Rheumatic diseases clinics of North America
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Rheum. Dis. Clin. North Am. · Feb 1998
ReviewPerioperative medical considerations in patients with rheumatoid arthritis.
Patients who suffer from chronic rheumatologic diseases, such as rheumatoid arthritis, frequently require orthopedic surgical intervention during the course of their illness. This article provides the reader with an overview of approaches to postoperative risk stratification. Reviewed are the basic concepts that underlie perioperative medical management, including such issues as the preoperative medical assessment, the currently employed anesthetic techniques, and approaches to postoperative analgesia. The impact of comorbid conditions on surgical outcome is discussed as are specific clinical problems that have particular relevance to the patient with rheumatoid arthritis.
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Rheum. Dis. Clin. North Am. · May 1996
ReviewTrigger points and tender points: one and the same? Does injection treatment help?
Trigger points are defined as areas of muscle that are painful to palpation and are characterized by the presence of taut bands and the generation of a referral pattern of pain. Tender points are areas of tenderness occurring in muscle, muscle-tendon junction, bursa, or fat pad. When tender points occur in a widespread manner, they are usually considered characteristic of fibromyalgia. ⋯ Although experienced examiners can generally identify the same tender points, interrater reliability of trigger points has been low in most studies. There is continued controversy regarding the defining characteristics and homogeneity of myofascial pain because of the variability of the examination findings. In appropriately selected patients, it appears that myofascial trigger point injections can be helpful in decreasing pain and improving range of motion in conjunction with a comprehensive exercise and rehabilitation program.
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Rheum. Dis. Clin. North Am. · Nov 1995
ReviewAntineutrophil cytoplasmic autoantibody testing in vasculitides.
This article summarizes the most recent findings concerning the clinical relevance of antineutrophil cytoplasmic autoantibody (ANCA) testing for patients with idiopathic vasculitis and with diseases known to be associated with secondary vasculitis. The clinical value of granular cytoplasmic pattern (c)ANCA (proteinase 3 [PR3]-ANCA) and perinuclear fluorescence pattern (p)ANCA (myeloperoxidase [MPO]-ANCA) testing in Wegener's granulomatosis (WG) and microscopic polyangiitis (MPA), respectively, is now well established; however, the various subspecificities beside myeloperoxidase (MPO), which also include the perinuclear staining pattern, are detectable not only in vasculitis, but equally in a heterogeneous patient population with a spectrum of autoimmune diseases and idiopathic chronic inflammatory diseases of the bowel, liver, and so forth. Future studies must establish the specificity, sensitivity, and role of these pANCA subspecificities usually measured by enzyme-linked immunosorbent assays for distinct disease entities in clinical medicine. In summary, despite the relatively poor understanding of the immunopathogenesis of ANCA-associated disease, cANCA (PR3-ANCA) and pANCA (MPO-ANCA) continue to be important clinical markers of the so-called "ANCA-associated vasculitides" (i.e., WG, MPA, and Churg-Strauss syndrome).
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Agents ranging from simple analgesics to antiinflammatory drugs to powerful immunomodulators have been used for the treatment of rheumatoid arthritis with varying success. Despite the availability of agents that are believed to be "second line" or "disease modifying," many patients either do not respond adequately to available agents or must discontinue their use because of intolerable or dangerous adverse reactions. For this reason, researchers continue to search for more efficacious and less toxic agents for patients with rheumatoid arthritis. This article describes pharmaceutical agents currently under investigation for use in rheumatoid arthritis, including the antiinflammatory agents, zileuton and tenidap, and the immunosuppressive agents, leflunomide, mycophenolic acid (RS-61443), tacrolimus (FK-506), sirolimus (rapamycin), amiprilose (therafectin), cladribine (2- chlorodeoxyadenosine), and azaribine.
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Rheumatologists have been pioneers in the development and use of clinical measures for outcome assessment. The Lansbury Index (1958) and the Empire Rheumatism Gold Trial (1960) used sophisticated double-blind pseudo-placebo-controlled trial designs and standardized prespecified clinical outcome measures to establish the clinical usefulness of a drug whose benefit did not become evident until it was administered for several months. ⋯ In 1980, the Health Assessment Questionnaire and the Arthritis Impact Measurement Scales were added. Future development of paradigms for the decision process in the clinical management of individual rheumatoid arthritis patients will no doubt incorporate standard outcome measures to provide the data upon which management decisions can be based.