What do nails reflect about diseases?

NAILS AND GENERAL HEALTH

The condition of the nails may offer clues to the general health of an individual. Certain illness cause changes in nails that can help doctors diagnose them more easily. Some nail disorders that may be linked with illnesses include: Beau's lines: These are indentations or grooves that run transverse (horizontally) across your nails. They can appear when growth at the nail root is significantly affected by severe illness such as a heart attack, measles, or pneumonia. Clubbing: The fingertips widen and become round while the nails curve (both, longitudinally and horizontally) around your fingertips. It is caused due to thickening of connective tissue as compensation for chronic lack of oxygen. It can indicate underlying lung disease, cyanotic heart disease or renal failure in many patients who present with the same. The change in nails in this case is usually permanent.

Half-and-Half (Lindsay's nails): There is an arc of brownish discoloration which may appear in a small percentage of people with kidney disorders. Onycholysis: This is a condition where the nail separates from the nail bed. So these parts appear yellowish, while the parts still placed firmly on the nail bed appear normal, pink. This problem is usually associated with physical injury (trauma), psoriasis, drug reactions, fungal disease or contact dermatitis from using nail hardeners. Onycholysis may also be seen in hypo or hyperthyroidism, iron deficiency, or syphilis. Spoon nails: In this condition, nails soften and look scooped out like a spoon with a depression that is usually large enough to hold a drop of liquid. This condition indicates iron deficiency. Terry's nails: Here, the entire nail looks opaque and white, the lunula is obliterated, and only the nail tip has a dark pink to brown band. This can be indicative of underlying cirrhosis, congestive heart failure, adultonset diabetes, cancer, or aging. Pale white nails: usually indicate anemia and are present in combination with white palms and pale pink lips.

The skin provides a protective shield against heat, light, injury and infection. It also
y y y

y y

regulates our body temperature, so we don t need to go into hibernation in winter like some animals have to, to save up their body energies. stores water and fat, so we don t break our bones everytime we trip by mistake. acts like a sensory organ, so we get goose bumps in the back of our neck if someone is watching us from the back; we get goose bumps the moment we feel cold; we can feel soft , hard , surfaces by pressing our fingers over it. prevents water loss so we can stay a whole day without drinking water, though it s best to drink 8-10 glasses of water daily. disposes waste from the pores on the skin, so we need to bathe regularly to keep our skin healthy.

The s 's charac eris ics s ch as thic ess c r and texture vary throughout the body s surface For example the head contains more hair follicles than any here else while the soles of the feet contain none The s in on the soles of the feet and the palms of the hands are much thic er, so they can bear the brunt of the physical exertions they undertake The skin is an ever-changing organ, with very specialized structures, to perform specific functions and is made up of three layersy y y

epidermis dermis subcutaneous fat layer

The Epidermis:
The epidermis is the thin, yet protective outer layer of the skin, which is made up of three parts:
       
y

St tu o n u (out ost p t) This layer consists of fully mature keratinocytes containing fibrous proteins (keratins) The outermost layer is continuously shed. The stratum corneum prevents the entry of most foreign substances as well as the loss of fluid from the body. Keratino tes ( iddle part) This layer, just beneath the stratum corneum, contains living keratinocytes (squamous cells), which mature continuously and add to the stratum corneum. Basal layer (inner part) The basal layer is the deepest layer of the epidermis, containing basal cells. These cells continuously divide, forming new keratinocytes that replace the cells that are shed from the skin's surface.
   

The epidermis also contains melanocytes, which are cells that produce elanin (skin pigment that protects us from the UV rays of the sun) and Langerhans' cell (the frontline defense of the immune system in the skin).

The Dermis:
The dermis is the middle layer of the skin. It contains:
y y y y y y y

blood vessels lymph vessels hair folli les with sebaceous (oil) glands and apocrine (scent) glands are associated with it. sweat glands collagen bundles fibroblasts nerves
!

The dermis is held together by a protein called collagen, made by fibroblasts. This layer also contains nerves that give us the sensation of pain, itch, temperature, touch etc.

The Subcuti

The subcutis is the deepest layer of skin. The subcutis, consisting of a network of collagen and fat cells, which helps to conserve the body's heat and protects the body from injury by acting as a shock absorber The multiple layers of the skin, each with their myriad parts and structures are tailored to perform certain specific functions in the body. All of these have to perform normally and in tandem to keep the skin healthy and growing.
$

Anatomy of the bone

What is the Bone made of and how does it work?

y y

The human bones are unique living tissue and are the strongest structures in the body. Built out of calcium, phosphorus and other minerals, they form the reservoir of important minerals and blood cells in the body.

#"
http://img.tfd.com/vet/thumbs/gr47.jpg

y y

The outer shape and structure of the bone differs in each part of the body but anatomically, they are broadly classified into l : li e the ones in the arm and the thi h and , li e the ones in the skull and the back. B ll ll l il i l i l i ) which constantly work together to maintain the bone thickness as well as supply mineral to the body whenever required. Bones also contain a special type of cells forming the inner core, the bone marrow, which produces all the components of blood red blood cells, white blood cells, platelets etc. T has currently taken an important place in research due to the potential of ll . The baby cells produced in the bone marrow, can not only differentiate into the different blood cells mentioned above, but with special treatment can be grown into different body tissues. This is a phenomenal finding for possible use in cases of organ damage, like that of the pancreas due to diabetes. It is also being tried in the treatment of a variety of disorders like cancers and genetic disorders.

i
y y y y

They give the entire body a shape and structure; imagine, without bones, we would just be a jelly-like blob of organs and blood vessels covered by skin. They protect all the i p ortant organs like the heart, lungs, brain, uterus etc. from direct trauma and pressure. They are an important source of minerals like calcium, and phosphorus in the body. They are also the site of production for blood cells and stem cells as described above.

Infection of Bone?
Osteomyelitis is an infection of bone or bone marrow, usually caused by pyogenic bacteria or mycobacteria. It can be usefully subclassified on the basis of the causative organism, the route, duration and anatomic location of the infection.

How is it caused?
In children it is thought that bacteria enter the bloodstream through the nose or bowel, and settle in areas of the bone which have been previously damaged by a small knock, or in parts of the bone with a good blood supply. The bacteria multiply and the body's defenses cause pus to form. This eats away the bone and an abscess forms which spreads through the bone and eventually comes to the surface. After a fracture, the bacteria enter the wound directly and settle on the bare ends. They then multiply and cause pus to form which eventually discharges back through the wound. In some people, the infection may start in another organ, such as the lung. From here, the germs can spread through the bloodstream into bone. People with diabetes are particularly prone to infection. If an ulcer develops on the toe or foot, it is not uncommon for the germs responsible to sooner or later penetrate through to the underlying bone. The symptoms in this case may be quite inapparent, and only some swelling may be noticed. In some children, especially the newborn, the bacteria may enter the bloodstream after blood tests or an intravenous drip feed. In other children, such as those who have sickle cell disease of the blood, damage to the bone as a result of the disease makes it more liable to become infected. In adults with diabetes, the reduced resistance to infection, poor blood circulation and a frequent loss of pain sensation all lead to a particularly insidious and often chronic osteomyelitis.

What are the symptoms?

y y y Bone pain Bone swelling Fever

dcWXRQa ` Rb VRa` YTXXWV RUT S RQ

0)&% ( 54%30

H7 P 6@@ C 876 EF @D@A 968D@6 C7A H7 C G E 876 EF @D@A E68D@6 C8 A9 8BA @ 89 876 I e

0)&% ( '&%

y y y y y

y y y y

Muscle spasm Local redness Local warmth Pain moving a nearby joint Specific symptoms depend on the bone affected: o Arm bone pain o Leg bone pain o Pelvis bone pain Symptoms of spinal osteomyelitis: o Mild fever o Spine bone pain o Worsening back pain o Back pain not relieved by rest o Back pain not relieved by simple analgesics o Back pain worse with movement Symptoms of chronic myelitis: o Recurrent myelitis o Recurrent bone pain o Pus drainage on skin o Recurring abscesses Blood clots Bone tissue necrosis Pus on the area Bone inflammation

How is it diagnosed?
Patient history, physical examination, and blood tests will help to confirm osteomyelitis: y y y y y y y White blood cell count shows leukocytosis. Erythrocyte sedimentation rate or C-reactive protein is usually elevated but nonspecific in acute cases. Cultures of the lesion indicate the source of the organism. Blood cultures help identify causative organism. Magnetic resonance imaging is best for detecting spinal infection. Computed tomography is best for visuali ing islands of dead bone. X-rays may not show bone involvement until the disease has been active for some time, usually 2 to 3 weeks. Bone scans can detect early infection. Diagnosis must rule out poliomyelitis, rheumatic fever, myositis, and bone fractures. The gold standard for diagnosing osteomyelitis is histopathologic and microscopic examination of bone.

How is it treated?
Osteomyelitis often requires prolonged antibiotic therapy, with a course lasting a matter of weeks or months. A PICC line or central venous catheter is often placed for this purpose. Osteomyelitis also may require surgical debridement (removal of dead, damaged or infected tissue to improve the healing potential of the remaining healthy tissue). Severe cases may lead to the loss of a limb. Initial first line antibiotic choice is determined by the patient's history and regional differences in common infective organisms. Hyperbaric oxygen therapy has been shown to be a useful adjunct to the treatment of refractory osteomyelitis.

Osteoporosis
What is Osteoporosis?
Osteoporosis is a disease of bone that leads to an increased risk of fracture. In osteoporosis the bone mineral density (BMD) is reduced leading to porous and thinning of bone bulk. Osteoporosis is most common in women after menopause, when it is called postmenopausal osteoporosis, but may also develop in men, and may occur in anyone in the presence of particular hormonal disorders and other chronic diseases or as a result of medications, specifically glucocorticoids, when the disease is called steroid- or glucocorticoid-induced osteoporosis (SIOP or GIOP). Given its influence on the risk of fragility fracture, osteoporosis may significantly affect life expectancy and quality of life.

what are the causes?

Risk factors for osteoporotic fracture can be split between non-modifiable and (potentially) modifiable. Nonmodifiable The most important risk factors for osteoporosis are advanced age (in both men and women) and female sex; estrogen deficiency following menopause is correlated with a rapid reduction in BMD, while in men a decrease in testosterone levels has a comparable (but less pronounced) effect Potentially modifiable
y

y y

Excess alcohol - small amounts of alcohol do not increase osteoporosis risk and may even be beneficial, but chronic heavy drinking (alcohol intake greater than 2 units/day), especially at a younger age, increases risk significantly. Vitamin D deficiency - low circulating Vitamin D is common among the elderly worldwide. Mild vitamin D insufficiency is associated with increased Parathyroid Hormone (PTH) production. PTH increases bone reabsorption, leading to bone loss. A positive association exists between serum 1,25dihydroxycholecalciferol levels and bone mineral density, while PTH is negatively associated with bone mineral density. Tobacco smoking - tobacco smoking inhibits the activity of osteoblasts, and is an independent risk factor for osteoporosis. Smoking also results in increased breakdown of exogenous estrogen, lower body weight and earlier menopause, all of which contribute to lower bone mineral density. High body mass index - being overweight protects against osteoporosis, either by increasing load or through the hormone leptin Malnutrition - low dietary calcium intake, low dietary intake of vitamins K and C Also low protein intake is associated with lower peak bone mass during adolescence and lower bone mineral density in elderly populations. Physical inactivity - bone remodeling occurs in response to physical stress. Weight bearing exercise can increase peak bone mass achieved in adolescence. In adults, physical activity helps maintain bone mass, and can increase it by 1 or 2%. Conversely, physical inacti vity can lead to significant bone loss. Excess physical activity - excessive exercise can lead to constant damages to the bones which can cause exhaustion of the structures as described above. There are numerous examples of marathon runners who developed severe osteoporosis later in life. In women, heavy exercise can lead to decreased estrogen levels, which predisposes to osteoporosis. Intensive training is often associated with low body mass index.

Heavy metals - a strong association between cadmium, lead and bone disease has been established. Low level exposure to cadmium is associated with an increased loss of bone mineral density readily in both genders, leading to pain and increased risk of fractures, especially in the elderly and in females. Higher cadmium exposure results in osteomalacia (softening of the bone). Soft drinks - some studies indicate that soft drinks (many of which contain phosphoric acid) may increase risk of osteoporosis;Others suggest soft drinks may displace calcium-containing drinks from the diet rather than directly causing osteoporosis.

What are the symptoms?

Osteoporosis itself has no specific symptoms; its main consequence is the increased risk of bone fractures. Osteoporotic fractures are those that occur in situations where healthy people would not normally break a bone; they are therefore regarded as fragility fractures. Typical fragility fractures occur in the vertebral column, rib, hip and wrist. Fractures:The symptoms of a vertebral collapse ("compression fracture") are sudden back pain, often with radiculopathic pain (shooting pain due to nerve compression) and rarely with spinal cord compression or cauda equina syndrome. Multiple vertebral fractures lead to a stooped posture, loss of height, and chronic pain with resultant reduction in mobility. Fractures of the long bones acutely impair mobility and may require surgery. Hip fracture, in particular, usually requires prompt surgery, as there are serious risks ass ociated with a hip fracture, such as deep vein thrombosis and a pulmonary embolism, and increased mortality. Falls risk:The increased risk of falling associated with aging leads to fractures of the wrist, spine and hip. The risk of falling, in turn, is increased by impaired eyesight due to any cause (e.g. glaucoma, macular degeneration), balance disorder, movement disorders (e.g. Parkinson's disease), dementia, and sarcopenia (age-related loss of skeletal muscle). Collapse (transient loss of postural tone with or without loss of consciousness) leads to a significant risk of falls; causes of syncope are manifold but may include cardiac arrhythmias (irregular heart beat), vasovagal syncope, orthostatic hypotension (abnormal drop in blood pressure on standing up) and sei ures. Removal of obstacles and loose carpets in the living environment may substantially reduce falls. Those with previous falls, as well as those with a gait or balance disorder, are most at risk.

How is it diagnosed?
The diagnosis of osteoporosis is made on measuring the bone mineral density (BMD). The most popular method is dual energy X-ray absorptiometry (DXA or DEXA). In addition to the detection of abnormal BMD, the diagnosis of osteoporosis requires investigations into potentially modifiable underlying causes; this may be done with blood tests and X-rays. Depending on the likelihood of an underlying problem, investigations for cancer with metastasis to the bone, multiple myeloma, Cushing's disease and other above mentioned causes may be performed.

How is it treated?
Medication: Bisphosphonates are the main pharmacological measures for treatment. However, newer drugs have appeared in the 1990s, such as teriparatide and strontium ranelate Hormone replacement Estrogen replacement therapy remains a good treatment for prevention of osteoporosis but, at this time, is not recommended unless there are other indications for its use as well. Selective estrogen receptor modulator (SERM): SERMs are a class of medications that act on the estrogen receptors throughout the body in a selective manner. Nutrition: Calcium:Calcium is required to support bone growth, bone healing and maintain bone strength and is one aspect of treatment for osteoporosis. Recommendations for calcium intake vary depending country and age; for individuals at higher risk of osteoporosis (after fifty years of age) the amount recommended is 1,200 mg per day. Calcium supplements can be used to increase dietary intake, and absorption is optimi ed through taking in several small (500 mg or less) doses throughout the day. Exercise: Multiple studies have shown that aerobics, weight bearing, and resistance exercises can all maintain or

increase BMD in postmenopausal women. Lifestyle: Lifestyle prevention of osteoporosis is in many aspects inversions from potentially modifiable risk factors. As tobacco smoking and unsafe alcohol intake have been linked with osteoporosis, smoking cessation and moderation of alcohol inta

What are Bone Tumours?

Tumour is the swelling caused by a bunch of cells growing abnormally together. They are called cancer or malignant only when they are capable of uncontrolled growth and spreading to other organs. Otherwise, tumours can be benign, where the cells will grow abnormally, but to a limited size, and will not spread to any other organ. An important point of difference in the case of bone cancer is that benign tumours of the bone are more common than malignant ones.
y

However, it can get cancerous too, even in childhood, which needs to be diagnosed ea to rly get prompt treatment. Bones are often involved in secondary cancers, i.e. the cancer spreads from an original site like the breast or the testis to the bones, and incidentally happen to get detected there first. Thus, detection of any malignancy in the bone should first arouse suspicion of a primary cancer somewhere else. After that possibility is ruled out, it is also important to differentiate between the various bone infections, compression fractures and benign tumours and then, primary bone can cer should be considered.

Types of benign bone tumours are:

y y y y y

Non-ossifying fibromaunicameral (simple) bone cyst Osteochondroma Giant cell tumour Enchondroma Fibrous dysplasia

Primary bone cancers are:

y

Multiple Myeloma- Multiple myeloma is the most common primary bone cancer. It is a malignant tumour of the bone marrow. Multiple myeloma affects approximately 20 people per million each year. Most cases are seen in patients between the ages of 50 and 70 years old. Any bone can be involved. Osteosarcoma- Osteosarcoma is the second most common bone cancer. It occurs in two or three new people per million people each year. Most cases occur in teenagers. Most tumours occur around the knee. Other common locations include the hip and shoulder. Ewing's sarcoma- Ewing's sarcoma most commonly occurs between 5 and 20 years of age. The most common locations are the upper and lower leg, pelvis, upper arm, and ribs.

Chondrosarcoma- Chondrosarcoma occurs most commonly in patients between 40 and 70 years of age. Most cases occur around the hip and pelvis or the shoulder.

What are the symptoms that I should look out for?

The most common symptom of a bone tumour is pain which may be dull aching type but may also be quite severe at times and is known to wake up patients at night.
y y

y y

A swelling or increased warmth or redness over an area with pain, although it must be differentiated from a bone infection- osteomyelitis. An injury at times brings attention to a tumour. Trauma does NOT cause tumours, but it may aggravate a cancerous area in the bone, leading to exaggerated pain at the site. A moderate injury may give rise to a fracture in a bone already weakened by the tumour. Some tumours can cause fevers and night sweats. Unexplained fever and sweating without any obvious cause justifies at least considering bone tumour as a possibility. In some cases, patients may only complain of a painless mass.

How will the doctors diagnose the cancer?

If you have any of the symptoms listed above, it is important you see the doctor at the earliest, as early diagnosis can help save the limb as much as possible.
y

Detailed history: The doctor will first take a detailed medical history of your symptoms, how and when they started, what other part of the body has had any similar or any other significant complain, which may indicate the involvement of any other organ too. He would also be keen to find out if you had any family history of any similar cancers. Physical examination: Here the doctor will examine the affected site to judge the extent of involvement and other significant characteristics of the tumour. Whether any other sites are likely to be involved like the breast, testis, prostate, uterus, and lungs will also be examined by him. Tests and Imaging: The doctor will need to take a couple of X-rays and preferably CAT scans and MRIs to carefully evaluate the extent of the tumour, the other structures involved and whether the tumour has metastasised (i.e., spread to another organ) from the origin to secondary organs. All of these factors will be important in deciding what type of treatment needs to be started for the patient. Also, in some cases, blood and urine tests will be required to confirm certain types of cancers like multiple myeloma where a special type of protein, called Bence Jones proteins are found in urine. Biopsy and pathological examination of the tumour piece: The doctor may want to take a biopsy from the swelling, using a hollow needle using anaesthesia or in some cases, the doctor may do an open biopsy after a significant part of the tumour has been surgically removed in the operation theatre. This will let him understand the exact type and stage of the tumour.

What are the options for treatment?

If you are diagnosed with a bone tumour, you may want to consider taking an additional second opinion to discuss the stage and options of treatment. Treating a benign tumour:
y y y

A benign tumour can usually be, managed by medical therapy and observation. A benign tumour that is too large in size and is creating problems in movement for e.g. near a joint may need to be removed surgically. In some cases, benign tumours may have a propensity to become malignant, so in such cases, the doctor may advise surgical removal of the same to be on the safer side.

Treating a malignant tumour: The options of treating a malignant tumour includey

Limb salvage surgery: This can be tried in early diagnosed cases where only the affected part would be surgically removed and the functionality of the limb would be preserved as much as possible. Amputation: In relatively severe cases, it is often quite difficult to preserve the limb without risking spread to the rest of the body. In these cases the affected limb has to be amputated in order to save the patient s life. A prosthesis or artificial limb would be fit in its place to correct the cosmetic deformity and restore functionality in the limbs. Chemotherapy: A chemotherapy course would be needed if the cells have spread into the blood stream, but cannot be localised by regular scanning procedures. The chemotherapy will directly act on killing tumour cells in the blood stream. Radiation therapy: Radiation therapy may be used as a palliative (painkilling) measure to reduce the size or vascularity (i.e., the extent of blood supply to the organ, as cancerous growths are very fast growing and have a very rich blood supply around them) of the tumour in severe cases, or before operating the affected site to reduce blood loss during surgery.

What are the types of Arthritis?

Arthritis may be of many types, but we will mainly discuss the two commonly seen types of arthritis:
y y

Osteoarthritis (OA) Rheumatoid Arthritis (RA)

What is Osteoarthritis?

y y y y y y

Osteoarthritis is a type of arthritis that is caused by the breakdown and eventual loss of the cartilage of one or more joints. Cartilage is a protein substance that serves as a cushion between the bones of the joints. Osteoarthritis is also known as degenerative arthritis. Osteoarthritis occurs more frequently as we age. Before age 45, osteoarthritis occurs more frequently in men. After age 55 years, it occurs more frequently in women. Osteoarthritis commonly affects the hands, feet, spine, and large weight-bearing joints, such as the hips and knees. Most cases of osteoarthritis have no known cause and are referred to as primary osteoarthritis. When the cause of the osteoarthritis is known, the condition is referred to as secondary osteoarthritis.

What causes Osteoarthritis? Primary osteoarthritis is mostly related to ageing.

y y y y y y

With ageing, the water content of the cartilage increases, and the protein makeup of cartilage degenerates. Eventually, cartilage begins to degenerate by flaking or forming tiny crevasses. In advanced cases, there is a total loss of cartilage cushion between the bones of the joints. Repetitive use of the worn joints over the years can irritate and inflame the cartilage, causing joint pain and swelling. Loss of the cartilage cushion causes friction between the bones, leading to pain and limitation of joint mobility. Inflammation of the cartilage can also stimulate new bone outgrowths (spurs, also referred to as osteophytes) to form around the joints. Osteoarthritis occasionally can develop in multiple members of the same family, implying a hereditary (genetic) basis for this condition.

Secondary osteoarthritis is caused by another disease or condition. Conditions that can lead to secondary osteoarthritis include:
y

y y

Obesity causes osteoarthritis by increasing the mechanical stress on the cartilage. In fact, next to ageing, obesity is the most powerful risk factor for osteoarthritis of the knees. The early development of osteoarthritis of the knees among weight lifters is believed to be in part due to their high body weight. Repeated trauma to joint tissues (ligaments, bones, and cartilage) is believed to lead to early osteoarthritis of the knees in soccer players. Crystal deposits in the cartilage can cause cartilage degeneration and osteoarthritis. Uric acid crystals cause arthritis in gout, while calcium pyrophosphate crystals cause arthritis in pseudogout. Some people are born with abnormally formed joints (congenital abnormalities) that are vulnerable to mechanical wear, causing early degeneration and loss of joint cartilage. Osteoarthritis of the hip joints is commonly related to structural abnormalities of these joints that had been present since birth. Hormone disturbances, such as diabetes and growth hormone disorders, are also associated with early cartilage wear and secondary osteoarthritis.

What are symptoms of Osteoarthritis?

y

y y y

y y y y y

y y

Osteoarthritis is a disease of only the joints. Unlike many other forms of arthritis (that are systemic illnesses), such as rheumatoid arthritis and systemic lupus, osteoarthritis does not affect other organs of the body. The most common symptom of osteoarthritis is pain in the affected joint(s) after repetitive use. Joint pain is usually worse later in the day. There can be swelling, warmth, and creaking of the affected joints. Pain and stiffness of the joints can also occur after long periods of inactivity, for example, sitting in a theater. In severe osteoarthritis, complete loss of cartilage cushion causes friction between bones, causing pain at rest or pain with limited motion. Symptoms of osteoarthritis vary greatly from patient to patient. Some patients can be debilitated by their symptoms. On the other hand, others may have remarkably few symptoms in spite of dramatic degeneration of the joints apparent on X-rays. Symptoms also can be intermittent. It is not unusual for patients with osteoarthritis of the finger joints of the hands and knees to have years of pain-free intervals between symptoms. Osteoarthritis of the knees is often associated with excess upper body weight, with obesity, or a history of repeated injury and/or joint surgery. Progressive cartilage degeneration of the knee joints can lead to deformity and outward curvature of the knees referred to as "bowlegged." Patients with osteoarthritis of the weight-bearing joints (like the knees) can develop a limp. The limping can worsen as more cartilage degenerates. In some patients, the pain, limping, and joint dysfunction may not respond to medications or other conservative measures. Therefore, severe osteoarthritis of the knees is one of the most common reasons for total knee replacement surgical procedures. Osteoarthritis of the cervical spine or lumbar spine cause pain in the neck or low back. Bony spurs, called osteophytes, that form along the arthritic spine can irritate spinal nerves, causing severe pain, numbness, and tingling of the affected parts of the body. Osteoarthritis causes the formation of hard, bony enlargements of the small joints of the fingers. Classic bony enlargement of the small joint at the end of the fingers is called a Heberden's node, named after a very famous British doctor. The bony deformity is a result of the bone spurs from the osteoarthritis in that joint. Another common bony knob (node) occurs at the middle joint of the fingers in many patients with osteoarthritis and is called a Bouchard's node. Dr. Bouchard was a famous French doctor who also studied arthritis patients in the late 1800s. Heberden's and Bouchard's nodes may not be painful, but they are often associated with limitation of motion of the joint. The characteristic appearances of these finger nodes can be helpful in diagnosing osteoarthritis. Osteoarthritis of the joint at the base of the big toe of the foot leads to the formation of a bunion. Osteoarthritis of the fingers and the toes may have a genetic basis and can be found in numerous women members of some families

How is Osteoarthritis diagnosed?

There is no blood test for the diagnosis of osteoarthritis. Blood tests are performed to exclude diseases that can cause secondary osteoarthritis, as well as to exclude other arthritis conditions that can mimic osteoarthritis.

y y

y y

X-rays of the affected joints can suggest osteoarthritis. The common X-ray findings of osteoarthritis include loss of joint cartilage, narrowing of the joint space between adjacent bones, and bone spur formation. Simple X-ray testing can be very helpful to exclude other causes of pain in a particular joint as well as assist in decision making as to when surgical intervention should be considered. Arthrocentesis is often performed in the doctor's clinic. During arthrocentesis, a sterile needle is used to remove joint fluid for analysis. Joint fluid analysis is useful in excluding gout, infection, and other causes of arthritis. Removal of joint fluid and injection of corticosteroids into the joints during arthrocentesis can help relieve pain, swelling, and inflammation. Arthroscopy is a surgical technique whereby a doctor inserts a viewing tube into the joint space. Abnormalities of and damage to the cartilage and ligaments can be detected and sometimes repaired through the arthroscope. If successful, patients can recover from the arthroscopic surgery much more quickly than from open joint surgery. Finally, a careful analysis of the location, duration, and character of the joint symptoms and the appearance of the joints helps the doctor in diagnosing osteoarthritis. Bony enlargement of the joints from spur formations is characteristic of osteoarthritis. Therefore, the presence of Heberden's nodes, Bouchard's nodes, and bunions of the feet can indicate to the doctor a diagnosis of osteoarthritis.

What is the treatment for Osteoarthritis?

Understanding the limitations
y

Aside from weight reduction and avoiding activities that exert excessive stress on the joint cartilage, there is no specific treatment to halt cartilage degeneration or to repair damaged cartilage in osteoarthritis. The goal of treatment in osteoarthritis is to reduce joint pain and inflammation while improving and maintaining joint function. Some patients with osteoarthritis have minimal or no pain and may not need treatment.

Simple preventive measures

y y

y y

Some patients may benefit from conservative measures such as rest, exercise, diet control with weight reduction, physical and occupational therapy, and mechanical support devices. These measures are particularly important when large, weight-bearing joints are involved, such as the hips or knees. In fact, even modest weight reduction can help to decrease symptoms of osteoarthritis of the large joints, such as the knees and hips. Resting sore joints decreases stress on the joints and relieves pain and swelling. Patients are asked to simply decrease the intensity and/or frequency of the activities that consistently cause joint pain. Exercise usually does not aggravate osteoarthritis when performed at levels that do not cause joint pain. Exercise is helpful in osteoarthritis in several ways. First, it strengthens the muscular support around the joints. It also prevents the joints from "freezing up" and improves and maintains joint mobility. Finally, it helps with weight reduction and promotes endurance. Applying local heat before and cold packs after exercise can help relieve pain and inflammation. Swimming is particularly well suited for patients with osteoarthritis because it allows patients to exercise with minimal impact stress to the joints.

y y y y y

y y

Other popular exercises include walking, stationary cycling, and light weight training. Physical therapists can provide support devices, such as splints, canes, walkers, and braces. These devices can be helpful in reducing stress on the joints. Finger splints can support individual joints of the fingers. Paraffin wax dips, warm water soaks, and nighttime cotton gloves can help ease hand symptoms. Spine symptoms can improve with a neck collar, lumbar corset, or a firm mattress, depending on what areas are involved. Some patients get significant relief from pain symptoms by dipping their hands in hot wax (paraffin) dips in the morning. Hot wax can often be obtained at local pharmacies or medical supply stores. It can be prepared in a Crock-Pot and be reused after it hardens as a warm covering over the hands by peeling off and replacing it into the melted wax. Warm-water soaks and nighttime cotton gloves (to keep the hands warm during sleep) can also help ease hand symptoms. Performing gentle range of motion exercises regularly can help to preserve function of the joints. These exercises are easiest to perform after early morning hand warming.

How medicines/supplements help?

y y

y y

Medications are used to complement the physical measures described above. Medication may be used topically, taken orally, or injected into the joints to decrease joint inflammation and pain. In many patients with osteoarthritis, mild pain relievers such as aspirin and acetaminophen (Tylenol) may be sufficient treatment. Studies have shown that acetaminophen given in adequate doses can often be equally as effective as prescription anti-inflammatory medications in relieving pain in osteoarthritis of the knees. Since acetaminophen has fewer gastrointestinal side effects than NSAIDS (Nonsteroidal anti-inflammatory drugs), especially among the elderly patients, acetaminophen is generally the preferred initial drug given to patients with osteoarthritis. Medicine to relax muscles in spasm might also be given temporarily. Pain-relieving creams applied to the skin over the joints can provide relief of minor arthritis pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) are medications that are used to reduce pain and inflammation in the joints. Examples of NSAIDs include aspirin, ibuprofen, and naproxen. It is sometimes possible to use NSAIDs for a while and then discontinue them for periods of time without recurrent symptoms, thereby decreasing side-effect risks. The most common side effects of NSAIDs involve gastrointestinal distress, such as stomach upset, cramping diarrhea, ulcers and even bleeding. The risk of these and other side effects increases in the elderly. Newer NSAIDs called COX-2 inhibitors have been designed that have less toxicity to the stomach and bowels. Because osteoarthritis symptoms vary and can be intermittent, these medicines might be given only when joint pains occur or prior to activities that have traditionally brought on symptoms. Some studies, but not all, have suggested that alternative treatment with the food supplements glucosamine and chondroitin can relieve symptoms of pain and stiffness for some people with osteoarthritis. These supplements are available in pharmacies and health-food stores without a prescription, although there is no certainty about the purity of the products or the dose of the active ingredients because they are not monitored by the FDA.

y y y

Fish-oil supplements have been shown to have some anti-inflammation properties, and increasing the dietary fish intake and/or taking fish-oil capsules (omega-3 capsules) can sometimes reduce inflammation of arthritis. While oral cortisone is generally not used in treating osteoarthritis, when injected directly into the inflamed joints, it can rapidly decrease pain and restore function. Since repetitive cortisone injections can be harmful to the tissues and bones, they are reserved for patients with more pronounced symptoms. For persisting pain of severe osteoarthritis of the knee that does not respond to weight reduction, exercise, or medications, a series of injections of hyaluronic acid into the joint can sometimes be helpful, especially if surgery is not being considered. These products seem to work by temporarily restoring the thickness of the joint fluid, allowing better joint lubrication and impact capability, and perhaps by directly affecting pain receptors.

And Finally, surgery

y

y y y y

When conservative measures fail to control pain and improve joint function, surgery can be considered. Surgery is generally reserved for those patients with osteoarthritis that is particularly severe and unresponsive to the conservative treatments. Arthroscopy, discussed above, can be helpful when cartilage tears are suspected. Osteotomy is a bone-removal procedure that can help realign some of the deformity in selected patients, usually those with knee disease. In some cases, severely degenerated joints are best treated by fusion (arthrodesis) or replacement with an artificial joint (arthroplasty). Total hip and total knee replacements are now commonly performed in community hospitals throughout the country. These can bring dramatic pain relief and improved function.

Rheumatoid Arthritis What is Rheumatoid Arthritis?

y y y y y y y y

Rheumatoid arthritis (RA) is an autoimmune disease that causes chronic inflammation of the joints. Rheumatoid arthritis can also cause inflammation of the tissue around the joints, as well as in other organs in the body. Autoimmune diseases are illnesses that occur when the body tissues are mistakenly attacked by its own immune system. The immune system is a complex organization of cells and antibodies designed normally to "seek and destroy" invaders of the body, particularly infections. Patients with autoimmune diseases have antibodies in their blood that target their own body tissues, where they can be associated with inflammation. Because it can affect multiple other organs of the body, rheumatoid arthritis is referred to as a systemic illness and is sometimes called rheumatoid disease. While rheumatoid arthritis is a chronic illness, meaning it can last for years, patients may experience long periods without symptoms. Typically, however, rheumatoid arthritis is a progressive illness that has the potential to cause joint destruction and functional disability.

y y

y y

A joint is where two bones meet to allow movement of body parts. Arthritis means joint inflammation. The joint inflammation of rheumatoid arthritis causes swelling, pain, stiffness, and redness in the joints. The inflammation of rheumatoid disease can also occur in tissues around the joints, such as the tendons, ligaments, and muscles. In some patients with rheumatoid arthritis, chronic inflammation leads to the destruction of the cartilage, bone, and ligaments, causing deformity of the joints. Damage to the joints can occur early in the disease and be progressive. Moreover, studies have shown that the progressive damage to the joints does not necessarily correlate with the degree of pain, stiffness, or swelling present in the joints. The disease is three times more common in women as in men. It afflicts people of all races equally. The disease can begin at any age, but it most often starts after age 40 and before 60. In some families, multiple members can be affected, suggesting a genetic basis for the disorder.

What causes Rheumatoid Arthritis?

y y

y y

The cause of rheumatoid arthritis is unknown. Even though infectious agents such as viruses, bacteria, and fungi have long been suspected, none has been proven as the cause. The cause of rheumatoid arthritis is a very active area of worldwide research. Some scientists believe that the tendency to develop rheumatoid arthritis may be genetically inherited. It is suspected that certain infections or factors in the environment might trigger the immune system to attack the body's own tissues, resulting in inflammation in various organs of the body such as the lungs or eyes. Regardless of the exact trigger, the result is an immune system that is geared up to promote inflammation in the joints and occasionally other tissues of the body. Immune cells, called lymphocytes, are activated and chemical messengers (cytokines, such as tumor necrosis factor/TNF and interleukin-1/IL-1) are expressed in the inflamed areas. Environmental factors also seem to play some role in causing rheumatoid arthritis. Recently, scientists have reported that smoking tobacco increases the risk of developing rheumatoid arthritis.

What are the symptoms of Rheumatoid Arthritis?

y

The symptoms of rheumatoid arthritis come and go, depending on the degree of tissue inflammation. When body tissues are inflamed, the disease is active. When tissue inflammation subsides, the disease is inactive (in remission). Remissions can occur spontaneously or with treatment, and can last weeks, months, or years. During remissions, symptoms of the disease disappear, and patients generally feel well. When the disease becomes active again (relapse), symptoms return. The return of disease activity and symptoms is called a flare. The course of rheumatoid arthritis varies from patient to patient, and periods of flares and remissions are typical. When the disease is active, symptoms can include fatigue, lack of appetite, low-grade fever, muscle and joint aches, and stiffness. Muscle and joint stiffness are usually most notable in the morning and after periods of inactivity. Arthritis is common during disease flares. Also during flares, joints frequently become red, swollen, painful, and tender. This occurs because the lining tissue of the joint (synovium) becomes inflamed, resulting in the

y y y

y y y

production of excessive joint fluid (synovial fluid). The synovium also thickens with inflammation (synovitis). In rheumatoid arthritis, multiple joints are usually inflamed in a symmetrical pattern (both sides of the body affected). The small joints of both the hands and wrists are often involved. Simple tasks of daily living, such as turning door knobs and opening jars can become difficult during flares. The small joints of the feet are also commonly involved. Occasionally, only one joint is inflamed. When only one joint is involved, the arthritis can mimic the joint inflammation caused by other forms of arthritis, such as gout or joint infection. Chronic inflammation can cause damage to body tissues, cartilage and bone. This leads to a loss of cartilage and erosion and weakness of the bones as well as the muscles, resulting in joint deformity, destruction, and loss of function. Rarely, rheumatoid arthritis can even affect the joint that is responsible for the tightening of our vocal cords to change the tone of our voice, the cricoarytenoid joint. When this joint is inflamed, it can cause hoarseness of voice.

Systemic Symptoms:
y y y

y y

Since rheumatoid arthritis is a systemic disease, its inflammation can affect organs and areas of the body other than the joints. Inflammation of the glands of the eyes and mouth can cause dryness of these areas and is referred to as Sjogren's syndrome. Rheumatoid inflammation of the lung lining (pleuritis) causes chest pain with deep breathing or coughing. The lung tissue itself can also become inflamed, and sometimes nodules of inflammation (rheumatoid nodules) develop within the lungs. Inflammation of the tissue (pericardium) surrounding the heart, called pericarditis, can cause a chest pain that typically changes in intensity when lying down or leaning forward. The rheumatoid disease can reduce the number of red blood cells (anemia) and white blood cells. Decreased white cells can be associated with an enlarged spleen (referred to as Felty's syndrome) and can increase the risk of infections. Firm lumps under the skin (rheumatoid nodules) can occur around the elbows and fingers where there is frequent pressure. Even though these nodules usually do not cause symptoms, occasionally they can become infected. A rare, serious complication, usually with long-standing rheumatoid disease, is blood-vessel inflammation (vasculitis). Vasculitis can impair blood supply to tissues and lead to tissue death. This is most often initially visible as tiny black areas around the nail beds or as leg ulcers.

How is Rheumatoid Arthritis diagnosed?

y y

The first step in the diagnosis of rheumatoid arthritis is a review by the doctor of the history of symptoms, examination of the joints for inflammation and deformity, the skin for rheumatoid nodules, and other parts of the body for inflammation. Certain blood and X-ray tests are often obtained. The diagnosis will be based on the pattern of symptoms, the distribution of the inflamed joints, and the blood and x-ray findings. Several visits may be necessary before the doctor can be certain of the diagnosis. A doctor with special training in arthritis and related diseases is called a.

y y y

y y

The distribution of joint inflammation is important to the doctor in making a diagnosis. In rheumatoid arthritis, the small joints of the hands, wrists, feet, and knees are typically inflamed in a symmetrical distribution (affecting both sides of the body). When only one or two joints are inflamed, the diagnosis of rheumatoid arthritis becomes more difficult. The doctor may then perform other tests to exclude arthritis due to infection or gout. The detection of rheumatoid nodules (described above), most often around the elbows and fingers, can suggest the diagnosis. Abnormal blood antibodies can be found in patients with rheumatoid arthritis. A blood antibody called "rheumatoid factor" can be found in 80% of patients. Another antibody called "the antinuclear antibody" (ANA) is also frequently found in patients with rheumatoid arthritis. A blood test called the erythrocyte sedimentation rate (ESR) is a measure of how fast red blood cells fall to the bottom of a test tube. The ESR is used as a crude measure of the inflammation of the joints. The ESR is usually faster during disease flares and slower during remissions. Another blood test that is used to measure the degree of inflammation present in the body is the C-reactive protein. The rheumatoid factor, ANA, ESR, and C-reactive protein tests can also be abnormal in other systemic autoimmune and inflammatory conditions. Therefore, abnormalities in these blood tests alone are not sufficient for a firm diagnosis of rheumatoid arthritis. Joint x-rays may be normal or only show swelling of soft tissues early in the disease. As the disease progresses x-rays can show bony erosions typical of rheumatoid arthritis in the joints. Joint x-rays can also be helpful in monitoring the progression of disease and joint damage over time. Bone scanning, a radioactive test procedure, can demonstrate the inflamed joints. The doctor may elect to perform an office procedure called arthrocentesis. In this procedure, a sterile needle and syringe are used to drain joint fluid out of the joint for study in the laboratory. Analysis of the joint fluid, in the laboratory, can help to exclude other causes of arthritis, such as infection and gout. Arthrocentesis can also be helpful in relieving joint swelling and pain. Occasionally, cortisone medications are injected into the joint during the arthrocentesis in order to rapidly relieve joint inflammation and further reduce symptoms.

How is Rheumatoid Arthritis treated? Understanding the limitations

y y y

y y

There is no known cure for rheumatoid arthritis. To date, the goal of treatment in rheumatoid arthritis is to reduce joint inflammation and pain, maximize joint function, and prevent joint destruction and deformity. Early medical intervention has been shown to be important in improving outcomes. Aggressive management can improve function, stop damage to joints as seen on x-rays, and prevent work disability. Optimal treatment for the disease involves a combination of medications, rest, jointstrengthening exercises, joint protection, and patient (and family) education. Treatment is customized according to many factors such as disease activity, types of joints involved, general health, age, and patient occupation. Treatment is most successful when there is close cooperation between the doctor, patient, and family members.

Simple preventive measures

y y y

y y

Proper, regular exercise is important in maintaining joint mobility and in strengthening the muscles around the joints. Swimming is particularly helpful because it allows exercise with minimal stress on the joints. Physical and occupational therapists are trained to provide specific exercise instructions and can offer splinting supports. For example, wrist and finger splints can be helpful in reducing inflammation and maintaining joint alignment. Devices, such as canes, toilet seat raisers, and jar grippers can assist daily living. Heat and cold applications are modalities that can ease symptoms before and after exercise.

How medicines can help?

y

y y

Two classes of medications are used in treating rheumatoid arthritis: fast-acting "first-line drugs" and slow-acting "second-line drugs" (also referred to as disease-modifying antirheumatic drugs or DMARDs). The first-line drugs, such as aspirin and cortisone (corticosteroids), are used to reduce pain and inflammation. The slow-acting second-line drugs, such as gold, methotrexate and hydroxychloroquine promote disease remission and prevent progressive joint destruction, but they are not anti inflammatory agents. The degree of destructiveness of rheumatoid arthritis varies from patient to patient. Patients with uncommon, less destructive forms of the disease or disease that has quieted after years of activity ("burned out" rheumatoid arthritis) can be managed with rest, pain and anti-inflammatory medications alone. In general, however, patients improve function and minimize disability and joint destruction when treated earlier with second-line drugs (disease-modifying anti-rheumatic drugs), even within months of the diagnosis. Most patients require more aggressive second-line drugs, such as methotrexate, in addition to anti-inflammatory agents. Sometimes these second-line drugs are used in combination.

And Finally, Surgery

y y

In some patients with severe joint deformity, surgery may be necessary. Surgery may be recommended to restore joint mobility or repair damaged joints. Doctors who specialize in joint surgery are orthopedic surgeons. The types of joint surgery range from arthroscopy to partial and complete replacement of the joint. Arthroscopy is a surgical technique whereby a doctor inserts a tube-like instrument into the joint to see and repair abnormal tissues. Total joint replacement is a surgical procedure whereby a destroyed joint is replaced with artificial materials. For example, the small joints of the hand can be replaced with plastic material. Large joints, such as the hips or knees, are replaced with metals. Finally, minimizing emotional stress can help improve the overall health of the patient with rheumatoid arthritis. Support and extracurricular groups afford patients time to discuss their problems with others and learn more about their illness.