Introduction the Rheumatology and Rheumatoid Arthritis Flashcards
What Is Rheumatology?
Rheumatology is the Medical Specialty that deals with the investigation, diagnosis and management of patients with arthritis and other related conditions
This incorporates more than 200 disorders including inflammatory arthritis, connective tissue disease and bone disease
What Is Arthritis?
Arthritis is Inflammation of a Joint or Joints!
what are the symptoms of arthritis?
Pain
Stiffness
Swelling
Functional Impairment
Systemic Symptoms
what are the signs of arthritis?
Tenderness
Swelling
Restriction of Movement
(Heat)
(Redness)
Systemic Features
what is the Spectrum of Rheumatic Disease?
RA
Sero negative arthritis
Crystal Arthritis
Connective Tissue Diseases
Systemic Vasculitis - giant cell arteritis
Bone Disease
Osteoarthritis - most prevelant
what is the defnition of RA?
Rheumatoid Arthritis is a chronic auto immune systemic illness characterised by a symmetrical peripheral arthritis and other systemic features
It is one of the commonest chronic illnesses and may be associated with joint damage, disability and premature mortality
RA: Classification-1987 ARA Criteria:
what is the different criteria?
Picture showing:
RA: Classification: 2010 EULAR/ACR
Score more highly for more joints that are affected
RA: Epidemiology:
what is the prevelance?
approx 1% of population ie approx 4 000 cases in Grampian (40 000 in Scotland)
1% have rheumatoid disease in some shape or form, mild or severe
RA: Epidemiology:
what is the incidence?
approx 200 new cases in Grampian/annum
RA: Epidemiology:
what is the F:M
3:1
RA: Epidemiology:
what is the age of onset?
peak age 4th/5th decade but may occur at any age from 16 years
Often in people of working years
what ar ethe 2 main things involve din the aetiology of Rheumatoid Arthritis?
Genetics
Environment
how is genetics involved in the aetiology of RA?
Overall incidence of RA ~1% rises to 2-4% in siblings and 12-15% in monozygotic twins
Genetic contribution to RA estimated to be ~50-60%
Closest association with specific amino acid sequences at positions 70-74 of DRb1 (shared epitope)
how is the environment involved in the aetiology of RA?
Cigarette Smoking
Chronic Infection eg Periodontal disease
Certain environmental features predispose
what is the pathogenesis of RA?
Pathological: Synovitis
Inflammation can affect many different parts of the anatomy around the joints of supporting structures
Key feature is inflammation around the synovial membrane leading to hypertrophy – synovitis
Secondary features on bone, cartilage etc
another picture relation to the previos flash card about arthritic joints
for RA what investigations may be used?
(US shown below - Diagnostic US has been used, helps to interoperate the clinical signs better when there is uncertainty of synovitis)
Clinical assessment – history and examination
Rheumatoid Factor (IgG, IgM) - used to be done lots, not as much now, not offered
Anti Cyclic Citrullinated Antibodies (anti CCP, ACPA) - Anti CCP should be used, greater specificity for the disease, also have important pathological role in rheumatoid disease, important both diagnostically and pathologically
(X-ray may be useful, wont see this in early stages)
Rheumatoid Arthritis - what are the ysmptoms of arthritis?
Pain - Pain of arthritis will feel different form pain in a broken leg
Stiffness
Immobility
Poor function
Systemic Symptoms
Symptoms of inflammation
Rheumatoid Arthritis - what are the clinical signs of arthritis?
Swelling
Tenderness
Limitation of Movement
(Redness)
(Heat)
If you examine your patient and find evidence of joint swelling, tenderness and limitation of movements chances are you are seeing the clinical signs of arthritis
RA: Clinical
where does it effect?
Lots of different arthritis
What does the arthritis of rheumatoid look like?
Rheumatoid will hit lots of joints, where as gout will tend to hit one
Rheumatoid will be many joints and tends to be symmetrical/bilateral
Often peripheral joints – hands and feet, but can be anywhere
RA: Clinical
what may RA look and presnet like?
No substitute for examining joints, feel synovial swelling
Left shown classical swelling, normally see the hills and valley between the MCP joints
Right shows – late disease as failed treatment
Think of picture on the left rather than the right
Soft boggy swelling shown in middle
feeling of synovitis is the same regarding of what joint you are feeling
RA: Clinical (Systemic)
what are the systemic features?
a) Non-specific - Fatigue/lassitude, Weight loss, Anaemia
b) Specific - Eyes, Lungs, Nerves, Skin, Kidneys
c) Long term - CVS, Malignancy
(Nodules only occur in small percentage as showni n pictures)
RA:Clinical (Systemic)
pictures showing more severe and extreme forms
Vasculitic appearance on the left
Eye specific manifestations on the right
how is assessment of RA done?
Disease Activity Score
www.das28.com
DAS<2.4 represents clinical remission
DAS>5.1 represents eligibility for biologic therapy
Measure disease activity
Objective and subjective measures
what is the outocme of RA? (historic)
50% of patients dead or disabled within 20 years of diagnosis (1987)
50% out of workplace within 2 years of diagnosis
Life expectancy shortened by approx 7 years
Work place disability is an important consideration managing rheumatoid disease
what is the outocme of RA? (NAO report 2010 - up to date figues are hard to get)
75% of cases diagnosed during working life
Approx 33% will have stopped working within 2 years
Approx 50% will be unable t0 work due to disability within 10 years of diagnosis
A person with RA will have, on average 40 days sick leave/year (compared with 6.5)
Conclusions:
Rheumatoid Arthritis is one of the commonest, severe, chronic conditions of adulthood with potentially _________, disabling arthritis and a range of ________ effects
Rheumatoid Arthritis can be _________ treated
Outcomes way better than they have ever been in the ____
progressive
systemic
effectively
past
