The document discusses rheumatoid arthritis (RA), a chronic inflammatory disease that affects the joints and can damage heart tissue over time. It provides definitions of RA, discusses common symptoms like joint pain and stiffness, outlines diagnostic criteria and investigations used to diagnose the condition, such as checking for rheumatoid factor in the blood. The document also summarizes the pathological stages of RA and long term effects like joint deformity and disability.
Still's disease, sometimes referred to as Adult-onset Still's disease (AOSD) is a rare systemic inflammatory disease characterized by the classic triad of persistent high spiking fevers, joint pain and a distinctive salmon-colored bumpy rash.
12.01.08(a): Rheumatoid Arthritis/Pathogenesis and Clinical Presentation of J...Open.Michigan
Slideshow is from the University of Michigan Medical School's M2 Musculoskeletal sequence
View additional course materials on Open.Michigan:
openmi.ch/med-M2Muscu
Still's disease, sometimes referred to as Adult-onset Still's disease (AOSD) is a rare systemic inflammatory disease characterized by the classic triad of persistent high spiking fevers, joint pain and a distinctive salmon-colored bumpy rash.
12.01.08(a): Rheumatoid Arthritis/Pathogenesis and Clinical Presentation of J...Open.Michigan
Slideshow is from the University of Michigan Medical School's M2 Musculoskeletal sequence
View additional course materials on Open.Michigan:
openmi.ch/med-M2Muscu
A Power Point Presentation on the Disease Rheumatoid Arthritis covering everything from explanation and history to causes, effects, treatments, diagnosis, and prognosis.
10 Alternative Therapies for Rheumatoid ArthritisWarren Breakwell
Rheumatoid Arthritis and chronic inflammation effect millions of people worldwide. And dealing with rheumatoid arthritis can be a long and arduous ordeal.
If you have rheumatoid arthritis, there are several non-drug treatments that can help you where medication can’t.
Physical therapy to help heal and strengthen a body part or a region that’s aching and giving you pain. Occupational therapists can also help identify assistive devices that can make your everyday tasks much easier.
Mind-body approaches can include mindfulness meditation, biofeedback, breathing exercises, and guided relaxation. Certain types of exercise—such as yoga, qi gong, and tai chi
And exercise is at the top of the list. Even though the prospect of exercising may seem painful, the right kind of activity can help prevent pain and disability.
Acupuncture can trigger the body to release the “feel-good” hormones known as endorphins, thus reducing pain. Herbal medicines in combination with acupuncture are all-natural, highly effective ingredients aimed at providing a respite from the pain as well as wide-ranging health benefits to your body.
Having a Rheumatoid arthritis can be isolating.
Being open with your family and friends about your condition so you feel comfortable asking for help when you need it—or just having a shoulder to cry on—can make a big difference in how you feel, both physically and mentally.
Rheumatoid arthritis is a progressive autoimmune condition that can damage joints over time. Treatment helps, but there are simple practices you can use in everyday life to take strain off joints and help prevent long-term damage.
Rheumatoid arthritis can attack at any age, can come on rapidly, and may be accompanied by other symptoms, such as fatigue. So it’s important that once you recognise that you may have symptoms that you are careful in performing everyday tasks.
An autoimmune disorder that inflames the lining of joints, rheumatoid arthritis (RA) affects more women than men. Join us for an overview of rheumatoid arthritis and other forms of arthritis, including symptoms and diagnosis as well as treatment and management strategies that can help you.
Rhematoid arthritis is systemic autoimmune inflammatory disorder of unknown etiology affecting multiple organ systems. These ppt includes comprehensive management of it.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
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Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
3. Q: What do comedienne Lucille Ball, French
painter Pierre-Auguste Renoir, Hollywood
actress Kathleen Turner and heart transplant
surgeon Dr. Christiaan Barnard have in
common?
5. Definition
RA is a non-suppurative, systemic inflammatory
disease of unknown cause characterized by a
symmetrical poly-arthritis affecting peripheral joints
& extra articular structures.
It is a chronic inflammatory disease affecting the
synovium & leading to joint damage & absorption of
adjacent bone.
The course of disease is variable but tend to be
chronic & characterized by exacerbations &
remissions.
6. INTRODUCTION
Chronic systemic inflammatory disease of unknown
etiology
Affects the synovial membranes of multiple joints
Prevalence 1-2% of the population
0.7% in rural area Indians
Female : Male ratio 3:1
Usual age of onset 20-40 years though individuals
of any age group may be affected
7. Hypothesized causes
1. Initiating factor therapy:
An initiating factors causes joint inflammation
It does not switch off after acute episode
2. Infectious theory:
Infection from diphtheroids & mycoplasms or from the
viruses – rubella, harpes zoster
3. Genetic predisposition:
Relative of people with RA are more prone to develop
the disease than rest of population.
8.
9. Genetics of RA
Genetic factors gives prevalence of 2%–12% in
first-degree relatives of RA sufferers – i.e. approx
ten times that of other population.
The human leukocyte antigen (HLA) component
accounts for around 30% of the genetic risk.
10. 1987 AMERICAN COLLEGE OF
RHEUMATOLOGY CRITERIA FOR RA
Patients must have 4 of the 7 criteria:
1. Morning stiffness lasting at least 1 hour*
2. Swelling in three or more joints*
3. Swelling in hand joints*
4. Symmetric joint swelling*
5. Erosions or decalcification on x-ray of hand
6. Rheumatoid nodules
7. Abnormal serum rheumatoid factor.
[*Must be present at least six weeks]
11. American Rheumatology Association
Remission Criteria for RA (Eberhardt a Fex 1998)
4 or more of the following criteria must be fulfilled
for at least 2 consecutive months:
1. Duration of morning stiffness not exceeding 15 min
2. No fatigue
3. No joint pain (by history)
4. No joint tenderness or pain on motion
5. No soft tissue swelling in joints or tendonsheaths
6. ESR<30mm after 1 hour for a female or <20mm after 1
hour for a male
12. Pathology
RA is generalized disorder of connective tissue
affecting –
Articular structure &
Extra articular structures
13. Progressive changes in joints
Stage I:
Inflammation of the synovial membrane spreads to articular
cartilage & other soft tissues.
Limitation of joint movt with pain & muscle spasm
14. Stage II:
Granulation tissue formation within synovial membrane
& spread to periarticular tissue.
Cartilage disintegration & joint filled with granulation
Thickening of joint capsule, tendon (with sheaths) &
impaired joint movt permanently.
15. Stage III:
Granulation tissue converted into fibrous tissue with
adhesion formation between tendon, joint capsule &
articular surface.
Articular surface cover partly by cartilage & partly by
fibrous tissue.
17. Extra articular changes
Nodule formation:
In the pressure area & may be
subcutaneous or intracutaneous.
They may present in organs such as
lung & heart.
Vascular changes:
It constitute inflammation of all size
arteries.
The lumen of small vessels can
become obliteration.
18. Clinical feature
Articular features
Pain Loss of function
Tenderness Stiffness
Swelling Deformity
Warmth over the joint Muscle wasting
Erythema Decreased ROM
19. Common Extra Articular Feature of RA
Nodules, Anaemia, Lymphadenopathy,
Systemic
Amyloidosis, Vasculitis, Felty’s Syndrome
Ocular Keratoconjunctivitis, Scleritis & Episcleritis
Bone Osteoporosis
Peripheral nerve entrapment, Peripheral
Neurology neuropathy, Cervical spine instability, Cervical
cord compression, nerve root compression
Pleuritis, Pleural effusion, Pulmonary alveolitis
Pulmonary
and fibrosis
Pericarditis & myocarditis, Pericardial effusion,
Cardiovascular
Conduction defect, Atherosclerosis
20. CLINICAL FEATURE
Swelling is confined to the
area of the joint capsule
Synovial thickening feels
like a firm sponge
Prominent ulnar deviation in
the right hand
MCP and PIP swelling in
both hands
Synovitis of wrist
26. Referral for Specialist Treatment
Refer for specialist opinion with any person
suspected persistent synovitis of undetermined
cause.
Refer urgently if any of the following apply:
1. The small joints of the hands or feet are affected
2. More than one joint is affected
3. There has been a delay of 3 months or longer between
onset of symptoms and seeking medical advice.
27. Do not avoid referring urgently any person with
suspected persistent synovitis of undetermined
cause whose blood tests show a normal acute-
phase response or negative Rh factor.
29. Investigation
There is no single diagnostic test for RA
Investigations are used to support the clinical
diagnosis and negative results do not exclude
the diagnosis of RA
No of test are available with rheumatologist
to rule out the different remarks of the disease
Acute phase reactants, Autoantibodies, Synovial fluid
examination, radiography, newer markers of inflammation etc
30. Investigations helpful in Dx of RA
Acute phase reactants (APRs) Uric acid/ Synovial fluid
Erythrocyte sedimentation analysis
rate (ESR) Urinalysis
C-reactive protein (CRP) Bone marrow examination
Full blood count (FBC) Thyroid function
Rheumatoid factor (RF) (TSH, T3,T4)
Antinuclear antibody (ANA) Hepatic enzymes
Urea & electrolytes (U&E) (SGOT, SGPT, alkaline
phosphatase)
Liver function tests (LFT)
Muscle enzyme (CPK,)
31. Acute phase reactant
These are the proteins produce by hepatocytes
Synthesis is effected by the proinflammatory
cytokines IL-6, IL-1 &TNF-alfa
The concentration of these protein may-
Increase (+ve APRs)
Decrease (-ve APRs)
32. Positive acute phase reactant
Ceruloplasmin
Mild elevation Complement C3
Complement C4
Alfa1-acid glycoprotein
Alfa1-proteinase inhibitor
Moderate elevation
Haptoglobin
Fibrinogen (causing elevate ESR)
C reactive protein
Marked elevation
Serum amyloid A protein
Negetive acute phase reactants
Albumin
Transferrin
33. Erythrocyte sedimentation rate (ESR)
ESR has been using as a reliable indicator of
inflammation & still clinically useful
Rises >24 hours after inflammation onset and
symptoms
Gradually returns to normal 4 weeks after resolution
It is a measure of rouleaux formation which is
dependent on the concentration of –
Fibrinogen, Immunoglobulin & Some other plasma protein
Normal ESR is – 0–20mm in females, 0–15 in male
34. In rheumatology -
Elevated ESR increases the probability of
inflammatory arthritis, whereas a normal ESR
increases the probability of non-inflammatory
condition like mech. pain
Moderately elevated ESR can help to asses the disease
activities in RA
35. C-reactive protein
It raises 24 hr after the onset of inflammation.
Short half life of 5-7 hours
Rapidly declines after condition resolves
Can raises up to 1,000 fold
It is a sensitive & early indicator of inflammation
The normal concentration is less then 0.6 mg/dl
In rheumatic conditions
The level range between 1-10 mg/dl except in systemic
vascuities (500 mg/dl)
36. Rheumatoid Factor
Rheumatoid factor (RF) is a term used to describe a
group of autoantibodies
The RF test is considered the basic screen and
hallmark for the autoimmune disorder RA
The three subclasses of RF include IgM, IgA and
IgG autoantibodies. Most tests for RF measure each
of these subtypes
37. The simultaneous presence of all 3 types is usually
only seen in RA
In patients with RA, IgM RF predominates & the
other subtypes are usually present in lower amounts
It is found in the sera of 80% of pts with RA
Extra-articular features of RA are common in pts
with high concentrations of rheumatoid factor
But it is a poor guide to the severity of joint disease
& to the success or otherwise of Rx
38. Antinuclear antibody (ANA)
The test is to exclude the systemic lupus erythromatus when
the test is negative
Presence of ANA increases the likelihood of an autoimmune
disease
It checks blood levels of antibodies that are often present in
connective tissue diseases or other autoimmune
disorders, such as lupus
There are also tests for individual types of ANA’s that may
be more specific to people with certain autoimmune disorders
ANA’s are also sometimes found in healthy people
Therefore, having ANA’s in the blood does not necessarily
mean that a person has a disease
39. Urea & electrolytes (U&E)
Mild elevation of alkaline phosphatase and
gamma-GT in rheumatic conditions
40. Uric acid/ Synovial fluid analysis
It is a simple test & provides valuable information
specially in mono arthritis patient
Joint aspiration is done to obtain a sample of
synovial fluid
The test provides important diagnostic information
whether
Crystals (found in pts with gout or other types of crystal-
induced arthritis)
Bacteria or viruses (found in pts with infectious arthritis)
are present in the joint.
42. Urinalysis
In this test, a urine sample is studied for
protein, RBC, WBC or casts
These abnormalities indicate kidney
disease, which may be seen in several rheumatic
diseases such as lupus or vasculitis
Some medications used in the Rx of arthritis can
also cause abnormal findings on urinalysis
43. Complete blood count (CBC)
CBC determines the number of WBC, RBC &
platelets present in a sample of blood
Some rheumatic conditions or drugs used to treat
arthritis are associated with a low WBC
(leukopenia), low RBC (anemia), or low platelet
count (thrombocytopenia)
When doctors prescribe medications that affect
the CBC, they periodically test the patient’s blood
44. White blood cell count (WBC)
This test determines the number of WBC present
in a sample of blood
The number may increase as a result of infection
or decrease in response to certain medications, or
with certain diseases, such as lupus
Low numbers of WBC increase a person’s risk of
infections
45. Hematocrit (PCV, packed cell volume)
This test and the test for hemoglobin measure the
number of RBC present in a sample of blood
A decrease in the number of RBC (anemia) is
common in people with inflammatory arthritis
and rheumatic diseases.
46. Liver function
Tests for liver function may give abnormal results
in patients with RA
Serum concentrations of transaminases & alkaline
phosphatase may be moderately elevated when
the disease is active
47. Thyroid function (TSH, T3, T4)
It was found that the mean T4 levels in the RA
patients were significantly higher
T3 levels were more than 2 SD above controls
T4 levels were higher in 27 patients
TSH levels were more than 2SD above
Thyroid hormonal defects are related with the disease
duration & not with the disease activity
48. Bone marrow examination
There is mounting evidence that osteoclasts are
involved in the pathogenesis of a component of
the focal bone erosions in RA
49. Muscle enzyme (CPK)
Patients with RA usually have low Creatine
Kinase (CK) values
Even mild rise in CK levels may suggest presence
of polymyositis, which may be confirmed on
muscle biopsy
High incidence of vasculitis in biopsied muscle
suggests that it may be the primary event in the
pathogenesis of myositis in RA
50. Labs (ARA recommended, but
do not exclude diagnosis)
Initial Labs
Complete Blood Count with differential
Rheumatoid Factor (Initially positive in 70%)
Sedimentation Rate (ESR) or C-Reactive Protein (C-RP)
Additional labs in preparation for rheumatic agents
Liver Function Tests
Renal Function tests
Markers of disease course
C-Reactive Protein (C-RP)
Erythrocyte Sedimentation Rate
Wrist X-Ray or Ankle X-Ray
Anticyclic citrullinated peptide antibody
51. Laboratory findings in RA
Anaemia: normochromic or hypochromic, normocytic (if
microcytic consider iron deficiency)
Thrombocytosis
Raised erythrocyte sedimentation rate
Raised C reactive protein concentration
Raised ferritin concentration as acute phase protein
Low serum iron concentration
Low total iron binding capacity
Raised serum globulin concentrations
Raised serum alkaline phosphatase activity
Presence of rheumatoid factor
52. Other causes of positive test for
rheumatoid factor
Other connective tissue diseases
Viral infections
Leprosy
Leishmaniasis
Subacute bacterial endocarditis
Tuberculosis
Liver diseases
Sarcoidosis
Mixed essential cryoglobulinaemia
53. Differential diagnosis of RA
Psoriatic arthritis--always seronegative
Primary nodal osteoarthritis
Other connective tissue diseases – SLE
Calcium pyrophosphate deposition disease
Polyarticular gout
Fibromyalgia
Medical conditions presenting with arthropathy –
thyroid disease
55. Principles of Treatment
Early initiation of treatment
Multidisciplinary team approach
Patient education
Assessment of response to treatment
Hospital admission
Complication (cost) of untreated disease
56. Early initiation of Treatment
Goals of early treatment
Symptom control
Reduction of joint damage & disability
Maintenance or improvement of quality of life
57. Multidisciplinary team approach
GP
Rheumatologist
Physical therapist
Occupational therapist
Nurse specialist
Dietitian
Podiatrist
Pharmacist
Social worker
58. Patient education
Should be adopted by all members of
multidisciplinary team in both 1ry & 2ndry care.
Should be provided with an information on
booklet & if possible one to one education.
59. Assessment of response to Rx
Quantification of disease activity & outcome is
important in assessing, comparing &
standardizing treatment of RA.
60. Clinical measures of response to Rx includes –
Patient opinion
Physician opinion
Extend of synovitis (no of swollen or tender or both)
Duration/ severity of stiffness after inactivity
Functional ability
Laboratory measures of response to Rx includes –
Acute phase response (ESR, CRP)
Anaemia
Radiological progression
61. Hospital admission
Multiple joint involved acute phase patient may
required hospitalization.
Selective patient may benefit from more intensive
hospital based Rx from multidisciplinary team.
It is essential to maintained specialist IP facilities
for selected RA patients.
62. Complication/ Cost of untreated
disease
Personal costs –
Lost work opportunities
Decreased leisure activities
Stress on relationships
Costs to society –
Loss of working skills of RA individuals
Loss of contributions to the home
The burden of economic cost for care
63. Management
Pharmacological management
Analgesics –
Simple analgesics should be used in place of NSAIDs
Paracetamol, Codeine Or Compound Analgesics
DMARDs should be introduced to suppress
disease activity.
Cyclo-oxygenase-2 (COX-2) Inhibitors.
64. Diet and complementary therapies
Inform people with RA that there is no strong
evidence that their arthritis will benefit with diet.
However, they could be encouraged for the
principles of a Mediterranean diet
Mediterranean Diet:
More Bread, Fruit, Vegetables & Fish
Less Meat & Replace Butter & Cheese With Products
Based On Vegetable And Plant Oils.
Fasting has shown to be benefit in some patient.
65. Diet and complementary therapies
Complementary therapies that although some may
provide short-term symptomatic benefit, there is
little or no evidence for their long-term efficacy.
If a person with RA decides to try complementary
therapies, advise them:
These approaches should not replace conventional Rx
This should not prejudice the attitudes of members of
the multidisciplinary team, or affect the care offered.
66. Approach to PT Assessment
Note the time of day you make assessment; this
could be very important for reassessment as many
patients have variation in symptoms throughout
the day.
For example, if you carried out your initial assessment
early in the morning, then reassessed at midday, you
could get very different responses because ........???
By noon her morning stiffness would have eased.
68. Subjective Assessment
Demographic details & history of present
condition
General health and past medical history
Present medication and drug history
Splints
Social history
70. How long does her morning stiffness last?
Does she have any systemic symptoms that might
impact upon your ideas for management?
e.g. has the RA affected her heart or does she fatigue
easily?
Has she had any physiotherapy before and how
has she responded?
71. Problem list
Pain in all joints affected especially hips & knees
Reduced range of movement in all affected joints
Reduced muscle strength
Reduced mobility both in bed & during
locomotion (no longer able to get around with
walking frame)
Reduced function.
72. Aims of Physiotherapy Rx
To reduce pain & stiffness
To maintain or increase ROM in affected joints
To maintain or increase muscle strength in
affected groups
To prevent deformities
To maximise function, independence and quality
of life
73. An Approach to Physiotherapy Rx
Despite pharmacological advances in Rx of RA
many patients still present with functional deficits
who need physiotherapy.
According to World Confederation of Physical
Therapists (WCPT)
Physiotherapy is ‘concerned with identifying &
maximizing movement potential, within the spheres of
promotion, prevention, treatment and rehabilitation’.
74. WCPT components of
physiotherapy interventions
Thermotherapy – hot/cold packs, paraffin/wax
baths and infrared.
Ice application –
It provides cooling to skin temp which is raise by
inflammation.
Cooling will diminish the rate of swelling &
production of irritants.
It also helps in alleviate some of pain.
Ice can be applied regularly @ 2/day
75. Heat application –
Acute conditions – Heat application to the inflamed
joint is not recommended.
Chronic conditions – Thermotherapy, especially
paraffin baths combined with ex, should included as an
intervention to improve ROM & decrease pain &
stiffness.
76. Therapeutic ultrasound
Therapeutic US without additional therapeutic
interventions is effective for reducing joint
tenderness caused by RA.
Continuous US is more effective for patients with
chronic RA.
Mechanical effect of both pulsed & continuous US
increases skin permeability, thus decreasing
inflammatory response, reducing pain & facilitating the
soft tissue healing process.
77. Both pulsed and continuous US reduce nerve
conduction velocity of pain nerve fibres.
Continuous US, however, has thermal effects that
reduce muscle spasms and pain.
The thermal effects also cause vasodilatation,
which enhances the excretion of chronic
inflammatory cells.
78. Pulse electromagnetic energy
There is minimal literature of PEME in RA
But in some studies it has shown to be effective
79. Interferential therapy
Helps in minimizing pain in RA
The electrodes needs to place carefully in pts with
high dose steroid
Used of such modalities may addicted to the patient
& when experiencing multiple joint pain it would
be impractical.
Dosage –
90 – 100 Hz – reduce nerve accommodation
50 – 100 Hz – improve healing, blood supply &
membrane permeability
80. TENS
It has been proven to be effective in managing
chronic pain.
Different dosage may be used with disease
activity levels
Many patient tend to substitute medication with
TENS.
81. Hydrotherapy
Hydrotherapy produces physiological, functional
and psychological benefits.
Long-term hydrotherapy reduces the rate of
hospital admissions and does not increase joint
destruction.
However, it is not suitable for all RA patients due
to contra-indications and the cost of hydrotherapy
reduces its widespread availability.
82. Joint Protection & Provision of
Walking & Disability Aids / Splinting
Provision of sticks or crutches
Reduce lower limb loading
Helps in pain relieve & improving mobility in RA.
However, redistribution of load to the small joints of
the upper limbs requires especially designed walking
aids, e.g. gutter frames
Splinting
It can reduce pain & improve function.
Splinting is usually applied by occupational therapists
(OTs), but a trained Therapist may supply splints.
83. Characteristics of an ideal splint
The splint should be –
Inexpensive
Easy & quick to make
Comfortable
Light & neat
Strong
Functionally accurate
Fitting optimal
Cosmetically accepted
84. Advantage of splinting
Correct deformities
Provide support & rest
Easy application & removal
Prevent dynamic instability
Offer functional efficiency
Reduce the impact of unwanted force on body
Provide means of strengthening, re-educative &
assistive aids.
85. Disadvantage of splint
Possibility of muscular weakness & wasting
Loss of mobility
Tendency to fixed in one position of splint
Fabrication, trial & application are painful.
88. Exercise therapy
On land & Aquatic physiotherapy includes –
Aerobic activities,
Flexibility
Strengthening ex,
Core stability ex,
Balance rehabilitation,
Promotion of lifestyle physical activity.
89. Manual therapy
Manual therapy– includes –
Mobilisation
Manipulation
Myofascial release
Trigger point therapy
Acupuncture and
Massage.
90. Course & Prognosis of RA
The course of disease is variable & unpredictable
Prognosis in term of function is reasonably good:
25 % - Remains fit for all-round activities
40 % - Moderate impairment of function
25 % - Badly disable
10 % - Wheelchair dependent
91. Prognosis is poor if –
RH-f is high
Erosion of the joint surface appear early
Nodules
Systemic manifestations