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American Family Physician Nov 2020Gout is caused by monosodium urate crystal deposition in joints and tissues. Risk factors include male sex; obesity; hypertension; alcohol intake; diuretic use; a diet... (Review)
Review
Gout is caused by monosodium urate crystal deposition in joints and tissues. Risk factors include male sex; obesity; hypertension; alcohol intake; diuretic use; a diet rich in meat and seafood; chronic kidney disease; a diet heavy in fructose-rich food and beverages; being a member of certain ethnic groups, including Taiwanese, Pacific Islander, and New Zealand Maori; and living in high-income countries. Gout is characterized by swelling, pain, or tenderness in a peripheral joint or bursa, including the development of a tophus. Diagnosis of gout can be made using several validated clinical prediction rules. Arthrocentesis should be performed when suspicion for an underlying septic joint is present; synovial fluid or tophus analysis should be performed if the diagnosis is uncertain. Colchicine, nonsteroidal anti-inflammatory drugs, and corticosteroids relieve pain in adults with acute gout episodes. Indications for long-term urate-lowering therapy include chronic kidney disease, two or more flare-ups per year, urolithiasis, the presence of tophus, chronic gouty arthritis, and joint damage. Allopurinol and febuxostat are used to prevent flare-ups, although febuxostat is associated with an increase in all-cause and cardiovascular mortality and is therefore not routinely recommended.
Topics: Adrenal Cortex Hormones; Allopurinol; Colchicine; Febuxostat; Gout; Gout Suppressants; Humans; Obesity; Risk Factors; Sex Factors; Uric Acid
PubMed: 33118789
DOI: No ID Found -
The Journal of the American Academy of... Mar 2021Septic arthritis continues to present challenges regarding the clinical diagnosis, workup, and definitive management. Urgent management is essential, so treating...
Septic arthritis continues to present challenges regarding the clinical diagnosis, workup, and definitive management. Urgent management is essential, so treating surgeons must efficiently work through differential diagnoses, identify concomitant infections, and do a timely irrigation and débridement. The incidence of methicillin-resistant Staphylococcus aureus is increasing, typically resulting in a more rapid progression of symptoms with more severe clinical presentation. The diagnostic utility of MRI has resulted in improved detection of concomitant septic arthritis and osteomyelitis, although MRI must not substantially delay definitive management. Early diagnosis followed by urgent irrigation and débridement and antibiotic therapy are essential for satisfactory long-term outcomes. Antibiotics should not be administered until blood cultures and arthrocentesis fluid are obtained, except in rare cases of a septic or toxic patient. Once cultures are obtained, empiric antibiotic therapy should commence and provide coverage for the most likely pathogens, given the patient's age. Laboratory markers, especially C-reactive protein, should be followed until normalization and correlate with resolution of clinical symptoms. Definitive antibiotic selection should be shared with a pediatric infectious disease specialist, who can help guide the duration of treatment.
Topics: Anti-Bacterial Agents; Arthritis, Infectious; Child; Humans; Magnetic Resonance Imaging; Methicillin-Resistant Staphylococcus aureus; Osteomyelitis; Retrospective Studies; Staphylococcal Infections
PubMed: 33273402
DOI: 10.5435/JAAOS-D-20-00835 -
International Journal of Oral and... Sep 2022Temporomandibular disorders (TMD) impact a significant proportion of the population. Given the range of management strategies, contemporary care should be... (Review)
Review
Temporomandibular disorders (TMD) impact a significant proportion of the population. Given the range of management strategies, contemporary care should be evidence-informed for different TMD types. A knowledge-to-action rapid review of systematic reviews published in the past 5 years and guidelines published in the past 10 years concerning the management of TMD was conducted. The Cochrane, Embase, MEDLINE, PEDro, and PubMed databases were searched. A qualitative data analysis was undertaken, with quality assessment completed using the AMSTAR 2 checklist. In total, 62 systematic reviews and nine guidelines considering a range of treatment modalities were included. In concordance with current guidelines, moderate evidence supports a multi-modal conservative approach towards initial management. Contrary to existing guidelines, occlusal splint therapy is not recommended due to a lack of supporting evidence. The evidence surrounding oral and topical pharmacotherapeutics for chronic TMD is low, whilst the evidence supporting injected pharmacotherapeutics is low to moderate. In concordance with current guidelines, moderate quality evidence supports the use of arthrocentesis or arthroscopy for arthrogenous TMD insufficiently managed by conservative measures, and open joint surgery for severe arthrogenous disease. Based on this, a management pathway showing escalation of treatment from conservative to invasive is proposed.
Topics: Arthrocentesis; Humans; Occlusal Splints; Systematic Reviews as Topic; Temporomandibular Joint Disorders
PubMed: 35339331
DOI: 10.1016/j.ijom.2021.11.009 -
Dental and Medical Problems 2022Ultrasound (US) is a widely available, low-cost, non-invasive, and safe medical imaging method that enables real-time observation. Ultrasound offers several advantages... (Review)
Review
Ultrasound (US) is a widely available, low-cost, non-invasive, and safe medical imaging method that enables real-time observation. Ultrasound offers several advantages for dentomaxillofacial images, such as portability, the possibility of dynamic and repeated examinations, patient comfort, and availability. It is a useful tool for recognizing the temporomandibular joint (TMJ) structures and their involvement during the course of different pathological processes, such as articular disk displacement, joint effusion and cortical erosion. In addition to its diagnostic use, US has been proposed as an auxiliary tool in minimally invasive procedures for arthrogenic temporomandibular disorders (TMD) to achieve an accurate puncture, recognize joint spaces and reduce surgical trauma. While US is widely used for large joints to visualize internal structures and guide the injection, this technique has only recently gained popularity for the TMJ procedures. Hence, the literature on this topic is scarce. The present review describes the potential advantages and the clinical technique of US guidance for TMJ arthrocentesis and intra-articular injection (IAI).
Topics: Humans; Arthrocentesis; Temporomandibular Joint; Temporomandibular Joint Disorders; Ultrasonography; Injections, Intra-Articular
PubMed: 36583838
DOI: 10.17219/dmp/146820 -
International Journal of Molecular... Jul 2021Temporomandibular joint osteoarthritis (TMJ OA) is a low-inflammatory disorder with multifactorial etiology. The aim of this review was to present the current state of...
Mechanisms of Action and Efficacy of Hyaluronic Acid, Corticosteroids and Platelet-Rich Plasma in the Treatment of Temporomandibular Joint Osteoarthritis-A Systematic Review.
Temporomandibular joint osteoarthritis (TMJ OA) is a low-inflammatory disorder with multifactorial etiology. The aim of this review was to present the current state of knowledge regarding the mechanisms of action and the efficacy of hyaluronic acid (HA), corticosteroids (CS) and platelet-rich plasma (PRP) in the treatment of TMJ OA.: The PubMed database was analyzed with the keywords: "(temporomandibular joint) AND ((osteoarthritis) OR (dysfunction) OR (disorders) OR (pain)) AND ((treatment) OR (arthrocentesis) OR (arthroscopy) OR (injection)) AND ((hyaluronic acid) OR (corticosteroid) OR (platelet rich plasma))". After screening of 363 results, 16 studies were included in this review. Arthrocentesis alone effectively reduces pain and improves jaw function in patients diagnosed with TMJ OA. Additional injections of HA, either low-molecular-weight (LMW) HA or high-molecular-weight (HMW) HA, or CS at the end of the arthrocentesis do not improve the final clinical outcomes. CS present several negative effects on the articular cartilage. Results related to additional PRP injections are not consistent and are rather questionable. Further studies should be multicenter, based on a larger group of patients and should answer the question of whether other methods of TMJ OA treatment are more beneficial for the patients than simple arthrocentesis.
Topics: Adolescent; Adrenal Cortex Hormones; Adult; Humans; Hyaluronic Acid; Injections, Intra-Articular; Osteoarthritis; Platelet-Rich Plasma; Signal Transduction; Temporomandibular Joint Disorders
PubMed: 34299024
DOI: 10.3390/ijms22147405 -
Journal of Cranio-maxillo-facial... Jan 2020Different treatment options for patients with arthrogenous Temporomandibular Disorders (TMDs) have been reported. However, evidence regarding the most effective... (Meta-Analysis)
Meta-Analysis Review
PURPOSE
Different treatment options for patients with arthrogenous Temporomandibular Disorders (TMDs) have been reported. However, evidence regarding the most effective intervention using network meta-analysis (NMA) has not been performed. Thus, we conducted a NMA of randomized clinical trials (RCTs) to identify the most effective treatment of arthrogenous TMDs with respect to pain reduction and improved mouth opening, and to generate a ranking according to their effectiveness.
MATERIAL AND METHODS
An electronic search on three major databases was undertaken to identify RCTs published before August 2019, comparing up to fourteen different treatments against control/placebo patients for arthrogenous TMDs with respect to pain reduction and improved mouth opening. The treatment variables were controls/placebo, conservative treatment (muscle exercises and occlusal splint therapy), occlusal splint therapy alone, intraarticular injection (IAI) of hyaluronic acid (HA) or corticosteroid (CS), arthrocentesis with or without HA, CS and platelet-rich plasma (PRP), arthroscopy with or without HA and PRP, open joint surgery, and physiotherapy. Frequentist NMA was performed using STATA software. Studies meeting the inclusion criteria were divided according to the length of follow-up (short-term (≤5 months) and intermediate-term (≥6 months to 4 years) and type of TMJ arthrogenous disorders; internal derangement (ID) and TMJ osteoarthritis (OA). The standardized mean differences (SMD) in post-treatment pain reduction and maximum mouth opening (MMO) were analysed.
RESULTS
Thirty-six RCTs were identified that performed comparative outcome assessments for pain and 33 RCTs for MMO. At the short term (≤5 months), IAI-HA (SMD = -2.8, CI: -3.7 to -1.8) and IAI-CS (SMD = -2.11, CI: -2.9 to -1.2) (all very low quality evidence) achieved a substantially greater pain reduction than control/placebo. At intermediate term (≥6 months), a statistically significant decrease in posttreatment pain intensity was observed following Arthroscopy-PRP (SMD = -3.5, CI: -6.2 to -0.82), Arthrocentesis-PRP (SMD = -3.08, CI: -5.44 to -0.71), Arthroscopy-HA (SMD = -3.01, CI: -5.8 to -0.12), TMJ surgery (SMD = -3, CI: -5.7 to -0.28), IAI-HA (SMD = -2.9, CI: -4.9 to -1.09) (all very low quality evidence), Arthroscopy-alone (SMD = -2.6, CI: -5.1 to -0.07, low quality evidence) and Arthrocentesis-HA (SMD = -2.3, CI: -4.5 to -018, moderate-quality evidence) when compared to the control/placebo groups. Relative to MMO, the most effective treatments for short- and intermediate-term improvement were the arthroscopy procedures (PRP > HA > alone, all very low-quality evidence) followed by Arthrocentesis-PRP (very low-quality evidence) and Arthrocentesis-HA (moderate-quality evidence). The non-invasive procedures of occlusal splint therapy, physical therapy, conservative therapy, placebo/control provided significantly lower quality outcomes relative to pain and MMO.
CONCLUSION
The results of the present meta-analysis support a paradigm shift in arthrogenous TMJ disorder treatment. There is a new evidence (though on a very low to moderate quality level) that minimally invasive procedures, particularly in combination with IAI of adjuvant pharmacological agents (PRP, HA or CS), are significantly more effective than conservative treatments for both pain reduction and improvement of MMO in both short (≤5 months) and intermediate term (6 months-4 years) periods. In contrast to traditional concepts mandating exhaustion of conservative treatment options, minimally invasive procedures, therefore, deserve to be implemented as efficient first-line treatments (e.g. IAIs and/or arthrocentesis) or should be considered rather early, i.e. as soon as patients do not show a clear benefit from an initial conservative treatment.
Topics: Arthrocentesis; Humans; Injections, Intra-Articular; Network Meta-Analysis; Randomized Controlled Trials as Topic; Temporomandibular Joint Disorders
PubMed: 31870713
DOI: 10.1016/j.jcms.2019.10.004 -
Current Opinion in Pediatrics Jun 2023The aim of this article is to review the recent guidelines and literature regarding the diagnosis and the treatment of common pediatric musculoskeletal infections:... (Review)
Review
PURPOSE OF REVIEW
The aim of this article is to review the recent guidelines and literature regarding the diagnosis and the treatment of common pediatric musculoskeletal infections: septic arthritis, osteomyelitis, pyomyositis, and Lyme disease.
RECENT FINDINGS
In the last decade, a better understanding of the causative organisms of common bacterial infections, including Kingella , leads to prompt targeted antimicrobial coverage in all musculoskeletal infections. Prompt diagnosis and treatment continues to be the mainstay in the treatment of children with osteoarticular infections. Efforts to improve early detection have lead to improving rapid lab diagnostic testing; however, more advanced diagnostics such as arthrocentesis for septic arthritis and MRI for osteomyelitis and pyomyositis, remain the gold standard. Shorter and narrowed antibiotic courses, with appropriate transition to outpatient oral treatment provide effective infection clearance and reduction in complications of disease.
SUMMARY
Advances in diagnostics, including pathogen identification as well as imaging continues to improve our ability to diagnose and treat these infections, although still lack ability to provide definitive diagnosis without more invasive nor advanced techniques.
Topics: Child; Humans; Pyomyositis; Osteomyelitis; Arthritis, Infectious; Anti-Bacterial Agents; Bacterial Infections
PubMed: 36802036
DOI: 10.1097/MOP.0000000000001234 -
Deutsches Arzteblatt International Jan 2022Involvement of the temporomandibular joint can be shown in 40-90% of patients with rheumatoid arthritis and juvenile idiopathic arthritis (JIA), although it is often...
BACKGROUND
Involvement of the temporomandibular joint can be shown in 40-90% of patients with rheumatoid arthritis and juvenile idiopathic arthritis (JIA), although it is often asymptomatic. Restricted jaw mobility and jaw pain can be found in approximately 20% of patients with JIA (prevalence: 70 per 100 000 persons). Early diagnosis and treatment of the underlying disease are essential for a good outcome, but uniform, consensus-based management is still lacking.
METHODS
The clinical practice guideline is based on the findings of a systematic literature review in multiple databases and a Delphi procedure to obtain consensus on the recommendations.
RESULTS
Most of the identified studies were retrospective. Patients with JIA should undergo clinical screening with a structured examination protocol once per year in childhood and adolescence, and thereafter as well if the temporomandibular joint is involved. The diagnosis of chronic rheumatoid arthritis of the temporomandibular joint is established with contrast-enhanced magnetic resonance imaging. Conservative treatment (antirheumatic basal therapy, local measures) is unsuccessful in less than 10% of patients. In such cases, arthroscopy and arthrocentesis can be used for temporary symptom relief and functional improvement. Intra-articular corticosteroid injections should be given only once, and only in otherwise intractable cases. In severe cases where all other options have been exhausted (<1%), open surgical treatment can be considered, including alloplastic joint replacement.
CONCLUSION
Oligosymptomatic and asymptomatic cases are common even with radiologic evidence of marked joint damage. The possibility of rheumatic involvement of the temporomandibular joint must be kept in mind so that serious complications can be avoided. Regular clinical evaluation of the temporomandibular joint is recommended, particularly for patients with juvenile idiopathic arthritis.
Topics: Adolescent; Arthritis, Juvenile; Arthritis, Rheumatoid; Humans; Magnetic Resonance Imaging; Retrospective Studies; Temporomandibular Joint; Temporomandibular Joint Disorders
PubMed: 34874262
DOI: 10.3238/arztebl.m2021.0388