● Rheumatologic diseases are a group of systemic diseases that affect multiple systems and organs, including systemic rheumatologic diseases, various types of arthritis, and many rare and uncommon diseases.
Rheumatologic diseases are often misdiagnosed and underdiagnosed, and should be brought to the attention of physicians and patients.
Focus on systemic prevention and treatment of osteoarthritis
Osteoarthritis is a chronic, degenerative joint disease, mostly characterized by pain in the finger joints, knees, hips, cervical and lumbar joints, restricted movement and joint deformation. In China, there are currently about 30 million middle-aged and elderly people with osteoarthritis, which is almost equivalent to the population of two Beijing cities. This shows how important it is to prevent and treat osteoarthritis.
Understanding the causes of osteoarthritis
Age Factors As the population ages, the prevalence of osteoarthritis increases significantly, and the older the age, the higher the prevalence; the prevalence is about 10% for people over the age of 45, and up to 40% to 60% for people over the age of 60.
Weight factors Osteoarthritis is also closely related to body weight, and the fatter a person is, the more likely he or she is to develop the disease.
Weight factors Certain occupational tasks and long-term joint weight imbalance may trigger osteoarthritis.
Endocrine factors The decrease in estrogen levels in women during menopause is also an important factor in the development of the disease.
How to detect patients with osteoarthritis
Symptoms
1. Patients are mostly middle-aged and elderly people over 45 years old, and osteoarthritis occurs more commonly in the knee and hip joints.
2, joint pain is characterized by mild to moderate intermittent dull pain in the early stages, aggravated by activity, and can be relieved after rest. Patients may suffer from transient synovitis resulting in joint swelling, short morning stiffness, hand numbness, sciatica, dizziness and other signs of nerve and blood vessel compression. Later, the pain may develop into persistent, or even tearing or pinprick-like pain. In severe cases, the pain cannot be relieved even after rest, and the pain increases at night. In the morning or after sitting for a long time, the joint often feels uncomfortable and stiff, as if it is stuck together, and can recover quickly after activity, usually within 30 minutes.
Signs Bony hypertrophy (such as Hebden’s nodes, Bouchard’s nodes, etc.), impaired joint movement and deformity, audible bone rubbing sound and palpable bone rubbing sensation can be seen.
Master the key points of prevention and treatment
1.Educate and guide residents and patients to reduce weight to reduce the burden on the joints.
2.Educate and guide patients to avoid excessive activities and joint weight-bearing. Because excessive exercise can aggravate joint damage, patients should.
① Reduce walking appropriately, to the extent that there is no painful discomfort after the activity. Those with significant joint pain should reduce the intensity of exercise and shorten the duration of exercise.
② Pay attention to joint warmth.
3.Treatment should be different from person to person.
(1) For milder symptoms, you can use topical medication and receive physical therapy to eliminate pain and restore joint function.
②In addition to physical therapy and massage for more severe symptoms, medication can be used (mainly divided into two categories: symptom control and condition improvement drugs).
③For those who have obvious joint function disorder and obvious joint deformity, if they cannot improve after standardized and correct medical treatment, surgical treatment can be adopted.
Three points of managing dry syndrome
Misconceptions that need to be corrected
At present, the main misconception of domestic and foreign physicians about dry syndrome is that this disease cannot be treated or does not need treatment. In fact, dry syndrome is not untreatable, and treatment with scientific methods can achieve long-term remission, prevent or reduce the involvement of liver, lung and kidney, and stop the occurrence of complications such as extra-glandular organs. However, due to sitting and waiting for the development of the disease for a long time, the condition of many patients becomes more and more serious, so that interstitial lung fibrosis, hyperglobulinemia, whole blood cell reduction and impaired liver and kidney function eventually appear. Therefore, doctors should correct the above-mentioned misconceptions and provide active management and treatment to patients with dry syndrome.
Grasp the main manifestations of patients
When community residents show the following manifestations, community doctors should highly suspect them of dry syndrome and actively suggest them to go to a higher level hospital for timely consultation and treatment.
Dry mouth Dry mouth, dry tongue, dry and cracked tongue and mirror tongue, need to drink water when talking and eating solid food, recurrent mouth ulcers and swelling of parotid and submaxillary glands, etc.
Dry eyes Dry eyes, photophobia, few tears, foreign body sensation, or even no tears, and often filiform discharge from the inner canthus of the eye. Ophthalmia often occurs.
Other manifestations Dryness of nose, throat and trachea; reduced gastric acid, atrophic gastritis, subclinical type of pancreatitis; dry skin and vagina.
Supervise patients for proper treatment
The pathological basis of dry syndrome is B-cell hyperfunction, which leads to excessive antibody production, causing lymphocyte infiltration of various exocrine glands (such as lacrimal gland, sublingual gland, submandibular gland, etc.), damage to lung and liver, and even lymphoma. Therefore, in addition to symptomatic treatment, the key is to suppress the overly hyperactive immune response.
The principles of medication i.e. follow the principles of individualized treatment: 1. For mild patients, strong chloroquine, leucovorin and other mild botanicals can be used. 2. Moderately severe patients should be given azathioprine, cyclosporine, leflunomide, etc. Cyclophosphamide can be considered for severe visceral involvement. 3. Standardize the use of hormones. Small doses of hormones can be given to those with obvious symptoms (but care should be taken to reduce the dose in time), and appropriate amount of immunosuppressants should be added.4. Symptomatic treatment, such as eye drops with sodium glassate, can not only relieve eye discomfort, but also prevent dry conjunctivitis, etc. Immunosorbent plasma exchange may be considered for those with many autoantibodies and poor response to medical therapy.
Three steps to managing ankylosing spondylitis
How to recognize ankylosing spondylitis
Recent studies suggest that the ratio of men to women with ankylosing spondylitis is 2:1 to 3:1; women have a slow onset, atypical symptoms, and milder disease. The possibility of ankylosing spondylitis should be suspected when the following manifestations occur.
1, intermittent pain and/or stiffness in the low back or sacroiliac region, with stiffness evident in the morning; as the disease develops, the pain increases at night and turning over is difficult. Later it develops into persistent pain and stiffness.
2. Asymmetric large arthritis or monoarthritis of the lower extremities, in which the knee, hip, ankle and shoulder joints are common.
3.Tendon terminal inflammation is more common, such as plantar fasciitis and Achilles tendonitis, which manifests as heel pain or plantar tingling pain.
4.Hip or hip pain.
5, conjunctivitis.
6.Sacroiliac joint and paravertebral muscles are positive for pressure pain, and the movement of the spine is limited in a certain direction.
7.Reduced thoracic extension and posterior cervical protrusion.
Community residents with the above-mentioned symptoms should be urged to go to the rheumatology department of a higher-level hospital for timely consultation and treatment.
How to achieve early diagnosis
Ankylosing spondylitis is often not diagnosed until 5 to 10 years after the appearance of clinical symptoms. The main reason for this is the late appearance of sacroiliac arthritis, which is a key diagnostic criterion. Therefore, it is important to obtain an early diagnosis before the appearance of radiological sacroiliac arthritis.
According to the criteria proposed in 2005, more than 90% of patients are likely to have ankylosing spondylitis if they meet the criteria of inflammatory back pain and 3 of the following conditions.
1. anterior uveitis.
2, tendon telangiectasia.
3, peripheral arthritis.
4, Good treatment response to multiple NSAIDs.
5, Increased acute phase reactants (CRP).
6, Family history of SpA positivity.
7, HLA-B27 positive.
8, MRI shows acute inflammatory damage to the sacroiliac joint.
Inflammatory back pain is the main symptom in the diagnosis of ankylosing spondylitis and can be considered if 4 of the following 5 criteria are present: 1. back pain occurs before the age of 40. 2. insidious attacks. 3. lasts for at least 3 months. 4. morning stiffness. 5. improves with exercise.
Supervise the patient to adhere to the correct treatment
The main drugs used to treat ankylosing spondylitis include
1. non-steroidal anti-inflammatory drugs. These drugs have anti-inflammatory and pain-relieving effects, reduce morning stiffness and tendon spasm. They are fast acting and are mainly used to relieve symptoms. The application of such drugs should emphasize individualization and avoid the combination of more than two drugs to reduce adverse reactions. At present, the commonly used drugs are diclofenac, sulforaphane and celecoxib, etc. The common adverse reactions are gastrointestinal reactions, rash and kidney damage, etc.
2. Slow-acting drugs. Mainly used to control the activity and development of the disease. Commonly used drugs include salazosulfapyridine, methotrexate, leflunomide, prednisone, etc. Other drugs are gold preparations, penicillamine, cyclophosphamide, azathioprine, reaction stop, etc. At present, the combination of slow-acting drugs is advocated to be more effective. Common adverse reactions are: gastrointestinal reactions, bone marrow suppression, hair loss, stomatitis, blood picture changes, liver function damage, etc.
3.Adrenocorticotropic hormone. Generally, they can be considered in the following cases.
① Combined with acute eye lesions, such as iritis and uveitis, can be used in eye drops and orally.
② When treatment with non-steroidal anti-inflammatory drugs is ineffective, small doses of oral or local injections of glucocorticoids can be used, but do not apply for a long time.
Rheumatoid arthritis is managed in this way
Recognize the risks and characteristics of the disease
Rheumatoid arthritis (RA) is an autoimmune disease characterized by chronic progressive joint lesions, most commonly in the small joints of the fingers, wrists, elbows, knees, ankles and feet. Patients may have extra-articular manifestations such as fever, anemia, subcutaneous nodules, vasculitis, pericarditis, and lymph node enlargement, and multiple autoantibodies may be present in the serum. If left untreated, repeated attacks and prolongation of the disease may lead to joint deformity and loss of function.
The onset of the disease is characterized by.
1. It occurs between 20 and 60 years of age, and is more common in women during their reproductive years.
2, the course of the disease is chronic.
3. There is symmetric swelling and pain in the wrist, metacarpophalangeal and proximal interphalangeal joints.
4. Morning stiffness is present.
5.Subcutaneous nodules may appear.
6.The blood test for rheumatoid factor is positive.
7.Hand x-ray has arthropathy.
Master the key to treatment
1, the diagnosis is clear on the use of drugs. Practice has proved that the treatment of RA should adhere to the early treatment. the principles of RA treatment are: early treatment, combination of drugs and individualized program.
2. Combined medication is effective. Combination medication refers to both giving NSAIDs and other drugs to relieve joint swelling and pain and systemic symptoms, and adding slow-acting anti-rheumatic drugs in time, so as to fundamentally slow down or stop the patient’s joint lesions. Although a few patients with mild disease may be effective with one slow-acting antirheumatic drug alone, most rheumatoid arthritis requires two or more slow-acting antirheumatic drugs to bring the disease under control.
Moreover, studies have confirmed that the therapeutic effect of combined drugs is significantly better than that of single drugs, and the incidence of adverse drug reactions is not significantly increased. Therefore, while paying attention to avoid adverse drug reactions, patients should receive a sufficient amount and a full course of slow-acting anti-rheumatic drug combination therapy.
3, adhere to the principle of individualization. In drug treatment, special attention should be paid to individual differences of patients: for severe RA or serum with high titer autoantibodies and multiple autoantibodies positive, duplex or triplex slow-acting anti-rheumatic drugs should be given; for young patients should avoid the use of tretinoin; for refractory patients who are not treated with regular slow-acting anti-rheumatic drugs, immunopurification (such as immunosorbent) can be taken; for joint cavity effusion, timely For patients with joint cavity effusion, puncture and intra-articular injection should be given, but care should be taken not to use too many drugs.
NSAIDs such as diclofenac, nimesulide or celecoxib should be selected according to the patient’s degree of illness, the presence of concomitant diseases, and liver and kidney function, rather than using the same drug for every patient. When the patient’s condition improves, the drug should be reduced to a smaller dose. Attention should also be paid to the characteristics of each NSAID and to the individual differences of the patient.
Slow-acting antirheumatic drugs can stop the progression of synovial lesions in RA patients and, if used properly, can lead to complete remission in most patients. These drugs include methotrexate, hydroxychloroquine, salazosulfapyridine, leflunomide, and penicillamine. A large number of clinical studies have demonstrated that the combination of slow-acting antirheumatic drugs can bring most patients with severe disease under control. For mild or early patients, consider using a slow-acting anti-rheumatic drugs alone.
4, do not use hormones indiscriminately. Hormone is not the drug of choice for RA, and most patients with RA do not need hormone therapy. In general, the correct use of non-steroidal anti-inflammatory drugs and the combination of slow-acting anti-rheumatic drugs, can make most patients’ disease under control. Only a minority of patients need to consider hormones when NSAIDs are ineffective or intolerable as a transitional treatment. And even if a patient has an indication for hormone use, the dose should be as small as possible and reduced or discontinued as soon as possible. In some patients with recurrent joint cavity effusion, intra-articular injection of trimethoprim can be used in principle, but the interval between two injections should not be less than 3 months.
Prevention and treatment of SLE should be regulated
Understanding SLE
Dangers of SLE Systemic lupus erythematosus (SLE) is a systemic autoimmune disease that can involve all systems and organs of the body, and renal failure, infection and central nervous system damage are the main causes of death in this disease.
Common symptoms
1, fever, fatigue, weight loss.
2, facial erythema and various rashes, skin irritation after sun exposure.
3.Hair loss.
4.Recurring mouth ulcers.
5.Joint pain, myalgia, muscle weakness.
6. Chest tightness, shortness of breath, dry cough.
7.Mental disorder, epilepsy, hemiplegia, etc.
8.Cold extremities turn from white to purple and then to red.
9.Epistaxis, gum bleeding, skin purpura, etc.
10.Lymph node enlargement of liver and spleen.
Related tests
1.Blood routine, urine routine.
2.Multiple autoantibodies (ANA, dsDNA, ENA, AnuA, AHA, mDNA, ACL, RF, anti-Hu, PCNA, etc.) positive.
3. Reduced complement and elevated immunoglobulin.
4, Positive lupus band test.
5, Kidney biopsy showed lupus-like lesions.
6.X-ray, CT and ultrasound examination.
Treatment goals Philosophy and principles
Treatment goals Long-term remission of SLE, disappearance of clinical symptoms, long-term stabilization or maintenance of all laboratory indicators in the normal range, and maintenance of hormones and immunosuppressive drugs at minimal doses or complete discontinuation are the treatment goals of rheumatologists. Community physicians should also be aware of this so that they can promptly supervise patients upon their return to the community.
Treatment philosophy Regardless of the severity of the patient’s condition, treatment should be based on a holistic philosophy, with attention to both pharmacological and non-pharmacological aspects. Pharmacological treatment should address the primary disease, comorbidities and drug-induced adverse reactions, while paying attention to the non-pharmacological treatment of the patient.
The treatment principle is to select the treatment plan according to the condition.
SLE has different forms of onset and various clinical manifestations, therefore, there are differences in the choice of medication for different patients. Patients with severe disease need to apply immunosuppressants or HCQ and other drugs, and follow up regularly. Because long-term use of immunosuppressive drugs may have adverse reactions such as blood, liver function and kidney function. Those who have mild adverse reactions can continue to receive treatment while closely monitoring and protecting the liver and kidneys, and those with progressive aggravation or severe adverse reactions should immediately stop the drug and change the treatment plan.
2, pay attention to the role of topical drugs. Topical drugs such as tacrolimus ointment and pimecrolimus cream have entered the clinical application or clinical research stage respectively, which have not only achieved better efficacy, but also no special adverse reactions have been reported, and are the drugs of choice for the treatment of SLE local rash. The glucocorticoid ointment or cream can cause skin atrophy, pigmentation and capillary dilation and other adverse reactions, and is gradually being replaced by new drugs.
3.Reducing adverse reactions. SLE patients receiving long-term glucocorticoid therapy (especially postmenopausal patients) need long-term calcium supplementation and VD, and oral alunophosphates to prevent osteoporosis. According to research, estrogen replacement therapy can significantly improve osteoporosis complicated by postmenopausal SLE patients, but there is a lack of international standards.
4. The principles of medication in remission and stabilization. Gradually reducing the dose of hormone or immunosuppressant or extending the interval of medication according to the disease is the principle of medication in the remission and stabilization period. Therefore, SLE patients who have achieved clinical remission need to adhere to the medication and pay more attention to regular review.
Three key points of gout management
Identify and urge patients to seek timely medical treatment
Physicians should urge community residents to seek timely medical care when they notice the following symptoms.
1. Men over 45 years old (less often women).
2.Habit of drinking alcohol and eating meat and seafood.
3.The first painful site is mostly the first metatarsophalangeal joint, and the lower limb joints are more involved than the upper limb.
4. The pain is often sudden and severe at night.
5. The reoccurrences are mostly single joint or multi-joint alternating attacks.
6. The pain may be self-limiting. Even without treatment, the pain can be relieved by itself after about 1 week. However, it can be repeatedly attacked, and the interval can be completely back to normal.
Publicizing the dangers of gout
Epidemiological studies show that the incidence of hyperuricemia and gout has increased significantly in the past 20 years due to changes in dietary habits and lifestyles, with the majority of patients being male. Hyperuricemia can not only cause arthritis and urinary stones, but is also significantly associated with cardiovascular disease, hypertension, diabetes mellitus and chronic renal failure. Gout has been shown to be an independent risk factor for cardiovascular disease, leading to increased mortality in patients.
Promote the implementation of prevention methods
1. Guide overweight residents to reduce their body weight. Studies have shown that an increased body mass index (BMI) is an independent risk factor for gout. As BMI increases, the prevalence of gout increases. When BMI is 21-23kg/m2, the relative risk of gout (RR) is 1.4; when BMI is 30-35kg/m2, the RR rises to 3.26. Therefore, moderate weight loss can prevent gout.
2, advocate drinking low-fat milk. It is usually believed that meat and seafood can raise blood uric acid. So the previous dietary guidelines recommended a low purine, low protein diet and restricted alcohol consumption. However, recent studies have found that there is no significant correlation between gout and total protein intake, but is closely related to insulin resistance. Limiting carbohydrate intake and increasing protein and unsaturated fatty acid intake improves insulin sensitivity and facilitates blood uric acid excretion, resulting in a reduced risk of gout.
Studies have also found that milk (especially low-fat milk) can reduce blood uric acid levels. This may be related to the fact that casein and whey protein in milk increase uric acid excretion. Therefore, some scholars believe that drinking low-fat milk regularly has a protective effect on gout patients.
3. It is recommended to limit alcohol consumption. The correlation between alcohol consumption and hyperuricemia and gout has always been recognized worldwide – the blood uric acid value is directly proportional to the total alcohol intake: a 10g increase in daily alcohol intake can increase the RR of gout by 1.17 times.
Among the various alcoholic beverages, beer has the strongest RR with gout: drinking more than 2 glasses of beer per day results in an RR for gout of 2.51. It has been analyzed that beer (even alcohol-free beer) is highly associated with high uric acid, probably due to the fact that beer is made from malt and guanine nucleosides are more easily absorbed.
However, studies have shown that wine is not significantly associated with high uric acid and does not increase the risk of gout. Daily wine consumption keeps uric acid levels low. It is speculated that this may be related to the antioxidants in wine or because wine drinkers place more emphasis on a healthy diet, which reduces the toxicity of alcohol.