By E. Gelford. Tennessee Technological University.
If a patient sufers from more serious skin fndings such as vasculitis discount toradol 10mg amex, their disease may war- rant systemic management discount 10 mg toradol mastercard. Treatment needs to be aggressive and may require higher dose corticosteroids or even cyclophosphamide buy 10 mg toradol fast delivery. Treatment of dry skin in Sjogrens syndrome is similar to managing xerosis in other conditions generic 10mg toradol visa. The patient should moisturize with a fragrance-free cream moisturizer once or twice a day. Moisturizing is performed immediately afer bathing or showering, while the skin is still damp, to prevent further evaporation from the skin. Sometimes in cases of ex- treme dryness, an ointment is suggested, for its barrier and protective properties (such as petrolatum jelly or Aquaphor). If this is used, then application should be onto damp skin, 8 as the ointment itself does not contain water. Excess, long, hot show- ers or baths should be avoided, in addition to heavily fragranced cleansers. The usual rec- ommendation is to cleanse with a moisturizing soap such as Dove fragrance-free bar, or a soap-free cleanser such as Cetaphil gentle cleanser or Aquanil cleanser. If the xerosis leads to pruritis, then safe anti-pruritic topical treatments are recom- mended. Oral antihistamines should be used with caution because of their anticholinergic efects. Some- times topical corticosteroids are used for pruritis, but their use should be limited due to long-term side efects such as skin atrophy, tachyphylaxis, and absorption. We generally do not like to use topical corticosteroids for more than a couple of weeks at a time, espe- cially the ultra-potent ones, but even the mid-potency ones. In the case of infammatory skin fndings, local treatment with potent topical steroids can augment systemic treat- ments. We always suggest constant daily sun protection for patients with autoimmune condi- tions. The most efective protection is sun protective clothing, since it will not wear of as sunscreens do. Ocular Therapy Symptoms of dryness result from the increased friction as the upper eyelid moves over the surface of the eye. This movement is facilitated by the tear flm that consists of a mixture of aqueous secretions and mucins produced by the lacrimal gland, and that contains a va- riety of proteins and nutrients derived not only from the lacrimal glands but also from the sera (transported into the tears by the lacrimal glands). The tear flm is stabilized by a lipid layer to prevent evaporation, and these lipids are made by Meibomian glands located at the edge of the lower lid; infammation of these glands leads to blepharitis, which is a common problem in dry eye patients. Artifcial lubricants: Patients can use over-the-counter preservative-free artifcial tears, lubricating ointments, and methylcellulose. Preservatives can lead to topical irritation, especially in the dry eye, where the concentration can become high. Other prescription ophthalmologic drops (such as an- tibiotics and glaucoma drops) may still have irritating preservatives. Various measures are employed to conserve the tear flm for as long as possible: t Side shields (e. Punctal occlusion If frequent installation of artifcial tears is inadequate or impractical, punctal occlusion is the treatment of choice. This technique involves sealing of the lacrimal puncta, through which the tears nor- mally drain away to the nose; 90 percent of drainage occurs through the inferior punc- tum. Several diferent types of punctual plugs are available and plugs (called intra-cannic- ular plugs) that do not protrude onto the corneal surface seem to be preferred (Hamano, 2005). Some ophthalmologists begin with preliminary temporary plugs to ensure that punc- tal occlusion does not result in excess tear accumulation. Tus, failure to improve comfort with these temporary devices does not preclude the use of permanent punctal occlusion. Also, temporary plugs might be used to avoid a permanent change in patients who might regain near-normal lac- rimal function with appropriate therapy. The availability of intra-cannicular plugs (that do not protrude into the ocular surface) has the added advantage that they can be removed non-surgically. When indicated, laser or hand-held thermal cautery can be used for a per- 308 Robert I. It is important to realize that punctal occlusion is a tear preservation strat- egy; as a result, it is of little beneft, unless supplemented with artifcial lubricants, in those with minimal to no tear production. Recognition of certain environments that exacerbate dry eyes should lead to increased use of methods to prevent ocular complications. It may take 2 or 3 days to build (heal) the tear flm but only 23 hours in a dry environment for it to be disturbed. The increased frequency of use of artifcial tears in these environments may help to prevent complications, and should even be started prophylactically. Topical cyclosporine The United States Food and Drug Administration approved the use of a cyclosporine oph- thalmic emulsion (0. Among 877 patients randomly assigned to receive twice-daily instillation of cyclosporine (0. Four hundred twelve patients previously dosed for 6 to 12 months with cyclosporine 0. Cor- neal staining, Schirmer tests, and symptom severity assessments were conducted during the frst 12-month extension, with a patient survey during the second 12-month extension. Improvements in objective and subjective measures of dry eye disease were modest, probably because of prior treatment with cyclosporine. The 8 Sjgrens Syndrome 309 results supplement the safety record of the commercially available cyclosporine 0. Topical nonsteroidal eye drops (such as indomethacin) have been found to provide symptomatic relief, but they should be used with caution and under close monitoring, and the treatment should be promptly discontinued if corneal epithelial defects develop or worsen during treatment (Aragona et al. The source of lipids in the tear flm is the Meiobian glands that are predomi- nately located in the margin of the eyelids near the eyelashes. Application of warm compresses followed by eyelid scrubs comprise the most critical elements of efective blepharitis con- trol. Oral Therapy One of the most important consequences of oral dryness is the loss of teeth. Saliva has multiple functions within the oral cavity that include: t lubrication of the mucosa so that the tongue can help with cleaning out residual food that leads to dental plaque and bacteria; t bufering of acids that reabsorb calcium from teeth; as well as t the ability to modulate viral, bacterial, and fungal populations in the mouth. Although fre- quently grouped together, it is important to consider dental caries as distinct from peri- odontal disease. For individuals with very low to no salivary production, the amount of phosphate and calcium ions available for incorporation onto the tooth surface and enhancement of the remineralization process may be limited. Tese individuals could possibly beneft from the exogenous addition of calcium phosphate ions commercially available as a toothpaste, in specialized chewing gums, and as a solution. Tese fndings are consistent with the observation that individuals with salivary dysfunction are prone to root and incisal caries, rather than cor- onal caries. Another clinical trial examined the caries preventive efect of a mouth rinse containing casein derivatives coupled to calcium phosphate in patients with Sjgrens syndrome and dry mouth secondary to radiation therapy (Hay and Morton, 2003). The majority of studies supporting the addition of calcium and phosphate as an aid to remineralization have been primarily short-term stud- ies in animals and humans. Tere is currently no agreed-upon formulation/concentration of calcium phosphate or consensus on how ofen exposure should occur which could in- fuence the results of any clinical trial. Defnitive proof would require large long-term clin- ical trials, which are notoriously difcult and expensive(Hay and Morton, 2003; Hay and Tomson, 2002). Artifcial sweeteners that are not fermentable by acid-producing bacteria have also been implicated in the promotion of the remineralization process(Pers, dArbonneau et al. Convincing data primarily from studies done with children has shown that cer- tain natural sweeteners such as xylitol and sorbitol (usually in a chewing gum formula- tion) have a signifcant anti-caries efect. Tere has been some suggestion that the caries- preventative efect of xylitol/sorbitol is due to the efect of chewing alone, via the produc- tion of saliva(Wu and Fox, 1994; Wu, 2003). But other mechanisms have been suggested including: the growth inhibition of caries-inducing bacteria, the selection of xylitol-resis- tant strains with a resultant shif to less virulent and cariogenic strains, and the binding of xylitol to surface receptors on Strep. The mainstay in the prevention of dental caries remains fuoride (Daniels and Wu, 2000).
The assessment also took into account that a new review on chronic neck and shoulder pain in 2007 had established moderate documentation of a correlation between quickly repeated movements of the upper arms and the disease buy toradol 10 mg with amex. Example 4: Claim turned down prolapsed cervical disc (moderate lifting work without lifts on neck/shoulder) A man worked in the music industry for 20 years buy toradol 10 mg fast delivery. This involved lifting work when loading and unloading stage equipment purchase toradol 10mg, technical equipment and instruments from a lorry and when building a stage discount toradol 10 mg online, lifting about 3. The last 10 years he worked as a stage assistant, building stages and transporting light and sound equipment as well as instruments. After 20 years he had problems with the back of his neck and was diagnosed with a prolapsed cervical disc. The Committee found that the prolapsed cervical disc had not been caused, mainly or solely, by the work as a driver and stage assistant for many years. The Committee took into consideration that the lifting work had not generally been stressful for the neck, and the lifts were not regular heavy lifts on the neck and shoulder girdle. Example 5: Claim turned down prolapsed cervical disc (heavy healthcare work, no time correlation) A woman worked for 28 years as a healthcare assistant in various healthcare institutions, hospital departments and homecare. The first 22 years the work was characterised by many heavy healthcare tasks with more than 30 patient handlings per day. This was stressful for her neck because the patients held onto her neck while being transferred. The last 6 years she had less stressful work in homecare and in this period she had no transfers with direct loads on the neck. After 28 years she developed neck pain and was diagnosed with a prolapsed cervical disc. The Committee found that the prolapsed cervical disc had not, mainly or solely, come about as a result of the healthcare work as she had had no direct loads on the neck for 6 years up to the onset of the disease, and the previous transfers of patients had not been frequent besides. Example 6: Claim turned down degenerative arthritis and muscular tension of neck (truck driver) A man drove forklift trucks for 26 years. The first 8 years the truck was without a drivers cab, and therefore he suffered a lot of exposure to cold. Throughout the whole period he drove backwards about half of the working time and therefore often turned his neck backwards. After 6 years work he developed pain of the neck and subsequently both shoulders. A medical specialist later diagnosed him with degenerative arthritis of the neck and chronic muscular tension of the neck and shoulder region. The Committee did not find that the degenerative arthritis of the neck and the chronic muscular tension of the neck and shoulder girdle had been caused, mainly or solely, by the described work as a truck driver for a number of years. The Committee took into consideration that there was no medical documentation of any causality between the described exposures in the form of cold and frequent turning of the neck and the reported diseases, and that the work had not led to any direct impact on the neck and shoulder that constituted a special risk of developing degenerative arthritis of the neck or chronic muscular tension of the neck and shoulder region. In addition, 4 months a year, he performed heavy lifting work, cleaning the silos. This work involved single lifts of about 70-80 kilos and a total daily lifting load of more than 10 tonnes. The Committee found that the prolapsed lumbar disc had mainly developed as a consequence of the work in the sugar factory for 13 years. They took into consideration that the combination of high lifts of the rod and the continual upward knocking in postures that were awkward for the back, for two thirds of the year, had been very stressful for the back. At the same time, for one third of the year, he had performed heavy lifting work with extremely heavy and back-loading single lifts. Example 2: Recognition of chronic low-back pain (awkward lifts and many downward jumps from trains) A man worked as a train station worker for a considerable number of years. Towards the end of the period he developed daily low- back pain radiating into the right buttock. The Committee found that the chronic low-back pain had been caused mainly by shunting work for more than 10 years. The Committee took into consideration the combination of a daily and often awkward load of about 3-4 tonnes, recurring and very heavy single lifts, and many back-loading downward jumps from trains. Example 3: Recognition of prolapsed lumbar disc (very heavy lifting work 4 months/year for 25 years) A man worked as a harbour worker (casual labourer) for a bit less than 4 months a year for 25 years. The work consisted in loading and unloading ships with manual lifts of sack goods, boxes and ox carcasses. The first 10-15 years the work was extremely stressful with a daily lifting load of about 50 tonnes and single lifts between 40 and 110 kilos. Towards the end of the period he developed low-back pain and was diagnosed with a prolapsed lumbar disc. The Committee furthermore took into consideration that the load period, converted to an employment rate of 8 months per year, was equivalent to a total of 11-12 years. Example 4: Recognition of chronic low-back pain (awkward working postures) 21 A mechanic worked for 15 years in various garages. The first 5 years the work consisted in repairing and replacing engines and gear boxes, changing wheels and brakes, and sheet metal work. More than half of the working day was spent in the pit, where he had to work with his back stooping or bent sideways. The daily lifting load was 3-5 tonnes and involved generally occurring, heavy single lifts of up to about 70 kilos. Subsequently he worked for 10 years in a number of different employments, as a sheet metal smith two thirds of the time and as a general mechanic one third of the time. He nearly always performed the work lying under the cars, in a stooping posture, lying with his knees bent and a flexed back or huddled up. The Committee found that the chronic pain had been caused mainly by the work as a mechanic for 15 years. The Committee took into consideration that the work had mainly been done in back-loading, huddled-up or stooping working postures under cramped conditions, and that this exposure in itself constituted a special risk of developing a chronic low-back disease. In addition there had also been extremely heavy lifting work for about 5 years out of the total exposure period. Example 5: Recognition of chronic low-back pain (slaughterer handling livestock) A 49-year-old man had worked as a slaughterhouse worker for 24 years. Many of them were hard to handle, and the work of taking them to the killing place led to knocking about, hard pulls, falls and actual flying through the air. Once the animal had arrived at the killing place, the slaughterhouse worker tied it to a hook and shot it. Then he had to position a chain on the animals legs, in order for it to be lifted by a crane. However, many of the animals fell down in such a way that he had to drag/pull them up to 1 metre to get to the chains. He managed to kill up to 150 livestock per day, and each animal weighed 300-400 kilos. When pulling about half of the animals to the chains at the killing place, he handled a total of about 20 tonnes per day. Towards the end of the period he developed chronic low-back pain, and x-rays showed degeneration of the lumbar spine (commencing degenerative arthritis). The Committee found that the chronic low-back disease had been caused mainly by the work. They took into consideration that the work had involved special loads on the back when he struggled with livestock outside the stable and furthermore very heavy handling of dead animals at the killing place. Example 6: Claim turned down chronic low-back pain (heavy lifting work for 4 years and periodic lifting work) A man worked as a beer delivery man for 4 years. Before the employment in question, he had worked for 3-4 years as a fire guard, which did not involve any work that was stressful for the back. Previously, for various periods of time over 3 years, when working as a welder in a shipyard, he had back-loading work. As a young man he had worked as an errand boy in the vegetable market, where he had moderate to heavy lifting work. The Committee found that the chronic low-back pain had not been caused, mainly or solely, by the work as a beer delivery man or by one of his previous periodic employments with back-loading work. This exposure alone could not be deemed to constitute any special risk of developing a chronic low-back disease. Before this, in his long employment as a fire guard, he had not had back-loading work. Therefore there was no time correlation with the previous periods of back- loading work as a welder, errand boy and worker in the vegetable market. Hip Example 1: Claim turned down degenerative arthritis of left hip (moderate lifting work and jumping down from a refuse lorry) A man worked for 16-17 years as a refuse collector.