Current rheumatology reports
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The anti-neutrophil cytoplasmic antibody-associated vasculitides include granulomatosis with polyangiitis (Wegener's granulomatosis) and microscopic polyangiitis. The introduction of therapy with cytotoxic agents such as cyclophosphamide transformed these diseases from fatal diagnoses to chronic conditions characterized by cycles of relapse and remission. Modern treatment strategies have focused on minimizing cyclophosphamide exposure or eliminating its use altogether. ⋯ For patients with non-life threatening disease, methotrexate may be used to induce and maintain remission, although some patients may have a higher long-term risk of relapse as a result. For patients with life-threatening disease, plasma exchange may be an effective adjuvant therapy. This article reviews seminal studies from the past decade that have contributed to the current standard of care.
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The course of axial spondyloarthritis (axSpA), including ankylosing spondylitis (AS), is strongly influenced by the degree of disease activity over time, which is mainly based on inflammation, and by the impairment of function, which is based on structural damage-mainly, new bone formation-and inflammation. In AS, nonsteroidal anti-inflammatory agents are currently recommended as the first choice of medical therapy, and there is also a clear role for regular exercise and physiotherapy in order to preserve and prevent loss of spinal mobility. For patients who have insufficiently responded to conventional medications, there are now four biologics approved for the treatment of patients with active AS in many countries, all directed against TNFα: infliximab, etanercept, adalimumab, and golimumab; studies with certolizumab are currently ongoing. ⋯ Biologics other than TNF blockers are currently not recommended for the treatment of patients with axSpA, because of insufficient evidence of clinically relevant efficacy. The anti-IL-17a antibody secukinumab may be efficacious, on the basis of a proof-of-concept trial. Finally, first data on biosimilars of TNF blockers have recently been presented.
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Osteoarthritis (OA), low back pain (LBP), and fibromyalgia (FM) are common chronic pain disorders that occur frequently in the general population. They are a significant cause of dysfunction and disability. Why some of these chronic pain disorders remain localized to few body areas (OA and LBP), whereas others become widespread (FM) is unclear at this time. ⋯ Tonic and/or intense afferent nociceptive barrage can result in central sensitization that depends on facilitatory input from brainstem centers via descending pain pathways to the spinal cord. Abnormal endogenous control of these descending pathways can lead to excessive excitability of dorsal horn neurons of the spinal cord and pain. Ineffective endogenous pain control and central sensitization are important features of OA, LBP, and FM patients.
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Churg-Strauss syndrome is an uncommon disease of unknown cause described initially by Churg and Strauss in 1951. Even though it was initially thought to be a variant of polyarteritis nodosa, its pathological, clinical, and laboratory features show that it is related to the small vessel vasculitides, and it is now classified as an antineutrophil cytoplasmic antibody-associated vasculitis. ⋯ Two different clinical subtypes defined by the presence of antineutrophil cytoplasmic antibodies recently have been recognized. Recent advances in the treatment and pathophysiology of Churg-Strauss syndrome are reviewed in this article.
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Review Comparative Study
Does sleep differ among patients with common musculoskeletal pain disorders?
Most patients with chronic musculoskeletal pain report poor-quality sleep. The impact of chronic pain on sleep can be described as a vicious circle with mutual deleterious influences between pain and sleep-associated symptoms. ⋯ Furthermore, many other methodologic issues complicate our ability to generalize findings (low external validity) to first-line medicine. Because sleep alterations in common musculoskeletal pain are neither specific nor pathognomonic, the aim is to provide a critical overview of the current understanding of pain and sleep interaction, discussing evidence-based and empiric knowledge that should be considered in further research and clinical applications.