Medicine RSS feed: Current Issue. Medicine is a continually updated, evidence based review journal covering internal medicine and its subspecialties. Medicine is an authoritative and comprehensive resource that provides all clinicians, irrespective of specialty, with ready access to up-to-date information on mechanisms of disease, diagnosis and management so that patient care may be optimized. The layout of the Journal, including the extensive use of colour and illustration, enables fast assimilation of key information. For ease of reference, Medicine is available in journal format and online. Medicine has an outstanding Editorial Board, plus an eminent group of 35 Chapter editors and over 750 authors, all of whom are recognized experts in their field. The editorial content of the Journal is assured by a rigorous peer review process. http://www.medicinejournal.co.uk/?rss=yesElsevier Inc.en © 2009 Published by Elsevier Inc. All rights reserved. Medicine1357-3039383March 2010 © 2009 Published by Elsevier Inc. All rights reserved. healthpermissions@elsevier.comhttp://www.medicinejournal.co.uk/article/PIIS1357303910000356/abstract?rss=yesContents10.1016/S1357-3039(10)00035-6Medicine 38, 3 (2010)2010-03-01Medicine2010-03-01383S1357-3039(10)X0003-2OFCOFChttp://www.medicinejournal.co.uk/article/PIIS135730391000037X/abstract?rss=yesEditorial Board10.1016/S1357-3039(10)00037-XMedicine 38, 3 (2010)2010-03-01Medicine2010-03-01383S1357-3039(10)X0003-2iihttp://www.medicinejournal.co.uk/article/PIIS1357303909003284/abstract?rss=yesIt has been estimated that there are over 200 different types of musculoskeletal disorder. Although we cannot cover all of these diverse conditions in this issue of Medicine, a wide range of topics from crystal arthropathies to imaging joints are covered. We are living in a very exciting era for medicine in general and rheumatology in particular. Until recently, the treatments introduced for patients with arthritis were largely ad hoc but are now, by degrees, being replaced by therapies which target individual cells or molecules, because basic research strongly supports the view that they are actually responsible, in part, for the etiopathogenesis of these diseases. Although the best-known examples are the use of the tumour necrosis factor alpha-blockers in the treatment of patients with rheumatoid arthritis, these drugs have also been shown to be helpful in other conditions, including psoriatic arthritis and ankylosing spondylitis. In addition, new approaches are emerging for other diseases, such as the drug febuxostat which is effective in gout. These new drugs are being introduced to supplement and perhaps ultimately replace standard therapies.Rheumatology: introductionDavid Isenberg, Anisur Rahman10.1016/j.mpmed.2009.11.003Medicine 38, 3 (2010)2010-03-01Medicine2010-03-01383S1357-3039(10)X0003-2Introduction125125http://www.medicinejournal.co.uk/article/PIIS1357303909003442/abstract?rss=yesAbstract: Musculoskeletal conditions (MsC) are a major burden to the individual, society and the health service. Approximately 10% of GP consultations are for MsC. Most new consultations are for self-limiting conditions such as soft tissue rheumatism, chronic widespread pain and arthralgia. Incident cases of osteoarthritis are ten times more common than rheumatoid arthritis (RA). The prevalence of MsC is higher in women and rises with age. It is likely that MsC prevalence will continue to rise as life expectancy increases. Costs for MsC include those to healthcare services, to society and indirect costs. One-fifth of all incapacity claims in Great Britain are for MsC. Combined costs for RA patients amount to £7000 per person affected per year. Major hip procedures cost on average £7800 and major knee procedures on average £4471. Risk factors for MsC include age and gender. The prevalence of certain MsC varies depending on ethnicity, lifestyle factors and genetic predisposition. The main consequences of MsC are chronic pain and disability. The burden of MsC is high and the impact of these conditions on the health service and society will continue to rise alongside increasing life expectancy.The burden of musculoskeletal conditionsSarah Parsons, Deborah P.M. Symmons10.1016/j.mpmed.2009.11.007Medicine 38, 3 (2010)2010-03-01Medicine2010-03-01383S1357-3039(10)X0003-2Introduction126128http://www.medicinejournal.co.uk/article/PIIS1357303909003302/abstract?rss=yesAbstract: Rheumatological diseases include conditions that affect only limited regions of the locomotor system and also conditions that can have widespread systemic effects. The rheumatological history must reflect both of these aspects. The main symptoms of joint disease are pain, stiffness, swelling and deformity. It is also important to enquire about functional impairment and resultant disability. Systemic diseases can be associated with non-specific symptoms, such as fever, anorexia and weight loss. A careful systems review is important in eliciting specific symptoms.The rheumatological historyJane E. Dacre, Jennifer G. Worrall10.1016/j.mpmed.2009.11.005Medicine 38, 3 (2010)2010-03-01Medicine2010-03-01383S1357-3039(10)X0003-2Assessment of the rheumatological patient129132http://www.medicinejournal.co.uk/article/PIIS1357303909003296/abstract?rss=yesAbstract: The locomotor system is extensive and locomotor problems are common. The most efficient and effective way to examine the locomotor system is to perform a screening examination, the GALS (gait, arms, legs, spine) screen, followed by a more detailed examination of any abnormal findings. This detailed, regional examination of individual joints follows the principles of ‘look, feel, move, function’.Rheumatological examinationJane E. Dacre, Jennifer G. Worrall10.1016/j.mpmed.2009.11.004Medicine 38, 3 (2010)2010-03-01Medicine2010-03-01383S1357-3039(10)X0003-2Assessment of the rheumatological patient133138http://www.medicinejournal.co.uk/article/PIIS1357303909003272/abstract?rss=yesAbstract: Infection, crystal arthropathies, osteoarthritis, trauma and a variety of systemic diseases can create a painful, swollen peripheral joint of which septic arthritis is the most serious cause. Synovial fluid (SF) analysis is widely used to aid the diagnosis and management of both acute and chronic arthritis, and can be diagnostic in patients with bacterial infections or crystal-induced synovitis. Most native joints can be aspirated by any physician competent to do so, but where there is difficulty, joints can be aspirated under ultrasound guidance. In cases of suspected infected prosthetic joints, these must be referred to the orthopaedic surgeons for aspiration in theatre under strict asepsis. The SF should be sent to the laboratory promptly for microscopy, culture and crystal search using polarized light microscopy. Ordinarily SF is viscous, straw-coloured and essentially acellular, but in diseased states components of the SF can vary in characteristic ways. Although a positive Gram stain and culture can clinch the diagnosis of septic arthritis, the absence of organisms on Gram stain or a negative subsequent synovial fluid culture does not exclude a diagnosis of septic arthritis. A recent systematic review of the literature has shown that, although no investigation had sufficient sensitivity and specificity to confirm the diagnosis of septic arthritis in all cases, the single most useful investigation is synovial fluid microscopy and culture. All doctors in training should gain experience in joint aspiration to save delays in diagnosis.Synovial fluid testsIsraa Al-Shakarchi, Gerald Coakley10.1016/j.mpmed.2009.11.002Medicine 38, 3 (2010)2010-03-01Medicine2010-03-01383S1357-3039(10)X0003-2Assessment of the rheumatological patient139141http://www.medicinejournal.co.uk/article/PIIS1357303909003260/abstract?rss=yesAbstract: Plain radiography plays an important role in the differential diagnosis of arthritis. Rheumatoid arthritis is associated with erosion, osteopenia and soft tissue swelling in a diffuse, bilateral symmetrical distribution in the proximal hands and feet. In contrast, seronegative arthritis shows bony proliferation and often involves the axial skeleton. Radiographic features of osteoarthritis are joint space narrowing, subchondral sclerosis, cysts and osteophytes. Newer techniques of magnetic resonance imaging and ultrasound show great promise for the early detection of arthritis and the demonstration of early response to treatment.ImagingR. Hodgson, P.J. O'Connor10.1016/j.mpmed.2009.11.001Medicine 38, 3 (2010)2010-03-01Medicine2010-03-01383S1357-3039(10)X0003-2Assessment of the rheumatological patient142145http://www.medicinejournal.co.uk/article/PIIS1357303909003430/abstract?rss=yesAbstract: Crystal arthropathies are a diverse group of disorders characterized by deposition of various minerals in joints and soft tissues leading to inflammation. The patterns of presentation for different types of crystal arthritis are often characteristic enough to differentiate them from each other and from other types of inflammatory arthropathies, but mistakes can be made, leading to delayed or incorrect management. Gout is the most common of all the crystal arthropathies, and its prevalence and clinical complexity appear to be increasing. In addition to gout, which is caused by monosodium urate crystal precipitation, two other main crystal types can be associated with inflammatory symptoms because of their deposition in and around joints. These are calcium pyrophosphate dihydrate, which causes pseudogout, and basic calcium phosphate (BCP/hydroxyapatite). The most accurate way of diagnosing the common forms of crystal-associated arthritis is through the identification of specific crystal types in synovial fluid, although this is less reliable for BCP. Crystal arthritis can cause severe pain, and management generally revolves around the control of acute flares, followed by prevention of recurrent episodes, where possible. For many years the prophylaxis of gout has depended largely on the use of allopurinol, but new drugs such as febuxostat may prove to be useful for those patients who cannot tolerate allopurinol. Biologic treatments are similarly providing exciting novel treatment strategies as the pathophysiology of the disorder becomes better understood.Crystal arthropathiesSpencer Ellis, G. Koduri10.1016/j.mpmed.2009.11.006Medicine 38, 3 (2010)2010-03-01Medicine2010-03-01383S1357-3039(10)X0003-2Crystal arthropathies146150http://www.medicinejournal.co.uk/article/PIIS1357303909003454/abstract?rss=yesAbstract: Osteoarthritis (OA) is the most common form of joint disease, and its impact is set to grow as the prevalence of obesity rises and our elderly population increases. Many clinicians regard OA as being simply a disease of ‘wear and tear’, and by implication one in which disease modification is not possible. Such prejudices have led to significant academic apathy in this disease, which is reflected not only in our poor understanding of disease pathogenesis but also in the accurate classification of disease, and the development of sensitive tools for diagnosis and prognostic assessment. The recent identification of key degradative enzymes in cartilage, and the use of mouse models to study disease pathogenesis have greatly changed our outlook. The next decade is likely to see significant advances in our understanding of and treatment for this condition.OsteoarthritisTonia L. Vincent, Fiona E. Watt10.1016/j.mpmed.2009.11.008Medicine 38, 3 (2010)2010-03-01Medicine2010-03-01383S1357-3039(10)X0003-2Osteoarthritis151156http://www.medicinejournal.co.uk/article/PIIS1357303909003612/abstract?rss=yesSport and exercise medicine is the UK's youngest medical speciality, having been granted speciality status in 2005. For many years sports physicians have provided medical support to elite sportspersons. However, there is now a concerted effort to deliver sports medicine to recreational sportspersons, and to develop the emerging concept of exercise medicine – making health-enhancing physical activity available to the whole nation. People who train seriously and compete in their sport are frequently injured. The most common injuries are to muscle, tendon or bone. In recent years the mechanisms underlying the capacity of musculoskeletal tissues to regenerate from injury have been elucidated. With increased understanding of the pathophysiology of injury, directed therapeutic technologies such as platelet-rich plasma, which utilizes the body's own healing mechanisms, have been developed. It is not just injuries from which people engaging in exercise can suffer. Although the benefits of regular moderate-intensity exercise on morbidity and mortality are uncontestable, people who engage in more intensive exercise can develop difficulties with the respiratory, cardiac and endocrine systems, but these problems can usually be dealt with by a sport and exercise medicine physician. Finally, health-enhancing physical activity by the UK population is being encouraged in order to prevent morbidity from obesity and type 2 diabetes.What's new in… Sport and exercise medicineLeon Creaney10.1016/j.mpmed.2009.12.001Medicine 38, 3 (2010)2010-03-01Medicine2010-03-01383S1357-3039(10)X0003-2What's new157161http://www.medicinejournal.co.uk/article/PIIS1357303910000150/abstract?rss=yes in the UK the incidence (new-onset diagnosis) of osteoarthritis (OA) and rheumatoid arthritis (RA) is approximately the sameSelf-assessment/CPD10.1016/j.mpmed.2010.01.001Medicine 38, 3 (2010)2010-03-01Medicine2010-03-01383S1357-3039(10)X0003-2Self assessment162162