R.U.R. - Rossum s universal robots. from robota serf-work, hard work

Transkript

1 KAREL ČAPEK ( ) Czech novelist, dramatic, journalist, recognized writer R.U.R. - Rossum s universal robots ROBOT- from robota serf-work, hard work 1922 The Makropulos Affair(Věc Makropulos) play about human immortality, not really from a sciencefiction point of view. The celebrated opera by Leoš Janáček is based on it The Absolute at Large (Továrna na absolutno) novel which can be interpreted as a vision of consumer society Krakatit novel, the plot of which includes a prediction of a nuclear-weapon-like explosive War with the Newts (Válka s mloky) satirical novel.

2 Anti-Nazi plays from the 1930s 1937 The White Disease (Bílá nemoc) earlier translated as Power and Glory 1938 The Mother (Matka) Other works Stories from a Pocket and Stories from Another Pocket (Povídky z jedné a z druhé kapsy) a common name for a cycle of short detective stories (5 10 pages long) that shared common attitude and characters, including The Last Judgement. The Gardener's Year (Zahradníkův rok, 1929) is exactly what it says it is: a year-round guide to gardening, charmingly written, with illustrations by his brother Josef Čapek. Pictures from the Insects' Life (Ze života hmyzu), also known as The Insect Play or The Life of the Insects, with Josef Čapek, Nine Fairy Tales: And One More Thrown in for Good Measure (Devatero Pohádek a ještě jedna od Josefa Čapka jako přívažek, 1932) Dashenka, or the Life of a Puppy (Dášenka čili Život štěněte, 1933) Travel books Letters from Italy (Italské listy, 1923) Letters from England (Anglické listy, 1924) Letters from Spain (Výlet do Španěl, 1930) Letters from Holland (Obrázky z Holandska, 1932) Travels in the North (Cesta na Sever, 1936)

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9 How to Diagnose Inflammatory Back Disease History Insidious onset, duration >3 months Symptoms begin before age 40 Morning stiffness >1 hour Activity improves symptoms Systemic features: Skin, eye, GI, and GU symptoms Peripheral joint involvement Infections

10 How to Diagnose Inflammatory Back Disease (cont d) Physical examination Limited axial motion in all planes Look for signs of infection Staph, Pseudomonas, Brucella, and TB Systemic disease (AS, Reiter s, psoriasis, IBD) Ocular inflammation Mucosal ulcerations Skin lesions

11 ANKYLOSING SPONDYLARTHRITIS (M. Bechtěrev) (4) MB chronic systemic inflammatory disease with axial skeleton involvement, sacroiliacal joints invovlement, rhizomelic or periferal joints involvement, with entosopathy. Trend to fibrosis, ossifications and with extraarticular manifestation Epidemiology prevalence ~ 1%, M:Ž 7-9:1, decenium Patology Non-spec. Inflammation Entesitis, (pelvic region, heels) Erosive chondritis/osteitis fibrotisation, ossification quadratisation of vertebral bodies, synostosis SI, ankylosis Synchondrosis manubriosternal and pubic Damage of aorta, lung fibrosis.

12 AS CLINICAL PICTURE (I) (5) Constitutional Acut onset/flare low-grade fever, weight lost, anorexia, sweating Inflammatory back pain At rest (nocturnal/morning) back pain Morning stifness, exercise helps, intermitent, later stable ( 3 months) Sacroileitis Pain and stiffness in sacral/gluteal area Worsening with walking down-stairs Tenderness of SI, posit. Menell s Spondylitis Pain L/S, Th/L and C spine (dominant ), ascendent / descendent type Muscular spasm, Limitation of ROM of the spine (1. 5. stage) - limitation dorsal /ventral/lateral flextion and rotation - limitaitio of respiration movements ( 2.5 cm) restrictive ventilation disorder Thomayer, Schober, Stibor distance, fleche acc. Forestier Typical posture anteflextion, Th kyfosis, aplanation of L lordosis, semiflextion of knees, muscle atrophy

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15 M. Bechtěrev změny habitu

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17 Testing Spinal Mobility: Schober s Test Two midline marks 10 cm apart starting at the posterior superior iliac spine (dimples of Venus) Remeasure with lumbar spine at maximal flexion Less than 5 cm difference suggests pathology cm

18 AS Early Late Thomayer s distance synovitis Ossification

19 SpA examination of SI joint

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21 AS clinical picture (II) (6) Artritis (30-50%) rhizomelic form shoulders and hips - acute synovitis ev. episodic/prespondyl. (knees ) - f. erosis /destructive, ankylosing arthritis f. periferal scandinavian females Entezitis Inflammatory, ossifications Achilles tendon, plant. Aponeurosis, trochanteric, tuber ossis ischii Extra-articular Asymetric iritis/iridocyklitis (25%) aortitis Lungs fibrosis IgA nephropathy AA amyloidosis atlanto-occipital subluxation, sy. cauda equina Prognosis benigne but also malignant forms

22 AS examinations (7) LABORATORY RAF - SE, CRP, 2 a -globulins, IgA RF and ANF negat., HLA-B 27 90% Anemia Proteinuria AA amyloidosis (?) RADIOGRAPHY Positive in advanced disease X-ray criteria of sacroileitis 0 negative 1 uncertain changes SI 2 minimal changes (juxtaarticular sclerosis ) 3 erosions, JSN, ankylosis- partial, transarticular bridging 4 ankylosis ( synostosis ) Spondylartritis - quadratisation of vertebral bodies osteoporosis, bridging syndesmophytes, bony intervertebral ankylosis ( bamboo spine) - Calcification of paravertebral tendens Erosive /ankylosing arthritis Dg. initial changes CT, MRI event. 99 Tc-bisfosfonat scintigraphy

23 M. Bechterew radiographic changes Loss of joint space SI synostosis Erosion Widening of SI joint, erosions, sclerotisations Erosion and osification of ligaments

24 M. Bechterew radiographic changes fussion of vert. bodies Sclerotisation osteofytes Erosion and ossification Erossion and ossification Loss of joint space

25 M.Bechtěrev radiografie, 99 TC-scintigrafie a CT vyšetření sakroileitida - rozšíření štěrbiny,transos.můstky sakroileitida eroze ( ozubení poštovní známky ) sakroileitida asymetr. pozitivita 99 TC sintigrafie CT obraz časné sakroileitidy

26 M. Bechtěrev MRI MR SI skloubení T1 obraz - eroze kyčelní kosti vlevo, distálně eroze oboustranně MR eroze a transartikulární můstky ( RTG obraz normální) T2 STIR MR známky zánětu dřeně s edémem

27 M. Bechtěrev radiografie a kostní scintigrafie RTG spondylodiscitida 99 TC-scintigrafie-discitida Spondylodiscitida L4 MR-T1 degenerativní a pozánětlivé změny obratlů (RTG negat.) RTG Stp. TEP před 15 lety

28 Modified New York Criteria for the Diagnosis of AS Clinical Criteria Low back pain, > 3 months, improved by exercise, not relieved by rest Limitation of lumbar spine motion, sagittal and frontal planes Limitation of chest expansion relative to normal values for age and sex Radiologic Criteria Sacroiliitis grade 2 bilaterally or grade 3 4 unilaterally Grading Definite AS if radiologic criterion present plus at least one clinical criteria Probable AS if: Three clinical criterion Radiologic criterion present, but no signs or symptoms satisfy clinical criteria

29 ASAS (Assessment of SpondylArthritis international Society) klasifikační kritéria pro axiální i periferní SpA U pacientů s 3 měsíční bolestí zad a věkem na počátku <45 let POUZE u pacientů periferními projevy Sakroiliitida (rtg/mri) a 1 SpA projev* HLA-B27+ a 2 SpA projevy* Artritida / entezitida / daktylitida plus * SpA projevy Zánětlivá bolest zad artritida entezitida (pata) uveitida daktylitida psoriáza Crohnova nemoc/ kolitida dobrá odpověď na NSAIDs familiární výskyt SpA HLA-B27 zvýšené CRP Rudwaleit M, et al. Ann Rheum Dis. 2011;70: senzitivita: 79.5% specificita: 83.3% 1 SpA projev uveitida psoriáza Crohnova nemoc / kolitida předcházející infekce HLA-B27 sakroiliitida 2 SpA projevy artritida entezitida daktylitida anamnéza IBP familiární výskyt SpA

30 Therapy of AS Blockers of TNFα or secukinumab (anti IL17) Local corticosteroids Sulfasalazin NSA Axial forms Periferal forms Zoching J et al., Ann Reum Dis 2006

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32 PSORIATIC (SPONDYL) ARTHRITIS (I) (10) PsA inflammatory, seronegative disease of the joint and/or axial skeleton in psoriasis 5-10% pacients with psoriasis, y, M:F 1:1 ¾ after the skon manifestation, 15%oin the same time, 10% before ~ 40% posit. of HLA-B 27, genet. predisposition, posit. FH asymetric artritis, entezitis, tenosynovitis, daktylitis Klinical types Asymetric oligoartikular form (~ 20-40%) DIP, PIP event. MCP/MTP and knees, hips daktylitis, tenovaginitis, onycholyisis nail pitting Symetric destructive polyartritis RA like (~ 30-50%) DIP Asymetric artritis DIP (~ 5-15%) Mutilating artritis with sacroileitis (~ 5%) digiti telescopici X-ray mutilations( pencil in cup ) Axial form without periferal joints involvement (~ 25%) AS like

33 Ps SpA CLINICAL picture overlaps SAPHO sy. Synovitis, Akne konglobata, Psoriasis, Hyperostosis, Osteitis/Osteomyelitis Extraartikular- eyes, skin, renal Examinations Laboratory non- specific RAF-SE, CRP, -globulina event. IgA, CH 50, CD4/CD 8, negativity RF, ANF Imaging Radiography MR Bone scintigraphy

34 Ps SpA dolíčkování nehtů incip. onycholýza onycholýza a diskolorace

35 PsSpA postižení DIP PsSpA postižení DIP RA-like forma psoriatické artritidy PsSpA artritida DIP PsSpA onycholýza, artritida DIP PsSpA onychodystrofie, daktylitida ( klobáskový prst )

36 PsSpA asymetrická oligoartritida PsSpA mutilující artritida, distorse a deviace kloubů ( krátké prsty ) pencil-in-cup deformity PsSpA deformující artritida klobásková daktylitida, onychodystrofie PsSpA mutilující artritida, digiti telescopicí PsSpA RTG obraz mutilující artritidy, osteolýza, zkrácení prstů

37 PsSpA osteolýzy, destrukce kloubů, pencil-in-cup PsSpA parasyndesmofyt PsSpA časná sakroilitida a spondylitida PsSpA pokročilá sakroileitida a spondylitida PsSpA 99 TC scintigrafie při normálním RTG obraze a) aktivita v oblasti paty úponu plantární aponeurózy b) pozitivita v oblasti prox.falang 1. a 2. prstu levé nohy

38 Therapy of PsA

39 Therapy of PsA Therapie with DMARDs Sulfasalazin: mild form (minor efect on skin) Metotrexate: severe form (minor efect on skin) Leflunomide: severe form (+ effect on skin) Cyklosporine A (combination with MTX): severe form (+ effect on skin)

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44 ENTEROPATIC SPONDYLARTRITIS (12) ENTEROPATIC SpA Ulcerative colitis Crohnc disease

45 Reiter s Syndrome (Reactive Seronegative asymmetric arthritis Following: Urethritis or cervicitis Infectious diarrhea Often associated with: Inflammatory eye disease Balanitis, oral ulceration, or keratoderma Enthesopathy Sacroiliitis Arthritis)

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47 Reactive arthritis ReA erythema nodosum ReA erozivní balanitis circinata ReA - episkleritida

48 ReA fibrozitida kalkanea ReA asymetrická sakroileitida ReA atypické solitární osifikace na páteři ReA asymetrický parasyndesmofyt, obraz býčího rohu

49 Reiterův sy. oboustranná konjuktivitida Reiterův sy. tendovaginitida Achilovy šlachy balanitis circumscripta keratoderma blenorrhagica asymetrická artritida spondylitida parasyndesmofyt sakroileitida transart. můstky

50 eroze eroze patní kosti, známky přilehlé kostní novotvorby kostní novotvorba Reiterův sy. tendovaginitida a entezopatie Achilovy šlachy

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