My Rheumatology

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My Rheumatology
2012-01-26 15:49:25
arthropathies bone disease

Arthropathies, bone disease and that
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  1. How does rheumatoid arthritis typically present?
    • Symmetric
    • Pain
    • Early morning stiffness
    • Synovitis
    • Usually lasts longer than 6 weeks
    • Found in DIP/PIPs and wrists
  2. How does psoriatic arthritis typically present?
    • Usually DIP disease, often asymmetrical oligo or symmetrical poly
    • Psoriasis, with nail/skin changes
    • Mutilation
    • Spinal involvement
    • Dactylitis
  3. Define
    - Spondylitis
    - Rheumatoid arthritis:
    - Psoriatic arthritis:
    • Spondylitis: Inflammation of spine joints
    • Rheumatoid arthritis: Autoimmunity to synovial joints
    • Psoriatic arthritis: Arthritis related to psoriasis
  4. Outline the clinical features of spondyloarthropathies
    • Not autoimmune
    • Back pain, with insidious onset and night pain
    • Doesn't improve with exercise or rest
    • Onset <40yrs
    • Loss of lumbar lordosis
    • Spinal ligament calcification
  5. What are the criteria for diagnosing psoriatic arthritis?
    • Caspar: >3
    • Evidence of current psoriasis, or a past personal/family history = 2 pts
    • Typical psoriatic nail dystrophy (onchyolysis, pitting, hyperkeratosis) = 1pt
    • Negative test for rheumatoid factor
    • Present or past dactylitis (must be witnessed by a physician)
    • Radiograph showing ill-defined ossification near joint margins (not osteophytes) in hands or feet
  6. What serological investigations are used in diagnosing rheumatoid arthritis?
    • Inflammatory markers
    • FBC
    • Rheumatoid factors (<10-25% in healthy people)
    • Anticyclic citrullinated peptide
  7. Describe the pharmacological management of chronic inflammatory arthritis
    • Analgesia, including NSAIDS
    • Steroids
    • DMARDS, e.g. methotrexate, sulfasalazine, gold salts
    • Biologics
  8. What is the 'triple therapy' used in a chronic inflammatory arthritis?
    • Methotrexate: Inhibits purine metabolism (DHFR antagonist effect not useful)
    • Hydroxychloroquinine: Inhibits acid proteases, stabilising lysosomes and preventing exocytosis = no Ig
  9. What are the most common primary and secondary bone tumours?
    • Primary: Myeloma
    • Secondary: lung, breast, prostate, kidney and thyroid
  10. List some clinical features of bone tumours
    • Bone pain
    • Destruction
    • Pathological fracture
    • Spinal; vertebral collapse, cord/root compression, hypercalcaemia
  11. Outline the mechanism of action of bisphosphonates
    • Pyrophosphate analogues, which incorporate into the hydroxyapatite matrix until absorbed
    • Promote: Apoptosis
    • Inhibit: osteoclastogenesis, inhbit diphosphate synthase
  12. What are the indications for biphosphonate use?
    • Postmenopausal/male osteoporosis
    • Steroid induced osteoporosis
    • Paget's
    • Skeletal metastases
  13. How is fracture risk assessed?
    • Age/weight/height/sex
    • Previous fracture or family history
    • Smoker/>2 units alcohol daily
    • Glucocorticoids
    • R.A.
    • Osteoporosis
    • Femoral neck BMD
  14. Describe some new treatments to reduce fracture risk
    • Oestrogen HRT: Aids all fractures
    • Denosumab: Monoclonal antibodt preventing RANK-L binding to osteoclasts
    • Strontium: Taken up by osteoblasts and increase bone deposition
    • Calcitonin: opposes PTH to reduce bone resorbption
  15. Outline common causative organisms of septic arthritis
    • S.Aureus
    • N.Gonorrhoeae
    • H.Influenzae (especially in children)
    • TB
  16. In septic arthritis, what antibiotic(s) should be used in:
    - A patient with no risk factors for atypical organisms
    - High risk of gram negative sepsis (elderly, UTI, surgery)
    - MRSA, gonococcus/meningococcus
    • Flucloxacillin
    • 3rd generation cephalosporins
    • Vancomycin
  17. Define crystal arthropathy, acute and chronic gout
    • Uric acid crystals, as part of 'gout', deposit in joint and soft tissue
    • Acute gout is when precipitation in the joint causes inflammation
    • Chronic gout is when larger crystals become deposited
  18. Outline the diagnosis and treatment of gout
    • Diagnosis: Joint aspiration for microscopy, serum urate levels and U+Es (uric acid from chronic renal failure)
    • Treatment: High dose NSAIDS, colchicineor corticosteroids. Xanthine oxidase inhibitors. Uricosuric agents
  19. What is 'pseudogout'?
    • When calcium pyrophosphaste crystals are deposited in joints or extra-articular tissues
    • Crystals are rhomboid, unlike gout crystals
  20. Define 'reactive arthritis'
    • Inflammation of the synovium of a joint, in the absence of infection
    • Occurs following an infection
    • Acute, asymmetrical lower limb pain/inflammation
    • Pathogenesis unknown
  21. Outline the process of diagnosing a patient with acute joint pain and swelling
    • Assume septic arthritis unless definite alternate diagnosis
    • Urgent aspiration and other investigations
    • If not septic, investigate for other causes
    • If septic, empirical antibiotic treatment
  22. Define osteoarthritis
    • Most common type of arthritis
    • Occurs in synovial joints, with cartilage loss and accompanying periarticular bone change
    • Inflammation of articular and periarticular structures, with alteration in cartilage structure
  23. Describe some perdisposing factors for osteoarthritis
    • Obesity
    • Genetics
    • Female
    • Hypermobility
    • Trauma
  24. Outline the surgical treatment of osteoarthritis
    • Bearing surfaces replaced
    • Restoration of normal joint mechanics
    • Improves function, reduces deformity and relieves pain