Showing posts with label Rheumatology. Show all posts
Showing posts with label Rheumatology. Show all posts

23 December 2013

Spondyloarthropathies Ppts and latest 500 published articles



Spondyloarthropathies

Spondyloarthritis (or spondyloarthropathy) is the name for a family of inflammatory rheumatic diseases that cause arthritis. The most common is ankylosing spondylitis, which affects mainly the spine.Others include: Axial spondyloarthritis, which affects mainly the spine and pelvic joints; peripheral spondyloarthritis, affecting mostly the arms and legs; reactive arthritis (formerly known as Reiter's syndrome); psoriatic arthritis; and enteropathic arthritis/ spondylitis associated with inflammatory bowel diseases.

Seronegative Spondyloarthropathies
Beth L. Jonas, M.D.
http://www.med.unc.edu

Seronegative Spondyloarthropathies
http://www.med.wayne.edu

Spondyloarthropathies
Kevin Latinis, M.D./Ph.D.
http://www2.kumc.edu

The Demise of the Physical Exam
Cam Hebson, MS
http://www.uab.edu/

Bones Joints - Soft Tissue Tumors
http://faculty.ccc.edu

Medical and Psychosocial Aspects of Rehabilitation Counseling
http://courses.phhp.ufl.edu

Joint and Soft Tissue Injection in Primary Care
Peter J. Carek, MD, MS
http://academicdepartments.musc.edu

Pulmonary Manifestations of  Polymyositis / Dermatomyositis
Sjögren’s Syndrome and  Ankylosing Spondylitis
http://medicine.utah.edu

Autoimmune Diseases
Misty Mauldin
http://faculty.smu.edu

Rheumatoid Nodule
Praharsha R. Menon
http://www.fpm.emory.edu

Rheumatology
B. WAYNE BLOUNT, MD, MPH
http://www.fpm.emory.edu

Bone Pathology
Richard Anderson, MD
http://www2.uic.edu/

Rheumatology Labs
http://peds.stanford.edu

Latest 500 Published articles of Spondyloarthropathies

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03 November 2013

Metatarsophalangeal joints ppts and Latest 250 Published articles



Metatarsophalangeal joints

Musculoskeletal Exam
http://www.uky.edu/

Metabolic Diseases of the Bone
http://www.austincc.edu

Orthopedics Chronic problems
http://home.sandiego.edu

Detection by ultrasound of small calcium deposits within cartilage in patients without radiographic chondrocalcinosis
Eric Russell, DO; Humaira Hussain, MD; Angel Checa, MD
http://www.drexelmed.edu

The Ankle and Foot Joints
http://faculty.unlv.edu/

Lower Extremity Injuries
http://education.gsu.edu/

Exercise Biomechanics
http://courses.k-state.edu/

Foot & Ankle
https://www.mc.vanderbilt.edu

More than you ever wanted to know about the foot
MAJ Joel L. Shaw
http://www.usuhs.edu

The Ankle and Foot Joints
Anatomy and Physiology of Human Movement
http://www.uni.edu/
http://www.uni.edu/

The Ankle
http://wweb.uta.edu

FOOT  TARSALS, METATARSALS & PHALANGES
http://academic.evergreen.edu

The Foot
Briant W. Smith, MD
http://medicine.ucsf.edu

The Foot
http://www2.fiu.edu

Bandaging and Taping
Jennifer L. Doherty, MS, LAT, ATC
http://www2.fiu.edu/

THE PHYSICAL EXAM:  Musculoskeletal Component
http://www.med.unc.edu/

Clinical Approach to Acute Arthritis 
Yolanda Farhey, MD
http://www.med.uc.edu

Latest 250 Published articles on Metatarsophalangeal joints

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09 July 2012

Systemic Lupus Erythematosus (SLE)



Systemic Lupus Erythematosus
Steve Beesley
http://ruby.fgcu.edu/

Systemic Lupus Erythematosus
http://isites.harvard.edu/

Systemic Lupus Erythematosus (SLE)
Heidi Roppelt, MD
https://cbase.som.sunysb.edu/

Systemic Lupus Erythematosus
Cassidy Summers, Tricia Molett, Summer Lashley, Kelly Winship
http://mailer.fsu.edu

Systemic Lupus Erythematosus (SLE)
http://www.austincc.edu/

Lupus
http://sest.vsu.edu/

SLE: Fighting Self Sabotage
Susan Manzi, MD, MPH
http://www.pitt.edu

Autoimmune diseases
Henry O. Ogedegbe, PhD., C(ASCP)SC
http://ruby.fgcu.edu

What’s New in Lupus
Jennifer H. Anolik, MD, PhD
http://www.urmc.rochester.edu

Emergency Issues in Pediatric Rheumatology
Elivette Zambrana-Flores
http://www.pediatrics.emory.edu

Neuropsychiatric Lupus
SEULI BOSE BRILL, MD
https://medicine.med.unc.edu/


Latest 200 full text articles free access

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29 June 2012

Hypermobility syndrome



Hypermobility describes joints that stretch more than normal. For example, some people can bend their thumbs backwards to their wrists, bend their knee joints backwards, put their leg behind the head or other contortionist performances.

Benign Joint Hypermobility Syndrome
Rebecca L Byers
http://www2.medicine.wisc.edu/

Marfan Syndrome and related disorders
SARA FABER
https://medicine.med.unc.edu/

Marfan’s Syndrome
ROZINA MITHANI
http://www.meddean.luc.edu/

Systemic stiffness: a determinant of blood pressure?
http://www.pitt.edu/

Connective tissue disorders
http://www.med.umich.edu

Medial Tibial Stress Syndrome
Bryan Bates
http://www.lhup.edu/

Rheumatology
Dennis A. Peacock
http://www.medschool.lsuhsc.edu/

Ehlers-Danlos Syndromes
Emily Chang
https://medicine.med.unc.edu/

Thoracic and Lumbar Spine Special Tests and Pathologies
http://www2.fiu.edu/

Considerations for Pediatric Adjusting
http://w3.palmer.edu/oneill/

Afibrinogenemia
http://www.medicine.wisc.edu/

Ankle and Lower Leg Rehabilitation
http://mundo.cabrillo.edu/

Cervical and Lumbar Evaluations
Brittany Annis
http://eportfolios.ithaca.edu/

The Mechanics of Spinal Manipulation
http://w3.palmer.edu/

Microfibrils: Elastic Tissues
http://www.mechamlab.wustl.edu/Lab%20Web%20Page.data/Library/FTP_Folder/MF_MAGP.ppt

The Ankle and Lower Leg
http://www2.fiu.edu/~dohertyj/Chapter%2015_Eberman.ppt


127 Published articles on Hypermobility syndrome

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23 March 2012

Ankylosing Spondylitis



Ankylosing Spondylitis is a form of chronic inflammation of the spine and the sacroiliac joints, which causes back pain and stiffness.

Exercise in Ankylosing Spondylitis
Prof. Pál Géher MD
Exercise in Ankylosing Spondylitis.ppt


Ankylosing Spondylitis
LCDR Paul Kruszka, MD USPHS
Ankylosing Spondylitis .ppt

Pulmonary Manifestations of Polymyositis/Dermatomyositis Sjögren’s Syndrome and Ankylosing Spondylitis
Cheryl Pirozzi, MD
Pulmonary Manifestations of Polymyositis/Dermatomyositis.ppt

Spondyloarthropathies
Ori Elkayam M.D
Spondyloarthropathies.ppt

Ankylosing Spondylitis
Ankylosing Spondylitis.ppt

Ankylosing Spondylitis
Swanthri De Silva  M.D
Ankylosing Spondylitis.ppt

Ankylosing Spondylitis
ankylosing-spondylitis.ppt

Identification of relevant ICF categories in patients with Ankylosing Spondylitis according to the health professionals: a Delphi exercise
Annelies Boonen
ICF categories in patients with Ankylosing Spondylitis.ppt

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22 March 2012

Polymyalgia rheumatica



Polymyalgia rheumatica (PMR) is an inflammatory disorder involving pain and stiffness in the shoulder and usually also the hip.

Polymyalgia Rheumatica
Sarah Hughes, MD
Polymyalgia Rheumatica.ppt

Giant-Cell Arteritis
James Hawk MD
Giant-Cell Arteritis.ppt

Microscopic Polyangiitis - MPA
Jennifer O’Brien
MPA.ppt

Soft Tissue Rheumatism
Gary Kunkel, M.D.
SoftTissueRheumatism.ppt

Rheumatology
Kevin Latinis, M.D./Ph.D.
Rheum101Latinis.ppt

Fibromyalgia Syndrome (FMS)
Raymond H. Flores, MD, FACR
Fibromyalgia Syndrome.ppt

Back Pain and Lumbar Stenosis In Older Adults
Back Pain and Lumbar Stenosis.ppt

The Musculoskeletal Examination in the Elderly
R Williams, MD
Musculoskeletal_Examination_in_the_Elderly.ppt

Connective Tissue Diseases
Edward D. Buckingham, MD, Byron J. Bailey, MD
Connect-Tissue.ppt

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10 February 2012

Polymyalgia rheumatica PMR - ppts and 50 publications



Polymyalgia rheumatica (PMR): Is an inflammatory disorder involving pain and stiffness in the shoulder and usually also the hip.Polymyalgia rheumatica is a disorder that almost always occurs in people over 50 years old. The cause is unknown. PMR may occur alone, or with or before giant cell arteritis (also called temporal arteritis), which is inflammation of blood vessels (usually in the head)

Rheumatology
by Kevin  Latinis, M.D./Ph.D.
http://www2.kumc.edu/internalmedicine/students/documents/Rheum101Latinis.ppt

Rheumatology
by B.  Wayne Blount, MD, MPH
http://www.fpm.emory.edu/Family/didactics/powerpint/RHEUMATOLOGY.ppt

Blood Vessels - Vascular Abnormalities
by Frank A. Acevedo, PA-C
http://iris.nyit.edu/~facevedo/PowerpointPresentations/BloodVessels.ppt

Back Pain And Lumbar Stenosis In  Older Adults
http://www.pitt.edu/~super7/PC/pc0301.ppt

Fibromyalgia  Syndrome (FMS)
by Raymond  H. Flores, MD, FACR
http://medschool.umaryland.edu/minimed/powerpoint/2007/flores.ppt

Polymyalgia Rheumatica
by Sarah Hughes, MD
http://www.med.unc.edu/medicine/web/Polymyalgia%20Rheumatica,%201-24-06.ppt

Microscopic Polyangiitis MPA
by Jennifer O’Brien
http://www.med.unc.edu/medicine/web/9.22.08%20O%27Brien.%20MPA.ppt

Soft  Tissue Rheumatism
by Gary  Kunkel, M.D.
http://umed.med.utah.edu/ms2008/Vault/MuscSkel/20051121-2-SoftTissueRheumatism.ppt

Fibromyalgia
by Erin  Fouch
http://depts.washington.edu/rheum/education/papers/fouch.ppt

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15 May 2009

Polymyalgia rheumatica



Polymyalgia rheumatica
Polymyalgia rheumatica (meaning "pain in many muscles" in Greek), abbreviated as PMR

Polymyalgia Rheumatica
Presentation by:Anna Mae Smith,Lock Haven University

Polymyalgia Rheumatica
Presentation by:Sarah Hughes

My Grandparents’ Arthritis
Presentation by:Celso R. Velázquez MD
University of Missouri-Columbia

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27 April 2009

Patient Management Strategies in Arthritis



Patient Management Strategies in Arthritis
Presented by: Anna Mae Smith, MPAS, PA-C
Lock Haven University of PA


Physician Assistant Program
DJD/Osteoarthritis

* Obesity
o increase in body mass
o altered biodynamics of gait
o genetic predisposition (genetically obese mice are susceptible to osteoarthritis)
o altered metabolism (e.g., estrogens)
Risk Factors

* Occupational
Treatment

* Physical measures may be subdivided into..
o Exercise
o Supportive devices
o Alterations in activities of daily living
o Thermal modalities
Exercise

* Associated with reduced pain & improved function.
o Passive range of motion
o Rest periods
o Active: range of motion, isometric, isotonic, isokinetic
* Improved muscle tone reduces muscle spasm and prevents contractures. It is theorized that improved muscle support of the joint will retard the progression of osteoarthritis.

Which Exercises
* Swimming
* Biking (Stationary)
* Walking

Support Devices & Orhotics

* Devices such as canes, forearm crutches, crutches, and walkers can improve balance and decrease pain.
* The total length of a properly measured cane should be equal to the distance between the upper border of the greater trochanter of the femur and the bottom of the heel of the shoe. This should result in elbow flexion of about 20°.
* The cane should be held in the hand contralateral to and moved together with the affected limb. The healthier limb should precede the affected limb when climbing up stairs; when climbing down stairs, the cane and the affected limb should be advanced first. The cane can unload the affected hip by 60%.

Modified activities of daily living
* Proper positioning and support when sitting, sleeping or driving a car
* Adjusting ways of performing such activities as getting dressed, etc.
* Adjusting furnishings around the house or at work (e.g., raising the level of a chair or toilet seat)

Thermal modalities
* Superficial heat (e.g., hot packs, paraffin baths)
* Deep heat (e.g., ultrasound)
* Cold applications (e.g., cold packs, vapocoolant sprays)

HEAT

* The therapeutic value of applying heat includes decreasing joint stiffness, alleviating pain, relieving muscle spasm, and preventing contractures.
* The use of heat is contraindicated over tissues with inadequate vascular supply, bleeding, or cancer. Heat should also be avoided in areas close to the testicles or near developing fetuses.

Miscellaneous

* Pulsed electromagnetic fields
* TENS
* Acupuncture
* Chiropractic
* Spa, massage, and yoga therapy


Short acting drugs
Long Acting Agents
Hyaluronic Acid Derivatives
DIET

* Avoid coffee, artificial additives, red meats & processed foods
* Limit tomatoes,potatoes,eggplants, peppers, & simple carbohydrates(white flour & refined sugar).
* Fresh fruits & veges, complex carbs, wheat germ & oily fish
* Vit. A 10,000iu/day
* Vit. C 2grams/day
* Vit. E 600iu/day
* Vit. B6 50 mg/day

First-line therapy

* Anti-inflammatories
* Aspirin
* Nonsteroidal anti-inflammatory
Second Line Therapies

* Antimalarials (chloroquine, hydroxychloroquine)
* Sulfasalazine
* Methotrexate
* Gold salts
* Auranofin
* Parenteral gold
* D-penicillamine
* Azathioprine
* Cyclosporin A
* Combination therapies
* Corticosteroids
* Systemic steroids
* Low-dose oral
* Parenteral pulse steroids
* Intra-articular

Investigational

* EPA (eicosapentaenoic) - anti-inflammatory effect of fish oil fatty acid
* Plant seed oils particularly those extracted from evening primrose oil and borage seed oil that contain large amounts of gamma linolenic acid.
Light Therapy

* Extracorporeal photochemotherapy and extracorporeal protein A immunoadsorption
Vitamins

* Vit. C 2grams/day
* Vit. E 600iu/day
* B complex vitamin
* Calcium 1200-1500/day
* Selenium 100mg/day
* Zinc 30mg/day

Hydrotherapy

* Cold compresses when acutely inflamed followed by alternating hot & cold
* Massage - lavender, tiger balm & chamomile oils

Herbs

* Black cohosh
* Wild yam
* Willow bark
* Licorice

Patient Management Strategies in Arthritis.ppt

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Patient Management Strategies in Fibromyalgia



Patient Management Strategies in Fibromyalgia
Presentation by: Anna Mae Smith,MPAS, PA-C
Lock Haven University of PA

Education

* Not a ‘psychiatric’ illness
* Usually chronic but controllable
* Not deforming or Life-threatening
* Medications that improve sleep appear to be the best treatment!

Amitriptyline & Cyclobenzaprine

* They tend to increase NREM Stage IV sleep
* the availability of brain serotonin
* decrease muscle spasm
* Decreases patients' reports of pain intensity
* Sleep quality
* Improvements in pain threshold or tender point counts
* Loses effect after 6 months

Alprazolam and ibuprofen
Other Treatments

* Aerobic Exercise
* Cognitive Behavior Therapy
* Biofeedback
* Hypnotherapy
* Acupuncture
* Inject trigger points with steroids
* Treat underlying depression if needed

Diet
* avoid the following:
* refined sugar
* alcohol
* caffeine
* foods high in saturated fats
* high-calorie, high-fat, low-food-value junk food
* A moderate diet containing the following ratio (based on percentages of calories, not grams):
40% carbohydrate/ 30% protein/ 30% fat for each meal and snack
* Water…8/8oz

Herbs

* Ginseng and gotu kola, have both been found to improve energy and mental alertness.
* Ginseng is known to contain a steroid
* Valerian Root
* St John’s Wort
* Gingko Biloba
* Grape See Extract
* Devils Claw Root

Patient Management Strategies in Fibromyalgia.ppt

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Rheumatoid Arthritis



Rheumatoid Arthritis
Presentation by: Anand Lal, M.D.


Rheumatoid Arthritis

* Chronic systemic inflammatory disease of unknown etiology
* Affects the Synovial Membranes of multiple joints
* Prevalence 1-2%
* Female : Male ratio 3:1
* Usual age of onset 20-40 years though individuals of any age group may be affected
* Pathologic finding: chronic synovitis with pannus formation. The pannus erodes cartilage, bone, ligament and tendons. In the acute phase effusion and other manifestations of inflammation are evident; in the later stages ankylosis of the joint may set in. In both the acute and chronic phase, there may be widespread inflammation of the tissues around the joint that can lead to significant joint destruction.

* Clinical presentation
o usually presents insidiously;
o prodromal syndrome of malaise, weight loss and vague periarticular pain and stiffness may be seen
o less commonly, the onset is acute, triggered by a stressful situation such as infection, trauma, emotional strain or in the postpartum period.
o the joint involvement is characteristically symmetric with associated stiffness, warmth tenderness and pain
* Clinical Features
o the stiffness is characteristically worse in the morning and improves during the day; its duration is a useful indicator of the activity of the disease. The stiffness may recur especially after strenuous activity.
o the usual joints affected by rheumatoid arthritis are the metacarpophalangeal jts, the PIP jts, the wrists, knees, ankles and toes.
o Entrapment syndromes may occur especially carpal tunnel syndrome

* Labs
o Rheumatoid factor, an IgM antibody is seen in the sera of 75% of patients with rheumatoid arthritis. High titers of rheumatoid factor are associated with severe disease.
o Rheumatoid factor is also found in other diseases like syphilis, sarcoidosis, infective endocarditis, TB, leprosy, parasitic infections; in advanced age and in asymptomatic relatives of patients with rheumatoid disease.
o Antinuclear antibody are seen in 20% of patients with rheumatoid arthritis, though their titer is lower than in SLE

* Labs
o The ESR is elevated both in the acute and chronic phases of the disease
o a moderate anemia is often present which is usually hypochromic normocytic
o the white count is normal or slightly increased but leukopenia may occur, often in presence of splenomegaly (e.g., Felty’s syndrome)
o the platelet count is often elevated in proportion to the degree of joint inflammation
o joint fluid examination is valuable. The fluid is translucent to opaque and has between 3000 and 50,000 WBCs /microL. There are 50% or more polymorphonuclear leukocytes. The culture is negative.

* X-ray
o of all the laboratory tests, x-ray changes are most specific for rheumatoid arthritis. However, they are not sensitive and usually are negative during the first 6 months of the disease

* X-rays
o the earliest changes occur in the wrist or feet and consist of soft tissue swelling and juxta-articular demineralization. Later, diagnostic changes consisting of joint space narrowing and erosions develop. The erosions are first seen at the ulnar styloid and at the juxta-articular margin, where the bony surface is not protected by cartilage. Diagnostic changes also occur in the cervical spine with C1-2 subluxation, but this can take several years to develop.

* Differential Diagnosis
o Rheumatic fever: migratory arthritis, elevated ASO and dramatic response to Aspirin
o Systemic Lupus Erythematosus: Butterfly rash, discoid lupus erythematous, photosensitivity, alopecia, high titers of Anti Ds-DNA, renal and CNS disease
o Osteoarthritis: no constitutional manifestations and no evidence of joint inflammation
o Gouty Arthritis: usually monoarticular initially but can become polyarticular in the later years
o Pyogenic arthritis: usually monoarticular, fever and chills, abnormal joint fluid
o Chronic Lyme disease: commonly monoarticular and associated with positive titers
o Human Parvovirus infection: arthralgia more common than arthritis, rash may be present, serologic evidence of parvovirus B19 infection
o Polymyalgia rheumatica is associated with proximal muscle weakness and stiffness
o several cancers produce paraneoplastic syndromes including polyarthritis; e.g., hypertrophic pulmonary osteoarthropathy produced by lung and gastrointestinal cancers. Diffuse swelling of the palmar fascia has been associated with several cancers including ovarian cancer.

* Treatment
* Treatment (Disease Modifying Agents (DMARDs)
* Prognosis
Rheumatoid Arthritis.ppt

Read more...

Reactive Arthritis



Reactive Arthritis
Presentation by: Walter Eisenhauer MMS, PA-C

Reactive Arthritis

* Also known as Reiter’s syndrome
o Named after Hans Reiter, a German Physician in 1916
o Symptoms of Arthritis, Conjunctivitis, Non Gonococcal Urethritis following bouts of bloody dysentery
o > 75% HLA B27 positive
* Secondary immune reaction, in susceptible individuals, to primary infection:
o Yersinia
o Campylobacter
o Shigella
o Salmonella
o Chlamydia
* Classified as a seronegative spondyloarthropathy
* Occurs 2-4 weeks after inciting infection
* Most responsible organisms have an affinity for mucous membranes
* Terms Reactive Arthritis & Reiter’s Syndrome Synonamous
* First manifestation usually non gonococcal Urethritis
o occurs in both venereal and non venereal forms of the disease
o Mucopurulent discharge
o Dysuria
o Prostatitis
o Epididymitis
* Females
o Dysuria
o Vaginal discharge
o Purulent cervicitis
* Conjunctivitis
o follows urethritis by several days
o Sx often mild and transient
o acute anterior Uveitis possible
* Articular symptoms typically appear last
* additive
* oligoarticular
* lower limbs most common
* Keratoderma blennorrhagicum
* Circinate Balanitis

Glossitis/ Mucocutaneous Lesions
* Aortic Valve involvement 1-2% of cases
* Amyloidosis
* Neurologic complications
o peripheral neuropathies
o encephalopathy
o transverse myelitis

* Clinical course
o Normally limited course running 3-12 months
o 15% with prolonged relapsing arthritis
+ ? Relapse
+ ?Reinfection
o Ankylosing Spondylitis in 10% of cases
o Relation to HIV- probably due to increased risk of concurrent infection not HIV as initiator
* Laboratory findings
o Normochromic, normocytic anemia
o Leukocytosis
o Acute phase reactants:
+ ESR
+ C-reactive Protein
* HLA-B27 positive 75%
* Synovial fluid- highly inflammatory
* Sterile cultures- negative gram stain
* X-Ray reveals periostitis with eventual new bone growth
* Treatment:
Idiopathic Inflammatory Bowel Disease
Whipple’s Disease
Ankylosing Spondylitis
Ankylosing Spondylitis
Clinical Picture
Syndosmophytes
Patient Instructions

* No cure but can be well managed
* Education of patients =increased compliance
* Early diagnosis important
* NSAIDS Vocational support
* Exercise Screen first degree relatives
* Surgical measures
Treatment

Reactive Arthritis.ppt

Read more...

Rheumatologic Examination



Rheumatologic Examination
Presentation by:Walter Eisenhauer MMS PA-C

Approach to Disorders of the Joints
* Etiologies of Joint Pain
+ Traumatic
+ Infectious
+ Degenerative
+ Metabolic
+ Immunologic
+ Neoplastic

Diagnosis

* Based on
+ History
+ Physical
+ Lab
+ X-ray
* Origination of Joint Symptoms
+ Synovium Cartilage Periarticular structures
+ Inflammatory Non-inflammatory

History

* Duration of Joint Symptoms
* Rapidity of Development
* Self Limited Symptoms Vs Persistent
* Number and Location of Affected Joints
* Pattern of Affected Joints
+ Symmetric
+ Asymmetric
* Sequence of Joint Involvement
+ Additive
+ Migratory
* Pain at Rest/Following Exercise
* Gelling
* Precipitating Events-Illness
* Morning Stiffness
* Symmetric Distribution of inflammatory changes-RA
* Weight Bearing Joints After Exercise-DJD
* Migratory-Rheumatic Fever
* Additive-RA
* Persistent Low Back Pain in Young Man-Ankylosing Spondylitis
* Acute Inflammation-Infection/Crystal Deposition Disease
* Chills/High Fever
* Constitutional Sx-RA/Neoplasm/infections
* Medications-Pronestyl Induced Lupus


Past Medical History

* Hepatitis
* Rubella, Mumps, Parvovirus
* Reynauds
* Iritis-Ankylosing Spondylitis
* Inflammatory Bowel Disease

Social History

* Sexual Practices
* Work
* S/S Depression-Anxiety
* Stress
* Diet-CA++/Purines

Physical Examination

* Skin
+ Nodules on extensor surfaces
+ Psoriatic Rashes
+ Nails
+ Signs of Vasculitis
+ Mucocutaneous lesions of Reiters Syndrome
+ Eye Dryness

Examination of the Joints

* Examine even Unaffected Joints
* Examine Peri-Articular Surfaces
+ Atrophy Effusions Erythema
+ Palpation
* Establish Range of Motion
* Palpate Exact Location of Tenderness
* Temperature
* Assess Muscle Strength/Tone
* History will help guide complementary exams:
+ Risk for CA and Assoc Wt Loss-Examine high risk systems
+ Abdomen/Bowel Sx- Examine abdomen
+ Fever-Cardiac
+ Pulmonary Sx-Lung

Classification of Joints

* Synarthrosis-No Movement
+ Suture-Cranial
+ Synchondrosis-Epiphysis/Diaphysis
* Amphiarthrosis-Slight movement
* Diarthrosis-Synovial
* Ball and Socket Saddle-Thumb Carpal/MC
* Hinge Gliding-intervertebral
* Pivot-Atlantoaxial
* Condyloid-Wrist

Examination

* Waiting Room Diagnosis
* Inspect Gait
* Ability to Disrobe etc- good eval of ROM
* Inspect Muscles
* Goniometer for ROM

Motor Examination

* S.I.T.S.
+ Size-measure all major muscle groups
* upper/lower arms
* upper/lower legs
* Inspect for Involuntary Movements
* Evaluate Tone
* Strength Testing
+ 0-4 grading

Motor Strength Testing

* 0- No Movement
* 1-Slight Contraction
* 2-Full Range of Motion/No Gravity
* 3-Full Range of Motion/Gravity
* 4- Some resistance
* 5- Full Resistance

Examination of the Upper Extremities

* Shoulder
+ Inspect
* Contour
* Girdle
* Clavicles
* Scapulae
* Muscles-SITT/Biceps/Deltoid/Traps
* AC Joint
* Bicipital Groove
* Shoulder Shrug-Inspect for symmetry
* Abduction-180
* Adduction-50
* Internal Rotation(behind small of back)-90
* External Rotation(behind neck)-90

Elbow
Fibromyalgia Syndrome
Rheumatologic Examination.ppt

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Diagnostic Testing Rheumatologic and Connective Tissue Diseases



Diagnostic Testing Rheumatologic and Connective Tissue Diseases

Is it a rheumatologic or connective tissue disorder?

* The distinction between rheumatologic and connective tissue (collagen vascular) diseases is unclear.
* There is much overlap in disease presentation and laboratory testing
* In each, the body’s own proteins are recognized as foreign, and AUTO-antibodies produced


Case #1

Rheumatoid Arthritis Lab Work-up

* CBC (with diff)
* Sedimentation rate
* Rheumatoid Factor (RF)
* 40-60% have anemia of chronic disease; (suspect infection); mild WBC

Erythrocyte Sedimentation Rate (ESR)

* Nonspecific test for inflammatory process
* anticoagulated blood in calibrated tube; rate of sedimentation of RBCs in 1 hour
* normal <15m;<20f; add 10 past age 60
* Rate of sedimentation increases with
o increased fibrinogen 2 inflammatory process (occurs wi 12-24 hours)
o acute/chronic infection; tissue necrosis; tissue infarction; well established malignancy; rheumatoid/collagen diseases; abnormal serum proteins; pregnancy; obesity; anemia

Sedimentation Rate Uses

* An aid in detection and diagnosis of inflammatory condition (or to exclude)
* A means of following the activity, clinical course, or therapy of inflammatory diseases
* To demonstrate or confirm occult organic disease

Rheumatoid Factor (RF)

* RA and related diseases associated with increased immunoglobulins (autoantibodies):
o IgG variety antibodies
o IgM variety antibodies
o IgA variety antibodies
* RF is an IgM antibody directed against IgG
* Present in the sera of 75% of patients with Rheumatoid Arthritis
* Higher titer of RF are commonly associated with severe RA
* High titers also seen in syphyllis, sarcoid; infective endocarditis; TB; leprosy; parasitic infections; old age
* Presence of RF does NOT rule in RA
* Absence of RF does NOT rule out RA
* If the pretest probability of RA is high, the presence of RF is supportive of the diagnosis.
* If the pretest probability of RA is high, the absence of RF should not change your clinical diagnosis
* Order if symmetrical polyarthritis of uncertain origin
* There is no need to repeat RF testing once it is positive

Case #2

Systemic Lupus Erythematosus Lab Work-up
Antibodies in SLE
Antinuclear Antibody
(ANA)
ANA: peripheral pattern
ANA: solid/diffuse pattern
ANA: speckled pattern
Anti-nDNA Antibody
Anti-Sm Antibody

Case #3
Mixed Connective Tissue Disease Lab Work-up
Anti-RNP (ribonucleoprotein) Antibody
Case #4
Anti-RO/SSA and Anti-LA/SSB
Complement Levels
(C3, C4, CH50)
INFLAMMATION
Complement Activation Pathways
Complement Testing
HLA-B27 Antigen in Ankylosing Spondylitis
Case #5
Joint Aspirate Analysis
INFECTION

Diagnostic Testing Rheumatologic and Connective Tissue Diseases.ppt

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Polymyalgia Rheumatica &Temporal Arteritis



Polymyalgia Rheumatica &Temporal Arteritis
Presentation by: Anna Mae Smith, MPAS, PA-C

Polymyalgia Rheumatica

* A clinical syndrome characterized by aching and stiffness of the shoulder and hip girdle muscles affecting older patients, associated with an elevated ESR, lasting over 1 month and responsive to low dose steroids

Epidemiology

* Incidence/Prevalence in USA: Approximately 50/100,000 patients over age 50/year
* Predominant age: 60 or older. Incidence increases with age (rare under 50 years old).
* Predominant sex: Females > Male (2:1)

Signs & Symptoms

o Onset - abrupt or insidious
o Pain and stiffness shoulder and hip girdle
o Usually symmetrical
o Symptoms more common in the morning
o Gel phenomena (stiffness after prolonged inactivity)
o Constitutional symptoms - fatigue, malaise, depression, weight loss, low grade fever
o Arthralgias/arthritis (non inflammatory)
o No weakness (pain may limit strength)
o Muscle tenderness mild to moderate
o No muscle atrophy
o Decreased range-of-motion of joints on active motion usually due to pain
o May have signs and symptoms of giant cell arteritis

RISK FACTORS

o Age greater than 50
o Presence of giant cell arteritis

Differential Diagnosis

o Rheumatoid arthritis
o Other connective tissue disease
o Fibromyalgia
o Depression
o Polymyositis/dermatomyositis (check CPK, aldolase)
o Thyroid disease
o Viral myalgia
o Osteoarthritis
o Occult infection
o Occult malignancy (extensive search usually not necessary)
o Myopathy (steroid, alcohol, electrolyte depletion)

LABS

o ESR (Westergren) elevation greater than 50
o Anemia - normochromic/normocytic
o Creatine phosphdkinase (CPK)- normal
o Rheumatoid factor (RF) - negative (5-10% patients over 60 will have positive RF without disease)
o Mild elevations in liver function tests

TREATMENT
Patient Follow -up
PROGNOSIS

o Average length disease is 3 years (range 1-5 years)
o Exacerbation if steroids tapered too fast
o Prognosis very good if treated (may gradually remit even if no treatment)
o Relapse common
Henoch-Schonlein Purpura
Definition

* A vasculitis of small vessels characterized by nonthrombocytopenic, usually dependent, palpable purpura, arthritis, abdominal pain and nephritis
Epidemiology

SIGNS & Symptoms

o Onset can be acute or gradual
o 50% of patients have malaise and low grade fever
o Skin lesions occur in all identified patients:
+ Lesions appear on lower extremities and buttocks but may involve face, trunk and upper extremities
+ Begin as small wheals or erythematous maculopapular
o Lesions blanch on pressure but later become petechial or purpuric
o Lesions appear in crops
o Angioedema of scalp, lips, eyelids, ears, dorsa of hands and feet, back, scrotum and perineum may be seen
* Two-thirds of patients experience arthritis:
o Large joints (knees and ankles) are most commonly involved
* One-half of patients experience GI symptoms:
o Colicky abdominal pain associated with vomiting is most common
o Occult or gross blood in stool
o Hematemesis
o Intussusception, obstruction or infarction rarely occurs
o Pancreatitis
* Renal involvement is less common
o Hematuria, with or without casts or proteinuria
* Other manifestations
o Seizures, neuropathies
o Hepatosplenomegaly
o Lymphadenopathy
o Cardiac involvement
o Pulmonary hemorrhage
o Rheumatoid-like nodules

DIFFERENTIAL DIAGNOSIS

o Hemorrhagic diathesis
o Septicemia
o Intussusception
o Acute appendicitis
o Acute glomerulonephritis
o Familial IgA nephropathy
o Polyarteritis nodosa
o Systemic lupus erythematosus
o Inflammatory bowel disease
o Subacute bacterial endocarditis
o Rocky Mountain spotted fever
o Thrombocytopenic purpura
Labs

o Not diagnostic
o Sedimentation rate, white blood cell count may be elevated
o Coagulation studies, platelet count and complement determinations are normal
o Serum IgA elevated in 50%
o Urinalysis shows protein, red blood cells, white blood cells if renal

TREATMENT
COMPLICATIONS

o Hypertension
o Renal failure
o Intestinal hemorrhage
o Bowel obstruction or perforation
o Death very rare

PROGNOSIS

o Disease may last for a few days with transient arthritis; however, in many cases, the average duration is 4-6 weeks
o Occasionally recurrent
o 25% of patients with initial renal involvement will have persistently abnormal urine sediment

Polymyalgia Rheumatica &Temporal Arteritis.ppt

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Crystalline Arthropathies



Crystalline Arthropathies
Presentation by: Walter Eisenhauer MMSc, PA-C

Gout

* The Disease of Kings, The King of Diseases
o Predominately disease of adult men
o Females spared until postmenopause
o Uric Acid by product of Purine metabolism
o 10% of those with gout overproduce- the remaining 90% are underexcretors
* Urates circulate in plasma mainly in unbound form
o Referred to as urate pool
o Pool increases as Uric acid levels increase
o Excreted by two mechanisms
+ Renal
+ Bacterial oxidation in the gut
* Total Body urate Pool 1200 mg males/600 mg females
o 85% denovo synthesis
o 15% dietary intake of purines
o Purine restricted diet may only decrease serum urate level by 1-1.2 mg/dl
Urate – complete filtration

+ Presecretory tubular resorption 99%
+ Tubular excretion 50%
+ Post secretory resorption 80%
+ Excretion of 10% filtered load (600 mg/day)
+ Additional 1/3 excreted by pancreatic and intestinal juices
* Two Main Classifications
o Overproducers
o Under Excreters
* Overproducers
o 10%
o Primary
+ Idiopathic
+ Enzyme abnormalities in purine metabolism
o Secondary
+ Excessive dietary uptake
+ Myeloproliferative disorders
+ Severe muscle exertion
* Decreased excretion- 90%
o Primary Vs Secondary
+ Primary
# Unidentified defect in tubular secretion ( up to 40 % less)

* Secondary
+ Renal insufficiency
+ Diuretics
+ Low dose ASA
+ Cyclosporine
+ Ethambutol
+ Lead toxicity
+ Saturnine gout due to nephropathy
+ DKA
+ Starvation
+ Ketosis
+ Ethanol
+ Lactic acidosis
+ Predisposing illness- HTN, DM etc
+ Combined ETOH/G6PD deficiency
* Urate Pool substantially enlarged in Gout
o Non Tophaceous- 2-4gm
o Tophaceous 30 gm or more
* Urate solubility
o At physiologic ph 99% as urate not uric acid
o Soluability at 37degrees is 7.0 vs 30 degrees is 4.5 mg/dl
o Intrarticular temp at the knee is 33 degrees- ankle 29 degrees
* Acute Gout clinical features
o Males 4th-6th decade
o Consider enzyme abnormality if before 60
o 38% with normal uric acid
o Monoarticular 85-90%
o Podagra in 50%, ultimately 90%
o Primarily lower extremity joints
o Precipitated by
+ Surgery
+ Trauma
+ Febrile Illness
+ Excessive eating or ETOH consumption
* Systemic symptoms in polyarticular forms
o Fever
o Chills
o Elevated WBC/ESR
* Spontaneous resolution over days to weeks
* Females older, post menopausal
* Intercritical gout
o 7-10% only experience initial attack
o 62% with second attack within 1 year
o Majority with attack within 6-24 months
o Ultimately attacks more frequent and polyarticular

* Tophaceous Gout
o 3-21% develop
o Average 11.6 years after initial episode
o Typically ear, elbows, fingers, Achilles tendons but may appear anywhere
o Synovial tophi can lead to bone erosions
* Transplant Gout
o Primarily related to cyclosporine
o Acute gout often after one year
o Tophaceous gout within 5 years
o 13% decrease in ADL’s secondary to gout
* Renal Manifestations
o Stones presenting manifestation of up to 1/3
o Gouty Nephropathy-inter parenchymal deposits of monosodium urate crystals causing inflammation and scarring
o Acute Uric Acid Nephropathy caused by obstruction of tubules with uric acid crystals

* Diagnosis
o Can not make dx with blood studies
o Demonstrate crystals in synovial fluid
o Presence of tophi
o Presumptive on basis of clinical presentation
o Strongly negative birefringent, needle shaped, often intracellular crystals

* Xray
o Punched out lesions
o Asymmetric nodular soft tissue swelling
o Joint space narrowing- often asymmetric

* Treatment

Pseudogout

* CPPD- Calcium Pyrophosphate Dihydrate
* Chondrocalcinosis when calcium in cartilage
* Mimics presentation of Gout attacks
* Treat with NSAIDS
* Rule out Hyperparathyroidism

Crystalline Arthropathies.ppt

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Behchet's Disease



Behchet's Disease
Presentation by Anna Mae Smith, MPAS, PA-C
Lock Haven University

* Rare multisystem, chronic disease characterized by oral and genital mucocutaneous ulcerations, skin rashes, arthritis, thrombophlebitis, uveitis, colitis, and neurologic symptoms.
* Endemic in Japan and Northeastern Mediterranean region(Turkey & Iran)

EPIDEMIOLOGY
SIGNS & SYMPTOMS

o Aphthous stomatitis
o Genital ulcers - painful in the male, painless in the female
o Dermal - papulovesicular, erythema nodosum, pathergy, erythema multiforme, vasculitis, pyoderma
o Ocular - iritis, iridocyclitis, chorioretinitis, hypopyon, hemorrhage, papilledema, optic atrophy
o Morning stiffness - in 1/3
o Polyarthritis - self-limited and predominantly affecting lower extremities
o Thrombophlebitis - peripheral, pulmonary, cerebral, Budd Chiari syndrome
o Neurologic - cranial nerve palsy, hemiplegia, intracranial hypertension, meningomyelitis and recurrent meningitis, confusional state
o Gl - aphthous ulcers, colitis, melena
o Pulmonary infiltrates - possibly related to thrombosis
o Myopathy/myositis - rare
o Peripheral gangrene - rare
o Epididymitis
o Glomerulonephritis - rare

HYPOPYON – pus in the anterior chamber associated with uveitis

Diagnostic criteria

* Recurrent oral ulcers at least 3 times in a year
* Recurrent genital ulcers
* Eye inflammation
* Skin inflammation
o Pseudo folliculitis
o Acne-like lesions
o Erythema nodosum-like

DIFFFERENTIAL

o Reiter's syndrome and other forms of spondyloarthropathy
o Inflammatory bowel disease (Crohn's disease and ulcerative colitis)
o Syphilis
o Erythema nodosum
o Aphthous stomatitis
o Herpes simplex
o Stevens-Johnson syndrome
o Vasculitis
o Multisystem disease
o Thrombophlebitis related to coagulation factor deficiency

LABS

o Erythrocyte sedimentation rate elevation, but can be normal
o Immune complexes detected by Raji cell and C1q solid phase assays
o Cryoglobulin
o Hypergammaglobulinemia
o Circulating anticoagulation (rare)
o Anti-cardiolipin antibody (rare)

Special Tests

* None specific for Behcet's, but helpful in following disease course:
o Depression of plasma antithrombin III levels with active disease
o Increased fibrinolytic activity during attacks
o Anti-neutrophil cytoplasmic antigen antibodies, perinuclear variety
o Demyelinating antibodies in neuro-Behcet's syndrome
o Anti-cardiolipin antibodies, lupus anticoagulants
o Anti-endothelial antibodies


TREATMENT
Complications

o Death
o Blindness
o Paralysis
o Embolism/thrombosis - pulmonary, vena cava, peripheral
o Aneurysms
o Amyloidosis
o Thrombotic events, especially when anticardiolipin antibodies present
o Normal life expectancy, except with neurologic involvement
o Possible vision impairment
o Avoid English Walnuts!!

SWEET SYNDROME

Behchet's Disease.ppt

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Fibromyalgia



Fibromyalgia
Presentation by:Anna Mae Smith, MPAS, PA-C
Lock Haven University

Myofascial pain

* Minor tear in muscle that causes a localized irritation - trigger point
* Fibromyalgia - widespread myofascial (soft tissue) pain

Diffuse aching, stiffness & fatigue
Fibromyalgia Syndrome

* Most common rheumatic cause of chronic diffuse pain
* Generalized pain & symptom pain amplification syndrome
* Extremely common pain phenomenon occurring in a defined pattern & reproduced by pressure on "trigger points"

EPIDEMIOLOGY

* Incidence/Prevalence in USA: 3 in 100
* Predominant age: 18-70
* Predominant sex: Female > Male

DIfferential
* Hypothyroidism
* Psychogenic rheumatism
* Muscle strain/sprain
* Muscle disease
* Polymyalgia rheumatica
* Temporal arteritis

SIGNS & SYMPTOMS

* Typically insidious in onset
* Diffuse soft tissue pain
* Pain is increased in the morning, with weather changes, anxiety, stress
* Pain improved by mild physical activity or vacations (stress-relieving situations)
* Non-restorative sleep, with early morning awakening in an unrefreshed state.
* Abnormal non-rapid eye movement (non-REM) stage IV sleep
* Generalized fatigue or tiredness
* Anxiety
* Chronic headache
* Irritable bowel syndrome
* Tension headaches
* Subjective, non-confirmable complaints of swelling or numbness, not associated with objective neurologic findings
* Depression
* Reduced physical endurance
* Decreased social interaction
* Paresthesias – normal nerve studies
* Sensation of swollen hands!

Trigger Points

* Temporalis - above the ear
* Anterior to tragus of ear
* Scalenus capitis
* Sternocleidomastoid
* Low anterior neck
* Pectoralis minor
* Manubriosternal
* Anterior and posterior axillary folds
* Trapezius ridge
* Upper rhomboids
* Lower rhomboids
* Iliac crest
* Mid-buttocks
* Mid-rectus femoris
* Mid-vastus lateralis
* Quadriceps insertion - at the patella
* Humeral epicondyles


LABS

* ESR
* CBC
* TFT

TREATMENT

Prognosis

* With resolution of sleep disturbance, may resolve totally
* Aggressive physical therapy is critical in those who do not respond
* Approximately 5% do not respond to any form of therapeutic intervention.
Hypnosis may be attempted in that group.

FIBROMYALGIA .ppt

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19 April 2009

Fibromyalgia Syndrome (FMS)



Fibromyalgia Syndrome (FMS)
Presentation by:Mini-Med School 2007

Raymond H. Flores, MD, FACR
Department of Medicine
Division of Rheumatology & Clinical Immunology


Topics covered

* What is Fibromyalgia (FMS)?
* What causes it?
* Who gets it?
* How is it diagnosed?
* How is it treated?
* What are some of the common misconceptions about the syndrome?

What causes FMS?
Who gets FMS?
How is FMS diagnosed?
ACR classification criteria: fibromyalgia
Fibromyalgia: tender points
How is FMS treated?
Other Therapies for FMS

Fibromyalgia Syndrome (FMS).ppt

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Rheumatological Urgencies



Rheumatological Urgencies
Presentation by: Rochella Ostrowski

Medical History
Physical Exam
DDX

* Crystal induced arthritis (Gout, pseudogout)
* Septic arthritis
X ray L foot
Arthrocentesis
Polarizing Microscopy
Synovial Fluid
Gout
Gout Treatment
Indications for Chronic therapy of Gout
Which diagnostic tests would you order next?
Septic Arthritis
Gonococcal vs Non-gonococcal
Organisms in Septic Arthritis
Mechanisms of Joint infection
Conditions That Predispose a Patient to Joint Infections
Septic Arthritis Therapy
Giant Cell Arteritis
GCA Clinical Findings
Treatment of GCA
Most reasonable diagnoses?

* Giant Cell Arteritis
* Rheumatoid arthritis
* Polymyositis
* Dermatomyositis
* Sjogren’s syndrome
* Ankylosing spondylitis
* Primary Raynaud’s
* Scleroderma
* Systemic lupus erythematosus

Scleroderma
Periungual Erythema
Nailfold Capillaroscopy
Scleroderma Diagnosis and Treatment
Scleroderma Renal Crisis
Manifestations of Scleroderma Renal Crisis
SRC Risk Factors
SRC Therapy
Diagnostic Tests

Rheumatological Urgencies.ppt

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