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Am Fam Physician. 1999;59(6):1679

Rheumatoid Arthritis

(Great Britain—The Practitioner, November 1998, p. 743.) Symptoms of rheumatoid arthritis may present suddenly or may take years to develop into a full clinical picture. The distinction between rheumatoid arthritis and degenerative arthritis is based on the pattern of joint involvement and swelling, the duration of morning stiffness and the absence of an association with activity. Although rheumatoid factor and radiographic changes may be present early in the disease process, neither of these signs is required for diagnosis since it is based on clinical features. The course of rheumatoid arthritis is extremely variable, with risk factors for a poor prognosis including female sex, family history, insidious onset, extra-articular disease, early bone erosion and certain biochemical markers, such as rheumatoid factor. First-line therapy is based on lifestyle modification plus use of nonsteroidal anti-inflammatory drugs and analgesics as needed. Second-line drugs include sulfasalazine, methotrexate and gold. Corticosteroids may be useful in selected patients. Areas of increasing emphasis include involving patients and their families in therapeutic decisions and the potential availability of new drugs.

Chronic Urticaria

(Canada—Canadian Family Physician, October 1998, p. 2170.) Up to 20 percent of adults experience urticaria, but the condition becomes chronic (lasting more than six weeks) in only about one quarter of cases. Approximately one half of all patients with chronic urticaria experience angioedema, which may result in gross swelling of the face or even compromise of the airway. Most cases of chronic urticaria are believed to be autoimmune-related, and the condition is often associated with other autoimmune conditions, such as pernicious anemia, thyroiditis, vitiligo and adrenal dysfunction. The first line of management is to seek and eliminate any external cause or precipitant. Treatment is based on antihistamines in a dosage sufficient to block histamine H1 receptors while causing minimal adverse effects (such as sedation or anticholinergic effects). In severe cases, short courses of prednisone are useful. Toxic agents are not recommended for prolonged treatment of this benign condition. Patients with chronic urticaria should avoid using angiotensin converting enzyme inhibitors, nonsteroidal anti-inflammatory drugs, alpha blockers and beta blockers.

Adolescents with Mentally Ill Parents

(Australia—Australian Family Physician, November 1998, p. 987.) An unknown number of teenagers live with a parent who is mentally ill. At a time when their peers are establishing independence, these adolescents often have increased responsibility for housekeeping, care of younger siblings and other roles that are usually fulfilled by parents. They also frequently avoid seeking support outside the family because of fear or shame about exposing family problems to outsiders. They are particularly unlikely to reveal family problems to their peers because of fear of rejection. Support groups have had some success in enabling adolescents with a mentally ill parent to cope with added responsibilities and to maintain relationships and fulfill responsibilities outside the family. In addition to encouraging these adolescents to pursue their own needs and aspirations, support groups may help them avoid becoming overwhelmed by their situation and to recognize that they are not responsible for the parent's mental condition.

Causes of Localized Hair Loss in Children

(Australia—Australian Family Physician, October 1998, p. 954.) The most common cause of localized alopecia in children is repeated hair-pulling (trichotillomania), which produces irregularly shaped areas of incomplete alopecia containing damaged hairs of various lengths. The scalp usually appears normal but may show petechiae or pustules secondary to trauma. The scalp also appears normal in children with alopecia areata, but this condition produces a clearly circumscribed area of complete hair loss bordered by pathognomonic “exclamation point” hairs that are wider at the tip than close to the scalp. Hair loss that is secondary to dermatophyte scalp infection (tinea capitis) is associated with inflammation and scaling of the scalp with broken infected hairs either at the scalp level or close to the hair root. The scalp may appear to have black dots, which are caused by the stubble of broken hairs. Alopecia that is present from birth may result from in utero scarring (aplasia cutis) or nevus sebaceous, which has an orange, velvety appearance and becomes more prominent and wart-like during adolescence because of increased sebaceous activity.

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