Joint Rheumatoid Arthritis

Some of the most important physiological steroids are the adrenocortical hormones, synthesized by the adrenal cortex. Most of these hormones have either a carbonyl group or a hydroxyl group at Cl 1 of the steroid skeleton. The principal adrenocortical hormone is cortisol, used for the treatment of inflammatory diseases of the skin (psoriasis), the joints (rheumatoid arthritis), and the lungs (asthma). Figure 25-10 compares the structure of natural cortisol with two synthetic corticoids fluocinolone acetonide, a fluori-nated synthetic hormone that is more potent than cortisol for treating skin inflammation and beclomethasone, a chlorinated synthetic hormone that is more potent than cortisol for treating asthma. 

Rheumatoid arthritis (RA). An episodic inflammatory systemic disease with autoimmune pathogenetic mechanisms. It primarily affects the joints, causing symmetrical lesions and severe damage to the affected joints. Rheumatoid arthritis is the most common form of inflammatory joint disease (prevalence about 0.5-1%). 

Rheumatoid arthritis represents a chronic inflammatory disease of the joints. About 1% of the population in Germany suffers from this disease. Primarily the synovial membranes of the jounts are affected, however, the disease can also reach other organs such as the pleura, pericardium organ and skin blood vessels. The inflamed... 

IMPAIRED PHYSICAL MOBILITY. The patient may have an acute or chronic disorder with varying degrees of mobility. The patient may be in acute pain or have longstanding mild to moderate pain. Along with the pain there may be skeletal deformities, such as the joint deformities seen with advanced rheumatoid arthritis. Considering the nature of the patient s condition, the nurse s assistance with ambulation may be required. The nurse determines the degree of immobility of the patient and assists the patient as needed. 

The salicylates and nonsteroidal anti-inflammatory drug (NSAIDs) are important in the treatment of arthritic conditions. For example, the salicylates and NSAIDs are used in the treatment of rheumatoid arthritis (a chronic disease characterized by inflammatory changes within the body s connective tissue) and osteoarthritis (a noninflammatory joint disease resulting in degeneration of the articular cartilage and... 

Iron salts occasionally cause gastrointestinal irritation, nausea, vomiting, constipation, diarrhea, headache, backache, and allergic reactions. The stools usually appear darker (black). Iron dextran is given by the parenteral route Hypersensitivity reactions, including fatal anaphylactic reactions, have been reported with the use of this form of iron. Additional adverse reactions include soreness, inflammation, and sterile abscesses at the intramuscular (IM) injection site Intravenous (IV) administration may result in phlebitis at the injection site When iron is administered via the IM route, a brownish discoloration of tlie skin may occur. Fhtients with rheumatoid arthritis may experience an acute exacerbation of joint pain, and swelling may occur when iron dextran is administered. 

Fhtients with rheumatoid arthritis may experience an acute exacerbation of joint pain, and swelling may occur with iron dextran therapy. 

In rheumatoid arthritis the damage that is found in joints may also be a result of the inactivation of a-1-PI due to the oxidation of an essential methionine(s) residue in this protein. It has been found that a-l-PI purified from the synovial fluid of patients with rheumatoid arthritis contained four Met(O) residues and was not able to form a binary complex with elastase89. It is probable that the presence of the Met(Oj residues in a-l-PI from these patients results from a high level of oxidants produced by neutrophils in the inflammed joint. 

Tea extracts have been demonstrated to inhibit a wide range of inflammatory responses and may be useful in treating chronic inflammatory states. For example, rheumatoid arthritis is an inflammatory disease that causes pain, swelling, stiffness and loss of function in the joints. The antioxidants in green tea may prevent or reduce the severity of these symptoms by reducing inflammation and slowing cartilage breakdown (Adcocks et al, 2002 Haqqi et al, 1999). 

Figure 1.1 A typical e.s.r. spectrum of knee-joint synovial fluid obtained from a patient with rheumatoid arthritis. The signals detectable have g values that correspond to the nitrosylhaemoglobin adduct (gi = 2.083, 02 = 2.040 and gs = 2.003).

Although atherosclerosis and rheumatoid arthritis (RA) are distinct disease states, both disorders are chronic inflammatory conditions and may have common mechanisms of disease perpetuation. At sites of inflammation, such as the arterial intima undergoing atherogen-esis or the rheumatoid joint, oxygen radicals, in the presence of transition-metal ions, may initiate the peroxidation of low-density lipoprotein (LDL) to produce oxidatively modified LDL (ox-LDL). Ox-LDL has several pro-inflammatory properties and may contribute to the formation of arterial lesions (Steinberg et /., 1989). Increased levels of lipid peroxidation products have been detected in inflammatory synovial fluid (Rowley et /., 1984 Winyard et al., 1987a Merry et al., 1991 Selley et al., 1992 detailed below), but the potential pro-inflammatory role of ox-LDL in the rheumatoid joint has not been considered. We hypothesize that the oxidation of LDL within the inflamed rheumatoid joint plays a pro-inflammatory role just as ox-LDL has the identical capacity within the arterial intima in atherosclerosis. 

Jason, M.I.V. and Dixon, A. St. J. (1970a). Intra-articular pressures in rheumatoid arthritis of the knee. I. Pressure changes during passive joint distention. Ann. Rheum. Dis. 29, 261-265. 

Zhang, Z., Winyard, P.G., Chidwick, K., Farrell, A., Pemberton, P., Carrell, KW. and Blake, D.R. (1990). Increased proteolytic cleavage of ai-antitrypsin (ai-proteinase inhibitor) in knee-joint synovial fluid from patients with rheumatoid arthritis. Biochim. Soc. Trans. 18, 898-899. 

The goals of treatment for rheumatoid arthritis are to (1) reduce or eliminate pain, (2) protect articular structures, (3) control systemic complications, (4) prevent loss of joint function, and (5) improve or maintain quality of life. 

Rheumatoid arthritis (RA) is a complex systemic inflammatory condition manifesting initially as symmetric swollen and tender joints of the hands and/or feet. Some patients may experience mild articular disease, whereas others may present with aggressive disease and/or extraarticular manifestations. The systemic inflammation of RA leads to joint destruction, disability, and premature death. 

FIGURE 54-1. Patterns of joint involvement in rheumatoid arthritis. (From DiPiro JT, Talbert RL, Yee GC, et al, (eds.) Pharmacotherapy. 6th ed. New York McGraw-Hill 2005, Figure 89-3, p. 1673, with permission.)... 

Choy EH, Panayi GS. Cytokine pathways and joint inflammation in rheumatoid arthritis. N Engl J Med 2001 344( 12) 907—916. Cronstein BN. Low-dose methotrexate A mainstay in the treatment of rheumatoid arthritis. Pharmcol Rev 2005 57(2) 163—172. 

The musculoskeletal system consists of the muscles, bones, joints, tendons, and ligaments. Disorders related to the musculoskeletal system often are classified by etiology. Acute soft-tissue injuries include strains and sprains of muscles and ligaments. Repeated movements in sports, exercise, work, or activities of daily living may lead to repetitive strain injury, where cumulative damage occurs to the muscles, ligaments, or tendons.1-3 While tendonitis and bursitis can arise from acute injury, more commonly these conditions occur as a result of chronic stress.3,4 Other forms of chronic musculoskeletal pain, such as pain from rheumatoid arthritis (see Chap. 54) or osteoarthritis (see Chap. 55), are discussed elsewhere in this text. 

Fournier C. Where do T cells stand in rheumatoid arthritis Joint Bone Spine 2005 72(6) 527-532. 

Ellingsen T, Buus A, Stengaard-Pedersen K. Plasma monocyte chemoattractant protein 1 is a marker for joint inflammation in rheumatoid arthritis. J Rheumatol... 

Olszewski WL, Pazdur J, Kubasiewicz E, Zaleska M, Cooke CJ, Miller NE. Lymph draining from foot joints in rheumatoid arthritis provides insight into local... 

Kanbe K, Takemura T, Takeuchi K, Chen Q, Takagishi K, Inoue K. Synovectomy reduces stromal-cell-derived factor-1 (SDF-1) which is involved in the destruction of cartilage in osteoarthritis and rheumatoid arthritis. J Bone Joint Surg Br 2004 86(2) 296-300. 

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