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Dupuytren’s Contracture

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1 Dupuytren’s Contracture

2 Dupuytren’s Contracture
Fibrous tissue of the palmar fascia to shorten and thicken Common in men older than 40 years; in persons of Northern European descent; and in persons who smoke, use alcohol, or have diabetes (3 to 33 %) Present with a small, pitted nodule (or multiple nodules) on the palm, which slowly progresses to contracture of the fingers Progresses' faster in <50 yr olds Smoking and alcohol use increase the chance that surgery will be needed

3 Dupuytren’s Contracture
Found on the palm of the hand proximal to the metacarpo-phalangeal (MCP) joint. Can be bilateral Patients usually have difficulty with tasks such as face washing, hair combing, and putting their hands in their pockets. Note the site of the nodule and the presence of contractures; bands; and skin pitting, tenderness, and dimpling. Grade 1 disease presents as a thickened nodule and a band in the palmar aponeurosis; this band may progress to skin tethering, puckering, or pitting. Grade 2 presents as a peritendinous band, and extension of the affected finger is limited. Grade 3 presents as flexion contracture

4 Fibromyalgia

5 Characteristic features:
Chronic widespread pain for at least three monthsTender points in 11 of 18 specific anatomic locations Associated features Anxiety Cognitive difficulties Fatigue Headache (50%) (migraine)* Paresthesias, morniing stiffness Sleep disturbance *?a defect in the serotonergic and adrenergic systems

6 Associated Findings History of trauma, childhood abuse, anxiety, depression, or sleep disorder (alpha frequency rhythm, termed alpha-delta sleep anomaly ) Patients with high tender point counts are more likely to report adverse childhood experiences like loss of a parent or abuse Irritable bowel syndrome (IBS) Other disorders commonly associated with FM include: Irritable bladder Dysmenorrhea Premenstrual syndrome Restless leg syndrome Temporomandibular joint pain Noncardiac chest pain Raynaud's phenomenon and Sicca syndrome (Sjogren’s)

7 Other Diagnoses/Associated
Myofascial pain syndrome, Chronic fatigue syndrome, and Hypothyroidism.

8 Myofascial pain syndrome
Characterized by painful, tender areas in the muscles. It is a localized disorder without any systemic manifestations. It commonly affects the axial muscles. In contrast to the widespread pain of fibromyalgia, the pain in myofascial pain syndrome arises from trigger points in individual muscles. On examination, the presence of trigger points is characteristic of myofascial pain syndrome.

9 Chronic fatigue syndrome (CFS)
Chronic pain and fatigue are common to chronic fatigue syndrome and fibromyalgia. CFS an ongoing subclinical inflammatory process manifested by low-grade fever, lymph gland enlargement, and acute onset of the illness, whereas there is no evidence of inflammatory response in fibromyalgia.

10 Hypothyroidism Manifested by profound fatigue, muscle weakness, and generalized malaise, closely resembles fibromyalgia. Patients need to be examined for clinical signs of thyroid dysfunction and, if in doubt, thyroid function tests should be ordered to rule out hypothyroidism. (The differential diagnosis also might include metabolic and inflammatory myopathies (especially in patients taking statins), polymyalgia rheumatica, and other rheumatic diseases. )

11 optimal intervention is an approach that also includes nonpharmacologic treatments, specifically exercise and cognitive behavior therapy education, cognitive behavior strategies, physical training, and medications for treatment of fibromyalgia

12 Multi symptom condition
FIBROMYALGIA-Review Multi symptom condition

13 Multi symptom condition characterized by chronic widespread pain
Muscular pain Fatigue Sleep abnormalities Joint pain Headaches Restless legs Numbness Impaired memory Leg cramps Impaired concentration Nervousness Major depression

14 Patient-Reported Symptoms at Diagnosis of Fibromyalgia


16 Features 3 months or longer in all 4 quadrants of the body, but not centered in the joints Lower pain threshold: Allodynia-pain from normally non noxious stimuli Hyperalgesia-increased response to painful stimuli Under diagnosed and undertreated (Prevalence:2% to 4%)/ Onset usually at 20 to 55 years/ F:M 9:1 First-degree relatives of FM patients have 8 times the risk

17 ?etiology Pain amplification
Lower levels of metabolites of serotonin and norepinephrine in their cerebrospinal fluid Increased levels of pro-nociceptive transmitters substance P and glutamate that amplify pain impulses

18 No objective laboratory test or marker
exists, diagnosis is based on history and physical examination Chronic Widespread Pain for at least 3 months and pain on at least 11 of 18 specified muscle tendon sites of focal tenderness (“tender points” 11/18) Use of a structured interview with questions about generalized fatigue, headache, sleep disturbance, neuropsychiatric complaints, numbness or tingling, and irritable bowel symptoms.


20 ?TREATMENT Eval Criteria
SYMPTOM CRITICAL FOR EVAL% Pain 100 Fatigue 94 Patient global improvement Multidimensional function 86 Tenderness 74 Sleep 66 Health-related quality of life 65 Dyscognition 61 Stiffness 60

21 Current Knowledge About Pharmacotherapies
‘Off label’ SNRIs Anticonvulsants Tricyclic antidepressants (TCAs) Muscle relaxants SSRIs Opioids Nonsteroidal anti- inflammatory drugs (NSAIDs) and Cyclo-oxygenase (COX2) inhibitors FDA ‘approved’ Pregabalin(Lyrica) Duloxetine Hydrochloride (Cymbalta) Milnacipran Hydrochloride(Savella)

22 Duloxetine Hydrochloride (Cymbalta) Milnacipran Hydrochloride
Pregabalin (Lyrica) Duloxetine Hydrochloride (Cymbalta) Milnacipran Hydrochloride (Savella) Alpha2 receptor SNRI mg bid 75 mg bid May increase to 150 mg bid within 1 wk Maximum dose 225 mg bid 60 mg/d Start 30 mg/d for 1 wk, increase to 60 mg/d 50 mg bid (start 12.5 mg/d, increase on day 2 to 12.5 mg bid, on day 4 to 25 mg bid, after day 7 to 50 mg bid) Maximum dose 200 mg/d Angioedema, hypersensitivity reactions, peripheral edema Suicidality, orthostatic hypotension, serotonin syndrome Dizziness, somnolence, dry mouth, edema, blurred vision, weight gain, difficulty with concentration/attention Nausea, dry mouth, constipation, somnolence, hyperhidrosis, decreased appetite Nausea, headache, constipation, dizziness, insomnia, hot flush, hyperhidrosis, vomiting, palpitations, heart rate increase, dry mouth, hypertension

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