medications

TPMT helps to inactivate the metabolites produced by the drugs alone with xanthine oxidase. Individuals with absent TPMT activity cannot effectively break down these metabolites, leading to their accumulation

broken down to 6 thioGMP and TIMP by TPMT 

6thio: induces DNA strand breaks and base mispairs

the other one inhibits formation of ribosyl 5 phosphate and prevents production of purines (guanine and adenine)

• converted to mycophenolic acid
• inhibits IMPDH and thus purine synthesis

• heart failure 
• and can cause antibodies to form against this drug

a copy of the biologic medicine that is similar to BUT NOT IDENTICAL to the original medicine

• Certolizumab, golimumab, infliximab 
• etanercept, adalimumab

IL1 receptor antagonist 

can cause anaphylaxis

binds to IL6 receptor antagonist---causes neutropenia and thrombocytopenia

reactivate TB and cause lymphomas

bind to CD 20 on B cells and activate NK cells and cytotoxic T cells---INFUSION RELATED RXN INCLUDING RASH

infusion related is the main COPD exacerbation 

AVOID with TNF alpha blocking agents

APC activates T cell through binding of costimulators CD80/86 as well--this drug prevents this from happening so T cells cannot proliferate

• --check for latent diseases like TB and hepatitis B 
• --you can not have gotten a LIVE vaccine within 3 months of therapy/during 
• --increase risk of cancer (except rituximab)

mechanism is not known -- used to decrease inflammation but can cause nephrotoxicity

• hemorrhagic cystitis 
• cardiotoxicity

• metabolized to phosphoramide mustard in the liver 
• cross links DNA to prevent cell replication

• Nephrotoxicity 
• GINGIVAL hyperplasia 
• hepatotoxicity

Calcineurin usually phosphorylates TF and the TF is able to produce IL2--> calcineurin is inhibited by this drug and so IL2 and T cell activation is not occurring

• prodrug that is cleaved by bacteria in the colon into 
• sulfapyridine (intended effect mediated by this) 
• 5 ASA

• Eye exams are required at baseline and yearly-- drug can cause a bull's eye retinopathy 
• causes cardiomyopathy myopathy and anemia

Jak stat inhibitor causes decreased proliferation and differentiation of NK B and T cells 

also causes hepatotoxicity and GI perforation 

activated in the intestine to teriflunomide--> which inhibits DHODH and inhibit pyrimidine production

causes hepatotoxicity

• Renal
• hepatotoxicity 
• teratogenesis 

FOlate supplements are necessary

it also inhibits the dihydrofolate reductase-- preventing folic acid from being converted to the active form---DNA synthesis is altered, replication decreases apoptosis increases

CT: a lot of radiation, multiple XRs that are taken from many different views and combined into a single image 

MRI: no radiation, magnetic view (if someone came in with a lot of nails in their brain--avoid using an MRI) 

XR: radiation but more localized to where you want it done

it is good to get a weight-bearing XR-- gravity will be accounted for and you can see narrowing of the joint space

scintingraphy--PET scan

MRI--with or without--this is the modality of choice but clinically and with insurances-- the initial imaging ordered should be XR.

XR-- may require them to come back for a repeat incase you missed it the first time/or it didn't show as obviously on the initial xr.

the white is not continuous--suggesting a patellar tendon tear causing a patella alta pathology

• Normal patellar location should be in between the two condyles 
• in abnormal it sits above the condyles

black line--patellar tendon

the triangles: Anterior horn (near the patellar tendon) of the menisci and posterior horn

soft tissue is black--the PCL is usually thicker than the ACL

compression side: occur on the concave side (inferior medial)

tension side: occur on the convex side (superior lateral)-- restricts weightbearing because there is a greater chance that the fracture can break off

any sort of fluid--edema, inflammation-- is going to light up 

in t1 the bone will light up instead of the soft tissue

the contour is not nice and smooth implying a step off/fracture

Acetabular fracture

• order XR of the AP pelvis
• AP Hip 
• frog leg (take heel of the foot and rest it on the opposite knee

confirm with at least 2 different views (AP and lateral are the most common--but the main diagnosis is coming from the history using the image as a confirmatory)

1 VIEW IS NOT DIAGNOSTIC

Located on the medial tibia-- gracilis, semitendinosus, and sartouris all attach here--- people with osteoarthritis get greater articulation at the medial aspect causing bowing at the lateral side 

more pressure at the articulation end and causes bursitis

• sudden groin pain abdominal pain nausea and vomiting 
• --strangulated hernia is when there is no blood flow to the hernia and it can become necrotic

profound loss of knee flexion and some weakness with hip extension

obturator artery and perforating branches

treated by immobilizing the knee in 120 degree of knee flexion for 24 hours to avoid hematoma formation-- and then PT

complication: myositis ossificans

cause no active deficit

main hip flexor--loss will cause profound deficit

the iliac tubercle to gerdy's tubercle

smoking cessation 

Angiograph will show collateral blood vessels made to combat the decreased blood flow

• associated with smokers and caused by reduced blood flow 
• -gangrene
• -raynauds phenomena

it has a granulomatous biopsy but also with necrotizing fibers

Associated with hepatitis B--and does have cutaneous involvement

medium vessel-- asian children will present with rashes (hands and feet) that can desquamate-- they also present with strawberry tongue, and fever, joint pain 

NOT accompanied or preceded by a sore throat or sandpaper rash 

--> Tx: aspirin and Immunoglobulin

• affects the aorta and its branching arteries-- causes limb claudification, and pulse differences in the extremities 
• bruits 
• stroke

• polymalgia rheumatica-- symmetrical pain 
• and on biopsy is associated with giant cells and granulomatous appearance

there is a faint white line going across the joint (chondrocalcinosis)

requires synovial fluid sampling-- gout is needle like and has a negative infringence--- so when the crystals are parallel to the red compensator it appears yellow and blue when perpendicular--opposite with CPDD (positive and rhomboid)

8q and 5p-- 5p has a greater effect and linked with ANKH transmembrane protein that releases ATP, PPi into the extracellular matrix... ATP is the greatest contributor (ENPP breaks it into PPi) 

binds with calcium to form calcified deposits

• hypmagnesium 
• hypophospate 
• hyperparathyroidism 
• hemochromatosis

uricase--which is not found in humans--its a recombinant protein which is given to break down the uric acid

both inhibit tubular reabsorption of uric acid

hole punched/mickey mouse ears

they are granulomas surrounding the deposits of MSU crystals and are also seen in chronic forms of CPP disease 

they can result in destructive arthopathy

• salicylates 
• diuretics
• cyclosporine 
• pyrazinamide

blunt trauma

Mi: against DNA helix--benign 

SAE- against TF-- systemic systems (weight loss and fevers)

NXP- against nuclear matrix protein, calcinosis and edema

TIF--transcription factor, psoraisis and hyperkerototic lesions

MDP--against RNA helicase-- causes lung disease, severe skin path, and amyopathic

CK levels and other enzymes-- because correlated with muscle damage--

Anti synthease: anti jo-- associated with Raynauds, Arthritis, and mechanic fingers, LUNG disease 

Anti-SRP: severe--necrotizing myopathy with minimal inflammation 

HMCRP: against reductase--associated with statin use and causes necrotizing myopathy

• SSA SSB SCL 
• U1 U2 U3
• ANA

Dermatomyositis has IFN and CD4+ atrophy/perimysial inflammation 

Polymyositis is associated with CD 8

quotidian fever for at least 2 weeks (has to occur around the same time) 

atleast 2 of the following: serositis, rash (salmon pink), hepato/splenomegaly, lymphadenopathy

Macrophage Activation syndrome-- thrombocytopenia, low fibrinogen, elevated ferritin, AST, activated macrophages

• systemic (not associated with uveitis)
• oligo (less that 4 joints) --associated with uveitis (esp if ANA +)
• poly (more than 5 joints)--associated with uveitis greater risk if ANA and RF positive (Rf is worse prognosis)

• chlamydia, campylobacter
• e. coli 
• yersina 
• salmonella, shigella

• can't see (conjunctivitis) 
• can't pee (urinary complaints)
• can't climb a tree (arthritis)

antibiotics and aspirin 

• steroids if heart is involved 
• -all family members who test positive should be treated with antibiotics even if asymptomatic

throat culture for strep=+ or antibodies are present (ASO. DNAase B)

and 2 major or 2 minor, 1 major 

Major: joint pain (migratory, inflammatory), carditis, nodules, erythema margin, synder chorea

Minor: fever, arthralgia, acute phase reactants, PR interval prolonged

self resolving disease

accompanied by honey gold crusting—treated with mupirocin (impetigo)

IV  cephalosporin for scalded skin syndrome

furuncles first-line treatment is cephalosporin, folliculitis it is mupriocin

imiquimod, 5FU liquid nitrogen

• low risk: HPV 6 and 11
• high risk: 16 and 18

poxvirus… if adults get it it is usually sexually transmitted or HIV—cantharone imiquimod cryotherapy

EBV-- and cannot be scraped off like thrush can be 

treat it via HAART

orolabial herpes are commonly acquired during dental procedures

dentists are likely to acquire cold sores on their fingers-- because they come into close contact with individuals and their cold sores

is a pore forming molecule 

and MECA gene causes a mutation in the penicillin binding protein that acts as the trasnpeptidase to make the cell wall

- Aicar transaminase so Aicar increases inhibiting AMP deaminase- AMP increases causing decreased function of WBC