Module 11

Question 1

What are the clinical manifestations of rheumatoid arthritis?

Answer 1

Joint symptoms- symmetric swelling of multiple joints, stiffness in am, tenderness, and pain present. PIP joints of fingers, MCP joints, wrists and knees.
Rheumatoid nodules- occur over bony prominences, bursae and tendon sheaths, can be seen in lungs, sclerae and other tissues.
Ocular symptoms- dryness of eyes, mouth, and other mucous membranes. Can have scleritis, episcleritis due to scleral nodules and peripheral ulcerative keratitis
Other symptoms- interstitial lung disease, pericarditis, pleural disease

Question 2

Name some differential diagnoses for RA.

Answer 2

Osteoarthritis- spares the wrist and MCP joints. Osteoarthritis is not associated with constitutional manifestations and joint pain is usually relieved by REST

Gouty tophi- can resemble rheumatoid nodules but are not associated with rheumatoid factor

Chronic lyme arthritis typically involves one joint. Most commonly affects the knee and is associated with positive serologic tests.

Question 3

What are the treatment options available for RA?

Answer 3

Primary objectives in treating rheumatoid arthritis are reducing inflammation and pain, preservation of function, and deformity
Corticosteroids produce a prompt inflammatory effect and slow the rate of articular erosion
DMARD’s
1) synthetic DMARDs
Methotrexate 1st choice
Sulfasalazine 2nd line agent
Leflunomide (contraindicated in women who want children)
Antimalarials
Tofacitinib- used to manage serve RA that is refractory to methotrexate
2) Biologic DMARDs
Tumour necrosis factor inhibitors
Abatacept
Rituximab
Tocilizumab
2) Combination DMARD’s

Question 4

What is systemic lupus erythematosus and what are some of the clinical manifestations of the disease?

Answer 4

Inflammatory autoimmune disease characterized by autoantibodies to nuclear antigens. Can affect multiple organ systems.

Rash occurs over areas exposed to sunlight, joint symptoms in 90% of people, anemia, leukopenia, thrombocytopenia

Symptoms: fever, anorexia, malaise, and wt loss.

Question 5

What are some differential diagnoses for Systemic Lupus Erythematosus?

Answer 5

Drug induced lupus, RA, systemic vasculitis, scleroderma, acute drug reactions, inflammatory myopathies, viral hepatitis, sarcoidosis, and acute drug reactions

Question 6

What are treatment options for Systemic Lupus Erythematosus?

Answer 6

Treatment: 
	Rest and NSAIDs for joint symptoms
	Avoidance of sunlight
	Antimalarials
	Corticosteroids required for certain complications

Question 7

What are the clinical manifestations of anaphylaxis?

Answer 7

1) Urticaria, flushing, blotchy rashes, pruritus
2) resp distress, including wheezing, stridor, bronchospasm, airway angioedemia
3) GI symptoms including, cramping, emesis, and diarrhea
4) Hypotension, ie: light-headedness, dizziness, or syncope

Question 8

WHat is the first line treatment for anaphylaxis?

Answer 8

IM epi

best success rate is IM epi immediately when symptoms arise hence epi pens!!

Question 9

What are some adjunct therapies for treating anaphylaxis?

Answer 9

antihistamines, bronchodilators, corticosteroids

Question 10

What are the clinical manifestations of urticaria?

Answer 10

Puritis followed by hives, lesions appear in crops that last 2-3 hours then disappear only to flare up elsewhere later. Generally, fade in less than 24 hours. Episodes can occur as often as daily in chronic urticaria and can last up to 2 years.

Question 11

Name some treatment options for urticaria.

Answer 11

antihistamines taken regularly for several weeks. Antihistamines, such as cetirizine or fexofenadine, help by blocking the effects of histamines and reducing the rash and stopping the itching.

Question 12

What are some of the clinical manifestations of angioedema?

Answer 12

Involvement of deeper subcutaneous tissue with swelling of lips, eyelids, palms, soles, and genitalia
Angioedemia is NO more likely than urticaria to be associated with laryngeal edema or hypotension.

Question 13

What are some of the main causes of angioedema?

Answer 13

Main causes include asprin, NSAIDs, ace-inhibitor, angiotension receptor blocker, morphine, codeine, insect bites, penicillins

Question 14

What is the initial therapy for treating angioedema?

Answer 14

Initial therapy is hydroxyzine (H1-antihistamine)

Question 15

What is HLA and what is its association with connective tissue diseases?

Answer 15

human leukocyte antigen (HLA) system or complex is a gene complex encoding the major histocompatibility complex (MHC) proteins in humans. These cell-surface proteins are responsible for the regulation of the immune system in humans

Antigen presentation and T cell activation appear to be key to triggering an autoimmune response prompting investigation of many genes within this pathway for association with AID including several within the HLA.

Question 16

Name some autoimmune diseases associated with HLA?

Answer 16

Autoimmune diseases (AIDs) including type 1 diabetes (T1D), multiple sclerosis (MS), rheumatoid arthritis (RA), Graves’ disease (GD), ankylosing spondylitis (AS) and systemic lupus erythematosus (SLE)

Question 17

What are some hereditary risk factors for colorectal Cancer?

Answer 17

Family hx is present in 20% of pt’s with colon Ca.
Hereditary factors are said to contribute to 20-30% of the cases however they haven’t identified the gene responsible. Jewish ancestry.

Family hx of colorectal Ca or adenomatous polyps are one of the most important risk factors for colon Ca. If 1st degree relative suffered before age 45 you have a 4x greater risk of Ca. 2x greater risk if a family member suffered after age 45

Question 18

What are some hereditary risk factors associated with Breast Ca?

Answer 18

Women with a strong family history of breast ca, may be candidates for BRCA genetic testing. Women who are known to carry BRCA1 or BRCA2 have a 40-70% chance of developing breast Ca over the life span.

Question 19

What are some hereditary risk factors associated with cervical Ca?

Answer 19

Hispanic women are most likely to get cervical Ca, followed by African americans, Asians, and pacific islanders, and whites.
First nations are least likely to have this.

Black women have 2 x greater risk of death than white women with cervical Ca.

Black women are 1.5 times higher than white women to get cervical Ca.

Question 20

Describe primary prevention measures for various types of cancer and examples…

Answer 20

Primary prevention is that set of interventions that keeps a cancerous process from ever developing and includes health counseling and education, environmental controls. and product safety as examples.

Question 21

Describe secondary prevention measures for various types of cancer and examples…

Answer 21

Secondary prevention is that set of interventions leading to the discovery and control of cancerous or precancerous processes while localized, i.e., screening, early detection, and effective treatment.

Ie: breast Ca= mammograms, MRI , colon Ca=colonoscopy in those with suspicious, or clinical hx suggestive of Ca

Question 22

Review various treatment options and regimens for cancer.

Answer 22

See page 1612-1624 in Papadakis for table on all the options according to the type of Ca and various chemo agents.

Question 23

What does TNM stand for and what is it used for?

Answer 23

Used for staging of cancers.

T- tumor- tumor location, size, and level of tumour invasion
N- nodes- absence or presence and extent of nodal metastases
M- metastasis- absence or presence of systemic metastases
From here an overall stage is assigned I, II, III, or IV.

Question 24

Explain the staging for colon Ca.

Answer 24

Chemo has been shown to improve overall and tumour free survival rate

Stage 1- no adjuvant therapy is recommended. 5 year survival rate is approx. 87%
Stage II- survival rate is approx. 87%. No signif. Survival rate with adjuvant therapy has not been shown. However, at higher risk of reoccurrence
Stage III- survival rates with surgical resection alone is 30-50%
Post-op adjuvant chemotherapy significantly increases disease-free survival as well as overall survival by up to 30%
Stage IV- approx. 20% have metastatic when diagnosed. Potentially curable with resection. Tumor location has been found to have prognostic importance. Goals of therapy are to slow tumor progression and maintain reasonable quality of life.

Question 25

Explain the staging for Lung Ca.

Answer 25

Staging is divided into small cell (SCLC). and the other 4 types (NSCLC)

2 essential principles of staging NSCLC.

TNM system of staging
T- describes size and location of primary tumor
N- describes presence and location of nodal metastases
M- refers to the presence of absence of distant metastases
The TNM stages are further grouped into summary stages I-IV and these are used to guide therapy
Stage I-II- usually cured with surgery
Stages IIIB- IV- not cured through surgery
Stage IIIA- locally invasive disease and may benefit from surgery as part of multimodality therapy

SCLC
Divided into two categories:
Limited disease (30%)- tumour is limited to unilateral hemithorax
Extensive disease(70%)- tumour extends beyond the hemithorax including pleural effusion.
It is also recommended to stage based on the TNM system

Question 26

Describe the relationship of the CD4 count to opportunistic infections.

Answer 26

Certain infections may occur at any CD4 count. While others rarely occur unless the CD4 lymphocyte count has dropped below a certain level. Ie: a pt with a CD4 count of 600 cells/mcL, cough, fever…may have a bacterial pneumonia but would be unlikely to have pneumocystis pneumonia.

As CD4 counts decrease the risk of opportunistic infections over the 3-5 years increases!

Question 27

Who should be on antiretroviral therapy?

Answer 27

All pts regardless of CD4 counts should be offered antiretroviral therapy.

Question 28

How often should CD4 counts be monitored in pts on antiretroviral therapy?

Answer 28

every 3-6 months

Question 29

What are some key CD4 counts that would indicate a need for prophylaxis against some of these opportunistic infections?

Answer 29

Initiation of pneumocytis jirovecii prophylactic therapy is recommended when CD4 counts drop lower than 200 cells/mcL…

Initiation of mycobacterium avium prophylaxis is recommended when CD4 counts drop lower than 75-100 cells/mcL

CD4 counts measure immune dysfunction… however they do not measure how actively the HIV is replicating in the body.