ABC of Rheumatology E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Serie: ABC Series
• Sprache: Englisch

Seitenzahl: 580

Veröffentlichungsjahr: 2018

Beschreibung

ABC of Rheumatology continues to be a practical and informative guide to the assessment, treatment and management of common rheumatic and musculoskeletal conditions within primary care.

Fully updated to reflect developments in this fast growing field, the fifth edition covers overviews of all key areas of rheumatology, and includes new chapters on radiology and immunology, as well as expanded coverage on metabolic bone disease, chronic widespread pain, and complex regional pain syndrome.

Featuring highly illustrated chapters, boxed summaries and links to further resources, ABC of Rheumatology is an accessible reference for all primary care health professional, general practitioners, family physicians, junior doctors, medical students and nurses.

Leseprobe

Rheumatology

Fifth Edition

EDITED BY

Ade Adebajo

Associate Director of Teaching, University of Sheffield Medical School,Honorary Professor and Consultant Rheumatologist/Director of UndergraduateMedical Education, Faculty of Medicine, Dentistry and Health,University of Sheffield and Barnsley Hospital,South Yorkshire, UK

Lisa Dunkley

Consultant Rheumatologist and TPD Rheumatology (S Yorks),Royal Hallamshire Hospital,Sheffield, UK

This fifth edition first published 2018© 2018 John Wiley & Sons Ltd

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Library of Congress Cataloging‐in‐Publication Data

Names: Adebajo, Ade, editor. | Dunkley, Lisa, editor.Title: ABC of rheumatology / edited by Dr Ade Adebajo, Dr Lisa Dunkley.Description: Fifth edition. | Hoboken, NJ : John Wiley & Sons, Inc., 2018. | Series: ABC series | Includes bibliographical references and index. | Identifiers: LCCN 2017055315 (print) | LCCN 2017056755 (ebook) | ISBN 9781118793183 (pdf) | ISBN 9781118793206 (epub) | ISBN 9781118793213 (pbk.)Subjects: | MESH: Rheumatic DiseasesClassification: LCC RC927 (ebook) | LCC RC927 (print) | NLM WE 544 | DDC 616.7/23–dc23LC record available at https://lccn.loc.gov/2017055315

Cover Design: WileyCover Image: © Science Photo Library/GettyImages

Preface

This edition of ABC of Rheumatology welcomes a new co‐editor, Dr Lisa Dunkley. Lisa has a strong pedigree in medical education, having previously worked at the Department of Medical Education at University College in London, subsequently at the Leeds Rheumatology Department and now in Sheffield Teaching Hospitals and Sheffield Medical School. Her extensive expertise and experience have substantially enriched this new edition.

We have built on the earlier successful editions of the book and added new chapters on radiology and immunology. These new chapters reflect areas in which the field of rheumatology has experienced phenomenal growth in recent years. Musculoskeletal ultrasound is now a well‐established tool in the diagnosis of rheumatoid arthritis, whilst biological agents such as anti‐tumour necrosis factor drugs are commonly used in the treatment of several rheumatic conditions.

I thank all authors, old and new, for their excellent chapters. I also thank the publishers for their ongoing support for this book. It is our hope that this authoritative, up‐to‐date, yet easy‐to‐read book will continue to benefit students and healthcare professionals across the world and enable them to better understand rheumatic diseases as well as to appropriately treat patients with these conditions.

Ade AdebajoLisa Dunkley

Contributors

A. AbhishekClinical Associate Professor of Rheumatology and Honorary Consultant RheumatologistAcademic RheumatologyUniversity of Nottingham;Nottingham University Hospitals Trust, Nottingham, UK

Ade AdebajoAssociate Director of TeachingUniversity of Sheffield Medical SchoolHonorary Professor and Consultant Rheumatologist/Director of Undergraduate Medical EducationFaculty of Medicine, Dentistry and HealthUniversity of Sheffield and Barnsley HospitalSouth Yorkshire, UK

Mohammed AkilConsultant RheumatologistSheffield Teaching Hospitals NHS Foundation TrustSheffield, UK

Carol M. BlackEmeritus Professor of RheumatologyRoyal Free Hospital and UCL Medical SchoolLondon, UK

Edwin S.L. ChanAdjunct Associate Professor of MedicineDepartment of MedicineNew York UniversityNew York, USA

Bruce N. CronsteinPaul R. Esserman Professor of Medicine Department of MedicineNew York UniversityNew York, USA

Paul DavisEmeritus Professor of MedicineUniversity of AlbertaEdmonton, Canada

David D’CruzProfessor and Consultant RheumatologistLouise Coote Lupus UnitGuys and St Thomas’ HospitalsLondon, UK

Chris DeightonConsultant RheumatologistDerbyshire Royal InfirmaryDerby, UK

Elaine M. DennisonProfessor of Musculoskeletal Epidemiology and Honorary ConsultantMRC Lifecourse Epidemiology Unit, University of SouthamptonSouthampton General HospitalSouthampton, UK

Christopher P. DentonProfessor of Experimental Rheumatology and Consultant RheumatologistRoyal Free Hospital and UCL Medical SchoolLondon, UK

John DicksonCommunity Specialist in RheumatologyHonorary Senior LecturerUniversity of Bradford, Bradford, UK

Rajiv K. DixitClinical Professor of MedicineUniversity of CaliforniaSan Francisco;DirectorNorthern California Arthritis CenterWalnut Creek, USA

Michael DohertyClinical Associate Professor of Rheumatology and Honorary Consultant RheumatologistAcademic RheumatologyUniversity of Nottingham;Nottingham University Hospitals Trust, Nottingham, UK

Adrian DunbarGeneral Practitioner with a special interest in musculoskeletal medicine and chronic pain managementSkipton, North Yorkshire, UK

Richard EastellNorthern General Hospital;Professor of Bone MetabolismAcademic Unit of Bone MetabolismMellanby Centre for Bone ResearchDepartment of Oncology & MetabolismUniversity of Sheffield, Sheffield, UK

Helen FosterProfessor of Paediatric Rheumatology, Newcastle University;Honorary Consultant, Great North Children’s HospitalNewcastle upon Tyne Hospitals NHS Foundation TrustNewcastle upon Tyne; UK

Caroline GordonProfessor of Rheumatology and Consultant RheumatologistUniversity of Birmingham;Department of RheumatologySandwell and West Birmingham Hospitals NHS TrustBirmingham, UK

William R. GrantConsultant Rheumatologist and Honorary Senior LecturerDepartment of RheumatologyRoyal Hallamshire HospitalSheffield, UK

Andrew HamerConsultant Orthopaedic SurgeonDepartment of Orthopaedic SurgerySheffield Teaching Hospitals NHS Foundation TrustSheffield, UK

Andrew HassellConsultant RheumatologistStaffordshire and Stoke on Trent Partnership NHS Trust;Keele University School of MedicineKeele, UK

Philip S. HelliwellSenior Lecturer and Consultant RheumatologistLeeds Institute of Rheumatic and Musculoskeletal MedicineUniversity of Leeds, Leeds, UK

Samantha L. HiderSenior Lecturer and Honorary Consultant RheumatologistArthritis Research UK Primary Care CentreKeele UniversityKeele, UK

Robert InmanProfessor and Director of Spondylitis ProgramToronto Hospital –Western DivisionToronto, Canada

Rajendra Vara Prasad IrlapatiAssociate ProfessorDepartment of RheumatologyNizams Institute of Medical SciencesHyderabad, India

John IsaacsProfessor of Clinical Rheumatology and Honorary Consultant RheumatologistNewcastle University and Newcastle upon Tyne Hospitals NHS TrustNewcastle, UK

David IsenbergProfessor of RheumatologyCentre For Rheumatology, Department of MedicineUniversity College LondonLondon, UK

Jeffry KatzProfessor of MedicineCase Western Reserve University School of MedicineCleveland, USA

Andrew KeatConsultant RheumatologistArthritis CentreNorthwick Park HospitalHarrow, UK

Anna E. LitwicClinical Research FellowMRC Lifecourse Epidemiology Unit, University of SouthamptonSouthampton General HospitalSouthampton, UK

Christian D. MallenDeputy DirectorInstitute for Primary Care and Health SciencesNIHR Research Professor in General PracticeNIHR CLAHRC West Midlands;Deputy DirectorNIHR School for Primary Care Research Training LeadHonorary Professor in Rheumatology, University of Birmingham;Arthritis Research UK Primary Care CentreResearch Institute for Primary Care & Health SciencesKeele UniversityKeele UK

Eric L. MattesonProfessor of MedicineDivision of RheumatologyDepartment of Internal Medicine and Department of Health Sciences ResearchMayo Clinic College of MedicineRochester, USA

Eugene McCloskeyNorthern General Hospital; Academic Unit of Bone MetabolismMellanby Centre for Bone ResearchDepartment of Oncology & MetabolismUniversity of Sheffield, Sheffield, UK

Anne‐Marie McMahonConsultant in Paediatric and Adolescent Rheumatology;Honorary Senior Clinical LecturerSheffield Children’s HospitalSheffield, UK

Caroline MitchellGeneral Practitioner and Senior Clinical LecturerAcademic Unit of Primary Medical CareUniversity of SheffieldSheffield, UK

Robert MootsProfessor of RheumatologyUniversity of LiverpoolHonorary Consultant RheumatologistAintree University HospitalLiverpool, UK

Marisa Fernandes das NevesClinical ImmunologistMedicine IV DepartmentFernando Fonseca Hospital, Amadora;CEDOC – Chronic Diseases, Faculty of Medical SciencesNew University of LisbonLisbon, Portugal

Voon H. OngSenior Clinical Lecturer and Honorary Consultant RheumatologistRoyal Free Hospital and UCL Medical SchoolLondon, UK

Nicola PeelClinical LeadMetabolic Bone CentreNorthern General Hospital (Sheffield Teaching Hospitals Foundation Trust)Sheffield, UK

Rosalind Ramsey‐GoldmanSolovy Arthritis Research Society Research, Professor of MedicineNorthwestern University Feinberg School of MedicineChicago, USA

Vijay RaoUniversity of Birmingham;Department of RheumatologySandwell and West Birmingham Hospitals NHS TrustBirmingham, UK

Sarah RyanNurse Consultant RheumatologyStaffordshire and Stoke on Trent Partnership NHS TrustHaywood HospitalStoke on TrentUK

Evdoxia SapountziClinical Fellow in Paediatric RheumatologySheffield Children’s HospitalSheffield, UK

David G.I. ScottProfessor and Consultant RheumatologistNorfolk and Norwich University Hospital NHS Trust;Norwich Medical SchoolNorwich, UK

Michael ShipleyHonorary Consultant RheumatologistUniversity College London HospitalsLondon, UK

Heidi J. SiddleAssociate Professor and NIHR Clinical LecturerLeeds Institute of Rheumatic and Musculoskeletal MedicineUniversity of Leeds, Leeds;Foot Health DepartmentLeeds Teaching Hospitals NHS Trust, Leeds, UK

Simon SomervilleGP ResearcherArthritis Research UK Primary Care CentreKeele UniversityKeele, UK

Cathy SpeedProfessor of Sports and Exercise MedicineUniversity of St Mark and St JohnPlymouth;Consultant Rheumatologist, Sports and Exercise MedicineCentre for Health and PerfomanceCambridge, UK

David StanleyConsultant Shoulder and Elbow SurgeonBMI Thornbury HospitalSheffield, UK

Kay StevensonConsultant Physiotherapist and NIHR Knowledge Mobilisation FellowArthritis Research UK Primary Care CentreKeele UniversityKeele; Haywood Hospital, Burslem, UK

Nishanthi ThalayasingamClinical Research FellowInstitute of Cellular MedicineNewcastle UniversityNewcastle, UK

Mohammed TiklyProfessor of RheumatologyChris Hani Baragwanath Academic Hospital and University of the Witwatersrand, Johannesburg, South Africa

Lori TuckerProfessor of Paediatric RheumatologyBritish Columbia’s Children’s HospitalVancouver, Canada

Martin UnderwoodProfessor of Primary Care ResearchWarwick Clinical Trials UnitWarwick Medical SchoolThe University of Warwick CoventryWarwick, UK;Adjunct Monash Warwick Professor,Department of Epidemiology and Preventive Medicine Monash UniversityClayton, Australia

Richard J. WakefieldSenior Lecturer and Honorary Consultant in RheumatologyLeeds Institute of Rheumatic and Rehabilitation MedicineChapel Allerton HospitalLeeds, UK

Jennifer WalshNorthern General Hospital;Senior Clinical LecturerAcademic Unit of Bone MetabolismMellanby Centre for Bone ResearchDepartment of Oncology & MetabolismUniversity of Sheffield, Sheffield, UK

Louise WarburtonClinical Lead for Telford MSK Service (TEMS)Associate Medical Director, Shropshire Community NHS Trust;Senior Lecturer, Keele UniversityKeele, UK

Richard A. WattsConsultant RheumatologistDepartment of RheumatologyIpswich Hospital NHS TrustIpswich;Honorary ProfessorNorwich Medical SchoolNorwich, UK

Mark WilkinsonProfessor of Orthopaedic SurgeryUniversity of SheffieldSheffield; Honorary Consultant Orthopaedic Surgeon, Sheffield Teaching Hospitals NHS Foundation TrustPresident British Orthopaedic Research Society, UK

Anthony G. WilsonProfessor of RheumatologyEULAR Centre of Excellence/UCD Centre for Arthritis ResearchConway Institute of Biomolecular & Biomedical ResearchUniversity College DublinDublin, Ireland

List of Abbreviations

AAV

ANCA‐associated vasculitis

ACD

anaemia of chronic disease

ACE

angiotensin‐converting enzyme

ACR

American College of Rheumatology

ACTH

adrenocorticotrophic hormone

ADCC

antibody‐dependent cellular cytotoxicity

AIHA

autoimmune haemolytic anaemia

ANA

antinuclear antibody

ANCA

antineutrophil cytoplasmic antibody

APC

antigen‐presenting cell

APS

antiphospholipid syndrome

AS

ankylosing spondylitis

AST

aspartate aminotransferase

BAFF

B‐cell activating factor

BASDAI

Bath Ankylosing Spondylitis Disease Activity Index

BASFI

Bath Ankylosing Spondylitis Functional Index

BASMI

Bath Ankylosing Spondylitis Metrology Index

BLyS

B‐lymphocyte stimulator

BMD

bone mineral density

BMI

body mass index

CCP

cyclic citrullinated peptide

CDC

complement‐dependent cytotoxicity

CDH

congenital dislocation of the hip

CHB

congenital heart block

CI

confidence interval

CK

creatine phosphokinase

CKD

chronic kidney disease

COX

cyclo‐oxygenase

CRP

C‐reactive protein

CT

computed tomography

CTGF

connective tissue growth factor

DDH

developmental dysplasia of the hip

DEXA

dual‐energy X‐ray absorptiometry

DIC

disseminated intravascular coagulation

DIPJ

distal interphalangeal joint

DMARD

disease‐modifying drug

ELISA

enzyme‐linked immunosorbent assay

ERA

enthesitis‐related arthritis

ESR

erythrocyte sedimentation rate

ESWT

extracorporeal shock wave therapy

EULAR

European League against Rheumatism

FAI

femoro‐acetabular impingement

FMF

familial Mediterranean fever

FMS

fibromyalgia syndrome

GCA

giant cell arteritis

GFR

glomerular filtration rate

GI

gastrointestinal

GIO

glucocorticoid‐induced osteoporosis

GU

genitourinary

GWAS

genome‐wide association

HCPC

Health and Care Professions Council

HFCS

high fructose corn syrup

HIV

human immunodeficiency virus

HLA

human leucocyte antigen

HLH

haemophagocytic lymphohistiocytosis

HRCT

high‐resolution computed tomography

HSP

Henoch–Schönlein purpura

IAI

intra‐articular steroid injection

IBD

inflammatory bowel disease

IFN

interferon

IL

interleukin

INR

international normalized ratio

JAK‐STAT

Janus kinase‐

signal transducer and activator of transcription

JDM

juvenile dermatomyositis

JIA

juvenile idiopathic arthritis

JPsA

juvenile psoriatic arthritis

LBP

low back pain

LDG

low‐density granulocyte

LDH

lactate dehydrogenase

MAS

macrophage activation syndrome

MCP

metacarpophalangeal

MDT

multidisciplinary team

MHC

major histocompatibility complex

MIF

macrophage inhibitor factor

MMF

mycophenolate mofetil

MMP

matrix metalloproteinase

MRI

magnetic resonance imaging

mSASSS

modified Stoke AS Spinal Score

MSK

musculoskeletal

MTP

metatarsophalangeal

NET

neutrophil extracellular trap

NICE

National Institute for Health and Care Excellence

NSAID

non‐steroidal anti‐inflammatory drug

OA

osteoarthritis

OT

occupational therapist

PAH

pulmonary artery hypertension

PAWP

pulmonary artery wedge pressure

PET

positron emission tomography

PDB

Paget’s disease of bone

PH

pulmonary hypertension

PIP

proximal interphalangeal

PMR

polymyalgia rheumatica

PRP

platelet‐rich plasma

PUO

pyrexia of unknown origin

RA

rheumatoid arthritis

RANKL

receptor activator of nuclear factor kappa‐B ligand

RCT

randomized controlled trial

ReA

reactive arthritis

RF

rheumatoid factor

RNS

rheumatology nurse specialist

RP

Raynaud’s phenomenon

RSD

reflex sympathetic dystrophy

SI

sacroiliac

SLE

systemic lupus erythematosus

SoJIA

systemic‐onset JIA

SpA

spondyloarthritides

SPECT

single‐photon emission computed tomography

SRC

scleroderma renal crisis

SSc

systemic sclerosis

SUFE

slipped upper femoral epiphysis

TGF

transforming growth factor

TJR

total joint replacement

TNF

tumour necrosis factor

TRAPS

tumour necrosis factor receptor‐associated periodic syndrome

TTP

thrombotic thrombocytopaenic purpura

UI

uncertainty interval

US

ultrasound

WBC

white blood cell

CHAPTER 1Delivering Musculoskeletal Care Across Boundaries

Samantha L. Hider1,2, Simon Somerville1 and Kay Stevenson1,2

1 Arthritis Research UK Primary Care Centre, Keele University, Keele, UK

2 Haywood Hospital, Burslem, UK

OVERVIEW

The burden of musculoskeletal disease is increasing and the importance of a multidisciplinary care pathway in the management of these patients is well established.

A community‐wide approach encompassing the involvement and education of both patient and primary care physician will lead to earlier diagnosis, speedier and more appropriate secondary care referrals, and quicker treatment and ultimately improved clinical outcomes.

Innovative models of care have been developed within primary/secondary care interface services for patients with musculoskeletal disease.

Identifying patients with inflammatory arthritis for rapid secondary care referral remains a key challenge for primary care.

Introduction

The ever‐increasing demand upon acute hospitals to deliver emergency medicine means that the management of long‐term chronic conditions is being delivered in a number of different settings rather than the traditional acute hospital. This chapter discusses different ways of working to try to ensure that patients with musculoskeletal conditions receive timely, appropriate treatments with the ‘right person, right place and right time’.

One way of transferring rheumatological expertise to the community, without increasing the burden on the primary care team, is to develop the roles of the wider multidisciplinary team such as nurses, physiotherapists and occupational therapists. Such practitioners, working in an extended role, operate at a high level of clinical practice and cross traditional professional boundaries. This is particularly evident within musculoskeletal interface services.

Rheumatology in the community: the impact on primary care

Musculoskeletal problems are common in primary care, representing about 20% of all consultations, although these disorders often are not given the same priority as conditions such as cancer or cardiovascular disease. More years are lived with a musculoskeletal disability than any other condition. These patients often have other co‐morbidities such as depression and cardiovascular disease. Increasing life expectancy and risk factors such as obesity mean that larger numbers of patients with musculoskeletal problems will require help from health and social services in the future. The challenge is to fill gaps and improve co‐ordination of care within existing resources.

Who should be referred to secondary care?

The GP is often viewed as the gatekeeper to secondary care. A more modern and helpful approach is to consider both vertical (with secondary care) and horizontal integration of care, involving primary care‐based agencies such as physiotherapy and social care working together rather than in isolation to deliver individualized care.

Waiting times for new rheumatology appointments vary widely and depend on local resources but also, to some extent, on how clinicians triage referrals from GPs. The majority of patients seen in primary care will have non‐inflammatory problems such as osteoarthritis or back pain and most can be managed in primary care with appropriate advice and education or referral to primary care physiotherapy.

Effective triage depends largely upon the information contained in the referral letter. The GP is well placed to give an overall picture of the patient, particularly including psychosocial as well as biomedical issues. Recognizing and dealing with them is known to improve patient outcomes, reduce costs and increase efficiency. Helpful information to include in a referral letter is given in Box 1.1.

Box 1.1 Important information to include in a referral letter

Length of history

Pattern of joint involvement

The presence of joint swelling and/or stiffness

Referrals for and response to previous treatments

Results of investigations

Distress or disability – results of screening tools such as STarT Back

Significant co‐morbidity and risk factors

Other medical and psychosocial issues

A number of simple tools, such as the STarTBack tool for low back pain (Hill et al., 2011), are starting to be employed in primary care to quickly screen patients to identify which are at low risk of poor outcome and require minimal intervention and which may benefit from onward referral so that matched packages based on need can be implemented. The STarTBack tool is highlighted in Box 1.2.

Box 1.2 The STarTBack tool for back pain

Questions 1–8: tick box for agree/disagree

No

Yes

1

 My back pain has spread down my leg(s) at some time in the last 2 weeks

◻

◻

2

 I have had pain in the shoulder or neck at some time in the last 2 weeks

◻

◻

3

 I have only walked short distances because of my back pain

◻

◻

4

 In the last 2 weeks, I have dressed more slowly than usual because of back pain

◻

◻

5

 It’s not really safe for a person with a condition like mine to be physically active

◻

◻

6

 Worrying thoughts have been going through my mind a lot of the time

◻

◻

7

 I feel that my back pain is terrible and it’s never going to get any better

◻

◻

8

 In general, I have not enjoyed all the things I used to enjoy

◻

◻

9

 Overall, how bothersome has your back pain been in the last 2 weeks? (Not at all/Slightly/Moderately/Very much/Extremely) (score 1 for ‘very much/extremely’)

◻

◻

A total score of <3 = low risk, total score ≥4 = medium/high risk. (medium risk = scores from items 5–9 of ≤3, high risk = scores from items 5–9 of 4 or more).

Source: www.keele.ac.uk/sbst

A key challenge for the GP is how to spot the small number of patients with early inflammatory arthritis who will benefit from early secondary care and prompt treatment with disease‐modifying drugs (DMARDs). There are no specific examination or investigation findings that are diagnostic for rheumatoid arthritis (RA). Normal blood test results or a negative rheumatoid factor do not rule out RA but a positive test is not diagnostic of it either. Box 1.3 gives some clinical features that may be suggestive of inflammatory arthritis. The recent NICE standards of care emphasize the importance of rapid secondary care referral for all patients suspected of having rheumatoid arthritis (NICE, 2013).

Box 1.3 Features suggestive of inflammatory arthritis

Stiffness

of joints – especially early morning stiffness for >30 minutes.

Swelling

(synovitis) of any joints – especially wrists and/or metocarpophalangeal (MCP) joints and/or proximal interphalangeal (PIP) joints.

Squeezing

the affected joints is painful.

Given that the diagnosis of early inflammatory arthritis can be difficult, it is a good idea to refer too many rather than too few patients. Many rheumatology services operate an interface service or early synovitis clinic so access to early triage and diagnosis is facilitated.

An alternative method when considering secondary care referral, which may be useful in primary care, involves using the ‘red flag’ approach to identify patients with potentially serious pathology. Red flags are highlighted in Box 1.4 and may prompt consideration of further investigation or referral.

Box 1.4 ‘Red flags’ for regional pain syndromes

History of significant trauma

Fracture

Major soft tissue injury

Localized joint swelling and/or redness

Septic arthritis

Inflammatory arthritis

Haemarthrosis

Unremitting night pain

Malignancy

Inflammation/infection

Bone tenderness

Fracture

Malignancy

Infection

Systemic disturbance

Weight loss

Fever

Significant co‐morbidity

Previous malignancy

Patients with ‘red flags’ and certain other patients with specific diagnoses, including suspected inflammatory arthritis or connective tissue disorders, should be considered for referral to secondary care for further investigation and management. The next step is to decide how best to manage the remainder (the majority) of patients consulting with musculoskeletal problems. Many can be managed in primary care or may be referred to musculoskeletal interface services.

Musculoskeletal interface services