Rheumatology!

Question 1

Inflamation charaacteristics

Answer 1

Pain, swelling, redness, heat

tenderness, stiffness, crepitation, functional impairment

Question 2

joint numbers

Answer 2

mono
oligo 2-4
pauci <5
extended pauci 5-6
Poly 6+

Question 3

enthesis

Answer 3

where muscle joins bone

Question 4

what drives inflammation

Answer 4

acute phase reactants
CRF, fibrinogen
ESR non-protein APR that effects plasma viscosity as fibrinogen is consumed.
More inflammation the less viscous the plasma becomes and cells fall out of suspension faster
ESR is elevated with inflammation

Question 5

Initial immune indicators

Answer 5

before symptoms start to show up
RF +
Anti-CCP +
increased CRP

Question 6

RF factors are

Answer 6

usually IgM autoantibodies

Question 7

Rheumatoid factors

Answer 7

produced by RA synovium
fix complement - (consumed in RA joint)
complement fragments recruit/activate PMSs
complement coated antibody/antigen reaction

Question 8

what does damage to the joint

Answer 8

TNF and MAC

Question 9

pro inflammatory cytokines

Answer 9

TNF-a

IL 1

Question 10

RA epidemiology

Answer 10

women 3:1
25-45
improves during pregnancy

Question 11

ACR classification criteria for RA

Answer 11

morning stiffness > 1 hour > 6 weeks
swelling 3+ jts > 6 weeks
swelling hand jts  > 6 weeks
symmetric joint swelling > 6 weeks
rheumatoid nodules
Rheumatoid factor
erosions/osteopenia on hand x-ray
Need 4

Question 12

Joints RA goes after

Answer 12

Wrist, MCT, PIP, Knee, ankle, MTP

Question 13

what is pannus

Answer 13

t-cells/lymphocytes, dense inflammatory cells invading the joint space -> big swollen jts

Question 14

Hand changes RA

Answer 14

ulnar deviation
hand deformaties
synovitis
joint space narrowing and erosions

Question 15

Best imaging for RA

Answer 15

US and MRI

Question 16

had deformaties

Answer 16

boutonniere

swan neck

Question 17

What is felty syndrome

Answer 17

RA, splenomegaly and neutropenia

Question 18

Extra articular manifestations of RA

Answer 18

R Nodules - RF + neuromyopathy
Sjogren’s syndrome inflammatory Eye Dx
feltys osteoporosis
vasculitis lymphadenopathy
rehumatoid lung hyperviscosity
cardiac disease cryoglobulinemia
dermatologic amyloidosis

Question 19

Myelopathy in RA

Answer 19

transverse ligament of atlas becomes frayed
C1 translates on C2 - esp with leaning forward
muscle weakness in arms/legs
severe neck pain radiating to occiput
dysesthesias of fingers/feet
marble sensation in limbs/trunk
jumping legs
disturbed bladder fxn

Question 20

Inflammatory eye diseases in RA

Answer 20

scleritis
scleromalacia
sjogrens syndrome
small vessel vasculitis

Question 21

sjogrens syndrome treatment

Answer 21

anti inflammatories and immunosuppressive drugs

Question 22

Sjogrens associations

Answer 22

SS-a(Ro) and SS-b (La)

Question 23

Lab findings in RA

Answer 23

RF +
Anti CCP antibody +
ANA +
Elevated ESR/CRP
anemia, thrombocytosis, hyperglobulinemia
leukopenia/granulocytopenia
glucose in body fluids - very low

Question 24

Best diagnostic test

Answer 24

RF < 50 U/mL + anti-CCP

Question 25

High RF titer (>50) significance

Answer 25

good tool for diagnosis | good predictor for erosiveness

Question 26

Low RF titer (<50) significance

Answer 26

RF of little diagnostic value | need to add Anti-CCP to get diagnostic and prognostic value

Question 27

Goals of RA therapy

Answer 27

alleviate pain slow rate of Jt damage can't do: control disease activity, maintain fxn, max quality of life, reduce premature mortality, safe/efficacious

Question 28

Non pharm RA treatment

Answer 28

Education, phy/occup therapy, rest, articular rest | exercise, heat/cold, assistive devices, splints, weight loss

Question 29

Limits of NSAIDS

Answer 29

do not halt disease progression toxicity associated efficacy/toxicity - frequent switching

Question 30

limits of corticosteroids

Answer 30

chronic use has many side effects | "miracle drug in mexico clinic

Question 31

Limits of DMARDS

Answer 31

high discontinuation rate need for monitoring delayed onset of action

Question 32

Limits of biologic agents

Answer 32

opportunistic infections

Question 33

Methotrexate Pros

Answer 33

DMARD - 1x week long term clinical experience favorable rate of continuing therapy proven efficacy in moderate-sever RA

Question 34

Methotrexate Cons

Answer 34

lab monitoring every 4-8 weeks CBC, liver fxn tests, creatnine Toxicities: alopecia, hepatic, cat X myelosuppression, pulmonary

Question 35

Leflunomide - Pros

Answer 35

well absorbed po early onset of action stabilized benefit for long term use targets AI lymphocytes to reduce adverse effects rapid excretion w/ cholestryramine (gall bladder)

Question 36

Leflunomide - Cons

Answer 36

lack of clinical experience | tox: hepatic, gastrointestinal, teratogenic

Question 37

Biologic - toxicities

Answer 37

``` increase risk of infection reactiviating latent TB noplasia MS autoimmune disease ```

Question 38

Types of biologics

Answer 38

Anakinra - IL-1 receptor antagonist 1/2- 4-6 hours Infliximab - anti tnf-a AB 1/2 - 8-10 days Etanercept - soluble TNF receptor 1/2 3-5 days Adalimumab - Anti tnf-a AB 1/2 10-20 days

Question 39

ACR remission criteria

Answer 39

AM stiffness < 15 mins no fatigue, jt pain, jt tenderness/ROM pain no soft tissue swelling in jts or tendon sheaths ESR < 30 males < 20 femals need > 5 for > 2 months

Question 40

Clinical pearls RA

Answer 40

``` confirm, define extent of joint and extra articluar involve consider co-morbid disease full dose NSAID early DMARD use add biologic - when others fail low dose steroids to bridge pain mangement frequent monitoring ```