Term
| Joint pain - Non inflammatory |
|
Definition
Osteoarthritis
Avascular Necrosis |
|
|
Term
| Symmetric, Polyarthritis, Inflammation |
|
Definition
Rheumatoid Arthritis
Systemic Lupus
Erythermatosus (SLE) |
|
|
Term
| Asymmetric, Polyarthritis, Inflammation |
|
Definition
Psoriatic Arthritis
Reactive Arthritis (Reiters) |
|
|
Term
| Axial, Polyarthritis, Inflammation |
|
Definition
|
|
Term
| Monoarthritis, inflammatory |
|
Definition
Crystals (e.g. Gout)
Infectious Arthritis |
|
|
Term
| Osteoarthritis Radiographic Manifestations. Know for test. |
|
Definition
• Joint space narrowing (cartilage
loss)
• Subchondral sclerosis (Eburnation)
• Osteophyte formation
• Subchondral cysts |
|
|
Term
| Diffuse Idiopathic Skeletal Hyperostosis |
|
Definition
– Calcification of the anterior spinal
ligament
– Flowing osteophytes
– Involvement of at least four contiguous
vertebral bodies
– Sparing of posterior elements
– Maintenance of disc height |
|
|
Term
| Osteochondritis Dessicans |
|
Definition
– Articular cartilage and underlying bone loose in the joint.
– Frequently associated with minor
trauma
– Often a familial tendency
– Often seen in young adults |
|
|
Term
|
Definition
– Thinning and damage of cartilage of
patellofemoral joint
– More common in women
– May be associated with subluxation
• Management
– Quadriceps muscle strengthening
exercises
– Patellar taping
– Non steroidal anti-inflammatory drugs
(NSAIDs)
– Surgery
– Lateral release
– Avoid major surgery (e.g. patellectomy) |
|
|
Term
|
Definition
• Sensory neurologic deficit
• Joint deformity and destruction out of proportion to the severity of pain.
– Painless in the face of marked deformity
– Less painful than expected in view of the degree of deformity.
Management
• Education
• Reduce joint trauma
• DO NOT replace with artificial joints |
|
|
Term
Osteonecrosis
(Avascular Necrosis/Aseptic
necrosis) |
|
Definition
| 50% idiopathic, corticosteroids are a main known cause. Start w radiograph but MRI is best early detection. Stage 3 cresecent sign, bone not nourished by synovial fluid collapses. Stage 4 bone collapse and flattening of femoral head. |
|
|
Term
| Felty’s syndrome: A Triad |
|
Definition
�� RA
�� Splenomegaly
�� Neutropenia |
|
|
Term
|
Definition
Antibody against the Fc fragment of Ig.
75% of RA patients |
|
|
Term
| Myositis-specific antibodies (Ab) |
|
Definition
|
|
Term
|
Definition
ACE-inhibitors are the first-line anti-hypertensive agents
�� Accelerated HTN (10% normotensive)
�� Deteriorating renal function
�� Microangiopathic hemolytic anemia |
|
|
Term
| Cirtrullinated lung proteins |
|
Definition
| Produced by smoking, may be the inciting antigen in RA |
|
|
Term
|
Definition
1. Pain still present at rest. ↓ Range of movt
2. Morning joint stiffness improving w/ use
3. Fatigue, malaise, myalgia
4. Weight loss, anorexia
5. Fever
6. Ulnar deviation of fingers, radial deviation of wrist
7. Swan Neck: Hyperextension of PIP, Flexion of DIP
•Boutonniere: Hyperextension of DIP, Flexion of PIP
8. Involved joints are swollen, warm, painful, and stiff.
9. Baker’s Cyst: Synovial cyst in posterior knee: ↑ Intra-articular pressure causes outpouchings of synovium |
|
|
Term
|
Definition
Arise in regions subjected to pressure
•Firm, non-tender, round
•Central necrosis surrounded by palisading fibroblasts & lymphocytes |
|
|
Term
| Lab findings associated with RA |
|
Definition
1. Rheumatoid Factor in serum
•IgM reactive with the Fc part of the patient’s own IgG
•Highly characteristic of, but not specific for RA
2. Anticyclic Citrullinated Peptide Abs (Anti-CCP)
•Positive in ~70%. Highly specific.
3.*HLA-DR4-Positive Individuals
•Commonly get RA
4. Synovial Fluid: Inflammatory
•2,000-30,000 WBCs; >50% Neutrophils
•↑ Protein, Cloudy
•↓ Mucin content
•Thin |
|
|
Term
What things characterize the Noninfectious Inflammatory Myopathies:
1. Dermatomyositis
2. Polymyositis
3. Inclusion Body Myositis |
|
Definition
1. Proximal muscle weakness
2. ↑ Serum levels of skeletal muscle enzymes
3. Myopathic changes on EMG
4. Muscle biopsy evidence of inflammation
5. Women affected 2x as men |
|
|
Term
| Process of Diagnosis: Assessing a Patient with Muscle Weakness |
|
Definition
1. Patient presents with proximal muscle weakness
• Any person with proximal weakness must get an EMG
2. EMG: To determine if it’s a nerve problem or a muscle problem
• Person with abnormal EMG needs to get muscle biopsy
3. Muscle biopsy: Get sample on opposite side from where needle EMG was done |
|
|
Term
| Clinical signs of Dermatomyositis |
|
Definition
Course: Insidious
1. Rash precedes or accompanies muscle disease
•*Classic rash: Lilac or heliotrope discoloration of upper eyelids with periorbital edema
2.*Grotton Lesions: Symmetric scaling, red eruptions over knuckles, elbow, and knees
3.*Muscle weakness characterized by:
a) Slow onset
b) Bilaterally symmetric
c) Myalgias
d)*Affects proximal muscles first!
•Difficult to get up from chair
4. Dysphagia
5. ↑ Risk of cancer
6. Shawl Sign: Macular erythema around back & neck
7. Periungual Telangiectasias |
|
|
Term
| Clues to Dx of GCA in PMR patient |
|
Definition
• Headaches
• Visual changes (especially double vision or
sudden visual loss)
• Asymmetric arm pulses (large vessel variant)
• High fevers
• Significant weight loss (>10 #)
• Jaw claudication
• Lack of prompt response to low dose steroids |
|
|
Term
| How myositis and PMR differ |
|
Definition
| Myositis patients are weak but not painful, PMR is opposite |
|
|
Term
| How to differentiate between joint problem and a tendonitis or bursitis |
|
Definition
| If the joint is involved passive movement will be painful. IF the joint is not involved passive movement should be painless, unless your strectching the tendon over the bursa. Bursitits/tendonitis are usually painful to palpate as well. |
|
|
Term
|
Definition
• 10X more common in females
• 50% of cases occur after specific
emotional or physical trauma/illness
Treatment:
• Patient education – reassurance
• Analgesics
– Tylenol, NSAID, or tramadol
• Sleep
– Exclude treatable sleep disorder
– Tricyclic antidepressants
• Aerobic exercise
• Anti-seizure meds
– Gabapentin
– Pregabalin
• Depression/Anxiety management
– SSRI’s or dual uptake inhibitors |
|
|
Term
|
Definition
• Age > 50 (and incidence increases with age) ACUTE ONSET
• Bilateral aching and stiffness at
shoulders/neck and pelvic girdle
– Prolonged morning stiffness
– Persistent beyond 1 month
• ESR > 40
• Exclusion of other diseases
• Prompt response to low dose steroids
• ~15% of PMR pts will have GCA
• ~50% of GCA pts will have PMR |
|
|
Term
|
Definition
• Induces significant pain in DeQuervain’s tenosynovitis
• Thumb flexed into palm and covered with
fingers
• Wrist is passively moved ulnarly –
stretching the involved tendons |
|
|
Term
| DeQuervain’s tenosynovitis |
|
Definition
--Inflammation and narrowing of the tendon sheath of the abductor pollicis longus and the extensor pollicis brevis at the radial styloid
• Etiology
– Repetitive grasping with thumb while radially moving wrist
– Pregnancy and especially after the baby is born! |
|
|
Term
|
Definition
– Point tender over medial epicondyle
– Resistance to wrist flexion exacerbates pain |
|
|
Term
|
Definition
– Point tender over lateral epicondyle
– No swelling
– Normal elbow motion
– Pain with resisted wrist extension |
|
|
Term
| Two most common types of bursitis |
|
Definition
|
|
Term
| 4 of the following criteria = lupus. Listged by frequency of occurence. |
|
Definition
Malar rash
Discoid rash
Photosensitivity
Oral ulcers (painless)
Nonerosive arthritis
Serositis
Renal disorder
Neurologic disorder(seizure/psychosis)
Hematologic disorder
Immunologic disorder
Antinuclear antibody (ANA) |
|
|
Term
| What are the 4 main proposed routes of Pathogenesis for SLE |
|
Definition
i. Waste disposal hypothesis,
ii. Interferon signature,
iii. Immune complexes (serum sickness),
iv. Direct antibody toxicity |
|
|
Term
| i. Waste disposal hypothesis |
|
Definition
Multiple defects contribute to inability to appropriately manage cell products from apoptosis.
They include defects in inducing apoptosis, opsinization, engulfment, trafficking etc. |
|
|
Term
|
Definition
| Many genes are regulated through the interferon response elements. These are elevated in SLE patients and more so during flares. Some exceptions exist but it appears to be a generally true observation. It strengthens the potential role of viruses in triggering new disease and flares of existing disease. |
|
|
Term
| iii. Immune complexes (serum sickness) |
|
Definition
| This relates in part to the waste disposal hypothesis as it is a mechanism that disease results from an inability to appropriately handle excess immune complexes. |
|
|
Term
| iv. Direct antibody toxicity |
|
Definition
| This mechanism is best demonstrated in the hematologic manifestations of SLE. For example Coomb’s positive hemolytic anemia is a direct result of antibodies to the RBC, leading to hemolysis. |
|
|
Term
| What advantages do antimalarial drugs provide in SLE |
|
Definition
hydroxychloroquine (Plaquenil)
– Photoprotection
– Anticoagulation
– Lowers hyperlipidemia
• Decrease of 8.9+/-3 mg%
– Treats arthritis
– Decreases flares by
58%
– Improves renal disease
• Is protective in at risk pts |
|
|
Term
| List the Calcineurin Inhibitors |
|
Definition
|
|
Term
| List the antiproliferative drugs used in immunosupression |
|
Definition
*sirolimus
*mycophenolate mofetil
*azathioprine
*cyclophosphamide |
|
|
Term
| List the Antilymphocyte Drugs |
|
Definition
*Antithymocyte Globulin (Thymoglobulin)
*OKT3 (Muromonab-CD3) |
|
|
Term
| Il-2 Receptor Antagonists |
|
Definition
*basiliximab,
*daclizumab |
|
|
Term
|
Definition
modulation of cytokine and chemokine
production; inhibition of eicosanoid synthesis; marked inhibition of accumulation of basophils, eosinophils, and other leukocytes; and decreased vascular
permeability. |
|
|
Term
| Main Corticosteroid Side Effects |
|
Definition
1. Mood disturbance
2. Increased appetite; Weight gain, with fat deposits in your abdomen, face and the
back of your neck
3. Impaired glucose control in diabetics
4. Hypertension
5. Acute adrenal insufficiency (from overly rapid withdrawal) |
|
|
Term
|
Definition
| prevent activation of nuclear factor of activated T cells (NFAT) and subsequent expression of lymphokines (IL-2, antiapoptotic proteins). |
|
|
Term
| Calcineurin Inhibitors clinical uses |
|
Definition
1. Both inhibitors are indicated for organ transplant rejection
prophylaxis; tacrolimusis also used as rescue therapy
2. Cyclosporine also used to treat rheumatoid arthritis and psoriasis |
|
|
Term
|
Definition
forms a complex with FKBP-12, which leads to mTOR inhibition.
1. Sirolimus is indicated for prophylaxis of organ transplant
rejection in combination with a calcineurin inhibitor and glucocorticoids. In patients at high-risk for (calcineurin inhibitor associated)
nephrotoxicity, sirolimus is used with mycophenolate mofetil to avoid
permanent renal damage.
2. NOTE: sirolimus and cyclosporine interact, and should be separated by time. |
|
|
Term
|
Definition
inhibits de novo purine synthesis. Azathioprine is a pro-drug, converted in the body to the active
metabolites 6-mercaptopurine and 6-thioinosinic acid. |
|
|
Term
|
Definition
inhibits inosine monophosphate dehydrogenase, an enzyme that synthesizes guanine nucleotides. B and T cells are highly dependent on this pathway, while other cells have redundant pathways they can use.
replacing Azathioprine because it has less bone marrow supression. indicated for the prevention of organ
transplant rejection in adults and renal transplant rejection in children >2 years |
|
|
Term
|
Definition
Chimeric murine monoclonal antibody against human IL-2 receptor alpha subunit of activated T cells
-��Low side effects (anaphylaxis can rarely occur) |
|
|
Term
| Adverse effects of sirolimus |
|
Definition
| Thrombocytopenia*, hyperlipidemia* |
|
|
Term
|
Definition
Muromonab-cd3 antibody-monoclonal antibody to CD3 on T cell, leads to rapid internalization of receptor, preventing Ag recognition
-used to prevent or reverse acute graft rejection, repeated use
counterindicated
-side effects (“cytokine release syndrome”) minimized by
glucocorticoid treatment pre- and post- treatment, but should be
prepared for resuscitation if needed |
|
|
Term
|
Definition
purified gamma globulin from serum of rabbits immunized with human thymocytes
-*contains sytotoxic antibodies that bind CD2-4,8,11a,18,25,44,45
-used for induction immunosuppression, and treatment of acute renal transplant rejection with other agents
and HLA class 1&2 molucules on T-lymphocytes, thereby depleting circulating lymphocytes |
|
|
Term
|
Definition
| humanized immunoglobulin similar to Basiliximab which blocks IL-2 receptor |
|
|
Term
|
Definition
_Binds to CD52, a glycoprotein present on surface of all T and B cells and some bone marrow cells
_Used for for selected leukemias and lymphomas and for stem cell transplant procedures |
|
|
Term
| TNF inhibitors, names and uses |
|
Definition
(disease modifiers to treat rheumatoid arthritis)
– Etanercept - Recombinant version of TNF receptor
– Infliximab - Chimeric human/murine anti-TNF monoclonal antibody
• Anakinra– Human IL-1 receptor antagonist |
|
|
Term
| Interferons and uses and MOA |
|
Definition
-alpha (anticancer uses)
��beta (relapsing type multiple sclerosis)
��gamma (chronic granulomatous disease)
MOA is via inhibition of cell proliferation, and enhancement of
immune activities, including increased phagocytosis by macrophages and augmentation of specific cytotoxicity by T
lymphocytes |
|
|
Term
| Interleukins uses, MOA and side effects |
|
Definition
��IL-2 (enhance antitumor actions of cytotoxic T cells and NK cells)
MOA-enhances lymphocyte proliferation, cytotoxic and killer cell activity, induction of IFN-γ activity.
Side effects include serious cardiovascular toxicity, hypotension,
reduced organ perfusion, infection, and death. |
|
|
Term
| Bacillus Calumet-Guerin (BCG) |
|
Definition
-viable strain of Mycobacterium bovis that enhances macrophage activity
– BCG used for bladder cancer and melanomas |
|
|
Term
| epoetin alfa, darbepoetin |
|
Definition
| synthetic form of erythropoietin |
|
|
Term
| Nonbiologic Disease-modifying antirheumatic drugs (DMARDs) |
|
Definition
methotrexate, leflunomide, sulfasalzine, hydroxychloroquine, and
minocycline. |
|
|
Term
| Biologic Response Modifiers (BRM) or Biologic DMARDs |
|
Definition
| abatacept, adalimumab, etanercept, infliximab and rituximab |
|
|
Term
|
Definition
| NSAID - drug of choice for gout treatment because it inhibits urate crystal phagocytosis - adverse effects after indomethacin therapy are seen in 35-50% of patients |
|
|
Term
| Which NSAIDS have a short half life <5hrs |
|
Definition
ibuprofen, indomethacin, diclofenac, ketoprofen,
flurbiprofen |
|
|
Term
| Which NSAIDS have a long half life > 5 hrs |
|
Definition
| naproxen, sulindac, diflunisal, oxaprozin, nabumetone, ketorolac |
|
|
Term
| What kind of drugs are and are not effective in treating or preventing mucosal injury due to NSAID use? |
|
Definition
| Proton-pump inhibitors (PPIs) are effective. histamine H2 blockers (Ranitidine) not effective |
|
|
Term
| Uricosuric effects of aspirin |
|
Definition
| Salicylates act on the renal tubules to affect uric acid excretion. Lower doses (1 -2 g/day) result in urate retention. However, high doses (> 5 g/day) increase urate excretion |
|
|
Term
|
Definition
RA drug. Oral, indirect, pyramidine synthesis inhibitor, inhibits T, B and osteoclasts and cytokine production.
Toxicity/Side effects: * Hepatotoxicity, teratogenic |
|
|
Term
| Lateral epicondylitis, tennis elbow |
|
Definition
| Extensor carpi radialis brevis |
|
|
Term
|
Definition
| Pronator teres, flexor carpi radialis |
|
|
Term
| Internal rotation of shoulder involves what muscle |
|
Definition
|
|
Term
| External rotation of shoulder involves what muscles |
|
Definition
| Teres minor, Infraspinatus |
|
|
Term
|
Definition
indirect inhibition of pyrimidine biosynthesis results in cytostatic effect on B & T cells – may also be partially due to osteoclast inhibition.
�� Due to its unique mechanism of action, leflunomide efficacy may be additive to other antirheumatic agents
�� Frequently used with methotrexate
�� Toxicities: GI, diarrhea, alopecia,
hepatotoxicities - teratogenic |
|
|
Term
| How do tetracyclines work as anti RA drugs |
|
Definition
| inhibit matrix metalloproteinases |
|
|
Term
|
Definition
�� Infliximab
�� Adalimumab |
|
|
Term
| Recombinant human TNF-α receptor (blocks TNF) |
|
Definition
|
|
Term
| biologic DMARDs that target T cells |
|
Definition
Abatacept Mechanism: Selective costimulation modulator; inhibits T-cell activation by binding to CD80 and CD86 on antigen presenting cells.
�� Should not be use with anti-TNF therapy or anakinra |
|
|
Term
| DMARDs That target B cells |
|
Definition
Ritaximab - monoclonal antibody directed against the CD20.
�� Use: when other nonbiologic DMARDs fail
�� Toxicity: *hematopoetic toxicities, *CNS effects(fever, chills, headache), *GI toxicities (nausea, pain), others |
|
|
Term
| biologic DMARDs that target IL-1 |
|
Definition
|
|
Term
|
Definition
recombinant urate oxidase
�� Rasburicase catalyses the breakdown of uric acid to allantoin, an inactive and soluble byproduct, lowering high serum uric acid levels.
Used to treat tumor lysis syndrome. |
|
|
Term
|
Definition
�� Mechanism: Inhibits the enzyme xanthine oxidase – nonpurine
compound
�� Toxicities: similar to allopurinol except renal impairment may not require dose alteration, thromboembolic events, hepatic toxicities
�� Chance of acute gouty attack during initial phase of therapy, |
|
|
Term
|
Definition
�� Co-administration of colchicine or uricosuric agents required
�� Mechanism – Inhibits the enzyme
xanthine oxidase – disrupts purine
catabolism |
|
|
Term
| Which gout medications cam lead to kidney stones |
|
Definition
|
|
Term
|
Definition
�� Uricosuric agent
�� NSAID derivative
�� No antiinflammatory or analgesic
properties. It is about 3-6 times as potent as probenecid in its uricosuric activity
�� But has platelet inhibitory action |
|
|
Term
|
Definition
�� Uricosuric agent
�� Mechanism – decreased reabsorption of
uric acid in proximal tubule by competing at the active transport sites
�� Toxicities: GI irritation, allergic
dermatitis and rarely aplastic anemia
�� Initiation of therapy with probenecid can cause an acute gouty attack |
|
|
Term
|
Definition
Treats symptoms of gout.
�� Mechanism – inhibit microtubule
function – results in decreased
leukocyte migration, chemotaxis,
adhesion (inhibits PMN function)
�� Relieves symptoms but no effect on
decreasing the levels of uric acid
�� Combination therapy with allopurinol
and probenecid
�� Toxicities: GI disturbances, potential for hematopoetic toxicities |
|
|
Term
|
Definition
-starts in neck
• Overhead alleviates
• + Spurling’s test
• +/‐ Neuro findings
• Shoulder ROM nl |
|
|
Term
| Shoulder Pathology (differentiate from C5 radiculopathy) |
|
Definition
-starts in shoulder
-overhead painful
-+ impingement signs
-localized tenderness
-decreased range of motion |
|
|
Term
|
Definition
• DeQuervain’s tenosynovitis
• 1st CMC osteoarthritis
• Carpal instability
Easily localized to the wrist |
|
|
Term
|
Definition
• Starts in wrist/hand
• Three to five fingers
• + Phalen’s/Tinel’s
• EMG findings |
|
|
Term
|
Definition
| The patient is asked to hold their wrist in complete and forced flexion (pushing the dorsal surfaces of both hands together) for 30-60 seconds. This maneuver moderately increases the pressure in the carpal tunnel and has the effect of pinching the median nerve between the proximal edge of the transverse carpal ligament and the anterior border of the distal end of the radius. By compressing the median nerve within the carpal tunnel, characteristic symptoms (such as burning, tingling or numb sensation over the thumb, index, middle and ring fingers) conveys a positive test result and suggests carpal tunnel syndrome. |
|
|
Term
|
Definition
| way to detect irritated nerves. It is performed by lightly tapping (percussing) over the nerve to elicit a sensation of tingling or "pins and needles" in the distribution of the nerve |
|
|
Term
|
Definition
• At the elbow
• At Guyon’s canal
• Brachial plexopathy
• Consider EMG/NCS
C8 radiculopathy much less common |
|
|
Term
| Surgical Indications for cervical radiculopathy |
|
Definition
• Progressive neurological deficit
• Intractable pain
• Signs/symptoms of myelopathy
• Lack of response to 1st line treatment after 4‐6 weeks |
|
|
Term
| Cervical Myelopathy clinical presentation |
|
Definition
IF suspected get an MRI and refer to surgery quickly upon diagnosis
• Coordination / dexterity loss
• Balance / gait abnormalities
• Spasticity / sensory changes
• Bladder / bowel dysfunction
• Tandem Examination gait testing (sensitive)
• L’Hermitte’s phenomenon which is cervical flexion or extension that casues electrical shocks → back / legs
- UMN signs
-pathologic reflexes |
|
|
Term
|
Definition
| Indicates UMN findings. The test involves tapping the nail or flicking the terminal phalanx of the third or fourth finger. A positive response is seen with flexion of the terminal phalanx of the thumb. |
|
|
Term
| Acute Rheumatic Fever clinical manifestations |
|
Definition
1. Polyarthritis- migratory, lower joint, 2-4 weeks, no sequlae, responds to NSAIDs.
2. Carditis- Mitral > aortic, prolonged P-R.
3. Chorea-late manifestation, disappears during sleep.
4. Erythema marginatum-transient, truncal rash- pink-red irregular margins with central clearing, usually occurs early.
5. Subcutaneous nodules (less common)-over bony prominences, last 1-4 weeks
and are associated with severe, persistent carditis |
|
|
Term
|
Definition
1. (Bed rest through acute attack if no carditis is present; prolonged
bedrest is indicated when carditis is present.)
2. Aspirin (80-100 mg/kg/day) usually controls fever and articular complaints.
3. Corticosteroids for moderate to severe carditis.
4. Chorea: sodium valproate, carbamezapine, haloperidol, prednisone. |
|
|
Term
| Juvenile Idiopathic Arthritis (JIA). |
|
Definition
1. Prevalence 0.5 -1 case/1000 children < 16 years
2. Onset occurs at any age, peaks at 2-4 years
3. Female predominance 2:1
4. seven subtypes w oligoarthritis being the most common. |
|
|
Term
|
Definition
Systemic Onset JIA. 10% of JIA.
1) Paroxysmal fevers.
2) rash - salmon-colored macules on
trunk, most prominent with fever. May be evoked by stroking the skin (Koebner's phenomenon).
3) arthritis can seem trivial when compared with the systemic
disease, must be documented to make the diagnosis of JIA.
4) Systemic involvement of several organ systems manifested by hepatosplenomegaly, lymphadenopathy, pericarditis, myocarditis, leukocytosis, anemia, pleuritis, coagulapathy, varying frequencies and severity. |
|
|
Term
| Polyarticular Rheumatoid Factor Positive JIA |
|
Definition
a. <10% of all cases of JIA
b. 5 or more joints in first 6 months
c. arthritis usually symmetric
d. All children with this subtype test positive for rheumatoid
factor at least 2 times three months apart.
e. This is the equivalent of adult RA in children
f. Typically seen in older children, mostly teenage girls |
|
|
Term
| Polyarticular Rheumatoid Factor negative JIA |
|
Definition
a. 20-30% of all cases of JIA
b. 5 or more joints in first 6 months
c. arthritis usually symmetric
d. Children with this subtype test NEGATIVE for rheumatoid factor.
e. Potential for severe long term arthritis if not treated aggressively.
f. Typical age of onset is below 5 years
g. More common in girls |
|
|
Term
|
Definition
• Onset 1-4 years of age
• Female:male = 3:1
• Large joint asymmetroc arthritis
• Asymptomatic uveitis (10%)
-leg overgrowth, short toe |
|
|
Term
| Enthesitis related arthritis |
|
Definition
a. approximately 15% of all JIA cases
b. Arthritis + Enthesitis (inflammation of tendon/ligament insertions).
c. Or arthritis OR enthesitis Plus TWO of the following:
1. Presence of or history of sacroiliac joint tenderness and/or
inflammatory spinal pain
2. A positive HLA B27,
3. Arthritis in a boy over 6 years
4. Acute (SYMPTOMATIC) anterior uveitis
5. History of ankylosing spondylitis, enthesitis related arthritis,
sacroiliitis with inflammatory bowel disease, Reiters
Syndrome or acute anterior uveitis, in a first degree relative.
d. Arthritis tends to be asymmetric, and typically involves large joints
e. More common in boys than girls
f. Children with this subtype are at risk for developing acute uveitis
(presents with acute eye pain, photophobia, redness) |
|
|
Term
|
Definition
a. 5-10% of all JIA cases
b. Arthritis + Psoriasis.
c. Or arthritis Plus TWO of the following:
1. Dactylitis (inflammation of a digit; “sausage digit”)
2. Nail pitting or onycholysis
3. Psoriasis in patient or first degree relative
d. Arthritis may present months or years before psoriasis |
|
|
Term
| Chronic anterior uveitis /iritis |
|
Definition
a. inflammation of the iris and ciliary body which if unrecognized and
untreated can lead to blindness
b. generally asymptomatic, only detectable by slit lamp exam.
c. patients with oligoarticular disease with positive ANA are at
increased risk for developing chronic iritis
d. Children with ERA are at risk for ACUTE iritis. |
|
|
Term
| What type of JIA is most likely to persist into adulthood and be chronic |
|
Definition
|
|
Term
|
Definition
most common “vasculitis” in
childhood. Acute disease lasts 4 weeks.
1. Fever - usually hectic, not spiking, lasts one to two weeks (minimum 5 days)
2. Conjunctivitis- (starts within first few days). Non purulent.
3. Mucositis: Redness and cracking of the lips, "strawberry tongue" (starts within first few days)
4. Polymorphous rash on trunk and extremities (first few days)
5. reddening of palms and soles and indurative edema followed by desquamation around fingertips
6. Acute non-purulent cervical lymphadenopathy
7. Cardiac: most critical problem with potential long term sequelae. Cardiac aneurysms or dilation of coronary arteries in up to 40% of patients.
8. Other manifestations: diarrhea, abdominal pain, gallbladder hydrops, paralytic ileus, arthritis, aseptic meningitis, irritability, facial palsy, hemiplegia, encephalopathy,
acute iritis. |
|
|
Term
| Diagnostic Criteria for Kawasaki disease |
|
Definition
Fever lasting at least five days plus four of the five following:
1. Bilateral bulbar conjunctivitis
2. Oral mucous membrane changes, fissured lips, pharynx, or strawberry tongue.
3. Peripheral extremity changes, including erythema of palms or soles, edema of hands or feet (acute phase), and periungual desquamation (convalescent phase)
4. Polymorphous rash
5. Cervical lymphadenopathy (at least one lymph node >1.5 cm in diameter) |
|
|
Term
| Kawasaki disease treatment |
|
Definition
1. Intravenous gammaglobulin 2 gms/kg, may need a second dose in 10-15%
2. Aspirin 80-100 mg/kg/day while ESR is elevated, then 3-5 mg/kg/day if aneurysms are present.
3. Use of infliximab, corticosteroids and anti-platelet agents indicated in refractor cases |
|
|
Term
| CPPD: Associated Diseases |
|
Definition
– Hemochromatosis
– Hyperparathyroidism
- Hypophosphatemia
– Hypomagnesemia
- Wilson’s disease |
|
|
Term
| Conditions Associated With Hyperuricemia |
|
Definition
• Lymphomas (esp. Hodgkin’s disease)
• Myeloproliferative disorders
• Diabetes
• Psoriasis
• Sarcoid
• Glycogen storage disease |
|
|
Term
|
Definition
(osteitis deformans)—a metabolic bone disease characterized by excessive bone resorption and formation due to activated osteoclasts. Sarcomatous change in less than 1% of cases.
Bisphosphonate drugs are the treatment of choice. |
|
|
Term
|
Definition
A. Seen in first two decades, male predominance (3:1); in diaphysis or metaphysis.
B. Painful, waking from sleep at night, responsive to aspirin |
|
|
Term
|
Definition
| (exostosis) – most common benign bone mass. projection of the cartilaginous growth plate. Periostium over a cartilaginous cap, small % may turn into sarcoma. |
|
|
Term
|
Definition
A. Proliferation of mature hyaline cartilage in bone medullary cavity.
B. Usually solitary, but may be multiple within small bones of hands and feet. |
|
|
Term
|
Definition
| osteoclastoma. Arise in the epiphysis of long bones with a “soap bubble” lytic radiographic appearance, extending “to the end of the bone” (right down to joint). Benign but locally aggressive, tends to recur; rarely metastasizes; treated with surgical curettage and sclerosis of residual cavity; radiation may induce malignant transformation; most often seen between ages of 20 and 40. |
|
|
Term
| Aneurysmal bone cyst (ABC) |
|
Definition
A. Deforms the bone in aneurysmal fashion; metaphyseal location.
B. Produces pain and/or swelling clinically. Can fracture.
D. Histologically consists of hemorrhagic cysts with giant cells & cellular fibroblastic tissue with surrounding “eggshell” of new woven bone.
E. Most frequent in first two decades. |
|
|
Term
|
Definition
A. Abnormal persistence of fibrous tissue in bone; bone arises in it by “metaplasia”; occasionally may have cartilage within it. Due to systemic mutation of GNAS, a G protein coupled receptor.
B. Commonly in skull, ribs, jaws, neck of femur; usually 2nd & 3rd decades.
C. X-ray shows a hazy ground glass-like quality.
D. May thin the bone cortex with bowing (“shepherd’s crook” deformity) and fracture.
E. Usually is asymptomatic incidental finding on X-ray.
F. Histologically consists of misshapen bone trabeculae (like Chinese characters) arising directly out of fibrous tissue without osteoblastic rimming. |
|
|
Term
|
Definition
A. Most common primary malignant bone tumor; arise in the metaphysis of long bones (most often knee area); most often males; most often in teenagers & young adults when primary (later in life if due to a disease such as Paget’s); increased risk in persons with retinoblastoma gene.
B. Histologically, the hallmark is formation of osteoid (bone-like matrix) by spindle-shape malignant cells. |
|
|
Term
|
Definition
| The second most common primary malignant bone tumor; tends to arise in central skeleton (trunk, proximal humerus, proximal femur); cartilaginous tumors of small bones of hands and feet are almost always benign. Expand bone, erode cortex, and produces pain. |
|
|
Term
|
Definition
A. Appears in children and teenagers; arises in the diaphysis of long bones.
B. Histologically a “small round blue cell tumor.” Has glycogen and CD99.
C. Very aggressive and destructive, with local pain and fever. Invades skeletal muscle. |
|
|
Term
|
Definition
| young males, often on arms. Painful & vascular, otherwise resemble usual lipomas |
|
|
Term
|
Definition
| relatively common sarcoma. Arises in deep soft tissue in adults >40 years old. Histologic types: well differentiated, myxoid / round cell, & pleomorphic |
|
|
Term
|
Definition
Almost all are rhabdomyosarcomas (malignant) – small blue cell tumors.
Most common sarcoma in children. Often in GU tract or head & neck. |
|
|
Term
| Benign tumor in the epiphysis |
|
Definition
|
|
Term
| Benign tumor in the metaphysis |
|
Definition
| Osteochondroma or Osteoid Osteoma |
|
|
Term
| Benign tumor in the diaphysis |
|
Definition
|
|
Term
| Malignant tumor of diaphysis |
|
Definition
|
|
Term
| Malignant tumor of metaphysis |
|
Definition
|
|
Term
| Intermedullary tumors (within the bone) |
|
Definition
Endchondroma Benign.
Chondrosarcoma Malignant. |
|
|
Term
| When to suspect small vessel vasculitis. Will be on the test. |
|
Definition
Mononeuritis multiplex.
Palpable purpura.
Pulmonary/renal syndrome. |
|
|
Term
| Takayasu’s arteritis (TAK) |
|
Definition
-Granulomatous arteritis of aorta and primary branches.
-Constitutional symptoms and high blood pressure
• Postural dizziness or extremity claudication.
• Exam: Pulseless, asymmetric BP, bruits
• Imaging: arterial stenosis
• Laboratory: elevated ESR/CRP, anemia
• Treatment: Steroids, immunosuppressive drugs |
|
|
Term
|
Definition
• Granulomatous arteritis of large and medium-sized arteries of aorta
• Ascending aorta, cranial aortic branch vessels, and
external carotid artery branches
• Age 74 y/o
• Northern European
• Insidious, one-sided headache
• Polymyalgia rheumatica ~40%
• Jaw claudication
• Scalp tenderness
• Visual loss
• Exam:
– Enlarged, tender, pulseless temporal artery
– Bruits
– Asymmetric blood pressures |
|
|
Term
| Polyarteritis nodosa (PAN) |
|
Definition
Medium vessel vasculitis. Can get little anyuerisms in the kidney/lung.
• Fibrinoid necrosis of muscular arteries supplying
the kidneys and GI tract
• Constitutional symptoms and weight loss
• Hypertension
• Postprandial abdominal pain
• Mononeuritis multiplex
• Digital necrosis
• Treatment: Steroids and cyclophosphamide |
|
|
Term
|
Definition
Medium vessel vasculitis.
• disease of children
• mucocutaneous lymph node disease
• Strawberry tongue
• Hand and feet skin desquamation
• Coronary arteritis
• Treatment: Aspirin and IVIG |
|
|
Term
| Primary angiitis of the CNS (PACNS) |
|
Definition
Medium vessel vasculitis.
• isolated to the intracranial arteries
• Anybody at any age
• Insidious headache
• Neurologic deficits
• Treatment: Steroids +/- cyclophosphamide |
|
|
Term
| Name the large vessel vasculitis syndromes that we learned |
|
Definition
|
|
Term
| Name the medium vessel vasculitis syndromes we learned |
|
Definition
| Polyarteritis Nodosa, Kawasaki disease |
|
|
Term
| Name the Small vessel vasculitis syndromes we learned. |
|
Definition
| Wegener’s granulomatosis, Microscopic polyangiitis, Churg-Strauss syndrome, Henoch-Schönlein purpura |
|
|
Term
|
Definition
Small vessel vasculitis.
– Granulomatous inflammation with vasculitis
– Upper and lower respiratory tract
• Sinusitis, saddle nose, otitis
• Hemorrhage, nodules, infiltrates
– Renal (crescentic, necrotizing,
pauci-immune glomerulonephritis)
– ANCA directed against proteinase 3
(cANCA)
– Treatment: steroids + CYC/MTX/AZA |
|
|
Term
| Microscopic polyangiitis (MPA): |
|
Definition
Small vessel vasculitis.
– Lungs (alveolar hemorrhage)
– Renal (crescentic, necrotizing, scant-immune glomerulonephritis)
– No granulomatous inflammation
– ANCA directed against myeloperoxidase (pANCA)
– Treatment: similar to WG |
|
|
Term
| Churg-Strauss syndrome (CSS): |
|
Definition
Small vessel vasculitis.
– Small- and medium- sized granulomatous arteritis
– Adult onset asthma
– Peripheral and tissue eosinophilia
– Nasal polyps, neuropathy, purpura, heart failure
– P-ANCA (less common than in WG and MPA) |
|
|
Term
|
Definition
– IgA immune complex vasculitis
– Palpable purpura
– Abdominal pain �� intussusception
– Hematuria
– Treatment: watch and wait vs. prednisone |
|
|
Term
| Main symptoms to think of for medium vessel vasculitis |
|
Definition
-Hypertension.
-Ischemic abdominal pain.
-GI bleed |
|
|
Term
| Main symptoms to think of for large vessel vasculitis |
|
Definition
-Pulseless
-Asymmetric BP
-Hypertension
-Claudication |
|
|
Term
|
Definition
• Vasculitis of any vessel
• Associated with:
– Iritis
– Mouth and genital sores
– Pathergy
– Superficial thrombophlebitis |
|
|
Term
|
Definition
| a term for the inward angulation of the distal segment of a bone or joint |
|
|
Term
|
Definition
| a term for the outward angulation of the distal segment of a bone or joint |
|
|
Term
| Treatment options for meniscus tears |
|
Definition
Initial non-operative treatment is recommended except with locked
bucket handle tears
i. Surgical treatment options – debridement vs. repair; Repair if a complete vertical longitudinal tear > 10 mm long; a tear within the peripheral 10 to 30% of the meniscus or within 3 to 4 mm of the meniscocapsular junction; a tear that can be displaced by probing; a tear without secondary degeneration; a tear in an active patient. When these criteria
are present then formal repair using a variety of techniques is reasonable. |
|
|
Term
| Anterior Cruciate Ligament Injuries |
|
Definition
a. 100,000 to 200,000 injuries per year
e. Anatomy – ACL originates from the medial and anterior aspect of the
tibial plateau and runs superior, posterior and laterally toward its
insertion on the lateral femoral condyle.
f. ACL also prevents excessive tibial and lateral rotation as well as varus
and valgus stress.
g. Injury mechanism – quick deceleration, hyperextension or rotational injury that does not involve contact with another person; often occurs
following sudden change of direction. Can be associated with MCL and
medial meniscus leading to a “terrible triad” of injuries. Medial meniscus
injured in 10 – 40% of acute injuries
j. Radiologic Evaluation – MRI – 80% have lateral femoral bone bruises;
Obtain 2 view knee which usually is normal unless chronic arthritic
changes seen with medial joint space narrowing in chronic injuries |
|
|
Term
|
Definition
-Most common cause of shoulder pain in adult; most common reason for visit
to orthopaedic surgeon for shoulder pain.
i. 4 view xray of shoulder can show calcification of the greater
tuberosity in chronic tears; large un-reparable tears will show loss
of concentric reduction of the glenohumeral joint with superior
humeral migration ii. MRI will show increased signal at the site of the tear on T2 weighted images; the coronals are best to look at the supraspinatus and infraspinatus.
Outcomes of non-operative treatment for full thickness rotator cuff tearsat
3 years 60% were improved, 30% worsened and 10% unchanged
g. Operative Treatment
i. All acute full thickness tears and failure of non-operative
management; Trend toward arthroscopic repairs – also reasonable
to be performed open or mini-open; outcomes – 85% healing
rates; 95% satisfaction at a mean of 5 years |
|
|
Term
| second most common reason for a visit to the primary care physician. |
|
Definition
| Low back pain, second to cold. Leading cause of disability in the working age population (34-50yo). |
|
|
Term
| The structures of the lumbar spine that are innervated include |
|
Definition
| 1. Vertebrae (periosteum), 2. Outer 1/3 of the annulus fibrosis, 3. Muscles, 4. Neural membranes, 5. Anterior dura only, not posterior. |
|
|
Term
| Natural course of low back pain |
|
Definition
| Most episodes of low back pain are self-limiting. With time people will do very well regardless of treatment. Even lumbar disc herniations and fractures, 80% of people will be back at baseline by 12 weeks. |
|
|
Term
| Red flags in history of low back pain |
|
Definition
| Recent history of trauma, new low back pain with Age >50yo, History of immunosuppression, History of Cancer, History of IV drug use, progressive neurologic deficit, new bowel or bladder dysfunction, recent unexplained fever or weight loss. |
|
|
Term
| What do you do if someone has one of the red flags for back pain? |
|
Definition
| immediate attention and work-up to rule out fracture, cancer, infection, spinal cord damage. |
|
|
Term
|
Definition
L2,3,4: hip flexion, knee extension, hip adduction.
L4,5: ankle dorsiflexion, hip abduction, knee flexion.
L5,S1: toe extension, ankle plantar flexion, ankle inversion/eversion. |
|
|
Term
|
Definition
L4: patellar reflex.
L5: medial hamstring reflex or posterior tibial tendon.
S1: Achilles reflex. |
|
|
Term
| Dermatomal sensation for low back pain work up. |
|
Definition
| Follow appropriate diagrams for peripheral nerves and dermatomes. Testing should be done for light touch, pin prick and vibration/proprioception. |
|
|
Term
| Indications for physical therapy for back pain are to... |
|
Definition
| increase flexibility, strength endurance and postural awareness. This should be the initial treatment for low back pain that does not resolve within 4 weeks and has no red flags on history. |
|
|
Term
| Contraindications for lower back pain therapy include |
|
Definition
| unstable fractures or ligamentous injury, progressive neurological deficit, acute spinal infection. Cancer and pregnancy should be noted to the therapist, as some modalities will be contraindicated. Patients with uncontrolled heart disease may be limited with exercise based therapies |
|
|
Term
|
Definition
| hard or bony swellings that can develop in the distal interphalangeal joints (DIP) |
|
|
Term
|
Definition
| hard, bony outgrowths or gelatinous cysts on the proximal interphalangeal joints |
|
|
Term
| First range of motion lost in hip |
|
Definition
| internal rotation, medial groin pain |
|
|
Term
|
Definition
NSAID of choice due to low toxicity -
metabolized via CYP2C9 |
|
|
Term
|
Definition
| available with misoprostol (Arthrotec) to decrease GI toxicity |
|
|
Term
|
Definition
celecoxib are the only NSAIDs that appear
to be effective for the regression of colorectal polyps |
|
|
Term
|
Definition
only “COX-2 selective” on the market –
cardiotoxicity warning - metabolized by CYP2C9 |
|
|
Term
| Leflunomide closely monitor for what |
|
Definition
|
|
Term
| Hydroxychloroquine toxicity |
|
Definition
|
|
Term
| Anti-TNF antibodies (Infliximab, Adalimumab adverse effects |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
should not be used in patients with severe
renal insufficiency, and never intravenously |
|
|
