papulopustulosa was not associated with any internal symptoms. Such extracutaneous reactions were observed, however, in severe forms of acne as in acne tetrade or acne conglobata (41% vs 17%). Acne fulminans revealed musculoskeletal manifestations and severe inflammatory signs in the blood. The high rate of kidney involvement with severe inflammatory types of acne was alarming. Three patients developed on acute glomerulonephritis, which evolved into a chronic form in two patients.

Acne Vulgaris↗

Self-assessment of disease activity by patients with rheumatoid arthritis.

OBJECTIVE: To determine the reliability of self-assessment of disease by patients with rheumatoid arthritis (RA), with a particular emphasis on the assessment of articular swelling. METHODS: A questionnaire was developed using components from validated instruments. Information was obtained on global function, global joint tenderness/swelling, and joint pain (10 cm visual analog scales), duration of musculoskeletal morning stiffness (grade 1-6), ACR functional score (grade 1-4), tender joint count (0-20), tender joint score (0-60), swollen joint count (0-20), and swollen joint score (0-60). Data were collected prospectively on 61 patients with RA in a teaching clinic or office practice by 4 staff rheumatologists. Patient questionnaires were completed within 24 h before physician assessments. Followup assessments were carried out on 27 patients after a mean interval of 3 months (range 0.5-6). RESULTS: At the initial assessment there was a significant correlation between patient and physician assessments for global function (r = 0.83; p = 0.01) [intraclass correlation coefficient (ICC) = 0.83; p < 0.01], global joint tenderness/swelling (r = 0.83; p < 0.01) (ICC = 0.83; p < 0.01), global joint pain (r = 0.83; p < 0.01) (ICC = 0.81; p < 0.01), duration of morning stiffness (r = 0.83; p < 0.01) (ICC = 0.85; p < 0.01), ACR functional score (r = 0.61; p < 0.01) (ICC = 0.62; p < 0.01), tender joint count (r = 0.57; p < 0.01) (ICC = 0.31; p < 0.01), and tender joint score (r = 0.60; p < 0.01) (ICC = 0.35; p < 0.01). However, there was poor correlation between patient and physician assessments for both swollen joint count (r = 0.16; p > 0.05) (ICC = -0.02; p > 0.05) and swollen joint score (r = 0.24; p > 0.05) (ICC = 0.12; p > 0.05). Longitudinal analysis indicated significant correlation between changes in patient and physician assessments in all variables except swollen joint count and score. CONCLUSION: Although there was good correlation between most variables for patient and physician assessments of disease activity in RA, there were substantial differences in the assessment of joint swelling. This objective determinant of disease activity cannot be ascertained in self-report measures of health status.

Adult↗

[Physical activity and bodily pain in children].

BACKGROUND: Musculoskeletal complaints are frequently reported not only by adults, but also by children. Sedentary lifestyle has been suggested as a possible cause. MATERIAL AND METHODS: 569 pupils in primary school in a Norwegian municipality, aged 10-15 years, answered a questionnaire on bodily pain, self-esteem, body image and physical activity. RESULTS: We found a tendency that the least and the most physically active children reported most complaints. The two groups reported complaints from different regions. INTERPRETATION: Whether complaints in childhood develop into adult chronic pain conditions, and whether increased activity among the most physically passive children can hinder such a development are still unanswered questions.

Adolescent↗

Developmental skeletal anomalies.

A genetic and molecular revolution is taking place in medicine today. Led by the Human Genome Project, genetic information and concepts are changing the way diseases are defined, diagnoses are made, and treatment strategies are developed. The profound implications of actually understanding the molecular abnormalities of many clinical problems are affecting virtually all medical and surgical disciplines. The ability to apply knowledge gleaned from the laboratory is our best hope for developing strategies to modify the pathologic effects of genes (by drug therapy), repair genes (gene therapy), and restore lost or affected tissues (tissue engineering). Instead of an empiric trial-and-error approach to therapy, it may become feasible to tailor treatment to the specific molecular malfunction. In this review we have chosen to emphasize a few selected musculoskeletal disorders, including skeletal dysplasias, spinal deformities, developmental dislocation of the hip, and idiopathic clubfoot. The logical extension of our understanding of the molecular players in many of these disorders is to establish precisely what the products of the affected genes do during skeletal development, and how mutations disturb these functions to produce the characteristic phenotype. Despite the many hypotheses generated from the work in human genetics, and the knowledge that has been gained from animal models, there remains a relatively poor understanding of how these genes interfere with skeletal development. Unraveling these mysteries and defining them in molecular and cellular terms will be the challenges for the near future.

Bone Diseases, Developmental↗

A study of out-of-hours telephone advice from an A&E department.

A prospective analysis of telephone calls to an accident and emergency (A&E) department during weekday evenings/nights and weekends was undertaken over a 3-month period. A telephone consultation record (TCR) proforma was developed to record information about each call for advice. The volume of calls, characteristics of callers and patients, nature of presented problems, and advice given were analysed. An average of 9.3 calls were documented during each weekend 24-hour period, and 3.3 calls during each weekday evening/night. Junior nurses took 93% of calls. Advice was sought for a broad range of problems, of which only 11% were musculoskeletal conditions or injuries. Twenty-six per cent of patients were advised to attend A&E, 35% were given self-care advice, and the remainder were advised to contact or see their GP. There is considerable potential to develop a nurse-provided telephone advice service, but the need for staff training and guidelines has to be addressed.

Adolescent↗

Ultrasound during dissection of cadaveric specimens: a new method for obtaining ultrasound-anatomic correlations in musculoskeletal radiology.

We report a new technique for ultrasound-anatomic correlations consisting of dissection of embalmed specimens during ultrasound examination. Our method consists of performing ultrasound during the different stages of dissection. The technique was developed by making observations of selected structures in two embalmed and two non-embalmed cadaver hands. The image quality was subjectively graded by consensus of two investigators, before and after denudation of the selected structures of the hand. As an example, the technique is demonstrated for the flexors at the metacarpophalangeal joint level, the extensor complex at the level of the proximal phalanx, and the dorsal hood of the second to fourth fingers. Before dissection the image quality in fresh specimens was graded moderate, and in embalmed specimens good. After dissection the image quality was good in fresh specimens and excellent in embalmed specimens. Our method is simple and does not require sophisticated material. Our results indicate that embalmed specimens could be better than non-embalmed specimens, because of the presence of artefacts in the non-embalmed specimens (gas deposits). The described methodology can yield excellent results regarding precise identification of different interfaces and structures, as observed at ultrasound.

Cadaver↗

The prevalence of rheumatic diseases in a Filipino urban population: a WHO-ILAR COPCORD Study. World Health Organization. International League of Associations for Rheumatology. Community Oriented Programme for the Control of the Rheumatic Diseases.

OBJECTIVE: To determine the point prevalence of musculoskeletal complaints and rheumatic diseases in a Filipino urban community. METHODS: A descriptive cross-sectional 2 phase survey was conducted in an urban community in Metropolitan manila. Phase I (screening) used face-to-face interviews, while phase II (examination) involved case identification of the rheumatic diseases. We sampled 670 households (3065 adults) using a multistage cluster sampling method. A pilot study was conducted to pretest the questionnaire for cross-cultural adaptation and validation, field procedures, sampling design, and data management plan. Standardized translated COPCORD questionnaires (blind translation and blind back-translation) were administered by trained interviewers. Two weeks after Phase I, Phase II was conducted at local health centers. The COPCORD questionnaire screened the number of cases with musculoskeletal complaints. Identification of cases with rheumatic disease was based on American College of Rheumatology (ACR) criteria. RESULTS: Respondents completed 3006 questionnaires (phase I response rate 98%). Of these 489 respondents had musculoskeletal complaints. Functional disability was reported in 25% among these respondents. We examined 353 (phase II response rate 72%), revealing 294 with rheumatic conditions. In 26 persons there were no abnormalities, while 32 had nonrheumatic conditions at examination. The most common rheumatic diseases were osteoarthritis (OA) (n = 124) and soft tissue rheumatism (n = 115). CONCLUSION: The prevalence of musculoskeletal complaints was 16.3% (95% CI 8.6-24.0) of the adult population in a FIlipino urban community. The total prevalence of rheumatic disease is 9.8% (95% CI 8.2-11.4). The prevalence of OA was 4.1% (95% CI 3.3-4.9) and soft tissue rheumatism 3.8% (95% CI 2.9-4.8). The prevalence of rheumatoid arthritis, 0.17% (95% CI 0-9.36), was notably low compared to the prevalence in other developing countries.

Adolescent↗

Treatment and the process of care in musculoskeletal conditions. A multidisciplinary perspective and integration.

Chronic musculoskeletal pain for which there is not an obvious underlying physical cause is one of the most common reasons for long-term disability. There is a need to develop better ways of managing these problems. Improving the understanding of the basis for decision making, the processes of care, and the beliefs and expectations of patients and health care professionals seems as fundamental as basic laboratory science is to understanding inflammatory arthopathies. Little is known about the beliefs and expectations of patients and health care professionals, nor the multitude of factors such as traditions within professional groups, education, and language that professionals use in decision making. When better understanding of these factors and the mismatch between professionals and patients is achieved, then theoretical frameworks, treatment approaches, and the education of professionals in appropriate management will be improved.

Attitude of Health Personnel↗