Skills in Rheumatology

This Open Access book presents practical approaches to managing patients affected by various rheumatological diseases, allowing readers to gain a better understanding of the various clinical expressions and problems experienced by these patients. Discussing rheumatology from an organ systems perspective, it highlights the importance ofdetailed musculoskeletal examinations when treating patients affected by rheumatological diseases. The book first explores the latest diagnostic approaches and offers key tips for accurate musculoskeletal examinations before addressing the various treatment modalities, with a particular focus on the most common joints involved in rheumatoid arthritis: the wrists and the metacarpophalangeal joints (2nd and 3rd). Featuring easy-to-understand flow diagrams and explaining the common medical problems associated with rheumatic disease, such as shortness of breath and anemia, it is not only a valuable resource to rheumatologists, but will also appeal to medical students, junior residents, and primary healthcare physicians

Skills in Rheumatology

This Open Access book presents practical approaches to managing patients affected by various rheumatological diseases, allowing readers to gain a better understanding of the various clinical expressions and problems experienced by these patients. Discussing rheumatology from an organ systems perspective, it highlights the importance ofdetailed musculoskeletal examinations when treating patients affected by rheumatological diseases. The book first explores the latest diagnostic approaches and offers key tips for accurate musculoskeletal examinations before addressing the various treatment modalities, with a particular focus on the most common joints involved in rheumatoid arthritis: the wrists and the metacarpophalangeal joints (2nd and 3rd). Featuring easy-to-understand flow diagrams and explaining the common medical problems associated with rheumatic disease, such as shortness of breath and anemia, it is not only a valuable resource to rheumatologists, but will also appeal to medical students, junior residents, and primary healthcare physicians

‘Giving a voice to the voiceless’: The lived experience of health-related quality of life in Bangladeshi patients with ankylosing spondylitis

Background This study aimed to explore the lived experience of health-related quality of life in ankylosing spondylitis (AS) among Bangladeshi patients who live in a deprived area of London. Ankylosing spondylitis is a complex systemic rheumatologic condition which is often characterised by severe disability and impaired health-related quality of life. Ankylosing spondylitis in Bangladeshi patients is under-researched, compared to the abundance of studies on health-related quality of life in other communities. Methodology In order to understand and interpret the essence of meaning behind the lived experience of twenty (20) Bangladeshi patients with ankylosing spondylitis, an interpretive phenomenological approach was used. More specifically, Max van Manen’s (1990) methodological framework guided and provided a structure to the enquiry into the life world of the Bangladeshi participants. The research was designed to answer the question: what is the lived experience of health-related quality of life in Bangladeshi patients with ankylosing spondylitis? In order to encourage the Bangladeshi patients to share their narratives and uncover meanings attached to their experiences, semi-structured individual face-to-face interviews were used to collect the data. An interpreter was used to aid translation and interpretation in the interviews with the non-English speaking participants. Data were analysed using van Manen’s three method approach of isolating thematic statements. Findings A phenomenological interpretation is offered through five identified global themes and twenty- three sub-themes, which are inextricably linked: the struggle to get a diagnosis, the nature of ankylosing spondylitis, the impact of ankylosing spondylitis, managing with ankylosing spondylitis and finding relief. Interpretation demonstrated the complex and often variable ways in which the Bangladeshi participants have experienced and are living with ankylosing spondylitis. Participants have faced a myriad of struggles in their journey to diagnosis and the ankylosing spondylitis symptoms are unpredictable and uncertain affecting every aspect of their lives. The participants narrated ways they are using to manage the illness and how they have found relief from the symptoms. Conclusion Ankylosing spondylitis affects the Bangladeshi participants in a significant way. Based on their cultural identity, this group hold onto specific health beliefs which they use to construct meaning about their lived experience of ankylosing spondylitis. There is a need to develop culturally appropriate models of service provision for this group, which are based on an understanding of the lived experience

Insights and Perspectives in Rheumatology

This book offers a range of perspectives on pathogenesis, clinical features and treatment of different rheumatic diseases, with a particular focus on some of the interesting aspects of Sjögren's syndrome. It contains detailed and thorough reviews by international experts, with a diverse range of academic backgrounds. It will also serve as a useful source of information for anyone with a passive interest in rheumatology, from the genetic and molecular level, through to the psychological impact of pain and disability

Bioregulatory systems medicine: an innovative approach to integrating the science of molecular networks, inflammation, and systems biology with the patient\u27s autoregulatory capacity?

Bioregulatory systems medicine (BrSM) is a paradigm that aims to advance current medical practices. The basic scientific and clinical tenets of this approach embrace an interconnected picture of human health, supported largely by recent advances in systems biology and genomics, and focus on the implications of multi-scale interconnectivity for improving therapeutic approaches to disease. This article introduces the formal incorporation of these scientific and clinical elements into a cohesive theoretical model of the BrSM approach. The authors review this integrated body of knowledge and discuss how the emergent conceptual model offers the medical field a new avenue for extending the armamentarium of current treatment and healthcare, with the ultimate goal of improving population health

Innate immunity and its control in the pathogenesis of inflammatory rheumatic diseases

The pathogenesis of inflammatory rheumatic diseases, including rheumatoid arthritis (RA) and spondyloarthropathies (SpAs) such as reactive arthritis (ReA), is incompletely understood. ReA is a sterile joint inflammation, which may follow a distal infection caused by Gram-negative bacteria that have lipopolysaccharide (LPS) in their outer membrane. The functions of innate immunity that may affect the pathogenesis, prognosis and treatment of these diseases were studied in this thesis. When compared with healthy controls, whole blood monocytes of healthy subjects with previous ReA showed enhanced capacity to produce TNF, an essential proinflammatory cytokine, in response to adherent conditions (mimicking vascular endothelium made adherent by inflammatory signals) and non-specific protein kinase C stimulation. Also, blood neutrophils of these subjects showed high levels of CD11b, an important adhesion molecule, in response to adherence or LPS. Thus, high responsiveness of monocytes and neutrophils when encountering inflammatory stimuli may play a role in the pathogenesis of ReA. The results also suggested that the known risk allele for SpAs, HLA-B27, may be an additive contributor to the observed differences. The promoter polymorphisms TNF 308A and CD14 (gene for an LPS receptor component) 159T were found not to increase the risk of acute arthritis. However, all female patients who developed chronic SpA had 159T and none of them had 308A, possibly reflecting an interplay between hormonal and inflammatory signals in the development of chronic SpA. Among subjects with early RA, those having the polymorphic TLR4 +896G allele (causing the Asp299Gly change in TLR4, another component of LPS receptor) required a combination of disease-modifying antirheumatic drugs to achieve remission. It is known that rapid treatment response is essential in order to maintain the patients work ability. Hence, +896G might be a candidate marker for identifying the patients who need combination treatment. The production of vascular endothelial growth factor (VEGF), which strongly promotes vascular permeability and angiogenesis that takes place e.g. early in rheumatic joints, was induced by LPS and inhibited by interferon (IFN)-alpha in peripheral blood mononuclear cells. These long-living cells might provide a source of VEGF when stimulated by LPS and migrating to inflamed joints, and the effect of IFN-alpha may contribute to the clinical efficacy of this cytokine in inhibiting joint inflammation.Luonnollinen immuunijärjestelmä käsittää kehon epäspesifiset vieraan materiaalin torjuntakeinot, jotka käynnistyvät nopeasti ennen spesifisen opitun immuniteetin aktivaatiota. Yksi tärkeimmistä luonnollisen immuniteetin toiminnoista on veren syöjäsolujen tarttuminen (adheesio) tulehduksen esiintuomiin molekyyleihin verisuonten seinämissä ja siirtyminen kudokseen hävittämään tulehduksen aiheuttajaa. Luonnollisen immuniteetin solujen keskeisiä reseptoreja ovat adheesiomolekyyli CD11b/CD18 sekä CD14/TLR4/MD-2, joka sitoo Gram-negatiivisten bakteerien LPS-rakennetta käynnistäen solussa mm. tulehdusvälittäjäaine TNF:n tuotannon. Tulehduksellisten reumasairauksien kuten reaktiivisen artriitin (ReA:n) ja nivelreuman (RA:n) patogeneesi tunnetaan puutteellisesti. ReA on spondyloartropatia (SpA) -tautiryhmään kuuluva niveltulehdus, jota edeltää nivelen ulkopuolinen, tyypillisesti Gram-negatiivisen bakteerin aiheuttama infektio. Tutkimuksessa havaittiin, että ReA:n sairastaneiden koehenkilöiden veren syöjäsolujen reaktio adheesioon (TNF-tuotannon käynnistyminen ja CD11b-tason nousu) tai LPS:ään (CD11b-tason nousu) oli voimakkaampi kuin ReA:a sairastamattomien. Täten syöjäsolujen reaktiivisuus voi liittyä ReA:n patogeneesiin. Luonnollisen immuniteetin geenien säätelyalueiden polymorfismit kuten CD14 -159C/T ja TNF -308G/A voivat vaikuttaa geenien luennan aktiivisuuteen ja tulehdusvasteeseen. Tutkimuksessa kaikilla naispotilailla, joilla SpA kroonistui, oli -159T eikä heistä kellään ollut -308A:ta, mikä voi kertoa hormoni- ja tulehdussignaalien yhteisvaikutuksesta SpA:ssa. Keskeistä RA-potilaan työkyvyn säilyttämiseksi on saada nopeasti hyvä hoitovaste. Tulosten perusteella TLR4 +896A/G -polymorfismi voi olla hyödyllinen hoitostrategian suunnittelussa: potilaat, joilla oli G-alleeli, eivät saavuttaneet remissiota yhdellä antireumaattisella lääkkeellä vaan tarvitsivat lääkeyhdistelmää. VEGF on kasvutekijä, joka lisää sekä verisuonten läpäisevyyttä että niiden kasvua, jota tapahtuu esim. reumaattisessa nivelessä. LPS:n havaittiin edistävän veren valkosolujen VEGF-tuottoa, mitä taas alfa-interferoni esti. Täten LPS:n stimuloima VEGF-tuotanto kudokseen siirtyvissä valkosoluissa voi olla turvotusta ja verisuonten kasvua edistävä mekanismi, ja tämän esto voi osin selittää alfa-interferonin tehoa esim. syövän kasvun ja nivelten tulehtuneisuuden vähentämisessä. Tutkimus edustaa lääketieteellistä perustutkimusta, jonka merkittäviä sovelluksia ovat tulehduksellisten reumasairauksien diagnostiikan, ennusteen ja hoidon kehittäminen

A systems approach to sub-typing of rheumatoid arthritis

The current health care system is severely challenged by for instance rising costs, fewer new blockbuster drugs and increasing numbers of hospitalizations due to side effects. Especially in the area of chronic diseases the current disease fighting strategy is failing and a more personalized medicine approach is needed. In this thesis new sub-types of rheumatoid arthritis are characterized with metabolomics analysis and symptoms patterns. The sub-types are based on diagnostic knowledge from Chinese medicine. The two sub-types of RA patients were found to have differences in apoptosis regulation of T-cells and differences in urine acylcarnitine levels. A questionnaire was designed to distinguish the two sub-types and to evaluate symptom patterns of arthritis patients. In the future the response to treatment of these sub-types of patients can be studied and specific treatment can be targeted to these sub-types.LEI Universiteit LeidenArtrose & Reuma StichtingAnalyse en stochastie