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DU PA Arthritis

Duke PA Arthritis

__ is effective in pain relief for those with OA exercise
formerly called degenerative joint disease osteoarthritis
most common cause of long-term disability in U.S. OA of the knee
__ is the most powerful risk factor for developing osteoarthritis Age
female to male ratio for osteoarthritis risk __:1 2
african american to caucasian ratio for osteoarthritis risk __:1 2
Type __ finger configuration associated with doubled risk of OA knees, hips, hands 3
higher __ shows a decreased risk for developing OA education
most affected joints in OA Knees, hips, base of big toe, base of thumb
when OA affects three or more joint groups generalized OA
loss of joint space, subchondral sclerosis, osteophytes, subchondral cysts characteristics of OA
__ can't see chondral erosions x-rays
Knee pain and x-ray osteophyte(s)-- plus --at least one of the following: (age > 50 y.o.morning stiffness(<30 min.), crepitus with motion) DIAGNOSTIC CRITERIA Knee OA
Mechanical pain, Gel phenomenon, Bony enlargement, Decreased ROM, Muscle atrophy other diagnostic features of knee OA
mild signs of __ in osteoarthritis inflammation
most significant way to decrease progression of OA weight loss
__ can improve arthritis symptoms by __% 15-30
contralateral to painful joint proper use of a cane
__ have questionable effectiveness in treating osteoarthritis of the knee unloader braces
__ is an effective treatment for patello-femoral pain patellar taping
squatting puts __ times your body weight on your knees 9
running puts __ times your body weight on your knees 4-7
walking puts __ times your body weight on your knees 3-4
kneeling, squatting, prolonged standing things to avoid when you have OA
sit in a __ stool if stationary at work if you have OA high
low toilets, low chairs, low beds, bath tubs things to avoid when you have OA
__ relaxed muscles, stimulates blood flow, good for OA heat
__ eases muscle spasms, blocks pain signals for OA cold
only thermal modality to raise hip joint temperature ultrasound
useless thermal modalities for OA infrared, diathermy
__ better for hip OA bicycle
__ better for knee OA elliptical
__ promotes joint preservation wt-bearing exercise
shock absorbers of the joints periarticular muscles
physiologic retirement plan muscle mass
__ helps combat sarcopenia weight resistance training
best done when muscles are warm stretching
jogging, stair-climbers, rowing machines, running and jumping sports not recommended for patients with OA
the go to OTC for OA acetaminophen
if response to acetaminophen is inadequated try low dose OTC NSAIDS
Start low, go slow, skip doses or eliminate __ as soon as possible NSAID
NSAIDS can cause __ GI bleeds
if you must use an NSAID b/c tylenol is inadequate also put the patient on a proton pump inhibitor
acts like a narcotic but is not as addictive tramadol (Ultram)
no real GI advantage after 12-18 months Clecoxib (Celebrex)
no evidence for an increase in cardiovascular events over other NSAIDS Clecoxib (Celebrex)
visco-supplementation hyaluronic acid
shows no slowing of disease progression but does have some pain relieving qualities, and is very safe Glucosamine, chondroitin
no benifit to __ for OA abrasion chondroplasy
autologous chondrocyte implantation carticel procedure
Osteochondral Auto Transplant System OATS procedure
longevity of this surgery is 15-20 years in 90-95% joint replacement surgery
gout is principally a disease of __ men
gout is to a lesser extent a disease of __ postmenopausal women
the prevalence of gout is directly related to the degree of __ hyperuricemia
overall gout occurs in __% of the adult male population 2-3
the prevalence of gout is __ dependant age
uric acid is the breakdown products of the purines __ adenine and guanine
__ of daily uric acid input comes from dietary sources 1/3
2/3 of the excretion of uric acid occurs in the __ kidneys
overall __% of patients with primary gout have increased uric acid production 10-20
__ of daily uric acid input comes from de-novo purine synthesis 2/3
__ can lead to uric acid overproduction, and secondary gout lymphomas, leukemias, disorders of hematopoiesis, wide spread psoriasis
clinically the most important stimulus to uric acid production is __ which can dramatically increase de-novo synthesis alcohol
__ can all lead to decreased urate clearance diuretics, aspirin, dehydration, and acidosis
__ has long been associated with gout lead nephropathy
uric acid accumulations tophi
trauma to the __ joint from weight-bearing activities may underlie its predominant involvement first metatarsophalangeal
__ sometimes leads to breakdown of tophi rapid lowering of uric acid blood levels
acute gouty arthritis is characterized by __ rapid crescendo onset
a patient with acute gouty arthritis will go to sleep with no symptoms and __ is awakened by severe pain, erythema, and swelling in the affected joint
__ is the most commonly involved joint in gout first metatarsophalangeal joint
gouty involvment of the first metatarsophalangeal joint podagra
the skin overlying a gouty joint is __ erythematous and warm
after the big toe the other joints most affected by gout in order instep, heel, ankle, knee, hands, wrists, elbows
the acute onset of inflammatory monoarthritis in a joint of the lower extremity particularly in middle aged and older men is likely to be __ gout
__ is common in gout low grade fever
patients with __ usually have a more insidious onset than patients with gout septic joint disease
the joint fluid in gout is __, with more than 10,000 WBC's and >90% PMN's inflammatory
__ are both pathognomonic for and for and essential to the diagnosis of acute gouty arthritis intracellular, needle shaped, negatively birefringent crystals
many patients have __ at the time of acute attack, therefore making serum levels unhelpful normal blood uric acid levels
gout may present as chronic polyarthritis
in contrast to the non-reactive margins in rheumatoid arthritis, x-rays of gout typically show sclerotic changes at erosive borders
RA joint progression in chronological order wrists, knees, elbows, ankles, hips, shoulders
RA joints are usually described as __ boggy
morning stiffness hall mark symptom of RA
with RA symptoms are worse in the __ am
with RA symptoms are worse after __ prolonged periods of rest
to qualify for RA quality morning stiffness, the stiffness has to last at least __ 1 hour
RA usually shows __ involvement bilateral
for a diagnosis of RA there must be at least one swollen joint in the hand
__% of those with RA will never develop serum rheumatoid factor 30
the criteria for RA must be present for __ weeks, to rule out polyarticular manifestations of infection 6
ulnar deviation, swan neck deformities, boutonniere deformities RA articular manifestations
feet are affected in __% of patients with longstanding RA 90
outside of the cervical spine __ usually does not affect the spine RA
usually involves the MCP's, PIP's, and DIP's RA
__ is rare but can occur in patients with longstanding RA tendon rupture
subluxation of the MTP's in RA can lead to a visible __ callous formation on the ball of the foot
no single diagnostic tests confirms __ RA
platelet counts are usually increased in patients with inflammatory diseases
patients who are RF negative tend to have __ as compared to those who are RF positive milder disease course
acute phase reactants associated with RA ESR, CRP, thrombocytosis
synovial fluid analysis in joints affected with RA show increased WBC's with predominant neutrophils
__ is common in RA, and is usually not fixable. it is not due to a lack in Iron. mild anemia of chronic disease
radiographic joint damage in RA is sometimes referred to as a __ rat bite
on radiograph the joint space narrowing in __ is usually more diffuse RA
Keratoconjunctivitis sicca dry eyes-extra-articular manifestation of RA
Pericarditis, premature atherosclerosis, vasculitis, valve disease, and valve ring nodules heart-extra-articular manifestation of RA
Pleural effusions, interstitial lung disease, bronchiolitis obliterans, rheumatoid nodules, vasculitis lung-extra-articular manifestation of RA
Entrapment neuropathy, cervical myelopathy, mononeuritis multiplex (vasculitis), peripheral neuropathy neurologic-extra-articular manifestation of RA
Anemia, thrombocytosis, lymphadenopathy, Felty's syndrome hematopoitic-extra-articular manifestation of RA
Nodules, fragility, vasculitis, pyoderma gangrenosum skine-extra-articular manifestation of RA
for treatment of RA with evidence of moderate-severe @ diagnosis start with __ DMARDs
adjunct treatment for RA glucocorticoids, NSAIDs, analgesics, physical, and occupational therapy
rare manifestation of RA + splenomegaly, leukopenia and recurrent pulmonary infections Felty's syndrome
rupture of synovial fluid from knee into calf; mimics DVT, cellulitis Baker's cyst
patients with RA have an increased risk for __ cardiovascular disease, accelerated atherosclerosis, increased rate of malignancy (lymphoma)
patients with RA can undergo __ spontaneous remission
estrogen protects against __ gout
peak age for gout in men __ years 40-50
peak age for gout in women >__ years 65
decreased renal clearance leading to gout underexcretion
increased renal production of uric acid leading to gout overproduction
__% of cases of gout are due at lest in part to decreased renal clearance leading to hyperuricemia
hyperuricemia and __ are associated hypertension
risk factors for gout infection, trauma, weight loss (extreme diets), hospitalization, dyslipidemia
__ are the 4 stages of gout, there can be decades in between stages hyperuricemia, acute gout, intercritical gout, chronic gout
uric acid levels increase at __ puberty
hyperuricemia is defined as serum uric acid level > __ mg/dL 6.8
most people with __ don't develop gout hyperuricemia
asymptomatic __ usually doesn't need to be treated hyperuricemia
dusky red is the color of __ gout
usually exquisitely tender (bed sheet sign) gout
may be difficult to distinguish from septic arthritis (similar lab features) gout
Peggy says this is the NSAID of choice for gout indomethacin
Treatment of choice for gout NSAIDs
limit/restrict offending foods, limit ETOH, increase fluid intake, weight loss lifestyle modifications for gout
beef, pork, canned sardines, foods with high yeast content, shellfish, asparagus, cauliflower, mushrooms, spinach foods high in purines
__ should be obtained before initiating therapy for acute gout 24 hour urinary uric acid measurement
__ is very allergenic and associated with severe side effects (bone marrow/liver failure, severe skin rashes) allopurinol
__ prophylaxis in a flair don't stop
fenofibrat, and losartan have mild uricosuric affects
aka interval gout intercritical gout
in gout this manifestation can resemble rheumatoid nodules tophi
CPPD Disease aka pseudogout
is a rheumatologic disorder with varied clinical manifestations due to precipitation of calcium pyrophosphate dihydrate crystals in the connective tissues chondrocalcinosis
can mimic RA, OA, or gout when symptomatic CPPD disease
often asymptomatic CPPD disease
may worsen OA when both exist CPPD disease
Calcific tendonititis frozen shoulder
inflammation at sites of attachment of bone to a tendon or ligament enthesopathies
characterized by enthesopathies and involvement of the sacroiliac joints Spondyloarthropathies
Formerly preceded by prefix “seronegative” denoting absence of rheumatoid factor Spondyloarthropathies
association with human leukocyte antigen (HLA) B-27 Spondyloarthropathies
if a patient with a spondyloarthropathy is HLA B-27 positive __ they are more likely to have eye symptoms, earlier onset, and more axial involvement
if a patient with a spondyloarthropathy is HLA B-27 negative __ they are more likely to have peripheral arthritis, skin and nail manifestations, gut symptoms
sites of enthesitis in the spondyloarthropathies Achilles' tendon, plantar fascia, symphysis pubis, ischium, iliac crest, greater trochanter, finger & toes, anterolateral ribs
Ankylosing SpondylitisReactive ArthritisPsoriatic ArthritisEnteropathic ArthritisUndifferentiated Spondyloarthropathy The Spondyloarthropathies
Ankylosing Spondylitis spondyloarthropathy
Reactive Arthritis spondyloarthropathy
Psoriatic Arthritis spondyloarthropathy
Enteropathic Arthritis spondyloarthropathy
insidious onsetworsens with inactivity; improves with exercisepersists greater than 3 monthsam stiffnessoften radiates to buttocks, thighs inflammatory characteristics of low back pain Enteropathic Arthritis
acute onsetworsens with activity; improves with restlast 2-4 weeksno am stiffnessrarely radiates non-inflammatory characteristics of low back pain Enteropathic Arthritis
Bilateral Sacroiliitis makes the diagnosis for ankylosing spondylitis
it can take as long as 10 years for someone with spondylitis to show arthropathy on __ plain film
uveitis, conjunctivitis, sicca symptoms eye manifestations of spondyloarthropathies
AI, conduction delays cardiac manifestations of spondyloarthropathies
IgA nephropathy, amyloidosis renal manifestations of spondyloarthropathies
c-spine fractures or dislocations neurologic manifestations of spondyloarthropathies
occult or overt colitis GI manifestations of spondyloarthropathies
manifestations only in psoriatic arthritis and reactive arthritis skin manifestations of spondyloarthropathies
males with Ankylosing Spondylitis tend to have more lumbar spine involvement
females with Ankylosing Spondylitis, tend to have more peripheral involvement, but when they do have spinal involvment it is in the c-spine
Mark at L5 make a mark 10 cm above that, have the patient bend at the hip. This distance should increase to 15 cm or more in the normal patient Shober maneuver, tests for ankylosing Spondylitis
most people with reactive arthritis are HLA B-27 positive
sausage digits dactylitis
enthesopathiesdactylitisinvolvement of skin & mucous membranesrecovery is usually spontaneous with good prognosischronic cases can occur ( SI joint & axial disease associated with chronicity)susceptibilty associated with HLA B- Clinical Features of Reactive Arthritis
Antibiotics if triggering infection is still presentRestNSAIDsConsider intra-articular corticosteroid injectionsChronic disease: consider DMARDs Treatment of Reactive Arthritis
Association with HLA B-27 is weak (<50%) Psoriatic Arthritis
An inflammatory arthritis found in 20-30% of patients with psoriasisUsually (75% of time) psoriasis precedes joint disease on average of 2 decadesPsoriatic findings may be occult (check scalp, nails, flexural areas)Male: female ratio is 1:1 Psoriatic Arthritis
Predominant involvement of DIPs, Symmetric polyarthritis clinically indistinguishable from RA (most common), Asymmetric oligoarthritis of small joints ( most characteristic), Arthritis mutilans with sacroilitisAS-type with sacroilitis and spondylitis 5 types of Psoriatic Arthritis
pencil in cup deformity is seen in psoriatic arthritis
NSAIDsCombination of NSAIDS + sulfasalazine work wellMethotrexate can be added in refractory casesOligoarthritis form: amenable to corticosteroid injectionsPhysical therap Treatment of Psoriatic Arthr
outside of arthritis patients with a spondyloarthropathie will most often have gut symptoms
patients with gut diseases (Crohn's) are more likely to have arthritis symptoms
male to female ratio with axial enterophathic arthirits __:1 1
GI symptoms and __ are usually temporally related arthritis flares
Extra-articular manifestations of enteropathic arthritis = __ Extra-intestinal manifestations of IBD
Low back pain: could it be sacroiliitis? Do __ test FABER
microbes reach joint usually via __ in infectious arthritis hematogenous spread
__ is a rare cause of infectious arthritis intra-articular
__ is the most commonly affecte joint in infectious arthritis knee
infectious arthritis is usually monoarticular
__ accounts for 2/3 of infectious arthritis cases in patients <40 years in adults gonococcal arthritis
__ are a greater risk for gonococcal arthritis women
syndrome of rash, fever, chills, migratory tenosynovitis of knees, ankles, wrists, feet and hands (~30-60%)~40% have skin lesions: papulovesicular or hemorrhagic, varying size monoarticular process: kneehip, ankle, wrist or elbow gonococcal arthritis
Treatment:patients should be hospitalizedceftriaxone 1gm (IM or IV) q 24 hours until clinical improvementpo cefixime or cefpodoxime for at least one week gonococcal arthritis
__ accounts for most cases of nongonococcal arthritis S. aureus
__% of nongonococcal arthritis cases are monoarticular 90%
order of joints affected by nongonococcal arthritis knee>hip>shoulder>wrist>elbow
moderate to severe pain surrounding jointeffusion, spasm, warmth and erythema commonchills and fever common but may be absent in as many as 20% of affected patients nongonococcal arthritis
Synovial fluid is essential for diagnosis and treatment nongonococcal arthritis
syphilis (rare), lyme disease, M. tuberculosis other (less common) etiologies of bacterial arthritis
usually a chronic monoarticular process, pain and swelling develop in affected joint over months to years tuberculosis arthritis
borrelia burgdorferi carried by Ixodes tick causes Lyme arthritis
reported in nearly all states lyme arthritis
Primarily in northeast from Massachusetts to Maryland and in Wisconsin, Minnesota, California, and Oregon lyme arthritis
__% of patients with Lyme disease who are untreated develop arthritis 70
most common etiology of viral arthritis hep B&C, rubella, and parvovirus
__ can be confused with RA parvovirus
Predilection for immunocompromised patients - DM, alcoholism, AIDS, post-transplant, corticosteroid therapy, chemotherapy fungal arthritis
gardeners and those occupationally or recreationally exposed to soil fungal arthritis
less common etiologies of fungal arthritis Aspergillus, Cryptococcus, Pseudallescheria, dematiaceous fungi
infection complicates __% of joint replacements 1-4
most common cause of early prosthetic joint infection S. epidermidis
most common cause of late prosthetic joint infection S. aureus
aggressive debridement and prolonged antibiotic therapy treatment of early prosthetic joint infection
removal of prosthesis and prolonged antibiotic therapy treatment of late prosthetic joint infection
Created by: bwyche