AFP Journal Review December 1, 2012

1. Lianne Beck, MD Assistant Professor Emory Family Medicine AFP Journal Review December 1, 2012

2. Articles • Treatment and Prevention of Kidney Stones: An Update • Diagnosis and Management of Rheumatoid Arthritis • Personality Disorders: Review and Clinical Application in Daily Practice • Management of Falls in Older Persons: A Prescription for Prevention

3. Treatment and Prevention of Kidney Stones: An Update • 10-15% risk in the US • Risk factors include obesity, insulin resistance, gastrointestinal pathology, living in warmer climates, certain dietary patterns and medications • Clinical presentation: Cramping, intermittent abdominal and flank pain, hematuria, nausea or vomiting, and malaise; fever and chills. May be asymptomatic

5. DDX • UTI/pyelonephritis • Interstitial cystitis, vaginitis, prostatitis • Cholelithiasis, cholecystitis • Musculoskeletal • PID • Renal or bladder neoplasm

6. DIAGNOSTIC WORK UP • UA • Urine cultures if febrile or leukocytes on UA • Plain radiograph. Uric acid stones and stones associated with protease inhibitor use may not be visible on a radiograph • US or spiral computed tomography can detect all types of kidney stones and may be necessary if the diagnosis is in question.

7. When to Refer • > 1 stone • Sx’s worsen with fever • Renal function is impaired • Stone passage is prolonged • Hydronephrosis • Pregnant • Stone is larger than 5 mm

9. Further Evaluation • History: IBD, bowel surgery, gout, DM, obesity or recent changes in weight, metabolic syndromes, hyperparathyroidism-associated conditions, frequent UTIs, CKD • Family History • Medications • 24-hour urine for calcium, phosphorus, magnesium, uric acid, and oxalate to determine stone composition • Serum Ca, Mg, Phos • Urine pH and specific gravity • Stone analysis

11. Prevention • Depends on the specific type of kidney stone and urine characteristics • All types: • Fluids (sp grav > 1.1015) • Wt loss • Glucose control • Check PTH if serum Ca elevated • Alkalinize or acidify urine based on pH and type of stone

12. Prevention • Calcium oxalate, cystine, and uric acid stones - urine should be alkalinized by eating a diet high in fruits and vegetables, taking supplemental or prescription citrate, or drinking alkaline mineral waters. • Calcium phosphate and struvite stones -urine should be acidified with cranberry juice or betaine.

13. Alkalinize • Potassium citrate: 10 to 20 mEq orally with meals (prescription required) • Calcium citrate: two 500-mg tablets per day with meals (each tablet contains 120 mg of calcium and 6 mEq of bicarbonate) • Acidify • Cranberry juice: at least 16 oz per day • Betaine: 650 mg orally three times per day with meals

14. Can Bacterial Infection Trigger Recurrence? • Bacteria exert both pathogenic and protective roles. • Struvite stones are associated with recurrent infections because of high urinary pH levels from urease splitting bacteria • Oxalobacter formigenes is an anaerobic bacterium that colonizes the intestinal tract, where it metabolizes oxalate to formate and carbon dioxide. • Absence of O. formigenes colonization predisposes persons to oxalate stones

15. Obesity • Weight loss could be detrimental to prevention of kidney stones if associated with a high animal protein diet, laxative abuse, rapid loss of lean tissue, or poor hydration. • High acid diets, such as the Atkins diet, increase the risk of uric acid stones.

16. Fructose • Associated with up to a 38 % higher risk of kidney stones. • Increased fructose intake increases urinary calcium excretion in persons with magnesium deficiency • Fructose is the only dietary carbohydrate known to raise uric acid levels. • Sugar-sweetened beverages and orange juice have been linked to gout.

17. ALTERNATIVE THERAPIES • Acupuncture and chiropractic manipulation may ease stone passage in patients with nerve impingement. • Phytonutrients in green tea, turmeric, and berries may reduce the risk of infection • Parsley may promote diuresis • The herb Agropyron repens may help achieve flushing of the urinary tract

19. Diagnosis and Management of RA • The most common inflammatory arthritis, with a lifetime prevalence of up to 1 % worldwide. • Onset peaks between 30 and 50 years. • In a large U.S. cohort, 35% of patients with RA had work disability after 10 years. • 50% of RA risk attributable to genetic factors • Smoking is the major environmental trigger for RA

20. Pathophysiology • Characterized by inflammatory pathways that lead to proliferation of synovial cells in joints. • Pannus formation leads to underlying cartilage destruction and bony erosions. • Overproduction of proinflammatory cytokines, including TNF and IL-6

21. Risk Factors • Older age • Family history • Female sex • Smoking • Early menarche (RR = 1.3 for those with menarche at 10 years of age or younger) and very irregular menstrual periods (RR = 1.5) increase risk. • Pregnancy often causes RA remission • Multiparity decreases risk • Breastfeeding decreases risk

22. Presentation • Pain and morning stiffness, lasting more than one hour, that involves wrists, proximal interphalangeal joints, and metacarpophalangeal joints • Boggy swelling due to synovitis or subtle synovial thickening may be palpable on joint examination. • Patients may also present with more indolent arthralgias before the onset of clinically apparent joint swelling. • Fatigue, weight loss, low-grade fever may occur with active disease.

23. Figure 1. Boggy swelling in proximal interphalangeal and metacarpophalangeal joints (more prominent on patient's right hand) in a patient with new-onset rheumatoid arthritis. Note that with joint swelling, the skin creases over the proximal interphalangeal joints become less apparent

27. DIAGNOSTIC TESTS • 50 to 80% of persons with RA have RF, anti-CCP, or both. • ANA is of prognostic importance in juvenile forms of this disease. • CRP and ESR are often increased with active RA and used to follow disease activity and response to medication. • CBC, renal and hepatic function • Xray of hands and feet to evaluate for periarticular erosive changes, which may be indicative of a more aggressive RA subtype.

28. DDX • Osteoarthritis • SLE • Systemic sclerosis • Psoriatic arthritis • PMR • Sarcoidosis • Spondyloarthropathy • Viral process • Gout or pseudogout • Fibromyalgia • Thyroid disorders • Vit D deficiency

29. Treatment • DMARDS • Biologic agents: monoclonal antibodies and recombinant receptors block cytokines that promote the inflammation • Nonbiologic agents: • Methotrexate recommended as the first-line treatment in patients with active RA. • Leflunomide (Arava) used as an alternative to methotrexate, although GI adverse effects are more common. • Sulfasalazine (Azulfidine) or hydroxychloroquine (Plaquenil) is recommended as monotherapy in patients with low disease activity or without poor prognostic features (e.g., seronegative, nonerosive RA).

30. DMARDS cont… • Combination therapy with two or more DMARDs is more effective than monotherapy. • If RA is not well controlled with a nonbiologic DMARD, a biologic DMARD should be initiated. • TNF inhibitors are the first-line biologic therapy and are the most studied of these agents. • If TNF inhibitors are ineffective, additional biologic therapies can be considered. • Simultaneous use of more than one biologic therapy (e.g., adalimumab [Humira] with abatacept [Orencia]) is not recommended because of an unacceptable rate of adverse effects.

31. Treatment

33. Others • NSAIDs and corticosteroids only for short-term • CAM: gamma-linolenic acid (from evening primrose or black currant seed oil) and Tripterygium wilfordii (thunder god vine) have potential benefits • Exercise and PT

34. Prognosis • Remission in 10 to 50 % of patients • More likely in males, nonsmokers, <40 yo, late-onset disease (> 65 years), shorter duration of disease, milder disease activity, without elevated acute phase reactants, and without positive RF or anti-CCP. • After the disease is controlled, medication dosages may be cautiously decreased to the minimum amount necessary. • Patients require frequent monitoring to ensure stable symptoms, and prompt increase in medication is recommended with disease flare-ups.

35. Prognosis • Patients with RA live three to 12 years less than the general population. • Increased mortality due to accelerated cardiovascular disease, especially in those with high disease activity and chronic inflammation.

37. Cardiovascular Disease

39. Personality Disorders • DSM IV: “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture.” • The pattern is inflexible and pervasive across a broad range of personal and social situations • Leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning • Stable and of long duration • Onset traceable to at least adolescence or early adulthood

40. Personality Disorders • 9 to 14.8 % of patients have at least one personality disorder • Many patients have multiple personality disorders or traits that span several types of disorders • Significant comorbidity exists with alcohol and chemical abuse, and with anger traits • Personality disorders tend to be stable over time • Treatments: CBT, DBT, mentalization-based therapy, transference-focused psychotherapy, and pharmacotherapy (e.g., typical and atypical antipsychotics, antidepressants, mood stabilizers)

41. Personality Disorder Types • Classified into clusters A, B, and C. • Cluster A: odd or eccentric personalities, includes paranoid, schizoid, and schizotypal personality disorders. • Cluster B: dramatic, emotional, or erratic personalities, includes antisocial, borderline, histrionic, and narcissistic personality disorders. • Cluster C: anxious or fearful, include avoidant, dependent, and obsessive-compulsive personality disorders