Rheumatology

Question 1

What is RA

Answer 1

Systemic autoimmune disorder; multiorgan dz

Question 2

Etiology of RA

Answer 2

Unknown

Question 3

What class of joints affected

Answer 3

Diarthrodial

Question 4

What part of joint affected

Answer 4

Synovial lining

Question 5

What is pathognomonic for RA.

Answer 5

Erosions ; erosive synovitis > articular destruction

Question 6

Composition of Diarthrodial joints (5)

Answer 6

1. Type 2 hyaline 2. Subchondral bone 3. synovial membrane 4. Synovial fluid 5. Joint capsule

Question 7

What is most important destructive element in RA?

Answer 7

Pannus

Question 8

Pannus is a membrane of ______ tissue that covers the ______ bone & cartilage at joint margins

Answer 8

Granulation; articular

Question 9

RA Female:male?

Answer 9

2:1

Question 10

RA prevalence: what % of general pop?

Answer 10

1%

Question 11

RA age range? Peak incidence?

Answer 11

20-60 . Prevalence rises with age. Peaks 4th- 5th

Decade

Question 12

Etiology of RA is unknown. Name 3 theories

Answer 12

Environmental ie infectious; genetic predisposition; immunogenetic > class II surface antigen-presenting cells

Question 13

RA diagnosis is made how?

Answer 13

Clinically

Question 14

$How is RA diagnosed clinically? (3)

Answer 14

1. Based on 1988 American Rheumatologic Association paper by Arnett et al ( current guidelines used by American College of Rheumatology (ACR) 2. Must satisfy 4/7 criteria
2. Criteria 1 through 4 must be present for at least 6 weeks

Question 15

$ Name ACR Criteria for RA (7)

Answer 15

AM Stiffness> Arthritis of 3 or more joints> Arthritis of the hand joints> Arthritis symmetric> rheum nodules > RF + > radio graphic changes

Question 16

Review ACR details

Answer 16

1.Morning stiffness
•in and around hrs
•must last at least 1 hour before max improvement
2. Arthritis of 3 or more joints
•3 or more joint areas simultaneously affected with STS or
Fluid observed by doc
•14 possible joint areas are bilateral PIP, MCP, wrist, elbow, knee , ankle, & MTP’s
3. Arthritis of the hand joints
•At least 1 joint swollen in wrist, MCP, and/or PIP
4. Symmetric arthritis
• simultaneous involvement at the same joint area bilaterally
5. RHEUMATOID NODULES
• subqt nodules over extensor surfaces, bony prominences, juxta-articular regions, observed by a doc
6. Positive serum RF
7. Radio graphic changes
• erosions, bony decalcification, & symmetric joint-space narrowing seen on hand & wrist X-rays

Question 17

$Compare/ contrast AM Stiffness in RA , OA, AS:

Joints, duration

Answer 17

Jts/ duration
MCP , PIP,MTP. > 1-2 hours: RA
DIP, < 30 mins
AS, LS spine , ~ 3 hours

Question 18

$What’s most common onset of RA? Insidious, acute, intermediate

Answer 18

Insidious> 50-70%. Weeks to months. Systemic or articular

Acute >10-20%. Over several days. Less symmetry . Muscle pain

Intermediate> 20-30%. Over days to weeks
Systemic is more evident

Question 19

What is lab test is definitive for RA?

Answer 19

No single test is definitive

Question 20

name typical lab findings in active dz

Answer 20

RF, Elevated acute phase reactants( ESR, CRP),CBC: | platelets! hypo, micro anemia , eosinophilia, synovial fluid , ab to CCP, hypergammaglobulinemia, hypocomplementia

Question 21

$ synovial fluid in RA: viscosity, WBC, PMN’s, appearance

Answer 21

Low, 1-75 K WBC’s/mm3 (> 70% PMN’s), transparent - cloudy

Question 22

% of patients with RA Who are RF +?

Answer 22

85%

Question 23

Radio graphic findings in RA

Answer 23

• Early Findings (2)
• Late Findings (3)
• characteristic findings

Question 24

Joints commonly involved in RA

Answer 24

Hands & wrists
Cervical spine – C1 to C2
Feet & ankles
Hip & knees

Question 25

Describe/ Name UE Joint deformities

Answer 25

``` BOUTONNIÈRE SWAN NECK ULNAR DEVIATION OF FINGERS TENOSYNOVITIS CARPAL BONE INSTABILITY ULNAR HEAD FLOATING RESORPTIVE ARTHROPATHY PSEUDOBENEDICTION SIGN SHOULDER ELBOW ```

Question 26

Describe cervical spine concerns in RA

Answer 26

Atlantiaxial joint subluxation What's most common? Ant or post Ans. anterior

Question 27

$ with cervical flexion, the atlanto-axial space should not increase sig. Any space larger than _____ is Considered abnormal

Answer 27

2.5-3mm

Question 28

Hip deformities Occur in what 50% of RA Patients? What is protrusio acetabuli?

Answer 28

50% Associated with hip arthritis Inward bulging of acetabulum into pelvic cavity;

Question 29

Extra-articular manifestations of RA

Answer 29

``` Constitutional Skin Vasculitic Ocular Pulmonary Cardiac--- see pericarditis card GI Renal Neuro Hematologic ```

Question 30

Extra-articular manifestations of RA | Delineate

Answer 30

Xxxx

Question 31

Subqt nodules are seen in ? (2)

Answer 31

Gout | RA

Question 32

What is Caplan's Syndrome ? (4)

Answer 32

• associated with RA and pneumoconiosis in coal workers • Granulomatosis response to silica dust • +RF Intrapulmonary nodules-- histologically similar to Rheumatoid Nodules

Question 33

What are cardiac findings assoc with RA?

Answer 33

``` Pericarditis $ classic findings • chest pain • pericardial friction rub • EKG abnormalities ( diffuse ST elevations) ```

Question 34

Pericarditis assoc with RA may lead Constrictive pericarditis with ? May be found in ____ of RA Patients How often symptomatic?

Answer 34

Right-sided heart failure Half Rarely

Question 35

In addition to pericarditis, what other cardiac finding is associated with RA ?

Answer 35

Valvular heart dz

Question 36

$ What is Feltys syndrome ?

Answer 36

Classic triad of: RA Splenomegaly Leukopenia

Question 37

``` Feltys syndrome Seen in _______RA with _____ Occurs in what decade of life? Duration of RA? Gender Assoc with ______ ulcers ```

Answer 37

``` Seropositive; nodules 5th or 7th > 10 years Women comprise 2/3 cases Leg ```

Question 38

Treatment of RA (6)

Answer 38

``` Education Rest Physical modalities Orthotics Meds Surgery ```

Question 39

Poor prognosticators (6):

Answer 39

``` +RF Rheumatoid nodules X-ray consistent with erosive dz Persistent synovitis Insidious Antibodies to CCP ( cyclic citrullinated peptides) ```

Question 40

Important determinants in classifying arthritis:

Answer 40

Inflammatory vs non-inflammatory Symmetric vs asymmetric Accompanied by systemic & extra articular manifestations

Question 41

ARTHRITIC DZ What 3 items will often lead to a specific dx?

Answer 41

Good H&P Appropriate labs Appropriate X-rays

Question 42

Clinical features that suggest inflammatory dz:

Answer 42

``` Acute painful onset Erythema overlying skin of joint Warmth of joint(s) Tenderness usually commensurate The degree of inflammation ```

Question 43

Lab & X-ray findings that suggest | An inflammatory process (4)

Answer 43

Increased WBC with left shift Increased ESR Group II joint fluid X-ray : STS, periostitis, bony erosions or uniform cartilage loss

Question 44

Inflammatory Arthritis may fall into 4 different groups. It may be mono or poly articular Name/Describe

Answer 44

1. Inflammatory CT 2. Inflammatory Crystal-induced 3. Inflammatory induced by infectious agents (e.g. Bacterial, viral, spirochete , tuberculosis , fungal 4. Seronegative spondyloarthropathies

Question 45

Non inflammatory arthritis may be classified as? (2)

Answer 45

Degenerative Metabolic ie lipid storage , hemochromatosis , ochrinosis, etc

Question 46

Many types of arthritis have a specific distribution in terms of ? Name 4. Name two other potential influencing factors

Answer 46

Age, gender, race , geographic appearance Genetics and occupation

Question 47

RA & Medications One of the main goals of pharmacotherapy in RA is to ________ systemic inflammation & consequently _________ joint erosions and deformities

Answer 47

Reduce

Question 48

Name the commonly used medications (3) hint: Name the three | Groups and examples

Answer 48

Non-DMARDS NDAIDS Glucocorticoids DMARDS -- mainstay of RA pharmacotherapy Biologicals Non-Biologicals

Question 49

Surgical intervention in RA (5)

Answer 49

Surgical fusion of c1-2 for atlantoaxial instability Synovectomy: most commonly? Arthroplasty: most common? Arthrodesis: typically for ? Tendon repairs: successful?

Question 50

``` Synovectomy: most commonly? Arthroplasty: most common? Arthrodesis: typically for ? Tendon repairs: successful? (RA) ```

Answer 50

Synovectomy: most commonly with Extensor tenosynovitis at wrist Arthroplasty: most commonly of knee and hip; shoulder, MCP infrequent; elbow rare Arthrodesis: typically for ankle, occ for wrist or thumb Tendon repairs: generally successful; most hand/wrist tendinopathies require tendon transfer

Question 51

Name non bio DMARDS (8) | Least to very toxic

Answer 51

``` Sulfasalazine-- safer MTX --- safer Cyclosporine Gold, IM/oral Azathioprine D-penicillamine Chlorambucil--- very toxic Cyclophosphamide ---very toxic ```

Question 52

Name 4 categories of bio DMARDS

Answer 52

Anti-tumor necrosis factor (Anti-TNF) agents: reduce levels of TNF-alpha Co-stimulation Modulators: prevent T-cell activation by interfering with antigen-presenting cell interaction with T cells Anti-B-cell antibodies Depletes B-cells Interleukin Antagonists Antagonizes IL-1 by binding to interleukin receptors

Question 53

Other drugs for RA ASA NSAIDS Corticosteroids ASA NSAIDS Common side effects(4):

Answer 53

GI Ulceration & bleeding Renal insufficiency Hepatic inflammation HTN

Question 54

Corticosteroids | Side effects

Answer 54

``` Hyperglycemia Inhibits immune response Osteoporosis PUDZ Emotional lability ```

Question 55

Anti-TNF Alpha Agent examples (3)

Answer 55

Etanercept ( Enbrel) = soluble receptor Infliximab ( Remicade)= chimeric antibody Adalimumab (Humira)= human monoclonal antibody

Question 56

Co-stimulation Modulators Give an example

Answer 56

Abatacept (Orencia)

Question 57

Anti-B-cell antibodies | Example

Answer 57

Rituximab

Question 58

Interleukin Antagonists | Name one

Answer 58

Anakinra (Kineret)

Question 59

What is ASA therapeutic level? Greater than ? Is toxic.

Answer 59

15-25 mg/DL ; 30