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Reactive Arthritis Infectionassociated Arthritis And Reiters Syndrome

Reactive or infection-associated arthritis is a type of spondyloarthropathy brought on by infection. Reiter's syndrome is a special case of infection-associated arthritis with a particular set of systems (discussed later). Affected children are often very ill, with fever, rash, and arthritis. Sometimes the arthritis is in only one large joint, but at other times it may be widespread, affecting many joints both large and small. It was originally termed reactive arthritis because the arthritis frequently begins shortly after a significant viral or bacterial infection. The name was changed to infection-associated arthritis to remind physicians that in some cases the infection is still present and may require treatment. The most common infectious agents that cause these forms of arthritis are bacteria (shigella, salmonella, neisseria, and chlamydia) and viruses (especially parvovirus B19). The arthritis associated with Lyme disease is also a form of infection-associated arthritis. Mild...

Patellofemoral Joint Pain

Hoke,2 a physical therapist, provided a good analysis of the mechanical causes of patellofemoral joint pain The knee extensor mechanism attenuates the shock, accepting body weight when the foot contacts the ground in running. This shock attenuation is accomplished through a smoothly controlled eccentric contraction of the knee extensors. The patel-lofemoral joint is a finely balanced system within the extensor mechanism, and multiple factors affect its alignment and function. The runner frequently experiences pain in the patellar region when this system lacks the necessary balance of power between medial and lateral forces. Excessive pronation of the foot also has been cited by multiple authors3,4 as a contributory factor in the development of anterior knee pain. The early peak in knee flexion after foot contact coincides with the peak in rear-foot pronation, and if the pronation of the rear foot becomes excessive, there will be adverse stress on the knee in the sagittal plane...

Rheumatoid Arthritis

RA, discussed at length in Chapter 1, is a symmetric autoimmune polyarticular arthritis. It also affects nonarticular structures. Patients may have vasculitis, pulmonary fibrosis, and inflammatory changes in ligaments, tendons, and fascia. Of patients with RA, 25 to 30 have cricoarytenoid arthritis, with symptoms of hoarseness, globus, odynophagia, and pain with speaking or coughing. If the joints become fixed in an adducted position, the airway can be severely obstructed. Cricoarytenoid

Enthesitis Related Arthritis

This subset was previously referred to as either juvenile ankylosing spon-dylitis or type II pauciarticular arthritis. It is a spondyloarthropathy usually manifesting as a predominantly lower limb arthritis and enthesitis (inflammation of the insertions of tendon, ligament, or joint capsule into bone). It is the only form of JIA to show a male preponderance (19), usually occurring in the early teens. If enthesitis is absent, then the diagnosis can still be made if arthritis and two other spondyloarthropathy-related features are present as described by the ILAR criteria for enthesitis-related arthritis (Table 3) (8). As seen in adults with spondyloarthropathies, acute painful anterior uveitis is a prominent extra-articular feature, usually occurring as an acute unilateral anterior uveitis with a high frequency of recurrence, sometimes in the contralateral eye. Anterior uveitis in these cases is likely to be extremely painful and therefore not liable to go undetected, in contrast to the...

Arthritis osteoarthritis

This is a joint disease characterised by the breakdown of articular cartilage, growth of bony spikes, swelling of the surrounding synovial membrane and stiffness and tenderness of the joint. It is also known as degenerative arthritis. It is common in the elderly and takes a progressive course. This condition involves varying degrees of joint pain, stiffness, limitation of movement, joint instability and deformity. It commonly affects the weight bearing joints - the hips, knees, lumbar and cervical vertebrae.

Treatment for Pauciarticular Onset Arthritis

Treatment for pauciarticular-onset arthritis usually consists of nonsteroidal anti-inflammatory drugs (NSAIDs). These drugs are discussed in detail in Chapter 20. I often use diclofenac for children with pauciarticular-onset disease that does not respond adequately to other NSAIDs. Naproxen, celecoxib, nabumetone, and diclofenac have the advantage of being given less frequently than ibuprofen. For children who have true pauciarticular arthritis, it is rare for additional medications to be necessary. Occasionally, there are children who have persistent swelling of one or two joints despite an adequate trial of NSAIDs. This is the point at which it is reasonable to consider injection of corticosteroids directly into the joint (intra-articular injection). These rarely have side effects and often provide rapid and dramatic relief for months. Most children can be talked through injection of one joint without undue distress, but anesthesia may be necessary if more than one joint must be...

Mechanical Complications of Obesity Arthritis

Obesity is frequently complicated by degenerative arthritis (DJD). Increased body weight leads to trauma of the weight-bearing joints and speeds the development of osteoarthritis in obesity. Knee and hip joints are particularly affected. However, obese patients have increased DJD of the hands, perhaps due to cytokines produced by adipose tissue, which may damage the cartilage in joints. Flattening of the arc of the planter surface of the feet (flat feet) occurs more frequently in obese people, presumably due to the stress of carrying excess body weight. Flat feet may lead to unsteady gait and aches and pains after walking. Increased fat deposition, particularly in the abdominal region, can change the natural curvature of the spine, causing lordosis and resulting in backache in obese people.

Enthesitisassociated Arthritis

Heel Insertion

The term spondyloarthropathy does not refer to a specific disease. Meaning arthritis involving the back, it describes a pattern of inflammation that may occur in children with a variety of underlying conditions. For many years, children with spondyloarthropathies were considered to have JA, but now these children are described as having enthesitis-associated arthritis. Although enthes-itis-associated arthritis is considered a subtype of juvenile arthritis, it is important to recognize that this is a very different disease from, for example, pauciarticular-onset arthritis. Remember, juvenile arthritis is being used as an umbrella term encompassing a large number of different conditions. In contrast to other types of arthritis, the spondyloarthropathies have a different pattern of joint involvement, a different prognosis, a different best medication, and a different cause. The first widely recognized group of children with spondyloarthropathies were teenage boys with swollen knees and...

Organizations Dedicated Primarily to Arthritic Conditions Juvenile Rheumatoid Arthritis Spondyloarthropathy Ankylosing

Box 7669 Atlanta, GA 30357-0669 (800) 283-7800 http The American Juvenile Arthritis Organization (AJAO, is now part of the Arthritis Foundation and may be accessed via its contact numbers. Arthritis Society of Canada 393 University Avenue, Suite 1700 Toronto, Ontario M5G 1E6, Canada (416) 979-7228 http Arthritis Insight http This is a Web-based, question-and-answer site with information for children and adults.The children's info is at http This is a site for children, teenagers, and young adults to share ideas, complaints, and the knowledge that they aren't the only ones in the world with arthritis.

The Center for Alternative Medicine Evaluation and Research in Arthritis CAMERA

Focuses on the investigation of the effectiveness of complementary therapies for the alleviation of conditions accompanied by acute and chronic pain, such as arthritis. CAM areas of interest include herbal medicine, homeopathy, and acupuncture. In 1999, the National Center for Complementary and Alternative Medicine (NCCAM) awarded a 7.8 million grant to the University of Maryland to establish a center for alternative medicine research in arthritis and related disorders. The Center for Alternative Medicine Evaluation and Research in Arthritis (CAMERA) is housed within the Complementary Medicine Program (CMP). Though the focus is currently on investigating the use of acupuncture, future projects involve studies with botanicals, including traditional Chinese herbal formulas.

Cytokine Targeting in Psoriasis and Psoriatic Arthritis Beyond TNFa

2.4 IL-15 in Psoriasis and Psoriatic Arthritis 37 Abstract. Targeting TNFa provided proof of concept for the role of proinflammatory cytokines in promoting cutaneous inflammation, particularly psoriasis. Recent studies have elucidated the presence of numerous cytokine and chemokine activities in psoriatic skin and synovium. There is considerable interest in the potential of such activities as novel therapeutic targets. IL-15 is an innate response cytokine that activates leukocyte subsets via binding to its unique IL-15Ra and shared P and y chain receptors. IL-15 promotes T cell memory and sustains local T cell activation, in part via prevention of apoptosis and mediates activation of monocytes, neutrophils and NK cells. IL-15 is up-regulated in psoriatic skin and psoriatic arthritis synovium. IL-15 blockade in a murine model of psoriasis led to marked suppression of typical psoriatic skin features. Clinical intervention in other chronic inflammatory disease states is now ongoing with...

Rheumatoid Factor Positive Polyarthritis JIA

This is classified as an arthritis involving five or more joints during the first six months of disease associated with a rheumatoid factor positive test on at least two occasions at least three months apart. This subtype is generally considered to be the juvenile form of erosive adult rheumatoid arthritis (RA) although erosions are often late due to the greater amount of cartilage the younger the patient. The peak age of onset is in mid to late adolescence although it can develop in much younger children. As in adult RA, there is a female predominance. Rheumatoid nodules and classical vasculitis are seen only in this group, in which all extra-articular manifestations found in adult RA may occur, including ocular, cardiac and pulmonary involvement. There are no major differences known between juvenile- and adult-onset arthritis pathological processes. There are however differences in outcome related to effects of joint inflammation occurring in a growing skeleton and the psychosocial...

Systemic Onset Juvenile Idiopathic Arthritis

Adult and pediatric disease are characterized by a daily spiking fever and an evanescent, non-fixed, macular erythematous rash that is most pronounced at the height of fever and arthritis. If arthritis is not present (as may be the case in early disease), the diagnosis may still be made in the presence of organ involvement, such as serositis (pericarditis or pleurisy), generalized lymphadenopathy, splenomegaly, or hepatomegaly. These features, coupled with a neutrophilia (greater than 13 x 109 L in 75 or more of patients) and elevated acute-phase reactants, may suggest infection, particularly if the arthropathy is not evident at disease onset with systemic features. Specific diseases in addition also require consideration and exclusion (Table 2). to adult-onset Still's disease where only 25 to 5 of patients achieve remission in their disease course (14,15). In some patients the systemic features, including the fever and malaise, respond well to nonsteroidal antiinflammatory drugs. In...

Rheumatoid Factor Negative Polyarthritis JIA

Extra-articular manifestations than in rheumatoid factor positive JIA and prognosis is less severe. There is an association to chronic asymptomatic anterior uveitis, but with a lower incidence than in the oligo-arthritis JIA subset, but there is a similar association with ANA positivity. In adults with rheumatoid arthritis, there is a subgroup of 25 of patients who are rheumatoid factor negative. In this adult seronegative subgroup, erosive joint damage and extra-articular manifestations are less common than in rheumatoid factor positive disease. The occult anterior uveitis and ANA positivity associations seen in juveniles are not, however, seen in adult disease.

Oligo Arthritis and Extended Oligo Arthritis JIA

Oligoarticular JIA is the most common subtype of JIA, representing 50 of all JIA (1). Oligo-arthritis affects young girls at least six times more frequently than boys, with a peak incidence below 3 years of age. The prevalence is between 20 and 30 per 100,000, and most ethnic groups are affected (9). Children with this form of JIA have four or fewer joints affected within the first six months of disease, although as many as one-third may subsequently progress to polyarticular involvement (10). Those that subsequently have a cumulative involvement of five or more joints are reclas-sified into the extended oligo-arthritis subtype. Specific exclusions include a positive family history of psoriasis or spondyloarthropathy and a positive rheumatoid factor. Children who remain oligoarticular for five years are unlikely to progress to extended oligo-arthritis. This group of patients are classically associated with antinuclear antibody (ANA 40-75 ), usually in low titre (less than 1 in 640)...

Post Streptococcal Reactive Arthritis and Rheumatic Fever

Post-streptococcal reactive arthritis is another form of infection-associated arthritis. It differs in that we know this form of infection-associated arthritis is initiated by a group A streptococcal infection. Poststreptococcal reactive arthritis behaves just like the other forms of infection-associated arthritis. Sometimes the arthritis is in a single large joint such as the hip, and at other times it can affect multiple joints. There is a lot of confusion regarding the relationship of post-streptococcal reactive arthritis to acute rheumatic fever. Since acute rheumatic fever is associated with possible damage to the heart and requires penicillin prophylaxis, this is an area of great concern. Acute rheumatic fever is defined according to the Jones criteria (see box). Children who develop a nonmigratory (not moving from joint to joint) arthritis after a streptococcal infection do not fulfill these criteria. As a result, many physicians do not treat these children with penicillin...

Treatment of Arthritis Associated with Gastrointestinal Complaints

Adalimumab has recently been approved as therapy for inflammatory bowel disease. This agent is extremely effective for the arthritis of IBD as well as for the disease itself. Use of adalimumab is increasing, as there is growing hesitation on the part of gastroenterologists to use NSAIDs in children with inflammatory bowel disease because of the medications' propensity to cause gastrointestinal side effects.

Complications of Psoriatic Arthritis

The primary complications of psoriatic arthritis are related to recurrent arthritis. Some children develop significant joint damage over the course of their disease. Serious eye involvement can occur in young children, and children with ANA-positive psoriatic arthritis must be monitored just as carefully as children with ANA-positive pauciarticular-onset JA. Fortunately, eye involvement is less common in teenagers but still possible. Persistent wrist and finger involvement is often prominent. In some children this seems to be the only evidence of disease. However, children may begin with only wrist involvement but years later develop problems in other joints. Elbow, neck, and jaw involvement is more common in children with this form of arthritis and must be looked for. However, hips, knees, ankles, and toes may also be involved. Because the arthritis can become widespread, it is important to do everything possible to bring it under control quickly and, if possible, to prevent it from...

Treatment of Reactive Arthritis

The most important step in the treatment for children with any kind of infection-associated arthritis involves making sure the infection is properly treated. Once it is clear that the infection associated with the arthritis is no longer active, these children should be treated just like other children with spondyloarthropathies. Most respond well to NSAIDs. In most cases, the arthritis resolves completely over a period of a few months. TNF inhibitors are sometimes required, while other children benefit from the addition of sulfasalazine. Intra-articular injection of corticosteroids may be useful if only one joint remains troublesome after the infection has been fully treated, but oral corticosteroids are rarely necessary. Physical therapy to maintain strength and range of motion is often necessary during the acute phase of the disease. Surgery should not be necessary for a child with infection-associated arthritis unless it is required to treat the infection.

Complications of Reactive Arthritis

Since, by definition, infection-associated arthritis resolves within a year of onset, long-term complications are infrequent. There may be complications related to the initial infection, but most children recover fully and do well. Reiter's syndrome, as noted previously, is a special case of reactive arthritis. It is distinguished from other cases of reactive arthritis by the occurrence of arthritis, urethritis (irritation of the urinary tract), and conjunctivitis. Children with Reiter's syndrome sometimes have rashes, particularly on their hands and feet. They may also have severe, painful acute anterior uveitis. When evaluating a child for the diagnosis of Reiter's syndrome, it is important to remember that the arthritis, urethritis, and conjunctivitis do not all have to be present on the same day. They may occur one after the other without ever overlapping in time. Although Reiter's syndrome with all of the findings is common in adults, it is rare in childhood.

Eye Complications of Juvenile Arthritis and Related Conditions

In juvenile arthritis and related conditions, the eyes may be involved even when there is no evidence of active joint disease. Ocular complications may take several forms. Children with pauciarticular-onset, polyarticular-onset, and psoriatic arthritis are all at risk of developing eye inflammation (chronic anterior uveitis). In this condition, inflamed cells accumulate in the eye and the resultant irritation may cause damage to the colored part of the eye (iris), the lens, and other structures (see Fig. 5-1 in Chapter 5). The most worrisome aspect of this inflammation is that often it does not produce pain or redness, and so it may cause serious eye damage before it is detected. Frequency of Routine Screening Ophthalmologic Examinations for Children with Juvenile Arthritis If you look carefully at the joint of a child with arthritis, the inflammation is centered in the synovium. This is the lining tissue, the normal function of which is to keep the joint clean of debris. Examination...

Stateoftheart Care For Children With Juvenile Arthritis

State-of-the-art care for children with pauciarticular-onset, polyarticular-onset, and systemic-onset juvenile arthritis requires that physicians and families make sure the inflammation is promptly brought under control and not allowed to cause continuing joint damage. In the past physicians believed that children who had evidence of low-grade active disease but seemed to be doing okay should not be treated aggressively. We now know this is wrong, as the earliest damage is to the rapidly growing cartilage, and this kind of damage does not show up on X-rays until years later, when it has become permanent bone damage. Failing to treat properly means continuing bone and joint damage and a continuing risk of further disease flares. Children whose disease comes under good control within six months of starting therapy will generally do well. Children with any type of juvenile arthritis whose disease is not under good control within six months of starting appropriate therapy are at increased...

Systemiconset Juvenile Arthritis

Systemic-onset juvenile arthritis refers to the onset of arthritis with fever and a characteristic rash. Systemic-onset juvenile arthritis has no relationship to adult-onset rheumatoid arthritis and most likely no relationship to the other forms of juvenile arthritis, either. It is best considered an entirely separate disease. Although all children with systemic-onset arthritis share key characteristics, the outcome of systemic-onset disease is so varied that it is difficult to believe it is in fact a single disease. There are several key points when making the diagnosis of systemic-onset arthritis. First, the fever must fall back to normal at least once each day. Second, the rash should have the characteristic salmon pink appearance it should never look like a bruise. It is occasionally itchy. Occasionally, there are children who develop fever and rash before the arthritis becomes evident. These children should always be followed carefully for the possibility of another diagnosis,...

Juvenile Rheumatoid Arthritis

The classification system for juvenile inflammatory arthritis (JRA) divides this form of childhood arthritis into three categories systemic, pauciarticular (four or fewer affected joints), and polyarticular. Among children with JRA, the most important ocular disease is chronic, nongranulomatous anterior uveitis. It occurs in about 20 of children with pauciarticular JRA, 5 to 10 of children with polyarticular JRA, and rarely, if ever, in those with the systemic type. Young girls with the pauciarticular subtype of JRA and a positive test for serum antinuclear antibodies are at the highest risk for developing chronic anterior uveitis. Onset is usually insidious and the children are frequently asymptomatic this type of uveitis is termed white eye because of its benign appearance to the causal observer. The uveitis may precede the arthritis by up to five years. In JRA, chronic anterior uveitis is bilateral in two-thirds of patients. Slit-lamp examination reveals cells and proteinaceous...

Is Glucosamine Really The Arthritis Cure

If you are among the millions who suffer from osteoarthritis I do not have to tell you about pain. Nagging, persistent and at times unbearable, pain is a way of life for you. For most of you, the search for relief from this grinding pain is a chore in and of itself. While exact numbers differ widely, according to Newsweek, there are 22 million with Osteoarthritis in the US. Whether your pain is in your knees, neck, hands, shoulders or any other joint, there have been some important advances made in treating these conditions. I'm going to discuss these advances with you and explain in detail how this information can help you take control of your osteoarthritis.

Role of Diet in the Management and Prevention of Degenerative Arthritis

Much less is known about the role of diet in the treatment of OA and other degenerative arthritides. The above discussion regarding n-3 PUFAs in RA also may pertain to OA, although the strength of the effect has not been studied as thoroughly. However, the same eicosanoid metabolism occurs in OA as in RA, with the exception that the disorder is limited to the joint rather than involving the whole body. Thus, fish oils may well be of benefit in OA. Antioxidant intervention with vitamin E may also be effective in OA, with several studies showing an effect comparable with NSAIDs. Although not strictly nutrients, glucosa-mine and chondroitin sulfate, which are two of the constituents of normal cartilage that decline with arthritis, have been shown to be useful when given as an oral supplement, especially in patients with early OA. suggesting that obesity seems to be a mechanical rather than systemic risk factor. Thus, maintaining body weight within the recommended ranges is probably the...

American Juvenile Arthritis Organization AJAO

A special council of the arthritis foundation that helps to serve the special needs of children, teens, and young adults with childhood rheumatic diseases and their families. Its members are parents, family members, doctors, nurses, occupational and physical therapists, social workers, young adults, and anyone with an interest in arthritis in young people. The AJAO serves as an advocate for and works to improve the quality of life for children with rheumatic diseases and their families by working toward better medical care, stimulating research, and providing education and support. The organization tries to increase awareness of childhood arthritis, promotes access to care by pedi-atric rheumatologists, develops education and support programs, advocates the needs of those affected by childhood arthritis, and encourages research and funding toward prevention, control, and cure. conferences and publishes educational materials ranging from free brochures to inexpensive self-help manuals....

Polyarticularonset Juvenile Arthritis

Polyarticular-onset disease is defined as arthritis involving five or more joints during the first six months of disease, without other explanation. In my opinion, any involvement of small joints indicates polyarticular-type disease even if initially there are fewer than five joints involved. Polyarticular-onset disease may occur in any age group but is found more often in girls than in boys. There are two major peaks in the age at onset of disease in young children between eighteen months and eight years of age and in older children and teenagers after eleven years of age. Some children start with only one or two arthritic joints, with the arthritis slowly spreading to other joints, while other children rapidly develop arthritis of multiple joints. Laboratory findings in children with polyarticular-onset arthritis are highly variable. Some have entirely normal laboratory tests, while others have elevated ESR and low hemoglobin. A small percentage of children with polyarticular-onset...

Pauciarticularonset Juvenile Arthritis

To base the distinction between pauciarticular-onset and polyarticular-onset JA only on the basis of the number of joints involved six months after onset may seem both confusing and of limited utility. After all, it's hard to tell exactly when someone's arthritis began, and the drawing of the line at five joints seems a bit arbitrary. However, the classification persists because it is generally useful. Children who have arthritis of the hands and feet, whether or not the large joints are affected, usually have more joints involved (because of the number of joints in those areas) and thus fall into the category of polyarticular onset. These children have a different prognosis (and probably a different disease) than children with only large joint involvement, who tend to fall into the category of pauci-articular onset because there are not that many large joints in the body. The proper classification should be onset with only large joints versus onset with small joints involved, with or...


Overall, current evidence from clinical trials suggest that devil's claw may be a useful treatment for arthritis however, it is suggested, as with many herbal medicines, that evidence of effectiveness is not transferrable from product to product and that the evidence is more robust for products that contain at least 50 mg of harpagoside in the daily dosage (Chrubasik et al 2003a, Gagnier et al 2004). An observational study of 6 months' use of 3-9 g day of an aqueous extract of devil's claw root reported significant benefit in 42-85 of the 630 people suffering from various arthritic complaints (Bone & Walker 1997). In a 12-week uncontrolled multicentre study of 75 patients with arthrosis of the hip or knee, a strong reduction in pain and the symptoms of osteoarthritis were observed in patients taking 2400 mg of devil's claw extract daily, corresponding to 50 mg harpagoside (Wegener & Lupke 2003). Similar results were reported in a 2-month observational study of 227 people with...

Psoriatic Arthritis

Psoriatic arthritis is another spondyloarthropathy that requires special attention. Pediatric rheumatologists continue to debate exactly who belongs in this group, since a child does not have to have psoriasis to have psoriatic arthritis, and children might have another form of arthritis and coincidentally have psoriasis. It is called psoriatic arthritis because over the course of as much as ten to fifteen years, many children who have this type of arthritis will develop psoriasis. Whether they eventually develop psoriasis or not, what's most important is that in children diagnosed with this condition, their disease behaves like the arthritis associated with psoriasis and responds to the same medications. There are varied criteria for the diagnosis of psoriatic arthritis. They require that the child have arthritis plus dactylitis or changes in the fingernails of a type often seen in children with psoriasis (onycholysis), as well as a close relative with psoriasis. Some physicians...

With Arthritis

Deodhar et al. were the first to report on the antirheumatic activity of curcumin in human subjects (107). They performed a short-term, doubleblind, crossover study in 18 patients with ''definite'' rheumatoid arthritis to compare the antirheumatic activity of curcumin (1200 mg day) with that of phenylbutazone (300 mg day). Subjective and objective assessment in patients who were taking corticosteroids just prior to the study showed Liacini et al. examined the effect of curcumin in articular chondrocytes. Interleukin-1 (IL-1), the main cytokine instigator of cartilage degeneration in arthritis, induces matrix metalloproteinase-3 (MMP-3) and MMP-13 mRNA and protein in chondrocytes through activation of mitogen-activated protein kinase (MAPK), AP-1, and NF-kB transcription factors (108). Curcumin achieved 48-99 suppression of MMP-3 and 45-97 of MMP-13 in human and 8-100 (MMP-3) and 32-100 (MMP-13) in bovine chondrocytes. Inhibition of IL-1 signal transduction by these agents could be...


Arthritis refers to the inflammation of a joint which causes pain and swelling of the joint. Arthropathy refers to non-inflammatory disease of a joint, which may have many different causes. There certainly is a higher incidence of joint problems in adults with Down's syndrome, but whether or not there is an increase in the incidence of auto-immune arthritis (such as juvenile rheumatoid arthritis, or JRA) is still being debated in the medical community. One researcher recommended a new condition be named 'arthropathy of Down's syndrome', since the diagnosis of juvenile rheumatoid arthritis is a diagnosis of exclusion (i.e. when you make sure that no other disease process is causing the arthritis, then JRA is all you have left). Most researchers, however, are willing to diagnose JRA in children and teens with Down's syndrome if the specific criteria are met. The treatment of arthritis in people with Down's syndrome is the same as in people without Down's syndrome. If the joint pains are...


There is strong evidence to suggest that glucosamine is effective in treating the symptoms of OA, as well as being effective in slowing the disease progression. A Cochrane review of 16 RCTs has concluded that 'there is good evidence that glucosamine is both effective and safe in treating osteoarthritis' and that 'glucosamine therapy may indeed represent a significant breakthrough in the pharmacological management of osteoarthritis' (Towheed et al 2003). Although most studies have been of OA of the knee, there is some clinical evidence that it is also active against OA of the spine (Giacovelli 1993) and temporomandibular joint (Shankland 1998). The National Institutes of Health (NIH) recently spent US 14 million on a Glucosamine Chondroitin Arthritis Intervention Trial (GAIT), a 24-week, placebo-controlled, parallel, double-blind, five-arm trial involving 1 583 patients that aimed to answer the question as to the efficacy of glucosamine hydrochloride and chondroitin by comparing...


Individuals who are overweight or obese increase their risk for the development of osteoarthritis. 16-18,91,92 The association between increased weight and the risk for development of knee osteoarthritis is stronger in women than in men. 92 In a study of twin middle-aged women, it was estimated that for every kilogram increase of weight, the risk of developing osteoarthritis increases by 9 to 13 percent. The twins with knee osteoarthritis were generally 3 to 5 kg (6.6 to 11 lb) heavier than the co-twin with no disease. 16 An increase in weight is significantly associated with increased pain in weight-bearing joints. 175 There is no evidence that the development of osteoarthritis leads to the subsequent onset of obesity. 91 A decrease in BMI of 2 units or more during a 10-year period decreased the odds for developing knee osteoarthritis by more than 50 percent weight gain was associated with a slight increase in risk. 93 clinical improvement in patients with osteoarthritis. 176...

Juvenile Arthritis

Arthritis is defined as pain, swelling, or limitation of motion in a joint. According to the criteria of the American College of Rheumatology, juvenile rheumatoid arthritis (JRA) is the proper diagnosis for any child with the onset of arthritis before sixteen years of age if the arthritis lasts at least six weeks in more than one joint or three months in a single joint, without other explanation. Based on this definition, every child with chronic arthritis has JRA. However, it is very clear that not every child with arthritis has the same condition. A five-year-old girl with a swollen knee and inflamed eyes does not have the same disease as a teenage boy with a swollen knee and ankle pain. They have different prognoses (probable outcomes in the future), different responses to medication (the best medicine for the little girl is unlikely to be the best medicine for the boy), and most likely different causes for their disease. Rheumatologists recognize more than fifty causes of chronic...

Looking at Related Medical Problems

Sometimes, people strongly suspect (or are sure) that they have fibromyalgia. Instead, however, they may have arthritis, Lyme disease, lupus, thyroid Extreme tiredness is one of the possible symptoms of many medical problems, including hypothyroidism, anemia, chronic fatigue syndrome, Lyme disease, arthritis, and oh, yes fibromyalgia, too. No wonder sorting it all out can be so hard sometimes To find out more about illnesses often confused with FMS, and how doctors sort them out, read Chapter 6.

Fatigue is associated with disability

Although fatigue is sometimes thought of as a trivial symptom, it is associated with considerable disability. Studies that have assessed the levels of disability in CFS sufferers suggest profound deficits. Two prevalence surveys (Buchwald et al. 1995 Wessely et al. 1997) used quality of life questionnaires and found a stepwise increase in disability from healthy subjects to those with chronic fatigue and those with CFS. Role performance (the ability to fulfil occupational or household functioning) was especially impaired. Patients with CFS have disabilities comparable to, or worse than, patients with many common medical illnesses such as heart disease, diabetes, or arthritis (Wells et al. 1989). This applies both to cases seen in clinical settings and those who do not consult. Patients with CFS who also suffer from psychological distress or depression have particularly severe impairments. Wessely et al. (1997) demonstrated a striking gradient of decreasing function in subjects with...

Useful Communication Strategies Importance of the First Question

When seeing a new referral it is very important to clarify the perception (both adolescent and parental) of why the adolescent has been referred to you. Adolescent-parent discrepancies may be readily revealed, even at this early stage in the consultation In several studies, the professional's lack of interest in the wider impact of the condition is reported by young people to impede effective communication (9,10,17). This is readily addressed by always starting the consultation with a non-disease-related question, for example, What have you been up to since we last met rather than How is your arthritis A useful aide-memoire is to draw a text box in the corner of the notes page with a reminder of an important event to ask about at the next visit, e.g., joined new football team, took part in a play, etc. The mere fact that you have remembered will convey the message that the young person has being listened to and that the rest of their life is important. Adolescent health professionals...

Chondroprotective Effect

The overall chondroprotective effect of chondroitin has been demonstrated in animal models, whereby oral or intramuscular chondroitin sulfate has been shown to protect rabbit articular cartilage from experimental chymopapain injury (Uebelhart et al 1998a) and inhibit the destruction of the cartilage extracelluar matrix (Sumino et al 2005). The chondroprotective action of chondroitin has been found to be potentiated by high sulfur mineral water in an animal model of osteoarthritis (Caraglia et al 2005).

Skills Training For Young People

Trips, camps, foreign travel Problem solving (including contingency planning) What would do if your arthritis flared and you were away from home What might you do if your friends are drinking alcohol at a party and you are still taking methotrexate What would you do if you didn't get accepted to a university How would you disclose your condition to a potential employer Accessing advice from

Impact Of Loss Of Motion

If any of your joints whether your hips, knees, or shoulders are tight, you may find that the number of positions you can move into independently is limited. This, in turn, may limit the types of activities you can do for yourself. Range-of-motion exercises are the most basic element of an activity program for people with MS. Moving joints through their full range of motion even once a day will help to prevent development of contractures (frozen joints) and of permanently reduced range of motion of a particular joint. Maintaining the flexibility of your joints and of the structures around them will also decrease spasticity of your muscles.

Depression Epidemiology

In a community-based study, the prevalence of depressive symptomatology in PD patients was six times that of healthy age- and sex-matched controls (2). In a registry-based study of 211,245 patients, Nilsson et al. (65) compared the incidence of depression in PD patients (n 11,698) with non-PD patients with diabetes (n 91,318) and non-PD patients with osteoarthritis (n 10,822) who were matched for degree of disability. An increased probability of developing a depressive episode was found for patients with PD when compared with the diabetes and osteoarthritis groups. Nilsson et al. (66) also showed that patients with an affective disorder (depression or mania) had an increased risk of being diagnosed with PD (odds ratio 2.2) when compared to patients with osteoarthritis or diabetes.

Educational Strategies

Knowledge regarding the disease and its treatment is a prerequisite for good medication adherence. Most treatment centers implement some form of patient and family education in their routine clinical practice. The National Arthritis Advisory Board in the United States has developed standards for arthritis patient education (82) and provided the following definition

Screening experiments for antiinflammatory properties

This chapter describes some examples of screening experiments aimed at identifying antiinflammatory constituents of plants. A large number of plants and herbs are known for their anti-inflammatory properties. Well-known examples are willow bark (contains salicin, from which aspirin is derived), Boswellia serrata (boswellic acids) and turmeric (curcumin). In addition to these, many other herbs have been suggested to be anti-inflammatory. Inflammation plays a role in many different clinical disorders. In addition to the obvious inflammatory diseases such as arthritis, asthma, Crohn's disease, psoriasis and so on, inflammation also plays an important role in diseases such as atherosclerosis, diabetes, Alzheimer's and many other diseases. In many of these, a disordered immune system contributes to the onset and or progression of the disease. et al., 2003). Adhesion molecules that are involved in the translocation of immune cells from the circulation into the sites of inflammation are also...

Finding Out Whether You Have Fibromyalgia

Part II is about discovering whether you have fibromyalgia, and part of that process is ruling out medical problems that may be impostors for your real problem of fibromyalgia. These conditions include chronic fatigue syndrome, myofascial pain syndrome, thyroid disease, forms of arthritis, and a few other illnesses that may surprise you, such as Lyme disease, lupus, and Raynaud's phenomenon (all discussed in Chapter 6). Then I move into diagnosing fibromyalgia. A good doctor is crucial to diagnosing and treating fibromyalgia, and I discuss the important role that doctors play in Chapter 7. I also offer advice on working with your regular doctor and, if that doesn't work, finding a new doc. Then I cover what actually happens (or should happen) during your physical exam to find out whether you have fibromyalgia.

Clinical Manifestations

Arthralgias and myalgias are frequent, but frank arthritis and myositis are uncommon. Gastrointestinal (GI) manifestations most frequently present as abdominal pain. The entire GI tract can be involved. Biopsies of affected sites may reveal vasculitis, granuloma formation, and or inflammatory eosinophilic infiltrates. Cardiac disease may be severe and is the most frequent cause of death (30), occurring in approximately 35 (15-85 ) of patients. Cardiac involvement most frequently includes heart failure, pericarditis, cardiomyopathy, and ischemic cardiomyopathy. Renal involvement is not as frequent in CSS as it is in WG and MPA. When present, renal disease is characterized by crescentic GN with scant or no immune-complex deposits.

Small Vessel Vasculitis

Henoch-Schonlein purpura (HSP) is the most common juvenile form of small vessel vasculitis. Although HSP is seen in adolescents, the peak age-of-onset is 4-6 years (18). There is an association with preceding infection in up to half of cases (38). HSP presents with the combination of non-thrombocytopenic palpable purpura over the lower extremities, abdominal pain, arthritis, and glomerulonephritis. Pathologically there is IgA deposition in the glomerular mesangium or the dermal vessels (39). HSP is a self-limiting disorder that carries an excellent prognosis. Although 20 to 50 of cases may be associated with renal involvement only 1 progress to chronic renal insufficiency (40). However, it should be noted that this risk is greater in adolescents (41).

Uncommon Chronic Systemic Inflammatory Disorders Periodic Fever Syndromes

Castleman's disease is a rare atypical lymphoproliferative disorder characterized by enlarged lymph nodes with striking vascular proliferations. It is separated into localized disease, usually observed in young patients, and multicentric disease, more common in older patients. Localized disease has a good prognosis with surgery. Multicentric disease can be associated with other systemic disorders such as HIV, AIDS, malignant lymphoma, and rheumatoid arthritis. Diagnosis depends on biopsy. Treatment options include surgery, chemotherapy, anti-herpetic treatments, antiretroviral therapy and monoclonal antibodies against IL-6 and CD20 (127). Prognosis depends on the underlying disorder.

The makeup of articular cartilage

Proteoglycans are nothing more than molecules composed of sugar and proteins. What they do inside your cartilage matrix is wrap themselves in and around the collagen fibers. So what happens then The proteoglycans add stretching capability and they act to capture water. Remember, we already said that 65 to 80 of your cartilage is made up of water. It is this squeezing in and out activity as your joints are in motion that is facilitated by these proteoglycans. And there is just one

Laboratory Findings In Lyme Disease

Children with Lyme disease almost invariably have a positive Lyme titer and a positive Western blot (see Chapter 22). In addition, they have elevated ESRs and white blood cell counts. While the elevated white blood cell count and ESR are commonly present in children with polyarticular-onset arthritis, they are infrequent in children with pauciarticular-onset disease. Some children with Lyme disease have positive tests for antinuclear antibody (ANA). They should not have rheumatoid factor (RF), antibodies to double-stranded DNA, or complement abnormalities.

Complications Of Lyme Disease

Fortunately, serious complications of Lyme disease are rare. The vast majority of children with Lyme-related arthritis recover promptly (within a few weeks) and completely with treatment. In children with Lyme who have large numbers of bands on their Western blot (e.g., nine or more), it is likely the infection has been present for a prolonged period. Some of these children will have continuing arthritis after the first thirty days of antibiotics. It is important to recognize that, like other causes of infection-associated arthritis, Lyme tends to provoke symptoms in those who have an underlying predisposition to arthritis. If the arthritis persists after appropriate treatment for Lyme disease, the emphasis must be on treatment of the arthritis, not continued antibiotics. For any child whose arthritis persists after a year we must assume that Lyme provoked an underlying arthritic disease it is that underlying disease that must be treated.

Outcomes Disease Activity

Systemic onset JIA is associated with the highest levels of inflammation in the pediatric population and the worst long-term functional outcome. However, in adulthood the levels of clinical inflammation are significantly lower than any other subset (2,3). This suggests that the concept of arthritis burning out may hold true in this specific subtype.

Studies on the Role of Exercise Fitness in the Etiology of Other Diseases

Obesity is defined as an excess of adipose tissue. This condition plays a central role in the development of diabetes mellitus and confers an increased risk for CHD, high blood pressure, osteoarthritis, dyslipoproteinemia, various cancers, and all-cause mortality. The prevalence of obesity has risen dramatically in recent years, despite a decline in daily energy expenditure during the past two decades in the United Kingdom of approximately 800kcalday-1 (3347kJday-1).

Sexual and Reproductive Health

Sexuality includes the adoption of certain gender roles (55). Society's definition of masculinity traditionally identifies the male as strong, practical, and the main bread winner in a family. The corresponding role for a woman traditionally identifies her as a wife, homemaker, attentive mother, and, more recently, an income provider. Arthritis may interfere with an individual's capacity to meet these expectations. Men with JIA are less sexually active and have greater difficulty establishing a permanent partnership than both healthy males and women with JIA (52). Poor body image, low self-esteem, social isolation, and fears of being unable to support a family or to fill the social role expected from a male in a relationship may all have contributed to this finding. Sexual activity can be adversely affected by arthritis, with pain, the fear of pain, fatigue, depression, and anxiety all potentially reducing libido (60,61). Many patients who are sexually active experience difficulties...

Antiinflammatory And Analgesic

Gingerol and 8-gingerol have been found to evoke capsaicin-like intracellular Ca2 + transients and ion currents in vitro and it has been suggested that gingerols represent a novel class of naturally occurring vanilloid receptor agonists that contribute to ginger's medicinal properties (Dedov et al 2002). This is supported by the finding that topical application of ginger creams or compresses produce an analgesic capsaicin-like effect on the release of the immunoreactive substance P from primary afferent neurons (Onogi et al 1992). In an animal study of chemically induced inflammation, ginger extract reduced oedema that was partly caused by serotonin-receptor antagonism (Penna et al 2003). Additionally, ginger oil has shown anti-inflammatory activity, significantly suppressing both paw and joint swelling in severe adjuvant arthritis in rats (Sharma et al 1994).

Other Physiological Effects

See also Antioxidants Diet and Antioxidant Defense. Arthritis. Cancer Epidemiology and Associations Between Diet and Cancer Effects on Nutritional Status. Cholesterol Sources, Absorption, Function and Metabolism Factors Determining Blood Levels. Coronary Heart Disease Hemostatic Factors Lipid Theory Prevention. Cytokines. Dairy Products. Fats and Oils. Fatty Acids Metabolism Monounsaturated Omega-3 Polyunsaturated Omega-6 Polyunsaturated Saturated Trans Fatty Acids. Immunity Physiological Aspects. Lipids Chemistry and Classification. Lipoproteins.

Children With Sle And Joint Problems

Although the family may not be aware of it, arthritis is often present when a child with SLE first comes to the doctor. It is usually very responsive to treatment with steroids or NSAIDs. As a result, arthritis is rarely a significant long-term problem. The exception is an unusual condition termed Jaccoud's arthropathy, a painless swelling, primarily in the fingers and wrists, that develops slowly during the course of SLE. It does not usually cause damage to the bones, but it may be painful and interfere with use of the hands. The explanation for this problem is unclear. Unfortunately, it does not respond well to medication. Unfortunately, the normal course of avascular necrosis is for the bone to crumble slowly under the continued stress of bearing weight. If this happens, it will be necessary for the joint to be replaced (see Chapter 23). In children with SLE, the hip is the joint most commonly affected, but shoulders, elbows, knees, ankles, and other joints all may be involved. The...

Future Work Conclusions and Recommendations

Inflammation and cell proliferation are at the base of many chronic diseases and conditions, especially atherosclerosis and cancer, but also diabetes, hypertension, arthritis, mental health, and various autoimmune diseases. Individuals carrying genetic variants for these conditions are much more prone to develop them because the high n-6 n-3 ratio leads to proinflammatory and prothrombotic states.

Table 78 Exercise Adaptations for Medical Problems

Arthritis To avoid stress on your joints, choose non-weight-bearing cardiovascular exercises, for example cycling and swimming. Taking breaks will help to minimize pain. You can strengthen the muscles around painful joints by doing isometric exercises (exercises that do not involve movement). If you have arthritis in your knees, for example, lie on your back, raise your leg 1 foot off the ground, and hold it for 30 seconds, with or without an ankle weight. This exercise strengthens your quadriceps muscles but places minimal stress on the knee joints.

The Impact Of Adolescent Pain On Quality Of Life

In the Roth-Isigkeit study, 54 of adolescents who reported pain also had problems with sleep and appetite, 49 had long-term absences from school and 47 were unable to meet friends (7). A separate outpatient survey showed that 72 suffered impairment in sports activities, 51 reported absence from school, 40 experienced limitations in social functioning, and 34 had problems with sleeping (77). Sleep disorders with frequent nocturnal arousals or daytime somnolence are common in children suffering juvenile rheumatoid arthritis (76) similar sleep disturbances are seen in adolescents with chronic pain. In the German cohort study, 41 of the young people reported sleep disturbances attributable to pain. This significantly increased with age. Restrictions at school, absenteeism, and problems with school activities are widely reported in this population.

IL15 in Chronic Inflammation

The foregoing description clearly renders IL-15 an intriguing candidate in the context of chronic inflammation. This has now been tested in a number of chronic inflammatory disease states (Table 1). Although expression data pertain to many of these diseases, most functional characterisation has been performed in inflammatory arthritis. We and other groups identified IL-15 and IL-15Ra expression at mRNA and protein levels in inflamed synovium and in peripheral blood from patients with RA (McInnes et al. 1997, 2003). Recently, IL-15 serum expression has been shown to rise progressively with RA disease duration (Gonzalez-Alvaro et al. 2003) . IL-15 levels are also higher in juvenile idiopathic arthritis and correlate with CRP. IL-15 expression is also reported in RA nodule tissues together with a predominantly Th1 cytokine milieu (Hessian et al. 2003). It is clear therefore that IL-15 is expressed at the site of pathology. The functional importance of IL-15 in inflammatory synovitis is...

An Electrifying Solution Transcutaneous Electrical Nerve Stimulation

Transcutaneous electrical nerve stimulation (TENS) is a machine-based therapy that's designed to deliver low-level electrical impulses to body areas that are in pain or spasm. The goal is to stimulate the nerve tissue to naturally release pain-fighting body chemicals. This treatment is used to help people with fibromyalgia, arthritis, and other medical conditions.

Prevalence and Risk Factors

Gout is the most common inflammatory arthritis in men more than 2 million men and women in the United States are afflicted. The prevalence of gout in the United States tripled between 1969 and 1981 but recently seems to have stabilized. This increase is thought to be due to a combination of factors, including aging of the US population, increased prevalence of diuretic treatment of hypertension,

Considering Chiropractors

Many people with arthritis or fibromyalgia find small to considerable relief at the hands of a chiropractor, a practitioner who manipulates the bones and muscle tissues in an effort to relieve pain and stiffness. A chiropractor is not a medical doctor instead, a chiropractor is a licensed professional who's received specialized training regarding the bones and nervous system. Tell the chiropractor about any other medical problems that you may have in addition to your fibromyalgia, such as arthritis, heart disease, osteoporosis, and so forth. This information is important to help tailor your treatment, guiding the chiropractor to go more easily in areas of the body that may be weak.

Considering Alternative Remedies and Treatments

Illions of people rely on alternative remedies and treatments to help them with their chronic ailments, and patients with fibromyalgia syndrome (FMS) are even more frequent users of alternative therapies. A study of 13,792 patients with fibromyalgia (reported in a 2007 issue of Arthritis & Rheumatism) revealed that 56 percent had used some form of alternative medicine, compared to 21 percent of the 41,427 people in the control group who didn't have fibromyalgia. So, if you've tried one or more forms of alternative medicine to ease your symptoms of FMS, you're definitely not alone

Treatment Of Dermatomyositis

For children without evidence of vasculitis who are not profoundly weak, a low or moderate dose of corticosteroids is often sufficient. Some children with dermatomyositis have mild arthritis when they first come to a doctor's attention. This usually responds well to treatment with corticosteroids, but a brief course of nonsteroidal anti-inflammatory drugs (NSAIDs) may also be beneficial. Hydroxychloroquine is another drug that is often useful as a steroid-sparing agent in children with mild disease, especially where rash predominates.

Applications Future Challenges

The draft sequence already is having an impact on finding genes associated with disease. Genes have been pinpointed and associated with numerous diseases and disorders including breast cancer, muscle disease, deafness, and blindness. Additionally, finding the DNA sequences underlying such common diseases as cardiovascular disease, diabetes, arthritis, and cancers is being aided by the human SNP maps generated in the HGP in cooperation with the private sector. These genes and SNPs provide focused targets for the development of effective new therapies.

Reviewing more Thought Court cases

Over the years, Connor, a 58-year-old high school teacher, became an avid outdoorsman, spending his summer vacations camping, fishing, and hiking. Although his arthritis has been getting progressively worse, Connor has tried to ignore the pain. In fact, he only consults his doctor when the pain becomes overwhelming. His doctor refers him to an orthopedic specialist who tells Connor he needs a hip replacement. Connor slips into depression at the news. He fills out some Thought Trackers and zeroes in on a malicious thought I'll never be happy again. Life will just be a downhill slide from here. He accuses this thought of increasing his misery and puts it on trial (see Worksheet 6-9). That's unreliable forecasting and magnification. I need to check with the doctor before I come to this conclusion. And there are many ways to manage pain. There are other people with arthritis who manage to have a good quality of life.

What is Physical Fitness

What does it mean to be physically fit The American College of Sports Medicine (ACSM) has defined physical fitness as a set of characteristics (i.e., the work capacity of your heart and lungs, the strength and endurance of your muscles, and the flexibility of your joints) that relate to your ability to perform physical activities.

Is the pain I have experienced part ofPD

It is said that pain and PD don't go together thus, pain appears to be something else, such as arthritis, bursitis, a bad back, or a frozen shoulder. However, pain is part of PD and has many forms. How common is pain is PD Perhaps 50 of people with PD complain of pain at one time, and in perhaps 50 of them 25 of all people with PD the pain is related to PD and not to something else. The pain may be related to PD if it fits a pattern, if it's worse where PD is worse, if it's relieved by PD drugs, or if there's no other cause.

Marc J Philippon MD Mara L Schenker BS

Femoroacetabular impingement (FAI) has been recently revealed as a significant cause of hip pain in the athlete 1 and as a predictor of early onset hip osteoarthritis 2-4 . The hip is highly reliant on its bony structure for stability and support during substantial loading in weight bearing and sport. As a result, any abnormality in bony morphology may alter the force distribution in the joint, and can potentially cause injury to the capsulolabral structure or articular cartilage. induce cam-type impingement, causing injury to the labium and adjacent articular cartilage 8-10 . Insufficient reduction of femoral neck fractures and decreased anteversion of the femoral neck have also been shown to cause cam impingement 11,12 . Pincer impingement may be caused by general acetabular overcoverage (coxa profunda) or acetabular retroversion 13,14 , and has been shown to be associated with osteoarthritis of the hip 15 . Demographically, cam impingement seems to be more common in young males and...

Systemic Lupus Erythematosus

SLE-SS patients seem to be very similar to primary Sjogren's syndrome patients. The systemic lupus erythematosus in these cases, when associated with Sjogren's syndrome, frequently is characterized by milder disease compared with systemic lupus erythematosus without Sjogren's syndrome, illustrated by a lower risk of severe renal disease and thrombocytopenia.13 However, they are more likely to have Raynaud phenomenon and arthritis,13 implying a possible protective effect of the Sjogren's syndrome phenotype with regard to the development of a full-blown lupus syndrome. One study, however, discovered an increased morbidity and mortality in systemic lupus erythematosus associated with other autoimmune diseases because of such events as thrombosis and lymphoma.7 Fatigue may be more prominent in systemic lupus erythematosus patients who develop features of Sjogren's syndrome.26 Again these findings underscore the similarity between SLE-SS patients and patients with primary Sjogren's...

Approach to Defining Cause of Chronic Enteropathy

There are numerous causes for chronic enteropathy in children and all methods of categorizing have their advantages and deficiencies. The majority of the worldwide burden of chronic enteropathy is due to malnutrition and secondary immune deficiency and should be readily diagnosed if in the associated context most other forms of chronic enteropathy are rare. Regardless, a detailed and careful history is of primary importance in determining the potential causes of chronic enteropathy in the individual child and avoiding unnecessary and costly investigations. Clues to early onset enteropathy may be contained in the prenatal history such as a mother's infectious status including exposure to HIV. In environments where antenatal ultrasonography is routine, fetal fluid-filled dilated loops of intestine and polyhydramnios may be an early indication of congenital enteropathy syndrome such as congenital chloride-losing diarrhea. A careful history of the age and time of onset of symptoms should...

Circadian Rhythms and Diseases

Clinical research has been conducted with varying numbers of study subjects to explore circadian rhythms associated with disease states. Peak time of disease activity is shown in Table 9.1. Several potential oral delivery methods have been described for targeting circadian rhythms, as described below. Such awareness is useful for diagnosis and treatment 16 . Osteoarthritis may be distinguished Allergic rhinitis Arthritis Osteoarthritis

The Analysis Of Quantified Handedness Measures Statistical Considerations

Another methodological issue pertains to the size of the experimental and control groups in handedness studies. Many studies are not powered with enough participants to show significant differences between the experimental and control groups. For example, suppose an investigator hypothesizes that the prevalence of right and left handedness (however measured and defined) are 10 and 30 , respectively, in a control group and an experimental group (e.g., patients with rheumatoid arthritis). In that hypothetical study, a minimum of 71 participants in each group would be necessary to demonstrate statistical significance at the 0.05 level with a power of 0.8 (20 chance of missing the effect) (Fleiss, 1981). Further, if the frequency of left handedness is less than 3-fold higher in the experimental group than the control group, or the frequency of right handedness in the control participants is greater than l0 , then even greater numbers of participants are necessary to demonstrate a...

Anterior Cruciate Ligament

The mechanism of injury is usually noncontact, with the foot planted when a twisting injury occurs at the knee. Athletes usually hear or feel a pop and have immediate pain and swelling within 24 hours. Contact injuries may also damage the ACL. On examination they can usually weight bear but have a large effusion. They have a positive Lachman test suggesting that the ACL is torn (Fig. 7). Radiographs are usually normal although a Segund Fracture is pathognomonic for an ACL tear (Fig. 8). An MRI may be useful in equivocal cases or in those with a soft endpoint on Lachman testing. Athletes with a torn ACL need surgical repair if they wish to return to cutting and pivoting sports as without an ACL, cutting and pivoting will damage the meniscus and may lead to early arthritis. Adolescents may also sustain a tibial spine fracture with the same mechanism that tears the ACL. Mechanisms that injure the ACL can also cause damage to the MCL or meniscus.

Free radicals and antioxidants

Various normal reactions and functions generate reactive oxygen species (ROS) and other compounds that are characterized by their high potential for causing oxidative damage to the body's DNA. proteins, membranes, and other components. Several of these compounds arc called free radicals because they contain an unpaired electron-Free radicals have a strong propensity to donate their unpaired electron to another compound or to abstract an electron from elsewhere to complement their own unpaired one. Their high and unspecilic reactivity gives them the power to modify most biological macromolecules and disrupt their structure. These relentless attacks are thought to be a major cause for progressive functional decline with aging (e.g. macular degeneration) anil major chronic diseases of adulthood, including cardiovascular disease, cancer, and rheumatoid arthritis. Nonetheless, some ROS are of ital importance for signaling and immune defense, and their elimination would probably be harmful....

Osteoporosis and Osteopenia

Osteoporosis and osteopenia are conditions involving decreased bone mass and hence a decrease in the strength of the bones with an increased risk of fractures. Osteopenia has been defined as having bone mass that is more than one standard deviation below the normal level, and osteoporosis as having bone mass that is more than two and a half standard deviations below normal. These definitions have been difficult to apply to children because the normal levels have not been well defined for children of different ages and races. However, precise medical definitions are not what parents should be concerned about. What it is important for parents to understand is that children who do not get enough calcium in their diet, children with chronic arthritis, children who take corticosteroids or certain other drugs (especially diuretics such as furosemide), and children with a variety of hormonal disorders are all at risk of decreased bone mass and easily broken bones. If your child is taking...

Kawasaki Disease Foundation

Onset of fever, which lasts for at least five days but averages 11 days without treatment. Often one symptom appears as another disappears, making the diagnosis challenging, especially for children who see different doctors during the early days of their illness. Arthritis in fingers and toes appears in about a third of patients. Although unusual, cardiac rhythm (electrical) disturbances may occur. The subacute phase begins as the fever drops. During this stage, the skin of the palms and soles starts to peel off, beginning under the fingertips and toes. Arthritis, if present, generally affects the larger weight-bearing joints in this phase. In those patients who develop coronary artery abnormalities, an echocardiogram will reveal dilation or aneurysms in this phase.

Chronic Rheumatic Diseases And Their Effect On Bone Density During Adolescence And On Peak Bone Mass

The effects of chronic illnesses such as the rheumatic disorders on bone density are well known. Failure to develop adequate bone mineralization is common in children with chronic arthritis. (For a comprehensive review, see Reference 24). Juxta-articular osteopenia can be evident in plain radiographs even in early disease, whereas diffuse osteopenia or osteoporosis can develop later and lead to the risk of vertebral collapse and long-bone fractures after minimal trauma. Multiple risk factors are known to be associated with decreased bone mass, and active arthritis has an osteopenic effect both around affected joints and systemically, by means of a complex and still partly unknown network of proinflammatory cytokines. For example, Henderson and coworkers have studied predictors of BMD in prepubertal patients never treated with glucocorticoids. Almost 30 of mild to moderately ill patients had low total body BMD parameters of disease severity (number of swollen joints, articular severity...

When to Withhold Your Childs Medication

This is a subject that is frequently overlooked. If your child is sick with the flu or a virus and not keeping anything down, you do not want to give him or her NSAIDs or immunosuppressive medications. The only arthritis medication that is vital to take even when one feels sick is corticosteroids (see below). All the other medications should be avoided, and you should call the doctor for instructions.

Inflammatory Conditions

Olive leaf extract is used to promote symptomatic relief in various inflammatory conditions, such as osteoarthritis and asthma, and as a gargle in tonsillitis and pharyngitis. The anti-inflammatory effects demonstrated by several major components in olive leaf provide a theoretical basis for its use however, clinical trials are not yet available to determine whether effects are significant and efficacy remains speculative. Alternately, olive oil supplementation has been tested in some clinical studies. Rheumatoid arthritis In some studies of RA in which fish oil supplements have been investigated, olive oil has been used as a placebo because it was generally regarded as containing neutral fatty acids however, in some instances olive oil produced significant improvements in disease activity, prompting further research. More recently, a study of 43 patients investigated the effects of placebo (soy oil), fish oil (3 g day), and a combination of fish oil (3 g day) and 9.6 mL day of olive...

What if the Medicine Is Not Working

If your child is taking the drug your physician recommended and it is not working, you might be expecting results too quickly. Some arthritis medicines do not make a big difference until they have been taken for several weeks. Other medicines may be very important, but instead of making the child feel better, they prevent him or her from getting worse. Be sure you talk to your doctor about your concerns. If you are not comfortable talking with your doctor or the office staff, you need to find a doctor you can be comfortable talking with.

Data From Existing Clinical Studies

The work described here has identified dryness and fatigue as the key patient-reported outcomes in PSS (with joint pain and Raynaud's also being frequent). In expert panel discussions, fatigue was felt to be a particularly important outcome domain in its own right, in relation to patients' disease experience.60,61 We have also shown that fatigue can improve following systemic therapy20 and there is increasing interest in fatigue as a secondary outcome measure in rheumatoid arthritis.25,40 Nevertheless, because fatigue has psychosocial as well as biological causes, there is reasonable hesitation to rely on it exclusively as a single primary outcome measure, particularly where biological therapy is being considered. Other approaches are to use fatigue as part of a composite symptomatic outcome measure (eg, with pain and dryness symptoms)32 or to incorporate fatigue into, or alongside, a systemic activity

Presentday Cultivation And Usage

Nowadays, the resinous juice is applied to cracked heels. It is highly valued for the treatment of malignant tumors, adjuvant arthritis, leukoderma, hemorrhoids, and ulcers. Bruised nuts are given as a vermifuge, and applied to the os uteri, to cause abortion. Nut oil is used externally in rheumatism and leprous nodules. Gum from the bark is used in scrofulous, venereal, and leprous afflictions, and in nervous debility. Ashes of the plant are used, mixed with other drugs, in snake bite and scorpion stings. The juice of the pericarp, mixed with lime, forms an indelible ink the juice is a component of some marking inks sold and used in Europe. It is also used for dyeing cloth (Chopra et al., 1992 Wealth of India, 1999).

Hazard Identification

Pinals and coworkers (1977) treated 30 rheumatoid arthritis patients and 30 controls daily with capsules containing 4.5 g of L-histidine for 30 weeks in a double-blind trial followed by 19 patients receiving this dosage for 10 additional months in a period of open treatment. It is not clear which adverse effects were examined however, the authors concluded that no adverse effects of the histidine therapy were noted. In a similar double-blind treatment design, Blumenkrantz and co-workers (1975) treated 42 patients (16 chronic uremic and 26 undergoing maintenance dialysis) with oral doses of 4 g d of L-histidine for 17.5 weeks. No adverse effects were reported however, it was not evident from the report which adverse effects were examined.

Metabolic Implications And Health Benefits Of Dha Epa And u3 Fatty Acids

Dietary EPA and DHA are packaged and transported through chylomicrons produced in the intestinal epithelial cells. The most relevant tissues that contain u-3 PUFA are hepatic, lung, kidney, spleen, plasma, heart, retina, and the vascular endothelium. EPA concentrates in the hepatic, renal, and blood cells, whereas DHA concentrates in the heart, retina, and brain. These PUFAs have three major roles cell membrane structure, precursors of eicosanoids, and effectors of protein activity (enzymes, receptors, and ionic channels). EPA is preferably incorporated associated with phosphatidyl choline (67 ) and ethanolamine (13 ) in platelets, whereas DHA accumulates with phosphatidyl ethanolamine (45 ) and choline (37 ). DHA is also incorporated into cardiolipin, a phospholipid only found associated with the cardiac muscle. Eicosanoides are hormones synthesized from 20-carbon FA, mainly araquidonic and EPA, and the enzymes cyclooxygenases and lipooxygenases (Figure 29.2). EPA is precursor of...

Chondral Injuries Of The

Chondral injuries of the hip may be seen in conjunction with a variety of hip disorders, and may result from an atraumatic or traumatic etiology. These disorders include labral tears, loose bodies, hip instability or dislocation, osteo-necrosis of the femoral head, slipped capital femoral epiphysis, hip dysplasia, and degenerative joint disease 12-17 . Chondral injuries can be acute, chronic, or degenerative, and may be partial thickness or full thickness lesions. As the experience with hip arthroscopy expands, so, too, will the ability to recognize the various injury patterns to the chondral surfaces of the hip. As our understanding of the pathologic processes contributing to chondral injury of the hip joint improves, perhaps we will be able to intervene preventing the progression to osteoarthritis.

Applications To Health Promotion And Disease Prevention

Include multiple sclerosis, rheumatoid arthritis, asthma, arteriosclerosis, etc. Those pathologies indicate a critical role for tissue infiltration by leukocytes in inflammatory disease pathogenesis. For immigration of circulating leukocytes into tissues, transmigration through the vascular endothelial layer involves two independently regulated events binding to vessel endothelium, followed by diapedesis. For this purpose, cell arrest is mediated by activation of adhesion receptors on the moving cell, followed by attachment to counter-receptors on other cells or endothelial cells, leading to an immobilized cell. Furthermore, the inflammatory response is mediated by a broad spectrum of mediators able to promote vascular events, edema, and, finally, the recruitment of inflammatory cells (Friedl & Weigelin 2008).

Adverse Effects And Reactions Allergies And Toxicity

The aqueous and oil extracts of the seeds have been shown to possess antioxidant, antiinflammatory, anticancer, analgesic, and antimicrobial activities. TQ has been shown to be the active principle responsible for many of the seed's beneficial effects. The toxicity of the fixed oil of N. sativa (L.) seeds in mice has been examined changes in key hepatic enzymes levels were not observed in rats, suggesting the safety of therapeutic doses of N. sativa (L.) fixed oil (Zaoui et al., 2002). Several findings have provided clear evidence that TQ possesses reproducible antioxidant effects through enhancing the oxidant scavenger system. The oil and TQ have shown potent anti-inflammatory effects on several inflammation-based models, including experimental encephalomyelitis, colitis, peritonitis, edema, and arthritis, through suppression of the inflammatory mediator prostaglandins and leukotrienes. The oil and certain active ingredients showed beneficial immunomodulatory properties, augmenting...

Adenosyk Methionine SAMe

Historical note SAMe was first discovered in Italy in 1952. About 20 years later, a stable salt was commercially manufactured and produced for injectable use. At first, it was investigated as a treatment for schizophrenia, for which it proved inappropriate however, successful trials in depressed patients began in the 1 970s and it was inadvertently found to improve symptoms of arthritis. Sincethen, numerous studies have been undertaken to examine the role of SAMe in both depression and osteoarthritis. To date, more than 75 clinical trials have been conducted using SAMe as a therapeutic agent, involving over 23,000 people.

Acknowledging Different Perspectives

Within the chronic illness literature, only a few studies of child-parent agreement pertain to childhood onset rheumatic diseases (13-20). These have found mixed (and often contradictory) findings including reports of no agreement (17) or poor agreement for pain (14) fair to good agreement for general health (14) fair to excellent agreement for functional disability (14,15,17) and fair agreement for health related quality of life (14,16,19). As such, they generally follow the pattern found in the wider literature, which suggests that parents and children tend to agree about easily observable behaviors compared with less overt phenomena (12). In a study which specifically addressed agreement between adolescents (with juvenile idiopathic arthritis, JIA) and their parents, approximately half did not show agreement in ratings for pain, general health perception, functional ability, and health-related quality-of-life (21). Agreement was associated with better disease-related outcome...

Adaptation Of Standard Ct In The Treatment Of Depression In Medically Ill Patients

There are more similarities than differences between standard CT and cognitive-behavioral interventions for depressed medical patients. Some of the differences stem from the fact that many of these patients are referred by their physician, urged by their spouse to see a therapist, or recruited for participation in a clinical trial. Their demographic profile tends to differ from that of depressed but otherwise healthy patients who seek CT on their own initiative. Although some chronic illnesses are prevalent among young adults, most of the major chronic illnesses are more common among middle-aged and older individuals. Consequently, patients with conditions such as arthritis or heart disease who are referred for CT are older on average than the majority of patients who are seen in more typical cognitive-behavioral practices.

Older Immunosuppressive Agents Cyclosporine and Tacrolimus

Cyclosporine (marketed as Neoral or Sandimmune) and tacrolimus (marketed as Prograf) are closely related immunosuppressive drugs that are primarily used to prevent organ transplant rejection. Cyclosporine was discovered first and is used more widely, but tacrolimus may be more potent and have fewer side effects. However, there is only limited experience with the use of tacrolimus for arthritis at present, and so I restrict the rest of this discussion to cyclosporine. Cyclosporine may be very beneficial in children with spondyloarthropathies, systemic-onset arthritis, arthritis associated with inflammatory bowel disease, dermatomyositis, and other vasculitic illnesses. It is also useful for the treatment of ocular inflammation (uveitis). However, a child's response to cyclosporine is unpredictable. Some children who have not responded to other medications have dramatically improved with the addition of cyclosporine. I have also used it in other children in seemingly identical...

Moving Yourself to a Better Frame of Mind

Both extremes are unreasonable positions to take. For example, although people who don't have fibromyalgia really can't feel your pain, they may have arthritis or another chronic-pain problem and, thus, can understand what chronic pain feels like, even if it's not your specific type of chronic pain. On some level, they should be able to grasp your problem. On the other hand, people shouldn't be expected to automatically sympathize with poor you even when those people are your own loving family members. You're setting yourself up for disappointment if you take either of these polar positions.

Other Medical Conditions

Most of the clinical trials published so far have been small, single-site studies, and only some have demonstrated favorable outcomes. In one study, for example, stroke patients were randomly assigned to 10 sessions of CT, an attention control intervention, or usual care. No significant differences were found on posttreatment measures of depression, functional status, or satisfaction with care (Lincoln & Flannaghan, 2003). Sharpe et al. (2001) randomly assigned patients with arthritis to eight sessions of CT or to usual care. The CT group scored significantly lower on the Hospital Anxiety and Depression Scale (HADS) at 6 months. In contrast, Parker et al. (2003) reported that a combination of CT and antidepressants for depression in patients with arthritis was not more efficacious than antidepressants alone.

Mycophenolate Mofetil

Mycophenolate mofetil (marketed as Cellcept) is a newer immunosuppressive drug that inhibits DNA synthesis. It is primarily used for the treatment of organ transplant recipients but has been increasingly used for the treatment of children with SLE and other vasculitic diseases. It has also been used in children with uveitis and in adults with psoriatic arthritis. At present, the role of mycophenolate mofetil in the treatment of children with arthritis has not yet been defined. It has been reported to be as effective as cyclophosphamide in high dosages, but most physicians have found the necessary dosage of mycophenolate mofetil to cause a significant incidence of stomach complaints, which force people to stop taking the medication. Too, practical clinical experience has not matched the success of the carefully selected patients in the published studies. More studies combining mycophenolate mofetil with other medications are under way.

Signposting Resources for Parents

Chat 2 Parents booklet specifically for parents of adolescents with arthritis The website of the American Juvenile Arthritis Organization - a council of the U.S.-based Arthritis Foundation - offers generic information for parents of adolescents U.K.-based Children with Chronic Arthritis Association U.K.-based charity for families with children with arthritis

Myalgic encephalomyelitis Chronic fatigue syndrome

This condition is characterised by extreme disabling fatigue that has lasted for at least six months and is made worse by physical or mental exertion and is not resolved by bed rest. The symptom of fatigue is often accompanied by some of the following muscle pain or weakness, poor coordination, joint pain, slight fever, sore throat, painful lymph nodes in the neck and armpits, depression, inability to concentrate and general malaise.

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