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GOUT, OSTEOPOROSIS, OSTEOMYLITIS AND Paget's DISEASE

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  • 1. GOUT, OSTEOPOROSIS, OSTEOMYELITIS AND Paget’s DISEASE
    J. Steuart Richards, MD
    Assistant Chief, Rheumatology Section
    VAMC, Washington, DC
    Assistant Professor of Medicine
    Georgetown University
  • 2. Definitions
    Gout is a syndrome caused by an inflammatory
    response to the formation of mono-sodium urate
    monohydrate crystals which develop secondary to
    hyperuricemia
    Hyperuricemia occurs when the serum uric acid level is
    > 7.0 mg/dl (420 μmol/L)
    Asymptomatic hyperuricemia occurs when serum uric
    acid is elevated but there are no signs of gout or renal
    calculus
  • 3. Prevalence of Gout
    Overall prevalence is 4.6% in men and 2% in women > 451
    6%-7% of VA population is estimated to have gout
    Incidence of gout estimated at 45.9/100,000 in 1995 -96 vs. 20.2/100,000 in 1977-782
    Contributing factors include - ↑ longevity, ↑ HTN,
    ↑ obesity, ↑ metabolic syndrome, ↑ ESRD, ↑ aspirin, ↑ transplantation use of cyclosporine
    1US National Health Survey of 1996 on self reported prevalence
    2Arromedee et al J Rheumatol 2002;29:2403-06
  • 4.
  • 5. Evolution of Hyperuricemia and Gout
    Over time, untreated, chronic hyperuricemia increases
    body urate stores, advancing the severity of the disease
    Painful
    Intercritical
    Segments
    Painless Intercritical
    Segments
    Flares last longer
    Flares occur
    more often
    Pain
    Intercritical
    segments decrease
    Persistent pain
    and stiffness
    Advanced
    Gout
    Asymptomatic
    Hyperuricemia
    Acute Flares
    Time
    Adapted from Klippel et al, eds. In: Primer on the Rheumatic Diseases. 12th ed. Arthritis Foundation; 2001:313.
  • 6. 2
    1
    1
    3
    1. Photos courtesy of Brian Mandell, MD, PhD, Cleveland Clinic.
    2. Photo courtesy of N. Lawrence Edwards, MD, University of Florida.
    3. ACR Clinical Slide Collection on the Rheumatic Diseases, 1998.
  • 7. Diagnosis of Gout
    Clinical
    Presence of monosodium urate crystals
    Presence of tophii
    Radiographic features
    Uric acid
  • 8.
  • 9. Causes of Disability in Gout
    Acute
    short term limitation of activity
    Dependent on:
    Location
    Severity
    Number of joints
    Frequency of attacks
    Duration of attacks
    Chronic
    Chronic limitation of activity
    Dependent on:
    Location
    Number of joints
    Severity of joint damage
    Superimposed flares
  • 10. Definition
    • Osteoporosis is a skeletal disorder characterized by compromised bone strength predisposing to an increased risk of fracture
    • 11. Bone strength reflects the integration of bone density and bone quality
    • 12. Bone density is grams of mineral/area or volume measured by DXA
    • 13. Bone quality encompasses architecture, bone turnover and damage accumulation
    NIH Consensus Development Panel. JAMA 2001
  • 14. Bone Loss with Advancing Age
  • 15. Secondary Causes of Osteoporosis
  • Clinical
    • Osteoporosis is asymptomatic unless a fracture occurs
    • 26. Hip fractures cause loss of mobility, dependence on assistive devices for walking, NH placement and increased mortality
    • 27. Vertebral fractures result in loss of height, change in posture, pain, sleep disturbance and increased mortality
  • Osteoporosis in Men
    • 3% - 6% of men > 50 have osteoporosis
    • 28. 28% - 47 % of men > 50 have osteopenia1
    • 29. Rates were highest for Caucasian and Asian men compared with AA men, Hispanic men were intermediate
    • 30. Mortality rate following hip fractures is almost double that of women 31% vs. 17%2
    1Looker AC et al J Bone Miner Res 11997; 2:1761-1768
    2Forsen L et al Osteoporosis Int 1999;10:73
  • 31. VA Perspective
    Prevalence of Osteoporosis in Men in a VA Rehabilitation Center
    Arthur Swislocki, MD; Jon A. Green, MD, PhD; Gerhard Heinrich, MD; Charles A. Barnett, MD; Ivan D. Meadows, MD; Ernest B. Harmon, BS; Mary F. Rank, RN, FNP; and Robert H. Noth, MD
  • 32.
  • 33. Hip Fractures
    • 1.6 million hip fractures occurs worldwide
    • 34. 28% occur in men
    • 35. Highest incidence in Caucasians
    • 36. 50% of men require institutionalization
    • 37. 1 year mortality post hip fracture for men is 31% vs. 17% for women
    Forsen L et al Osteoporosis Int 10:73, 1999
  • 38. Vertebral Fractures
    • Increases after the age of 55
    • 39. Men and women have a similar rate of vertebral fractures
    • 40. Association with poor sleep, pain, social isolation functional impairment
    • 41. Increased mortality
  • Disability and Osteoporotic Fractures
    Vertebral Fractures
    Pain
    Sleep disturbance
    Loss of height
    Respiratory disease
    Depression
    Loss of mobility
    Hip Fractures
    Loss of ambulation
    Need for walking aids or wheelchair
    Loss of independence, unable to live alone
    Chronic pain
  • 42. Osteomyelitis
    Definition:
    Infection of bone
    Acute or chronic
    Risk Factors:
    Trauma
    Diabetes
    Hemodialysis
    IV drug abuse
    Surgery
    Skin infections
  • 43. Complications
    Sepsis
    Septic arthritis
    Sinus tracts to skin
    Fractures
    Chronic osteomyelitis
    Avascular necrosis
  • 44. Disability from Osteomyelitis
    Acute
    Pain
    Limitation of function of affected bone
    Restricted movement for treatment with IV antibiotics
    Chronic
    Pain
    Fatigue
    Loss of function of affected limb
    Amputation
    Social isolation
    Depression
  • 45. Paget’s Disease
    Definition:
    Osteitis Deformans
    Focal disorder of bone metabolism
    leading to accelerated remodeling and bone overgrowth
    Involves:
    Pelvis
    Spine
    Skull
    long bone
  • 46. Paget’s Disease
    Often asymptomatic
    Symptoms depend on the bone
    involved:
    Pain
    Skeletal deformities
    Osteoarthritis
    Fractures
    Tumors
    Heart Failure
    Neurological symptoms
    Deformity of the affected bone
  • 47. Disability from Paget’s Disease
    Osteoarthritis
    Pain
    Limitation of movement
    Requiring assistive devices – cane, walker, wheelchair
    Sleep disturbance
    Heart Failure
    Limitation of work and exercise capacity
    Sleep disturbance