Musculoskeletal Disorders

SEATTLE -- Circulating fetal cells may account for why rheumatoid arthritis tends to improve or even disappear during pregnancy, according to researchers here.

For 2 days, a 60-year-old man with a history of gout had excruciating pain in the left big toe. During 2 previous episodes, colchicine had relieved his symptoms. On this occasion, colchicine failed to provide relief. The patient's first metatarsophalangeal joint of the left foot was erythematous, hot, and tender. He could not bear weight on the foot. Other physical examination findings were normal.

AMSTERDAM ? Two-year data from the extension of a major trial of Orencia (abatacept) suggest that the agent continued to prevent the advance of structural damage in rheumatoid arthritis, researchers reported here.

TORONTO ? Second-hand smoke can boost the risk of osteoporosis in pre-menopausal women, researchers reported here.

TORONTO ? The concept of calcium and vitamin D supplementation for prevention of osteoporosis, relegated recently to the realm of unfounded notion, got a spirited defense here.

ATLANTA ? Five years of breast cancer adjuvant therapy with an aromatase inhibitor, can lead to a 6% to 7% loss of bone mineral density, a trigger for osteoporosis for women who are borderline osteopenic when they begin treatment, investigators reported here.

In addition to the extensive body of literaturethat supports medical therapiesfor osteoporosis and for preventionof postmenopausal fractures, numerousstudies have explored thebenefits of exercise in both premenopausaland postmenopausal women.1The results of these studies indicatethat weight-bearing exercise and resistancetraining may play a role in preventingbone loss and increasing bonemass.

What strategies can reduce the risk of osteoporosis in patients receiving long-term glucocorticoid therapy?

Recommendations for women in their 20s who have osteoporosis or osteopenia.

Since gout can precipitate olecranon bursitis, should I routinely order a crystalanalysis for patients who present with this bursitis?

Which test--antistreptolysin O titers, coronary angiography, enzyme-linked immunosorbent assay (ELISA), Western blot testing for Borrelia burgdorferi, or genetic testing for long QT syndrome--would help you diagnose a young man with worsening chest pain, frontal headache, and diffuse muscle and joint pain?

Osteoporosis is no longer consideredage- or sex-dependent, although prevalencevaries by sex and race. Postmenopausalwhite women suffer almost75% of all hip fractures and havethe highest age-adjusted rate of fracture.Thanks to progress in our understandingof causes and treatments, thisdisease is largely preventable, and significantimprovements in morbidityand mortality are possible. The beststrategy for prevention and treatmentuses a team approach that involves thepatient, physician, health educators, dietitians,and physical therapists.

Are there any generally accepted guidelines for performing arthrocentesis in patients who are receiving anticoagulants?

The pyoderma gangrenosum on theright anterior tibial area of a 40-yearoldman was thought to be associatedwith his rheumatoid arthritis. However,the cause of many of these ulcersis unknown. The patient could not recallany recent trauma. At least half ofall pyoderma gangrenosum lesionsoccur in persons who do not have associateddiseases.1

A tiny papule that arose after minortrauma to her finger marked theonset of this lesion, according to the48-year-old patient. She reports thatthe papule rapidly evolved into apustule that grew within 2 weeks intoa painful, undermined, purple-edgedulcer. The lesion did not respond toantibiotic therapy. The patient had rheumatoid arthritis.

A 57-year-old man was referred forevaluation of an enlarging, painful,irregular ulceration on his lower abdominalwall. The patient recalledhaving a small, red, “blister-like” lesionthat had rapidly expanded to itscurrent size of 2.5 * 4.5 cm. Hedenied specific injury to the skin;however, he often wore jeans thatrubbed the area. The patient wastaking ibuprofen for seropositiverheumatoid arthritis.

Although inhaled corticosteroids play a major role in the management of asthma, their effects on bone mineral density (BMD) are a concern for some patients. Fuhlbrigge and associates evaluated the cost-effectiveness of such therapy in light of the potential adverse effects on BMD. They found that inhaled corticosteroid therapy compares favorably with other standard medical interventions. However, the use of high doses over an extended period can affect overall costs and health.

Rheumatoid arthritis (RA) affects 1% ofadults during their most productiveyears and can result in significant disability.The goals of therapy are to reducepain, limit joint destruction, andpreserve function.

Abstract: Smoking cessation is still the most important intervention in patients with chronic obstructive pulmonary disease (COPD), regardless of sex. There is some evidence that nicotine replacement therapy may be less effective in women than in men. However, women may derive greater benefits from a sustained quit attempt. For example, one study found that compared with men, women who were sustained quitters had a greater initial rise and a slower age-related decline in forced expiratory volume in 1 second. Men and women do not appear to differ in their response to bupropion or to the various types of bronchodilators. A number of factors contribute to the increased risk of osteoporosis in women with COPD. Both smoking and the degree of airflow obstruction have been identified as important risk factors for osteoporosis. Women may be particularly susceptible to the effects of smoking on bone metabolism. Immobility and decreased physical activity have also been shown to accelerate bone loss. (J Respir Dis. 2006;27(3):115-122)

Excess weight increases the risk of having a heart attack, stroke, high blood pressure, arthritis, diabetes, depression, fatigue, and certain types of cancer. Losing weight and keeping it off are very difficult for most persons who are overweight. Here are some suggestions to help you lose pounds and keep your weight down.

To easily drain an ulnar bursa or a patellar effusion of any size--and simplify preparation of the aspirate for transfer--use an evacuated blood draw kit with an 18-gauge needle attachment, a see-through-labeled tube coated with whatever anticoagulant your laboratory specifies, and several large additive-free tubes. Begin with the coated tube

Six months ago, I prescribed allopurinol for a patient with a history of podagra, several tophi in one toe, and an elevated uric acid level.

Most pain in or around the oral cavity is attributable to tooth or mucosal pathology. However, tooth or mucosal pain may also be caused by a variety of other conditions, including brain pathology; vascular inflammatory and cardiac disease; jaw infection or neoplasm; neuropathic abnormality not associated with central pathology; pathology in the neck and thoracic region; myofascial and temporomandibular joint pathology; and disease of the ear, eye, or nose, or of the paranasal sinuses, lymph nodes, and salivary glands. Accurate diagnosis is facilitated when the features of pain presentation in this region are understood.

16-month-old previously healthy child is hospitalized after 36 hours of worsening painful edema and erythema of the right lower leg and high fever with chills.

Abstract: Spinal tuberculosis is the most common form of osteoarticular involvement in patients with tuberculosis. Localized pain is a common presenting symptom. In patients who do not present until vertebral wedging and collapse have occurred, a localized knuckle kyphosis is obvious, especially in the dorsal spine. In some patients, a retropharyngeal abscess develops, causing dysphagia, dyspnea, and/or hoarseness. Peripheral joint tuberculosis is characterized by an insidious onset of slowly progressive, painful, and swollen monoarthropathy, most commonly affecting the hip or knee. The radiologic features include juxta-articular osteoporosis, peripheral osseous erosion, and gradual narrowing of the interosseous space. Treatment involves antituberculosis drugs; the indications for surgery are relatively limited. (J Respir Dis. 2005; 26(12):543-546)

A 12-year-old girl complains of left knee pain and swelling that resulted from a collision with another player while she was playing kickball the day before. Her left foot was planted as she tried to catch a ball, and she was hit on the outside of the left knee.

Abstract: Many patients with sarcoidosis are asymptomatic at presentation and have bilateral hilar adenopathy on a chest radiograph obtained for other reasons. Symptomatic patients usually present with chronic cough, dyspnea, or noncardiac chest pain. Extrapulmonary organ involvement is not uncommon. Lung biopsy shows well-formed noncaseating granulomas in a bronchovascular distribution. Interstitial lung disease also may result from collagen vascular disease, such as systemic lupus erythematosus and Sjögren syndrome. In patients with acute hypersensitivity pneumonitis, cough, dyspnea, and flu-like symptoms occur within 12 hours of exposure to the inciting antigen, such as pigeon stool or moldy hay. Some patients have a subacute or chronic course, probably as a result of continued exposure to the offending antigen. In acute hypersensitivity pneumonitis, the chest radiograph may show diffuse small nodules, whereas in chronic disease, reticular lines or fibrosis may be seen. (J Respir Dis. 2005;26(10):443-448)

An enlarging mass was noted on the dorsum of the right fifth toe of a 2-month-old boy during a well-child examination. The firm, immobile mass measured approximately 1 cm in diameter. A congenital abnormality was suspected; the patient was referred to a plastic surgeon for consultation.

A 15-year-old experienced pain in her toe, particularly when pressure was applied to the foot. An ingrown toenail was the cause of her discomfort.

A 38-year-old woman had become increasingly depressed by worsening psoriasis in conjunction with a flare of arthritis in her hands and fingers. The patient complained that she could not function optimally and that her quality of life had diminished.