Introduction to Rheumatology Flashcards
What are the functions of connective tissue?
- (bones, tendons, cartilage) Binds together, supports, and strengthens other body tissue
- (adipose)Protects and insulates internal organs
- Compartmentalises structures such as skeletal muscles
- (Blood)-major transport system within the body
- (adipose) site of stored energy resources
-Main site of IMMUNE RESPONSE
What are the things that make connective tissue connective tissue?
common embryological origin, they come from MESINKINE which orginates from the mesoderm -variability in vascularity(some connective tissues have a good blood supply but some don’t
What are the 3 components of connective tissue?
Cells: -Fibroblast -Macrophages -Mast cells -Plasma Cell -Lymphocytes -Leukocytes -Adipose cell
Fibres(ECM): -Reticular -Elastic -Collagen
Ground substance(ECM): -large rubbery jelly like material -made of of starches, proteins and water, multiadhesive Glycoproteins(gives structural support to connective tissues) and macromolecules
Describe the 3 main fibres of connective tissue?
Collagen: -Stongest, resistant, flexible, made of COLLAGEN
Elastic: -Smaller in diameter than collagen -Branch to form network -Made of protein called ELASTIN -Flexible -Found in blood vessels and skin
Reticular fibres: -Provide support for the walls of blood vessels -Reticulo refers to NET/MESH STRUCTURE -Made of COLLAGEN (but tends to be smaller diameter) and has a GLYCOPROTEIN COVERING
What are the roles of different cells in connective tissue?
Fibroblasts: -large flat cells with branching processes -Migrate throughout the connective tissue secreting the FIBRES and GROUND SUBSTANCES
Macrophages: -Develop from white blood cells =surround and engulf material by phagocytosis
Mast Cells: -Alongside blood vessels that supply connective tissue -Produce HISTAMINE(chemical that dialates blood vessels
Adipocytes: -fat cells -Store triglycerides
What is the main function of connective tissue matrix fibres?
Provides strength and support
What are the 4 main connective tissues?
- Proper connective tissue
- Cartilage
- Bone tissue
- Blood
What are the 2 types of proper connective tissue?
LOOSE: -Areolar(most common) -Adipose -Reticular
DENSE(tends to have more collagen): -Regular (tight collagen fibres e.g tendons and ligaments) -Irregular(skin dermis) -Elastic
What is the function of proper connective tissue?
- Binding tissue
- Resists mechanical stress esp, tension
What cells are in proper connective tissue?
- Fibroblasts
- Fibrocytes
- Defense cells
- Fat cells
What is the function of the cartilage?
- Strengthen and support connective tissue
- Resists compression
- Cushions and supports body structures
Is cartilage avasclar or vascular?
AVASCULAR and it has NO nerve supply
What cells are in the cartilage?
CHONDROBLASTS-in growing cartilage
-responsible for the development of the cartilage Chondrocytes
What is the most common form of cartilage in the body?
Hyaline cartilage
Where is hyaline cartilage?
end of long bones to cushion joints and at epiphyseal plates
How strong is hyaline cartilage?
weakest of the 3 types of cartilage as it doesn’t contain many collagen fibres
Which type of cartilage is the strongest?
FIBROCARTILAGE- because it has lots of THICK COLLAGEN fibres
This strength makes it a good shock absorber
What are the features of fibrocartilage?
- No PERICHONDRIUM (connective tissue that envelops cartilage)
- Chondrocytes scattered among visible bundles of collagen fibres
Where is fibrocartilage commonly found?
Invertebral discs
What are the features of Elastic cartilage?
-Provides strength and elasticity and maintains the shape of certain structures like the external ears
-CHONDROCYTES located in a threadlike network of elastic fibres
What are the different types of bone tissue and what are they composed of?
COMPACT: -Osteon-basic unit of compact bone -Lamellae-Concentric circles of matrix -Lacunae-spaces in the matrix that house cells -Osteocytes-Mature bone cells
SPONGY: -Trabeculae-columns of bone filled with red bone marrow
What are 3 main types of Rheumatological Disorder?
RHEUMATOID ARTHRITIS-autoimmune disorder effecting the joints resulting in warm INFLAMMED swollen painful joints. Symtoms typically get worse after est
SYSTEMIC LUPUS erythematosus- autoimmune disorder of the connective tissue. Affects multiple organ systems and joints
VASCULITIS-Is a group of disorders that destroy blood vessels by inflammation
What are the 2 broad categories of arthritis?
- Osteoarthritis
- Rheumatoid arthritis
What is thought to cause rhematoid arthritis?
- Genetic predispostition
- environmental triggers(Smoking etc)
What is the incidence of rheumatoid arthritis in the uk?
1%
Who gets Rheumatoid arthritis?
-older people -female -affects young people age 20-40 mainly
What happens in rheumatoid arthritis
-Inflammation of the synovial membrane leads to it and over a longer period of time can lead to erosion of the hyaline cartilage - if left untreated you can get narrowing of the joint space, bone erosion, bone destruction and very severe joint deformity
What cytokines are involved in regulating your inflammatory response in Rheumatoid arthritis?
TNF-alpha
IL-1
IL-6
IL-17
What things are thought to contribute to cartilage destruction?
MMP’s(Enzyme) Nirogen oxide
What does RANKL do ?
expressed by osteoblast, resulting in the formation of Osteoclasts = can cause bone destruction
What are the symptoms of Rheumatoid arthritis?
-Pain -Stiffness -JOint swelling
What are the key features of Rheumatoid arthritis?
Symptoms- often last the remainder of the persons life Inflammatory synovitis-palpable synovial swelling, Morning stiffness, symptoms get better throughout the day Polyarthritis-more than 3 joints being affected Symmetrical-If you have fingers and wrists affected on one side than they will be affected on the other
What are the differences between Rheumatoid arthritis and Osteoarthritis
Age: RA=30-50 OA=50+
Speed of Onset: RA-Rapid OA-Slow
Joint Pattern: RA-Bilateral, Symmetrical OA-Asymmetric
Movement: RA-Often better OA-often worse AM
stiffness: RA-over an hour OA-uncommon
Hand joints: RA-PIP, MCP OA-DIP, thumb, CMC
Wrist, ankle, elbow: RA-Common OA-uncommon Systematic symptoms: RA-common OA-uncommon
Joint Swelling: RA-Effusion, red warm OA-bony ESR/CRP: RA-elevated OA-Normal
Serology: RA-positive OA-negative RA-Inflammatory OA-degenerative RA-Autoantibodies OA-No antibodies RA-small joints OA-large weight bearing joints RA-poligoarthritsi OA-oligo arthritis(1 joint affected)
Where is swelling confined to in RA and how does it feel?
area of the joint capsule Synovial thickening feels like a firm sponge
What is a key visible problem caused by Rheumatoid arthritis?
Deformities Noduales- at elbows and hands, assosiated with severe RA that causes erosion Also assosiated with RHematoid Factor antibody: -45% positive in first 6 months -85% positive with established disease
What are the auto antibodies associated with RA?
Rheumatoid Factor AntiCCP Assosiated with nodules
What x ray changes do you see in Rheumatoid arthritis?
-Soft tissue swelling -Erosions -joint space loss -Subluxation -Erosions
Historically what is the typical course of RA?
Damage occurs early in most patients: -50% show joint space narrowing or erosions in the first 2 years -By 10 years, 50% of young working patients are disabled
What is the life expectancy of people with RA?
Lower: -Women 10 years less -Men 4 years less Many causes for this, most likely sue to cardiovascular disease which is increased alongside inflammation with RA pateints
What is the typical pattern of pain and stiffness in RA?
Inflammatory pattern- affects multiple joints, symmetrical, small joints, stiffness is early morning
How do we investigate RA?
-Blood tests (Check autoantibodies) -Check inflammatory markers -x-rays -ultrasound to check inflammation in soft tissue and joints that you cant see with x-rays
What are the principles of treating RA?
1)Diagnose -confirm diagnosis 2)Severity -Determine where the patient stands in the spectrum of disease 3) Treatment -When damage begins early start agressive treatment early 4)Monitor -Treatment for adverse effects -Disease activity, revise Rx as needed
How do you assess RA during the treatment process?
Assess current activity: -Morning stiffness, synovitis, fatigue, ESR Document the degree of damage: -ROM and deformities -Joint space narrowing and erosions on x-ray Document extra-articular manifestations: -Nodules, pulmonary fibrosis, vasculitis Assess prior Rx responses and side affects
What are the 3 therapies in the treatment plan of RA?
EDUCATION: -Use resources from the arthritis foundation and the ACR -Assistive devices -Multidisciplinary team EXERCISE: -ROM(range of motion), conditioning, and strengthening exercises MEDICATIONS: -Analgestic and/or anti-inflammatory -to relieve pain -immunosupressants, cytotoxic and biologic -steroids(short term) -Balance efficancy and safety with the activity
How do we treat RA long term?
Use DISEASES MODIFYING ANTI-RHEUMATIC DRUGS (DMARDs)
Give examples of some DMARDS traditional?
-MINOCYCLINE(may work best early) -Sulfasalazine, hyroxychloroquine(moderate effect, low cost) -Intramuscular gold(slow onset, decreases progression, rare reminisision, requires close monitoring)
What are some examples of new DMARDs used?
LEFLUNOMIDE: -pyrimidine inhibitor -Effect and side effects similar to those of MTX ETANERCEPT: -soluble TNF receptor,blocks TNF -Rapid onset, quite effective in refractory patients in short term trails and in combo with MTX -injection site reactions, long term effects unknown, expensive
What are 3 drug treatment options for RA?
NSAIDS: -symptomatic relief, improved function -No change in disease progression Low-dose prednisone: -May substitute for NSAID -Used as bridge therapy -If used long term consider prophylactic treatment for osteoporosis INTRA-ARTICULAR STEROIDS: -useful for flares
What are 4 immunosuppressive drugs used to treat RA?
Methotrexate: -Most effective single DMARD -Good benefir to risk ratio Azathioprine: -Slow onset, reasonably effective Cyclophosphamide -Effective for vasculitis, less so fro arthritis Cyclosporine: -Superior to placebo, renal toxicity Not commonly used anymore can be effective when combined with each other
What has a big effect on RA and other autoimmune conditions?
BIOLOGICAL THERAPIES: Work by working on specific biological targets e.g targeting cytokines therefore reducing inflammation by a lot e.g. TNF- alpha inhibitors
What side effects and complications are assosiated with RA medication?
Lots of these medicines work by dampening down your immune response, therefore increasing there risk of infection
Why and how do you monitor the treatment of RA with DMARDs?
-Need frequent monitoring as the blood, liver, lung, kidney are frequent sites of adverse effects -Most patients need to be seen 3-6 times a year
What other sites can RA effect
Liver Cardiovascular Neurological Musculoskeletal Bone marrow Spleen Dry/inflammed eyes Kidney damage due to protein accumulation
What are the 3 main undifferentiated connective tissue diseases and what are the symptoms?
Systemic lupus erythematosus(SLE): -Alopecia Malar rash(looks like a butterfly) -Arthralgia -Oral ULcers -Photosensitivity Scleroderma: -Reflux -Raynauds -Digital -Ulcerations RA: -Arthritis -Sicca symptoms
