Lisa M. Sullivan, PhD
However medicine technology cheap thorazine 50 mg on-line, this mechanism is accompanied by extinction of the differentiating Positive Negative stem cells because the clones they produce will not contain any stem cells symptoms testicular cancer order thorazine with a visa. Nonetheless treatment neutropenia generic thorazine 100mg overnight delivery, information about the control of stem cell renewal versus differentiation medicine woman strain purchase thorazine with mastercard, and how this might be ma system. The resistance of stem cells to cell cycle-dependent nipulated to improve haemopoietic cell regeneration, is still drugs, particularly to 5 uorouracil, has been used as one of incomplete. Control mechanisms could be intrinsic or extrinsic the stages in stem cell puri cation. Regulation in the bone marrow microenvir Stem cells are capable of self-renewal and differentiation when onment, and in the stromal layers of long-term bone marrow they divide and are responsible for producing all the mature blood cultures, may be mediated by adjacent cells or local cytokine cells throughout life. It binds tiate, the remaining 50% do not differentiate, but maintain stem to its receptor, c-Kit, expressed by haemopoietic stem cells and cell numbers. This could be accomplished by asymmetric cell is essential for normal blood cell production. Flt3 ligand is also division, so that each dividing stem cell forms one new stem cell a transmembrane protein and is widely expressed in human and one differentiated cell (Figure 1. It binds to Flt3 on haemopoietic cells and is important numbers of stem cells could divide symmetrically to form either for cell survival and cytokine responsiveness. This results in because it permits an increase in the proportions of symmetrical cleavage of the cytoplasmic portion of Notch-1, which can then self-renewing divisions and a reduction in the proportion of act as a transcription factor. There is evidence from murine studies that haemopoietic progenitor cells from different inbred mouse strains vary widely Figure 1. These observations indicate 5 Postgraduate Haematology that genetically determined constitutional variation in human cells. Accordingly, individual primitive cells were found to exhibit haemopoiesis is also likely to exist. Moreover, the fact that parameters such as clonogenic cell frequency and single stem cells expressed low levels of several of these genes, numbers, proliferation ability and capacities for mobilization indicating that nal lineage selection had not yet occurred. Associations have been reported between by the results of replating colonies composed of blast cells. This genetic markers and the frequency and activity of stem cells in revealed that the blast cells themselves were bipotent or oligopot mouse strains. De Haan and colleagues (2002) concluded that the ent progenitors for various lineages of blood cell development, expression levels of a large number of genes may be responsible and that the combinations of lineages found within individual for controlling stem cell behaviour. These collections of genes colonies appeared to be randomly distributed, although some may be analogous to those responsible for the interindividual combinations are more common than others. It is likely that differences in the expression levels of transcrip In contrast to the genetic basis for constitutional variation, tion factors determine the lineage af liation of a differentiating certain speci c genes have been demonstrated to in uence cell (Figure 1. Growing evidence implicates gene have been implicated in myeloid and erythroid/megakaryocyte products involved in cell cycle control, such as the cyclin lineage speci cations respectively. Stem cell plasticity Finally, lessons can be learned from studies of disease patho Reports that transplanted bone marrow cells can contribute to genesis. Many cell cycle control genes and genes promoting cell the repair and regeneration of a spectrum of tissue types includ death by apoptosis are tumour-suppressor genes that have been ing brain, muscle, lung, liver, gut epithelium and skin have found to be deleted or mutated in leukaemia and other cancers. The disease can be caused by Stem cell mutations in at least seven different genes. The mechanisms determining the blood cell lineages selected by the Neutrophils Monocytes/ Eosinophils Platelets differentiating progeny of stem cells probably involve aspects macrophages of the transcriptional control of lineage-speci c genes. Maturing and mature cells Moreover, cultured blood cells can transdifferentiate from one lineage to another. Cell fusion is an alternative mechanism the maturing and mature haemopoietic cells are recognizable accounting for the contribution of bone marrow cells to tissue on stained smears of blood or bone marrow. The they seem to lose tissue-restricted gene expression and become end-products of haemopoietic cell development are cells that are able to differentiate into mesenchymal cell types (osteoblasts, highly specialized for their different functions in the body. Cell death (apoptosis) the nal stage in the life of a blood cell is death and disposal by Progenitor cells apoptosis. Apoptotic cell death is a mechanism for disposing the progenitor cells are the progeny of stem cells, and it is of unwanted or excess cells, and it occurs widely in biological likely that some of the candidate stem cells measured in the systems. It ensures the destruction of cells without releasing any assays mentioned above are in fact intermediate between stem lysosomal or granule contents that would cause an in ammat and progenitor cells. Apoptosis involves a complex series of events from stem cells to progenitor cells, the probability of renewal that culminate in the activation of the caspase proteases, frag decreases and that of differentiation increases commensurately. This has been amply demonstrated by replating cells once they have ful lled their function. In addition, it has progenitor cell-derived colonies grown in vitro and observing also been proposed as a mechanism for negative regulation of secondary colony formation. Accordingly, a reduction in cell death could capacity for self-renewal is lost completely. Indeed, early kinetic account for an increase in haemopoietic stem and progenitor studies revealed that even promyelocytes divide two or three cell numbers. However, this mechanism presupposes that sub times before they differentiate into myelocytes. Haemopoietic cytokines and growth developed for the enumeration of clonogenic progenitor cells factors act as survival factors for haemopoietic progenitor cells in haemopoietic tissue. The availability of different assays has and prevent the death of factor-dependent cell lines in vitro. These tions of granulocytes, eosinophils, monocytes, erythrocytes and observations suggest that the apoptotic pathways may have regu megakaryocytes and are the most primitive cells in this class. The haemopoietic growth factors and cytokines are the soluble Colony formation in vitro is stimulated by haemopoietic regulators of blood cell production and are produced by several growth factors and cytokines. Different sequences have binding interactions with adaptor complexes, cytoskeletal struc been identi ed by deletional mutagenesis, which are required tures or molecular targets, for the selective activation of down for secretion, biological activity and receptor binding. Many haemopoietic growth factor and cytokine receptors belong to the haematopoietin receptor superfamily (Figure 1. These are type 1 transmembrane glycoproteins with modular Cytokine responses and signal transduction extracellular domains. All members dimerize when they bind the responses of haemopoietic cells to cytokines include sur their ligand. There are many receptor systems not only act in a linear-independent manner, examples of cytokines acting in synergy when the outcome is but also in uence the activity of other cell-surface receptor greater than expected from the sum of the individual cytokines systems. Also, cytokines are pleiotropic in their actions, and haemopoietic cytokine receptors, including interactions of c several cytokines are known to share the same functions. These include cell survival, cell Fibronectin domain cycle progression, proliferation and reorganization of the actin Transmembrane domain cytoskeleton. Thus, all of the haemopoietic growth factors appear to be capable of activating all of the major signal transduction path ways simultaneously. The several pathways that have been identi ed and the multiple responses, pleiotropism and redund Figure 1. Moreover, com that these biochemically documented phenomena, such as binations of cytokines may cooperate to activate further signal receptor transmodulation, transphosphorylation and physical transduction pathways that are not activated when cytokines are interaction, are biologically signi cant. Early studies of haemopoiesis Physiology of the cytokine response in long-term bone marrow cultures, in which stromal cells Colony formation in vitro is a simple model of haemopoietic support haemopoiesis for a prolonged period of time in vitro, regulation by cytokines, which involves the interaction of revealed periodic oscillations in the cell cycle activity of stem soluble proteins with speci c receptors on the surface of the cells that could be related to the presence of positive and nega target cells. In culture, the cytokines are freely available at a tive cytokines implicated in maintaining homeostasis of the uniform concentration and any cell which expresses the cor haemopoietic system. However, this is unlikely to be the situation in vivo where stem and progenitor cells are located in the haemopoietic microenvironment and Clinical applications of stem cell research there is a need to control haemopoietic cell production more precisely. Stem cell research has provided the growth points for several Several mechanisms have the potential to control the access of clinical activities as well as for advances in experimental cytokines to their target cells and are likely to be physiologically haematology. The fact that these cells are found predom Stem cell transplantation inantly in the haemopoietic microenvironment rather than freely distributed in the bloodstream and tissues indicates that Bone marrow and stem cell transplantation is the most obvious there is a mechanism to retain them there, and it has been extens application of stem cell research. It originated in early studies of ively demonstrated that stem and progenitor cells express cell the haematological reconstitution of mice whose bone marrow adhesion molecules that bind them to proteins expressed by had been ablated by ionizing radiation.
The multidrug regimen is continued well beyond the disappearance of clinical disease to eradicate any persistent organisms symptoms 8 days past ovulation cheap thorazine 50 mg online. For example medications hydroxyzine cheap thorazine online visa, the initial short-course chemotherapy for tuberculosis includes isoniazid treatment rheumatoid arthritis discount 50 mg thorazine with mastercard, rifampin treatment quinsy thorazine 50 mg amex, ethambutol, and pyrazinamide for 2 months and then isoniazid and rifampin for the next 4 months (the a continuation phasea; Figure 34. Before susceptibility data are available, more drugs may be added to the first-line ones for patients who have previously had tuberculosis or those in whom multidrug-resistant tuberculosis is suspected. The added drugs normally include an aminoglycoside (streptomycin, kanamycin, or amikacin) or capreomycin (injectable agents), a fluoroquinolone, and perhaps a second-line antituberculosis agent such as cycloserine, ethionamide, or para-aminosalicylic acid. Once susceptibility data are available, the drug regimen can be individually tailored to the patient. Patient compliance is often low when multidrug schedules last for 6 months or longer. It is the most potent of the antitubercular drugs but is never given as a single agent in the treatment of active tuberculosis. Decreased mycolic acid synthesis corresponds with the loss of acid-fastness after exposure to isoniazid. The activated drug covalently binds to and inhibits these enzymes, which are essential for the synthesis of mycolic acid. Antibacterial spectrum: For bacilli in the stationary phase, isoniazid is bacteriostatic, but for rapidly dividing organisms, it is bactericidal. Resistance: this is associated with several different chromosomal mutations, each of which results in one of the following: mutation or deletion of KatG (producing mutants incapable of prodrug activation), varying mutations of the acyl carrier proteins, or overexpression of InhA. Absorption is impaired if isoniazid is taken with food, particularly carbohydrates, or with aluminum-containing antacids. The drug diffuses into all body fluids, cells, and caseous material (necrotic tissue resembling cheese that is produced in tubercles). The drug readily penetrates host cells and is effective against bacilli growing intracellularly. Excretion is through glomerular filtration, predominantly as metabolites (Figure 34. Severely depressed renal function results in accumulation of the drug, primarily in slow acetylators. Except for hypersensitivity, adverse effects are related to the dosage and duration of administration. Peripheral neuritis: Peripheral neuritis (manifesting as paresthesias of the hands and feet), which is the most common adverse effect, appears to be due to a relative pyridoxine deficiency. Most of the toxic reactions are corrected by supplementation of 25 to 50 mg per day of pyridoxine (vitamin B6). Hepatitis and idiosyncratic hepatotoxicity: Potentially fatal hepatitis is the most severe side effect associated with isoniazid. It has been suggested that this is caused by a toxic metabolite of monoacetylhydrazine, formed during the metabolism of isoniazid. Its incidence increases among patients with increasing age, among patients who also take rifampin, or among those who drink alcohol daily. Other adverse effects: Mental abnormalities, convulsions in patients prone to seizures, and optic neuritis have been observed. Rifamycins: Rifampin, rifabutin and rifapentine Rifampin, rifabutin, and rifapentine are all considered to be rifamycins, a group of structurally similar macrocyclic antibiotics, which are first-line drugs for tuberculosis. Any of these rifamycins must always be used in conjunction with at least one other antituberculosis drug to which the isolate is susceptible. Because resistant strains rapidly emerge during therapy, it is never given as a single agent in the treatment of active tuberculosis. Antimicrobial spectrum: Rifampin is bactericidal for both intracellular and extracellular mycobacteria, including M. It is effective against many gram-positive and gram-negative organisms and is frequently used prophylactically for individuals exposed to meningitis caused by meningococci or Haemophilus influenzae. Rifampin is the most active antileprosy drug at present, but to delay the emergence of resistant strains, it is usually given in combination with other drugs. Rifabutin, an analog of rifampin, has some activity against Mycobacterium avium-intracellulare complex but is less active against tuberculosis. Elimination of metabolites and the parent drug is via the bile into the feces or via the urine (Figure 34. Hepatitis and death due to liver failure is rare; however, the drug should be used judiciously in patients who are alcoholic, elderly, or have chronic liver disease due to the increased incidence of severe hepatic dysfunction when rifampin is administered alone or concomitantly with isoniazid. Drug interactions: Because rifampin can induce a number of cytochrome P450 enzymes (see p. Rifabutin has adverse effects similar to those of rifampin but can also cause uveitis, skin hyperpigmentation, and neutropenia. However, for the intensive phase (initial 2 months) of the short-course therapy for tuberculosis, rifapentine is given twice weekly. To avoid resistance issues, rifapentine should not be used alone but, rather, be included in a three to four-drug regimen. It is bactericidal to actively dividing organisms, but the mechanism of its action is unknown. Pyrazinamide must be enzymatically hydrolyzed to pyrazinoic acid, which is the active form of the drug. Pyrazinamide is active against tubercle bacilli in the acidic environment of lysosomes as well as in macrophages. About one to five percent of patients taking isoniazid, rifampin, and pyrazinamide may experience liver dysfunction. Resistance is not a serious problem if the drug is employed with other antitubercular agents. Ethambutol can be used in combination with pyrazinamide, isoniazid, and rifampin to treat tuberculosis. Absorbed on oral administration, ethambutol is well distributed throughout the body. Both parent drug and metabolites are excreted by glomerular filtration and tubular secretion. The most important adverse effect is optic neuritis, which results in diminished visual acuity and loss of ability to discriminate between red and green. In addition, urate excretion is decreased by the drug; thus, gout may be exacerbated (see Figure 34. Streptomycin: this is the first antibiotic effective in the treatment of tuberculosis and is discussed with the aminoglycosides (see p. Infections due to streptomycin-resistant organisms may be treated with kanamycin or amikacin, to which these bacilli remain sensitive. Capreomycin is primarily reserved for the treatment of multidrug-resistant tuberculosis. Careful monitoring of the patient is necessary to prevent its nephrotoxicity and ototoxicity. Cycloserine is an orally effective, tuberculostatic agent that appears to antagonize the steps in bacterial cell wall synthesis involving D-alanine. Ethionamide: this is a structural analog of isoniazid, but it is not believed to act by the same mechanism. Adverse effects that limit its use include gastric irritation, hepatotoxicity, peripheral neuropathies, and optic neuritis. Supplementation with vitamin B6 (pyridoxine) may lessen the severity of the neurologic side effects. Fluoroquinolones: the fluoroquinolones, such as moxifloxacin and levofloxacin, have an important place in the treatment of multidrug-resistant tuberculosis. Macrolides: the macrolides, such as azithromycin and clarithromycin, are part of the regimen that includes ethambutol and rifabutin used for the treatment of infections by M. Bacilli from skin lesions or nasal discharges of infected patients enter susceptible individuals via abraded skin or the respiratory tract. The World Health Organization recommends the triple-drug regimen of dapsone, clofazimine, and rifampin for 6 to 24 months. Discount 50 mg thorazine visa. 6 surprising symptoms of a heat stroke.
As part of the medical record symptoms hypoglycemia cheap thorazine 100 mg amex, it must be accorded the same confdentiality as other sensitive medical information medicine numbers discount thorazine online american express. Therefore medicine in motion order thorazine 100 mg line, appropriate masking of the face can be performed to assure patient privacy medicine expiration purchase cheapest thorazine and thorazine. Ideal Clinical Photos: Clinical photos should be taken without any clothing on the trunk. The best position of the arms for lateral clinical photos has not been documented. Figure 41 Figure 42 Figure 43 Figure 44 25 Clinical Photographs and Radiographic Methodology to Evaluate Spinal Deformity Optimal Clinical Photos: Case 2. Figure 45 Figure 46 Figure 47 Figure 33 Figure 48 Figure 49 26 Clinical Photographs and Radiographic Methodology to Evaluate Spinal Deformity Optimal Clinical Photos: Case 3. Figure 50 Figure 51 Figure 52 Figure 33 Figure 53 Figure 54 27 Clinical Photographs and Radiographic Methodology to Evaluate Spinal Deformity Suboptimal Clinical Photos the bra obscures full appreciation of the thoracic prominence. Figure 55 Figure 56 A bra, a strap tied in the back, or long hair obscures full appreciation of the thoracic prominence on the forward-bending view. Figure 57 Figure 58 Figure 59 28 Clinical Photographs and Radiographic Methodology to Evaluate Spinal Deformity Suboptimal Clinical Photos Long hair, hospital gowns, bulky halter tops, or shorts positioned above the hips will obscure full appreciation of all aspects of the deformity. Figure 61 Figure 60 Figure 62 If you are unable to take pictures of female patients without any clothing on the trunk, the following page has information for use of a halter top that does not obscure visualization of the deformity. You can untie the waist strap for pictures taken from the back; even if the straps are not untied, they should not obscure the deformity. The measurements obtained from these radiographs are compared to predetermined numeric values that allow identifcation of structural and nonstructural curves. Step #1: Identifcation of the Primary Curve (Types 1-6) First the regional curves are identifed. To begin the classifcation, the structural or non-structural quality of each of the three curves must be determined. The T2-T5 sagittal alignment is evaluated in conjunction with the proximal thoracic spine. Occasionally it will be diffcult to decide between an A and B modifer, or a B and C modifer. In either situation, a B modifer should be assigned if a clear distinction cannot be made. If the T5-T12 sagittal Cobb is less than 10 degrees, the sagittal thoracic alignment is considered hypokyphotic and is assigned a minus modifer (-). If the sagittal Cobb is between 10 and 40 degrees, the sagittal alignment is considered normal (N). If the sagittal Cobb measurement between T5 and T12 is greater than 40 degrees, the sagittal alignment is considered hyperkyphotic and is assigned a plus modifer (+) (Figures 6a and 6b). Intraobserver and interobserver reliability of the classifcation of thoracic adolescent idiopathic scoliosis. Multisurgeon assessment of surgical decision-making in adolescent idiopathic scoliosis: curve classifcation, operative approach, and fusion levels. Adolescent idiopathic scoliosis: A new classifcation to determine extent of spinal arthrodesis. Curve prevalence of a new classifcation of operative adolescent idiopathic scoliosis: Does classifcation correlate with treatment However, as the vertebrae or discs become increasingly trapezoidal, this technique can be inaccurate (Figure 2). The software will automatically determine the centroid from the intersection of the midpoints of the lines derived from these selected points (Figure 4). Figure 4 this technique works equally well for trapezoidal and rectangular shapes, whether it is a vertebra or a disc (Figure 5). By convention, angles subtended with the left shoulder up are positive and angles subtended with the right shoulder up are negative (consistent with directionality of the T1 tilt angle). Typically, the end, neutral, and stable vertebrae are different vertebral segments. However, the end, neutral, and/or stable vertebrae may occasionally overlap in the same vertebra. Proximal thoracic kyphosis is measured from the upper (cephalad) end plate of T2 to the lower (caudal) end plate of T5 using the Cobb method. Mid/lower thoracic kyphosis is measured from the upper (cephalad) end plate of T5 to the lower (caudal) end plate of T12 using the Cobb method. In the event that the S1 end plate is diffcult to identify, an alternative technique for drawing the sacral end plate line is to construct a perpen L2 dicular line off the posterior sacral cortical line as shown in Figure 2. Line B is drawn from the center of C7 and is perpen A L5 dicular to the vertical edge of the radiograph. Alternative techniques for identifying the tilt of the sacrum/pelvis are identifed in Figures 1, 2, and 3. Finally, a line is drawn (4) at the intersection of the sacral end-plate line (3) and its intersection with line 2. However, because of the degenerative component found in or Lumbar many of these curves, the curves may Curve transgress the usual regional boundaries of the spinal segments. All vertebral segments within the sagittal or coronal deformity, regardless of regional spinal location, should be included when calculating the coronal Cobb and sagittal measurements. Figure 1 73 Adult Deformity Determination of Centroids Several techniques for identifcation of the centroid of a vertebral body or disc have been described. For the verte brae, the software will utilize four points selected (Figure 3) to identify Figure 3 the vertebral body in space. Figure 4 this technique works well for trapezoidal and rectangular shapes, whether it is a vertebra or a disc (Figure 5). Line B is drawn perpendicular to the vertical edge of the flm and its length is measured from the lefthand edge of the flm in millimeters to the center of C7. How ever, the end, neutral, and/or stable vertebrae may occasionally overlap in the same vertebra. This non-perpendicular alignment may occur when sacral or pelvic obliquity exists. Mid/Lower thoracic kyphosis is measured from the upper (cephalad) end plate of T5 to the lower (caudal) end plate of T12 using the Cobb method (see Figure 1).
The condition may then either persist or remit treatment croup generic thorazine 50 mg with visa, again depending on genetic and environmental in uences medicine hollywood undead cheap thorazine 50 mg. Pannus is the name given to the abnormal synovial membrane which gradually encroaches across the joint treatment zinc deficiency buy discount thorazine, destroying the articular cartilage in its wake medications used to treat bipolar buy thorazine 100 mg overnight delivery. Erosions may be found at the joint margin, in the centre of a joint, or in para articular tissues (Figure 4. Theyarecharacterisedbythefollowingfeatures: r cortical destruction; r undercut edges; r exposed trabeculae; r sharp or scalloped ridges; and r ascooped oor. The description, together with illustrations of the changes can be found in uvres complete de J. Tome 7 Maladies des vieillards, goutte et rheumatisme, Lescrosnier et Babe, Paris, 1890). Most of the normal joint surface has been destroyed and the joint is heavily eroded. Post-mortem damage to a joint may sometimes simulate an erosion but if the damage is recent, the colour of the damaged cortex will be lighter than the rest and this will make the cause obvious. Other destructive processes, including rodent gnawing should also present no dif culty. On X-ray, a true erosion will often have a sclerotic margin, showing that some remodelling has taken place during life; sclerosis will never be found with a pseudo-erosion or other post-mortem artefact. Note that the disease cannot be diagnosed with any certainty if the hands and/or the feet are not present. On this account, it diseases of joints, part 2 53 is certain that the true prevalence of the disease in skeletal assemblages is under estimated. Another group of the sero-negative arthropathies which share a number of features in common, including sacroiliitis and some degree of fusion of the spine, are known as the spondylarthropathies, a term rst introduced by Moll and his colleagues in 1974. The changes seen radiographically are a mixture of proliferation and erosions, the erosions rst appearing in the central portion of the joints. Radiograph of erosive osteoarthritis with gull-wing (small arrow head) and saw-tooth (large arrow head) lesions. There are also other forms that fail to conform with the criteria established for de nite entities and they are referred to as the undifferentiated spondyloarthritides. The sacroiliac joint are fused bilaterally and fusion extends the whole length of the spine with no skip lesions. Connor described this case in a letter to Sir Charles Walgrave in 1695 and in the Philosophical Transactions of the Royal Society. Spinal fusion is common with the formation of syndesmophytes which are ossi cations in the annulus brosus of the intervertebral discs. The fusion may stop at any level or go on to involve the entire spine from top to bottom. As the disease progresses, the spine mayshowaconsiderabledegreeofkyphosis;thiswasverylikelytohavebeentheend result in the past before the course of the disease could be modi ed by treatment. In the thoracic region, the costovertebral joints may be involved, in which case the ribs become fused to the vertebrae, and calci cation and ossi cation of interspinous and supraspinous ligaments is common. Extra-spinal enthesophytes are not com mon, but may be found around the calcaneum at either the insertion of the Achilles tendon posteriorly, or the plantar fascia on the inferior surface. The large joints are generally the rst affected, especially the hip and the shoulder, although other joints can also be involved. The condition existed long before the rst modern clinical descriptions of it appeared, however, and the arthritis associated with venereal disease was common in the nineteenth century and was said to have accounted for 3% of all admissions to three of the largest hospitals in London. In these, the most common precipitating event is an infection with Campylobacter, Chlamydia, Clostridium, Salmonella, Shigella or Yersinia species. It seems that once the immunological tap has been turned on, it cannot be turned off. The prevalence of ReA is not known with any precision, and different authors give different gures; it is certainly low, however, not more than 0. Nor is it clear exactly how many of those with triggering infections develop an arthritis but it might be as many as a half, although a lower gure is more likely. The vertebrae are joined by osseous bridges that appear on the lateral aspects of the vertebrae in the paravertebral 58 T Hannu, R Inman, K Granfors and M Leirisalo-Repo, Reactive arthritis or post-infectious arthritis These outgrowths of bone are asymmetric, they extend across the disc space and they may be well de ned or uffy in outline. Early in the disease, a clear space may be seen between the bony bridges and the vertebral bodies but they eventually fuse with the vertebral body as the disease progresses. Enthesophytes can be found at many sites, most particularly around the pelvis, lower legs and feet. Fluffy new bone may be present on the metatarsal or metacarpal shafts and around the ankle and knee. Subsets of psoriatic arthritis in order of frequency Order of frequency Subset 1 Asymmetric oligoarthritis 2 Symmetric arthritis similar to rheumatoid arthritis 3 Distal interphalangeal joints predominantly involved 4 Spondylitis predominant 5 Arthritis mutilans From Veale et al (1994)62 occur predominantly in those whose nails are affected and are noted especially in the distal interphalangeal joints of the hand, the sacroiliac joints and the spine; both sexes are equally affected. There is no consensus on the proportion of patients with psoriasis who will develop arthritis but it may be up to a third. After a lengthy review of the matter, Fitzgerald and Dougados concluded that PsA was, indeed, a condition in its own right. It may be this dif culty that has resulted in so few cases appearing in the palaeopathological literature. Erosions begin at the joint margin but may proceed centrally and their distribution may be unilateral, bilateral, symmetric or asymmetric. Resorption of the distal tufts of the phalanges is characteristic of PsA and progressive bone resorption may result in a much shortened phalanx. Arthritis mutilans is the name given to the very rapidly progressive osteolysis that causes severe deformity in the hands. Changes in the sacroiliac joint may be bilateral, unilateral, symmetric or asym metric, although bilateral, symmetric changes are the most common. Erosions may be present within the joint and sclerosis can be demonstrated on X-ray. In the spine, fusion is accomplished by the formation of paravertebral bony bridges, often starting in the lower thoracic and upper lumbar spine, as in ReA. There will also be many occasions when erosions are seen around a joint which cannot be put into any neat diagnostic box and the most that the palaeopathologist can do then is preferably photograph the lesion(s) and simply record it as an erosive arthropathy (or arthritis), not further classi ed. There should be no shame in being unable to classify erosive joint disease in every case. Many blame the widespread contamination of wine with lead for the increase in gout during this period. |
