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Phase 2 Harriet Ribbons and Caroline Hoernig

Rheumatology. Phase 2 Harriet Ribbons and Caroline Hoernig. The Peer Teaching Society is not liable for false or misleading information…. Aims:. Understand the different types of arthritis: Osteoarthritis Rheumatoid Arthritis Seronegative spondyloarthropathies Crystal arthropathies

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Phase 2 Harriet Ribbons and Caroline Hoernig

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  1. Rheumatology Phase 2 Harriet Ribbons and Caroline Hoernig The Peer Teaching Society is not liable for false or misleading information…

  2. Aims: • Understand the different types of arthritis: • Osteoarthritis • Rheumatoid Arthritis • Seronegativespondyloarthropathies • Crystal arthropathies • Understand Systemic Lupus Erythematousus (SLE) The Peer Teaching Society is not liable for false or misleading information…

  3. Arthritis Introduction: • Common joint condition • Causes pain and inflammation in a joint • 10,000 people per year seek help for arthritis • Symptoms include: • Joint pain • Joint tenderness • Joint stiffness • Inflammation around the joints • Restricted movement around the joints • Warm, red skin over the joints • Muscle weakness • Muscle wasting The Peer Teaching Society is not liable for false or misleading information…

  4. The Peer Teaching Society is not liable for false or misleading information…

  5. JOINT PAIN INFLAMMATORY NON-INFLAMMATORY Autoimmune Crystal arthritis Infection Non-Degenerative Degenerative Sports medicine Vasculitis Rheumatoid arthritis Seronegative Spondylarthropathy Connective tissue disease The Peer Teaching Society is not liable for false or misleading information…

  6. InflammatoryDegeneratve • Pain eases with use, worst at rest • Morning stiffness >60mins • Swelling usually due to joint effusions • Joints hot and red • Affects younger people • Hands and feet • Responds to NSAIDS • Pain increases with use • Morning stiffness <30mins • Bony swelling • Not clinically inflamed • Affects older patients, prior occupation/sport • Knees, hips, CMCP • Less convincing response to NSAIDS The Peer Teaching Society is not liable for false or misleading information…

  7. INFLAMMATORY The Peer Teaching Society is not liable for false or misleading information…

  8. Rheumatoid Arthritis (RA) • Affects synovial joints • Joints affected: • (DIP sparing) • PIP • MCP • Wrists • Feet • Bony erosions on XRay The Peer Teaching Society is not liable for false or misleading information…

  9. Hypertrophy synovium -> New capillary formation -> Inflammtion -> Synovial villi form and grow into bone -> PANNUS -> Cytokines released

  10. RA risk factors: • Increasing age (may occur at any age). • Female sex • Premenopausal • Smoking The Peer Teaching Society is not liable for false or misleading information…

  11. RA symptoms: • Pain • Morning stiffness • Myalgia • Fatigue • Weight loss • Joint pain • Synovitis of small joints • Mono/ bilateral arthropathy of the shoulder/ wrist • Tenosynovitis or bursitis • “Swan neck deformity” late on • “Boutonniere” deformity late on • Finger drop The Peer Teaching Society is not liable for false or misleading information…

  12. RA diagnosis: • 4 of the following symptoms: • Morning stiffness >1 hour >6 weeks • Arthritis >3 joints • Arthritis in hand joints • Symmetrical arthritis • Rheumatoid nodules • Positive RF • Radiological changes The Peer Teaching Society is not liable for false or misleading information…

  13. Z-Shaped thumb

  14. Hypertrophy synovium -> New capillary formation -> Inflammtion -> Synovial villi form and grow into bone -> PANNUS -> Cytokines released

  15. RA Xray changes: • Soft tissue swelling • Juxta articular osteopenia • Loss of joint space • Bony erosions The Peer Teaching Society is not liable for false or misleading information…

  16. Extra-articular involvement The Peer Teaching Society is not liable for false or misleading information…

  17. RA investigations: • Bloods: • FBC • Anaemia • ESR • High • RF • Positive in 80% • Anti CCP • Positive in 80% • ANA • <50% positive • ALL TESTS NEGATIVE IN 20% • Xray • Erosions seen • Periarticular osteopenia • (Joint space narrowing) The Peer Teaching Society is not liable for false or misleading information…

  18. RA treatment: • NSAIDs • Pain relief • Glucocorticoids • Intramuscular injections • Disease Modifying Anti Rheumatic Drugs (DMARDs): • Azathioprine, ciclosporin, penicillamine, leflunomide, methotrexate and sulfasalazine. • Can be used with steroids • Reduced damage to joints • METHOTREXATE side effects lung fibrosis, liver effects. • Biological drugs: • Rituximab (Anti CD20), etanercept (TNF inhibitor) and abatacept (T cell stimulator modulator) • Inhibits the immune system • Surgery The Peer Teaching Society is not liable for false or misleading information…

  19. DEGENERATIVE The Peer Teaching Society is not liable for false or misleading information…

  20. Osteoarthritis • Most common condition affecting synovial joints • All joint tissues involved, esp. articular cartilage • Risk factors; • Age • Sex • Genetics • Obesity • Trauma/occupation • ?protective effect of cigarette smoking • Knees (esp. medial compartment), hips and hands most commonly affected The Peer Teaching Society is not liable for false or misleading information…

  21. Radiological changes in OA The Peer Teaching Society is not liable for false or misleading information…

  22. Clinical features of OA • Symptoms; - PAIN - POOR MOBILITY • FUNCTIONAL IMPAIRMENT • Signs: • ALTERED GAIT • JOINT SWELLING/TENDERNESS • CREPITUS The Peer Teaching Society is not liable for false or misleading information…

  23. Treatment of OA • Education and lifestyle advice eg. lose weight! • Analgesia (topical, oral, transdermal) • Steroid injections • Surgery • Uncontrolled pain • Significant limitation of function • NB. Aim is to relieve pain not increase movement The Peer Teaching Society is not liable for false or misleading information…

  24. SERONEGATIVE SPONDYLARTHOPATHY The Peer Teaching Society is not liable for false or misleading information…

  25. SERONEGATIVE SPONDYLARTHOPATHY • High rate of HLA-B27 • Rheumatoid factor NEGATIVE. • Types • Ankylosing spondylitis • Psoriatic arthritis • Reactive arthritis • Enteropathic arthritis The Peer Teaching Society is not liable for false or misleading information…

  26. SERONEGATIVE SPONDYLARTHOPATHY • Ankylosing spondylitis • Psoriatic arthritis • Reactive arthritis • Enteropathic arthritis The Peer Teaching Society is not liable for false or misleading information…

  27. Ankylosing Spondylitis (AS): • Sacroilitis • Inflammation of one of both of the sacroiliac joints • Inflammatory back pain • Enthesitis • Inflammation of the enthesis (where the tendons/ ligaments enter the bone) • (Anterior uveitis) The Peer Teaching Society is not liable for false or misleading information…

  28. AS risk factors: • 20- 30 years • HLA-B27 linked • Caucasian • Men The Peer Teaching Society is not liable for false or misleading information…

  29. AS symptoms: • Back pain in the morning • Morning stiffness • Ossification of ligament/ tendon • Longer than 30 minutes • Pain improves with movement • Enthesitis • Ossification of capsule insertions • Synovitis • Common at the large peripheral joints • Stooped posture • “Bamboo spine” at a late stage • Micro-fractures The Peer Teaching Society is not liable for false or misleading information…

  30. 6 A’s of AS: • A Atlantic axial instability • A Atypical lung fibrosis • A Anterior uveitis • A Amyloidosis • A Autoimmune bowel disease and UC • A Aortic incompetance The Peer Teaching Society is not liable for false or misleading information…

  31. AS extra-articular symptoms: • Aortic incompetence • Cardiomegaly • Amyloidosis • Fractures • Fatigue • Weight loss • Low grade fever • Anaemia • Upper lobe pulmonary fibrosis • Iritis • Pleuritis • Osteoporosis The Peer Teaching Society is not liable for false or misleading information…

  32. AS investigations: • Bloods: • ESR • High • RF: • Negative • Xray • Sacroiliac changes • Ascending spread of disease • Facet joint involvement • Squaring of vertebrae • Syndesmophyte (bony growth in the ligament) • Ossification • Osteitis pubis (inflammation of pubis synthesis) • MRI (*Gold standard) • Joint erosions • Fluid The Peer Teaching Society is not liable for false or misleading information…

  33. AS treatment: • Exercise • Physiotherapy • NSAIDs • Pain relief • Disease Modifying Anti Rheumatic Drugs (DMARDs): • Azathioprine, ciclosporin, penicillamine, leflunomide, methotrexate and sulfasalazine. • Biological drugs: • Rituximab (Anti CD20), etanercept (TNF inhibitor) and abatacept (T cell stimulator modulator) • Inhibits the immune system • Local steroid injections The Peer Teaching Society is not liable for false or misleading information…

  34. SERONEGATIVE SPONDYLARTHOPATHY • Ankylosing spondylitis • Psoriatic arthritis • Reactive arthritis • Enteropathic arthritis The Peer Teaching Society is not liable for false or misleading information…

  35. Psoriatic arthritis: • Joints affected: • DIP • Spine • Nail involvement • Sacroiliac joints • In people with psoriasis or family history of psoriasis • Less severe than RA The Peer Teaching Society is not liable for false or misleading information…

  36. Psoriatic arthritis types: • Distal interpharyngeal arthritis (DIPJs) • Most typical form • Nail dystrophy • Seronegative symettrical polyarthritis • Similar to RA eg knees, wrists, DIPs (not MCPs) • Arthritis mutilans • 5% affected. • Xray shows periarticular osteolysis and bone shortening • Unilateral or bilateral sacroilitis • 15% affected. • Affects the cervical spine • Assymetrical arthritis • Warm red tender joints • Dactylitis in hands and feet • Juvenille onset • 20% childhood arthritis The Peer Teaching Society is not liable for false or misleading information…

  37. Psoriatic arthritis symptoms: • Stiffness and pain • Joint involvement: • DIP joint • Asymmetrical oligoarticular arthritis • Symmetrical polyarthritis • Arthritis mutilans (degeneration of joint) • Sacroilitis • Psoriasis (some cases): • Scalp • Perineum • Umbilicus • Nail lesions • Pitting • Onchyolysis • Splinter haemorrhages • Skin lesions: • Erythematous lesions • Pus • Erythroderma • Enthesitis • Dactylitis (sausage digits) • Synovitis • Subcutaneous nodules • Conjunctivitis and uveitis The Peer Teaching Society is not liable for false or misleading information…

  38. Psoriatic arthritis investigations: • Bloods: • ESR • High • FBC: • Anaemia • Xray The Peer Teaching Society is not liable for false or misleading information…

  39. Psoriatic arthritis treatment: • Exercise • NSAIDs • Pain relief • Disease Modifying Anti Rheumatic Drugs (DMARDs): • Azathioprine, ciclosporin, penicillamine, leflunomide, methotrexate and sulfasalazine. • Biological drugs: • Rituximab (Anti CD20), etanercept (TNF inhibitor) and abatacept (T cell stimulator modulator) • Inhibits the immune system The Peer Teaching Society is not liable for false or misleading information…

  40. SERONEGATIVE SPONDYLARTHOPATHY • Ankylosing spondylitis • Psoriatic arthritis • Reactive arthritis • Enteropathic arthritis The Peer Teaching Society is not liable for false or misleading information…

  41. Reactive arthritis (Reiter’s): • Triad of symptoms: • Can’t see (Conjunctivitis) • Can’t pee (Urethritis) • Can’t climb a tree (Arthritis) • Common in 18-30 • Commoner in lower extremities • 30% chronic. • Majority resolve within 3-24 months The Peer Teaching Society is not liable for false or misleading information…

  42. Reactive arthritis Causes: • Shigella • Chlamydia • Salmonella • HIV • Enterocolli. The Peer Teaching Society is not liable for false or misleading information…

  43. Reactive arthritis investigations: • Bloods: • ESR • High • ECG • Xray The Peer Teaching Society is not liable for false or misleading information…

  44. Reactive arthritis treatment: • NSAIDs • Pain relief • Steroids • Used in flare ups • Antibiotics • Treat the underlying cause • (DMARDs) The Peer Teaching Society is not liable for false or misleading information…

  45. SERONEGATIVE SPONDYLARTHOPATHY • Ankylosing spondylitis • Psoriatic arthritis • Reactive arthritis • Enteropathic arthritis The Peer Teaching Society is not liable for false or misleading information…

  46. Enteropathic arthritis: • Occurs in 10-15% of all IBD cases (Ulcerative colitis and Crohns) • HLA B27 linked in 50% of cases • Asymetrical arthritis • Mainly affects the lower limbs • Remission of IBD leads to improvement in symptoms • TREAT IBD TO TREAT ARTHRITIS The Peer Teaching Society is not liable for false or misleading information…

  47. CONNECTIVE TISSUE DISEASE The Peer Teaching Society is not liable for false or misleading information…

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