Osteoarthritis

Osteoarthritis means degenerative inflammation of the joints which is symbolized by loss of cartilage. It is the most common leading cause of disability among older people. It is very rarely found in people less than 40 years and is widespread in adults older than 60years. It is much more common in women than men.

Most commonly affected joints are cervical (neck region), lumbo sacral joints (back region), hip, knee, first metatarsal phalangeal joint (toe), Distal and proximal interphalangeal joints (which includes joints of small fingers).

What is Osteoarthritis?

Osteo means bones

Arthro means Joints

Itis means Inflammation

Osteoarthritis means inflammation of the joints which is due to degeneration of the hyaline cartilage in the joints. There are several reasons for the malfunction of joints but the most common universal reason which stands on the top of the list is the failure of the protective mechanisms of joints.

What constitutes the defensive mechanism of joints?

Joint capsule & ligaments, muscle, sensory afferents (nerves) and underlying bone are structures that provide support to the joints by limiting the movement of joints.

There is synovial fluid which reduces friction between articulating cartilage and reduces friction induced tear of the cartilage.

The ligaments along with muscle and tendon consist of mechanoreceptor sensory afferent nerve. These nerves provide signals to the spinal cord supplying the tendons and muscle thereby limiting the range of motions.

Muscles and tendons contract together at the appropriate time with proper power and acceleration to fulfil a movement. The muscle contraction decelerates any extra force provided to the joint.

The bone beneath the joint also acts as a shock absorber.

Failure of any of the above mechanism can lead to injury of the joints or osteoarthritis.

What are the risk factors for osteoarthritis?

1. Two main risk factors

Susceptible Joints

Overloading of Joints

Susceptible joints are increased age, female gender, racial/ethnic factors, Genetic susceptibility and nutritional factors & previous damage, developmental abnormality.

Overloading of joints which means the stress given to the joint is much more that the specified limit. But in certain group of people even simple daily activities can be a burden to the bones. Overloading can be occupation related and joints affected depend on the joint that is frequently used. This is because during the long hours of using the joints, the muscle become exhausted and effective protective mechanism is lost.

2. Age

As age increases the natural defensive mechanism of the joints becomes fragile. Women in older age are more prone to increased risk to osteoarthritis which may be due to loss of hormone after menopause.

3. Genetics and heritability

It is a hereditary disease and it also depends on the joint affected. Fifty percent of hand and hip joints have increased risk to pass on to the future generations whereas osteoarthritis of the knee has a risk of thirty percent. Multiple joint involvements i.e. Generalised Osteoarthritis is rather due to aging process.

4. Repeated use of Joints

Though exercise is considered as one of the treatment modality, certain type of exercises can increased risk of joint damage. Compared to non-runners elite runners have high risk of getting osteoarthritis in the later years.

Symptoms of osteoarthritis

Joint pain is usually movement related. Pain appears on joint use and resolves later. During the earlier stage of the disease, pain is episodic i.e. the pain is related to movement. For example, if a patient has osteoarthritis in knee, climbing stairs or running may aggravate the pain and the pain will subside in few days. When the disease progress the pain becomes continuous and troublesome especially at night.

Stiffness of the affected joint becomes prominent and morning stiffness may be present.

Investigations Required

There is no specific blood investigation available.

X-ray is an excellent method of investigation for osteoarthritis, though it is not helpful in the earlier stages of the disease.

Treatment

The main objective of the treatment is to limit the damage of joints and to reduce the level of pain. So it could be non-pharmacologic mode of treatment and pharmacological way of treatment.

Non-pharmacologic treatment

1. Avoid activities that overload the joint.
2. Increase the strength and condition of the muscles
3. Distributing the weight by using cane or crutch.

It is advisable to end the activities that precipitate pain. Weight loss in obese may also alleviate the symptoms.

As pain is the main symptom of osteoarthritis, it results in immobility. This immobility can lead to obesity which in turn will have a negative impact on the cardiovascular system. Thus this is a vicious circle. Thus exercise regimens will help in strengthening muscles across the joint. Aerobic exercise and/or resistance exercise will focus on strengthening of the muscles. If an exercise increases the pain, then that particular exercise should be avoided. Patient can contact the general practitioner who can refer you to a physiotherapist. A physiotherapist can advice you about particular exercise that can help to reinforce the strength of muscles.

Pharmacotherapy

Acetaminophen (paracetamol), Non-steroidal Anti inflammatory drugs (NSAIDS) and COX 2 inhibitors are the drugs that control osteoarthritis.

1. NSAIDS are the most familiar drugs to treat osteoarthritis pain. Primarily NSAIDS should be given according to the threshold of the pain. NSAIDS include Naproxen, Salsalate & Ibuprofen. If occasional treatment with NSAIDS is ineffective, daily treatment should be commenced.

NSAIDS has side effects which includes gastrointestinal toxicity, dyspepsia, nausea, and bloating, gastrointestinal bleeding and ulcer disease.

To minimise the effect, the following must be maintained:

a. Take medication after food.

b. Avoid use of two NSAIDs

c. Use a relatively safer NSAIDS.

d. If at risk of gastrointestinal bleeding, prescribe gastro protective agent.

2. Intraarticular injections: Glucocorticoids and hyaluronic acid

In case of severe pain, intraarticular injections with glucocorticoids will be helpful.

Surgery

For knee osteoarthritis, several operations are available which includes arthroscopic debridement and lavage.

Osteoarthritis is not a reversible disease, only the symptoms can be treated. So it is sensible to avoid activities that will provoke the symptoms.

Osteoarthritis ends here and I will see you in the next post with a different topic.

Viral Hepatitis

Hepatitis means inflammation of the liver caused by hepatitis virus. The pathogen involved in this is called hepatitis virus which includes Hepatitis A virus (HAV virus), Hepatitis B virus (HBV virus), Hepatitis C Virus (HCV virus), Hepatitis D virus (HDV virus) & Hepatitis E virus (HEV). There exists Hepatitis G virus and Hepatitis TT virus but it does not cause hepatitis. These agents cause the same similar symptoms, though they all have different route of transmission.

Hepatitis A virus It is RNA virus which belongs to Genus hepatovirus and Family picornavirus. It replicates in the liver and is excreted in the faeces of infected persons for about 2 weeks before the onset of clinical symptoms.

Mode of Transmission Contaminated food or water (Faecal- oral route).

Incubation period 4 weeks

Signs & symptoms Infected patient may have mild flu like symptoms of anorexia, Vomiting, fatigue, malaise, head ache and low grade fever. Later it could be followed by jaundice with dark urine and pale stools. Pain in joints and rash can go together with the jaundice. There may be enlargement of the liver.

Investigation Anti-hepatitis A immunoglobulin M remains for 3-6months after the primary infection and it shows acute infection.

Anti-hepatitis A immunoglobulin stays for many years.

Levels of liver enzymes Alanine aminotransferase and Aspartate aminotransferase are increased. Serum bilirubin level can be increased as well.

There is lecuopenia with a relative lymphocytosis. Prothrombin time is prolonged in severe cases and Erythrocyte sedimentation rate is increased.

Treatment Usually supportive. Your immune system will take care of the offender. You have to make sure you do not drink or eat fatty food.

Prophylaxis If you are travelling to high risk zones of hepatitis A then it is advisable to avoid eating in such conditions especially anything uncooked or raw.

Immunisation One could get vaccinated if he knows that he is travelling to a high risk country 4-6 weeks before travel. A single doses turns out to produce antibodies for one year. When a booster is given, immunity then can lasts for up to 10years.

Prognosis It has excellent with most patients having complete recovery. Death may occur due to fulminant hepatic necrosis. Some cases may occur with prolonged course with 7-20 weeks and is called ‘cholestatic viral hepatitis’. There might be hindrance with weakness following resolution of symptoms and biochemical parameters. This is known as post-hepatitis syndrome.

Hepatitis B Virus It is a DNA virus which belongs to hepadnovirus.

Mode of Transmission Unprotected sexual contact with infected, Sharing of contaminated needles & syringes, vertical transmission from mother to child especially during child birth. All bodily fluids saliva, semen, vaginal secretions and blood contains hepatitis B virus.

Incubation Period 1-6 months

Hepatitis B virus usually can occur in two phases. It can be acute phase when one gets infected and chronic phase when the virus persists in the body.

Signs & Symptoms Patient will feel generally unwell, abdominal pains, vomiting and fever. Later on patient will develop jaundice.

Symptoms usually disappear in few weeks and virus is cleared from the body within 3-6months. In some cases it develops into chronic hepatitis which stays for life long. When a patient is with chronic infection, it might be symptomless and the virus will remain in the body and the patient will be a carrier or a chronic inactive hepatitis B.

In some cases liver is inflamed all throughout and it is called chronic active hepatitis in which patient might experience symptoms or can be asymptomatic.

In later years after infection with hepatitis B virus patient may develop cirrhosis of the liver which is scarring of the liver and it results in deterioration of the function of the liver.

There is risk of developing hepatocellular carcinoma.

Investigation

Blood test shows presence of hepatitis B surface antigen.

Liver function tests which will show the elevation of the liver enzymes

Ultrasound scans of the liver. Biopsy of the liver should be done to check if there is any progressing cirrhosis of the liver.

Various other portions of the virus particles can be seen which shows various stages of infection.

Treatment

No treatment can be helpful but they can ease the symptoms.

In case of chronic hepatitis treatment is given to reduce the progression of liver damage.

Interferon: It is a substance which helps to fight against the immunity. It fights against infection by providing stronger immunity.

Anti-viral drugs: These drugs which help to fight against the infection.

Liver transplantation can be helpful as well.

Diet and Alcohol Normal balanced diet can be continued. It is advisable to avoid cirrhosis.

Prophylaxis Avoid risk factors such as shared needles, multiple male homosexual partners and prostitutes.

Standard precautions must be followed in hospitals to avoid accidental needle punctures and contact with infected body fluids.

Immunisation should be done to people at high risk.

Hepatitis D It is caused by Hepatitis D virus or Delta virus. It is a RNA virus which does not have the capability to replicate on its own but is usually active only in the presence of Hepatitis B virus.

Investigation Ig M anti-delta along with presence of Ig M anti-HBc appears at one week and disappears by 5-6 years when serum Ig G anti-delta is seen.

Hepatitis C

It is a single stranded RNA virus of the Flaviviridae family. It consists of six genotypes. Out of which, genotype one is the most common in U.K.

Mode of transmission Intravenous drug users and blood transfusion (In England from 1991 September blood has been screened for Hepatitis C virus)

Haemodialysis

Sexual contact with infected individual

Needle stick injuries

Perinatal transmission

Signs & symptoms Usually asymptomatic

People will experience malaise, anorexia and weakness with jaundice. Most patient present in later years with abnormal liver function test or with Chronic liver disease.

Extrahepatic manifestations include Arthritis, Glomerulonephritis associated with cryoglobulinaemia and porphyria cutanea tarda.

Investigation HCV RNA can be detected 1 or 2 weeks after infection

Anti-HCV is usually positive 6 weeks from infection

Treatment Patient should be educated about the disease.

Patient should not donate blood, tissue or organ.

Alcohol could accelerate the destruction of the liver; hence excess alcohol intake must be avoided.

Pegainterferon alfa-2a and ribavirin can be prescribed .

Hepatitis E It is a RNA virus which belongs to the family Calicivirus.

Mode of transmission Contaminated water is the main source of infection

Zoonotic spread with dogs, pigs and rodents carrying the virus.

Signs & symptoms Clinical features similar to Hepatitis A virus

It is self limiting.

Investigation

HEV RNA can be detected in the serum or stools by PCR

IgM anti HEV and IgG anti HEV

Treatment Usually supportive

Prevention Good hygiene and sanitation

Avoid tap water in high risk area

No vaccine is available

We will meet in the next blog with another interesting disease.

Migraine

Headache is the most significant complaint that we come across in our medical practice. Headache can be a symptom of another disease which means secondary to some other illness or it could be the disease itself. But in any case it needs immediate medical attention.

When do we say headache is secondary?

When there is a disease or illness like brain tumour, meningitis, temporal arteritis, glaucoma, intracranial haemorrhage and hypertension or even sinusitis & simple common cold could be a reason for head ache. In this situation when there is a cause for the headache we call it secondary headache.

When do we say headache is primary?

There is no organic cause i.e. no systemic illness or any health related issue that could provoke this headache. According to the International classification of the primary headache disorders are classified as following

1. Migraine
2. Tension type headache
3. Cluster headache and other trigeminal autonomic cephalalgia
4. Other primary headaches

In this post we will discuss about migraine which is the second most common cause of headache.

Migraine

It is a primary headache which is provoked by various stimuli. Stimuli of minute strength which do not incite headache in normal people could provoke headache in individual susceptible to migraine.

Stimuli can be

Loud noise

Bright lights

Stress

Weather change

Menstrual cycle

Alcohol

Excess/less sleep

Hunger

What is the mechanism of headache?

Migraine does not have any particular cause. Genetic factors may play a role. Migraine headaches are usually due to dilatation of the blood vessels which stimulates the nerve endings. Serum 5-hydroxytryptamine is increased before the onset of headache and decreases during headache. Medication which blocks 5-hydroxytryptamine have been developed which could help to prevent the attack.

How do you diagnose migraine?

Migraine can usually be divided into phases.

First phase Patient is healthy and does not have any complaints.

Second phase Patient will have a period of aura which consists of symptoms like nausea, vomiting, photophobia, vertigo, alteration of consciousness, flashing of lights or other symptoms . This prodromal phase lasts 15 minutes to one hour or more.

Third phase Headache

Fourth phase After headache, patient will feel tired and irritated.

Types of Migraine

Migraine with aura

Migraine without aura

Abdominal migraine

Menstrual migraine

Basilar migraine

Hemiparetic migraine

Opthalmoplegic migraine

Facioplegic migraine

Migraine does occur in children as well. Especially abdominal migraine, in which the child has abdominal pain for several hours but there is no headache may be mild. These patients experience the same episode with certain subset of symptoms like nausea, vomiting or any other aura symptoms. Children who experience this abdominal migraine are prone to develop migraine in their later years of life.

Diagnosing Migraine

Criteria

Headache lasts for 4-72hours in patient. Physical examination will be normal and no cause for the headache can be found.

At least 2 of the following

Unilateral pain

Throbbing pain

Aggravation by movement

Moderate or severe intensity

Any 1 of the following

Nausea/vomiting

Photophobia and phonophobia

Headache must be differentiated from other primary headaches especially tension type headache. The most significant feature of migraine is the presence of a second phase with a subset of symptoms before the onset of headache.

Treatment:

Patient should keep a diary of the number of attacks and the medications used during an acute attack.

MIDAS which stands for Migraine Disability Assessment Score is a questionnaire with number of questions regarding the headache and the limitations in your daily activity you had during an attack. This would facilitate the doctor to assess the extent of the disease.

Patient must learn about all possible activities that will elicit the headache and must try to avoid those circumstances.

We can also prevent migraine. But to whom do we prescribe preventive medications?

1. Patient who do not respond to treatment during an attack

2. Patient who respond poorly to drug therapy during an attack

3. Patients who have very frequent attacks i.e. >5 attacks in a month.

Treatment of acute attacks

Usually treatment of acute attack depends on the severity. If it is a mild attack then oral agent can be used but in case of severe attack parenteral therapy must be used.

Treatment of migraine includes drugs from the following three groups of drugs.

1. Anti Inflammatory agents

2. 5HT_1B/1D receptor agonists

3. Dopamine receptor antagonists.

In case of menses related headache ergotamine or oestrogen patches can be used.

In children, the reasons of migraine are due to hunger and dehydration. So it is necessary to have regulated meal timings and sleeping habit in children with migraine. For the treatment of migraine in children, we can use paracetamol or ibuprofen. Aspirin should not be used in children. Domperidone and prochlorperazine is suitable for children under 12years of age.

None of the medication should be used without proper counselling with your family doctor.

We will discuss about the various other kinds of headache in our future posts.

Reference

Fauci As, Kasper DL, Braunwald E, HauserSL, Longo DL, Jameson JL,Loscalzo:Headache in Harrison’s Principles of Internal Medicine, 17^th Edition.