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How does rheumatoid arthritis typically present?
- Symmetric
- Pain
- Early morning stiffness
- Synovitis
- Usually lasts longer than 6 weeks
- Found in DIP/PIPs and wrists
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How does psoriatic arthritis typically present?
- Usually DIP disease, often asymmetrical oligo or symmetrical poly
- Psoriasis, with nail/skin changes
- Mutilation
- Spinal involvement
- Dactylitis
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Define
- Spondylitis
- Rheumatoid arthritis:
- Psoriatic arthritis:
- Spondylitis: Inflammation of spine joints
- Rheumatoid arthritis: Autoimmunity to synovial joints
- Psoriatic arthritis: Arthritis related to psoriasis
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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
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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
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What serological investigations are used in diagnosing rheumatoid arthritis?
- Inflammatory markers
- FBC
- Rheumatoid factors (<10-25% in healthy people)
- Anticyclic citrullinated peptide
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Describe the pharmacological management of chronic inflammatory arthritis
- Analgesia, including NSAIDS
- Steroids
- DMARDS, e.g. methotrexate, sulfasalazine, gold salts
- Biologics
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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
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What are the most common primary and secondary bone tumours?
- Primary: Myeloma
- Secondary: lung, breast, prostate, kidney and thyroid
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List some clinical features of bone tumours
- Bone pain
- Destruction
- Pathological fracture
- Spinal; vertebral collapse, cord/root compression, hypercalcaemia
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Outline the mechanism of action of bisphosphonates
- Pyrophosphate analogues, which incorporate into the hydroxyapatite matrix until absorbed
- Promote: Apoptosis
- Inhibit: osteoclastogenesis, inhbit diphosphate synthase
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What are the indications for biphosphonate use?
- Postmenopausal/male osteoporosis
- Steroid induced osteoporosis
- Paget's
- Skeletal metastases
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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
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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
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Outline common causative organisms of septic arthritis
- S.Aureus
- N.Gonorrhoeae
- H.Influenzae (especially in children)
- TB
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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
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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
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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
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What is 'pseudogout'?
- When calcium pyrophosphaste crystals are deposited in joints or extra-articular tissues
- Crystals are rhomboid, unlike gout crystals
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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
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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
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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
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Describe some perdisposing factors for osteoarthritis
- Obesity
- Genetics
- Female
- Hypermobility
- Trauma
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Outline the surgical treatment of osteoarthritis
- Bearing surfaces replaced
- Restoration of normal joint mechanics
- Improves function, reduces deformity and relieves pain
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