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Unit 11 PBL cases > Rheumatoid arthritis > Flashcards

Rheumatoid arthritis Flashcards

1
Q

What are the aspects of the brachial plexus?

A

Roots
Trunks
Divisions
Cords
Branches

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2
Q

What are the roots of the brachial plexus?

A

C5, C6, C7, C8 and T1

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3
Q

What are the trunks of the brachial plexus?

A

Superior
Middle
Inferior

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4
Q

What are the divisions of the brachial plexus?

A

Anterior of the superior trunk
Posterior of the superior trunk
Anterior of the middle trunk
Posterior of the middle trunk
Anterior of the inferior trunk
Posterior of the inferior trunk

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5
Q

What are the cords of the brachial plexus?

A

Lateral
Posterior
Medial

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6
Q

What are the branches of the brachial plexus?

A

Musculocutaneous
Median
Ulnal
Axillary
Radial

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7
Q

What nerves branch of the roots in the brachial plexus?

A

C5 > Dorsal scapular N.
C5,6,7 >Long thoracic N.

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8
Q

What nerves branch off the trunks of the brachial plexus?

A

Superior > Suprascapular N.
Superior > Subclavius N

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9
Q

What nerves branch off the cords of the brachial plexus?

A

Lateral > Lateral pectoral
Posterior > Superior subscapular
Posterior > Thoracodorsal
Posterior > Inferior subscapular
Medial > Medial brachial cutaneous
Medial > Medial antebrachial cutaneous

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10
Q

Where are the pulse points in the arm?

A
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11
Q

What muscles are in the superficial anterior distal arm? what do they do?

A

Pronator teres - pronation and flexion of the forearm
Flexor carpi radialis - flexes hand at wrist joint, abducts the hand
Palmaris longus - flexion at wrist, stabilisation of palmar aponeurosis
Flexor carpi ulnaris - flexion at wrist, adducts hand at radiocarpal joint

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12
Q

What muscles are in the intermediate anterior distal arm? what are their roles?

A

Flexor digitorum superficialis - flexes hand at wrist, index, middle, ring and little fingers

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13
Q

What muscles are in the deep anterior distal arm? what are their roles?

A

Flexor digitorum profundus - flexes hand at wrist, index, middle, ring and little fingers
Flexor pollicis longus - flexes hand at wrist and flexes thumb
Pronator quadratus - pronates forearm at radioulnar joints

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14
Q

What are the muscles of the superficial posterior forearm? what are their roles?

A

Brachioradialis - flexes forearm at elbow joint
Extensor carpi radialis longus - extends hand at radiocarpal joint, abducts hand at radiocarpal and midcarpal joints
Extensor carpi radialis brevis - extends hand at radiocarpal joint, abducts hand at radiocarpal and midcarpal joint
Extensor digitorum - extends fingers apart form thumb
Extensor digiti minimi - extends little finger
Extensor carpi ulnaris - extends and adducts hand at radiocarpal jont

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15
Q

What are the muscles in the deep posterior forearm? what are their roles

A

Aconeus - elbow extension
Supinator - supinates forearm at wrist
Adductor pollicis longus - abducts and extends thumb at first CMJ
Extensor pollicis brevis - extends thumb
Extensor pollicis longus - extends thumb
Extensor indicis - extends index finger

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16
Q

What does RA lead to overall?

A

Synovial hyperplasia and hypertrophy
Leads to pannus formation (area of proliferating synovium that leads to erosion of bone and cartilage)

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17
Q

What is the initial pathogenesis of RA? Macrophages and FLS

A

Trigger unknown - RF?
Macrophages: secrete cytokines - TNF-a, IL-1B, IL-6
Fibroblast-like synoviocytes (FLS) cells:
Cytokines activate FLS > cells proliferate and osteoclasts activate > bone erosion
FLS stimulate RANKL expression (binds to RANK of mature osteoclasts and pre-osteoclasts and causes activation and differentiation > degrade bone)
FLS secrete proteases > degrade cartilage > cartilage release proteases (+ve feedback loop)
When FLS activated, migrate from joint-joint = symmetrical arthritis

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18
Q

What role do CD4+ cells and neutrophils in RA pathogenesis?

A

CD4+ cells:
react with arthrogenic agent > secrete cytokines IL-y > activate macrophage activity and stimulate FLS > synovial proliferation > pannus formation > IL-17 > neutrophils recruited > TNF-a, IL-1, Il-6 > proteases secreted > hyaline cartilage destruction > bone-bone articulation > increased bone destruction
Neutrophils :
In synovial fluid > secrete proteases and ROS > causes bone and cartilage erosion = inflammation

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19
Q

What roles do antibodies and angiogenesis have in RA pathogenesis?

A

Antibodies:
Germinal centres within the synovium include plasma cells > secrete antibodies against self-antigens - autoantibodies specific for CCPs/arginine residues that are converted to citrulline > drives production and maintenance of antibodies to citrullinated proteins
Antibodies to fibrinogen, type II collagen > forms antibody-antigen complexes > deposited into the joints
Antibodies (IgM, IgA) against Fc regions of IgG antibodies form the rheumatoid factor > deposited in the joints
Angiogenesis:
Synovial hypoxia drives angiogenesis via HIF
Cytokines - TNF-a - promotesvascular permeability and are angiogenic and adhesion molecules allowing for immune cells to migrate into joints and other joints

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20
Q

How do TNF-a blocker Adalimumab work?

A

High affinity, binds to TNF-a (pro-inflammatory cytokine) > neutralises biological function - interacting with p55 and p75 cell surface receptors = disrupts cytokine-driven inflammatory processes
Reduction in production of inflammatory proteins = reduced inflammation
TNF-a also leads to osteoclast maturation and and activation > reduced destruction of cartilage and bone

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21
Q

What is adalimumab used for and how is it administered?

A

Autoimmune conditions e.g RA, psoriatic arthritis
SQ injection into thigh and lower abdomen rotated every two weeks

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22
Q

What are the symptoms of RA? 12

A

Pain and stiffness in hands, wrists and feet
1 hour of morning stiffness
Soft tissue swelling of joints
Symmetrical joints
Rheumatoid nodules
Swan neck deformity
Ulnar deviation - fingers bend towards ulnar
Fatigue and sleep problems
Feeling of walking on marbles
Periarticular osteopenia
Synovitis
Tenosynovitis

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23
Q

What are rheumatoid nodules

A

Firm, non-tender lumps which appear under the skin
Not fully understood why
Linked to risk factors like smoking and presence of RF

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24
Q

What is swan neck deformity?

A

In advanced RA
Damage to ligaments and joints
DIP hyperflexion and PIP hyperextension
Boutonniere’s deformity is the opposite PIP hyperflexion and DIP hyperextension
No longer common, as patients treated early with DMARDs

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25
Q

What is ulnar deviation?

A

Due to inflamed MCP joints, causes fingers to be dislocated
As tendons pull on dislocated joints, fingers drift towards ulnal side

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26
Q

Why is fatigue and sleep problems common in RA?

A

Inflammation can lead to general weakness, drousiness and exhaustion
Pain can impact quality of sleep
Can take while to get comfortable to sleep
More likely to get fatigued
Medication and inactivity can lead to more tiredness

27
Q

Why is the feeling of walking on marbles a symptom of RA?

A

The fatty pad which protects the sole of the foot detriorates and gets pushed to the side
Causes pain and increased pressure, reduced shock absorption

28
Q

What is periarticular osteopenia?

A

This refers to loss of bone mineral bone density BMD that weakens bones
Indication of past inflammation around joint - one of earliest signs of RA

29
Q

What is synovitis?

A

Inflammation of the synovium of a joint
Immune system attacks the joint - type II collagen in articular cartilage > progresses to proliferating synovial tissue extends to articular cartilage and erodes from the joint surface down to subchondral bone

30
Q

What is tenosynovitis?

A

Inflammation of the fluid filled synovium within the tendon sheath
Typically in hands, feet and arm
Greatly reduces movement

31
Q

What are the symptoms of RA outside the joint?

A

Eyes: dry eyes, episcleritis, scleritis, scleromalacia
Skin: ulcers
NS: carpal tunnel syndrome, peripheral neuropathy, cervical myelopathy, vasculitis
Blood vessels: premature atherosclerosis, vasculitis
Lungs: pulmonary fibrosis, pulmonary nodules, pleurisy
Heart: pericarditis, pericardial effusion
Blood: anaemia, thrombocytosis

32
Q

Why does affect the eyes?

A

Inflammatory condition of collagen
Sclera and cornea primarily made from collagen
Episcleritis - red eye with pain
Scleritis - red eye without pain

33
Q

Why does RA affect the chest?

A

Inflammation of the pleural layers - thickening of pleural tissue, and fluid collects in pleural space
Can be diretly from RA, or treatments - immune system suppressed - chest infections

34
Q

Why may RA cause anaemia?

A

Uncontrolled inflammatory conditions
Chronic inflammation may impact ability to use stored iron to produce new RBCs
Can affect production of erythropoietin - decreased levels of RBCs

35
Q

What is the incidence and prevalence of RA?

A

Prevalence - 1% of the population, most common type of inflammatory arthritis
Incidence is low 3.6 women per 100.000
Peaks between 30-50 yrs
Peak age is 70 yrs
2-4x more common in women

36
Q

What are the risk factors for RA?

A

Genetics: family history
Gender: women more likely
Age: risk increases with age - most common between 30-60
Hormones: changes in hormone levels
Environmental factors: smoking, alcohol
Obesity
Occupational exposure: exposure to dust, asbestos

37
Q

What are the differential diagnoses for RA?

A

Osteoarthritis: typically asymmetrical, morning stiffness for 30 mins or less, improves with movement. Gradual onset Symptoms localised to joint. Commonly seen in weight bearing joints
Gout: accumulation of urate crystals in joints > inflammation. Sudden onset
Systemic lupus erythematosus SLE: systemic autoimmune disease, antinuclear antibodies

38
Q

How can you diagnose and monitor RA?

A

GALS examination
Joint inspection
Medical history
Blood tests - ESR, RF, anti-CPP
X-ray
Ultrasound

39
Q

What is the GALS examination?

A

Gait, arms, legs and spine
Tests for:
pain in TMK and MCP and MTP joints
diminished grip strength
impaired fist formation
inability to extend elbows fully
If abnormality detected, area should be further investigated

40
Q

What is involved in joint inspection?

A

Further inspection of look feel move
Swelling, tenderness and warmth
Positive MCP squeeze test
Symmetrically affected

41
Q

What medical history is taken to investigate RA as a diagnosis?

A

Family history of RA
Early morning stiffness more than an hour
Clinical judgement of persistent synovitis
Look for extra-articular features, involvement of other systems
Refer within 3 days if suspected

42
Q

What is ESR and how is it relevant to RA?

A

Rate at which RBCs in anticoagulated whole blood takes to descend in a standardised tube over an hour
If high, means they fall faster - will have more protein in them - sign of inflammation
Not specific to RA

43
Q

What is RF/RHF and how is it relevant to RA?

A

Rheumatoid factors are autoantibodies against the Fc portion of IgG (antibody)
RF can belong to any isotype of immunoglobulin
Any of these can be detected
ELISA can differentiate between different subtypes of RF
Presence of RF does not mean RA
Most common in RA is rheumatoid factor IgM

44
Q

What is a positive RF value?

A

Over 14 IU/ml
Higher the level the worse the joint destruction and greater chance of systemic involvement

45
Q

What is anti CPP and how is it relevant to RA?

A

Anti-citrullinated protein antibodies
These autoantibodies produced by B cell in the joint
If found, may show PADI enzyme is present - catalyse deamination of arginine amino acid to citrulline > citrullination of synovial proteins e.g. fibrin, keratin, type II collagen
More specific and sensitive than RF for RA, but not all RA patients have anti CPP

46
Q

What is a positive anti-CPP test?

A

Above 20 u/ml
Small minority of patients do not have autoantibody

47
Q

How will RA present on an X-ray?

A

JOINTS
- Joint erosion
- Bone space narrowing
- Osteopenia - increased radiolucency - darker
- Soft tissue swelling - earliest sign
- Eventual bone displacement
- Bilateral and symmetrical involvement
- Distal IP joints spared
LUNGS
- Pulmonary nodules

48
Q

How may RA present on an US?

A

Hyperplasia thickened synovium
Enlarged joint space
Doppler signal neurovascularisation in inflammation
Synovitis
Erosions
Tenosynovitis

49
Q

What CAMs may be used by patients for RA?

A

Keeping healthy weight - overweight puts pressure on joints
Diets - Mediterranean diets reduces symptoms related to chronic inflammation. Probiotics may lead to reduced inflammatory markers
Turmeric - immunomodulatory and anti-inflammatory ingredients that moderately effective in RA
Cod liver oil - source of omega 3 fatty acids which have anti-inflammatory effects
Reflexology - massage of hands and feet and ears in specific points to target different body regions

50
Q

Why is folic acid taken with methotrexate?

A

Methotrexate works by interfering with folate metabolism - side effects: mouth sores, nausea, fatigue
Folic acid helps offset side effects

51
Q

Why can’t trimethoprim and methotrexate be taken together?

A

Trimethoprim works by inhibiting bacterial dihydrofolate reductase, but also has an effect on the human dihydrofolate reductase
Trimethoprim breaks down methotrexate, causing it to build up in harmful levels - usually eliminated through kidneys, trimethoprim slows this down
Liver toxicity, bone marrow suppressions, other complications

52
Q

What type of drug is hydroxychloroquine?

A

Antimalarial
DMARD

53
Q

How does hydroxychloroquine work?

A

Affects function of lysosomes by increasing pH of lysosomes
Accumulation in organelles
Inhibits antigen processing, prevents alpha and beta chains of MHC class II dimerising
> Inhibits antigen presentation
> Reduces inflammatory response - high PH reduces MHC recycling - only high affinity complexes are presented
> Self peptides with low affinity won’t bind = reduced autoimmunity
Reduces cytokine release possibly by TLR inhibition
Increased pH makes ACE2 receptors which interact with spike proteins of SARS-CoV, less efficient

54
Q

What is hydroxychloroquine used to treat?

A

Uncomplicated malaria and chemoprophylaxis - preventing disease/infection
Lupus erythematosus
Acute an chronic RA

55
Q

What type of drug is sulfasalazine?

A

DMARD

56
Q

How does sulfasalazine work?

A

Metabolised by intestinal bacteria broken down into mesalazine and sulfapyridine
Targets COX and LOX enzymes, so inhibits leukotrienes and prostaglandins
Inhibits phospholipase A2 (LOX pathway) and COX 1 and 2 enzymes
COX2 inhibition reduces inflammation, apoptosis by reducing production of PGEs
Also inhibits folate metabolising enzymes - used for DNA synthesis

57
Q

What type of drug is methotrexate?

A

DMARD

58
Q

How does methotrexate work to treat RA?

A

Inhibits folate metabolism > prevents DNA synthesis > reduced ability to produce inflammatory cells, but not thought to be the main mechanism
Adenosine signalling: MTX inhibits AICAR which blocks adenosine deaminase > build up of adenosine
Adenosine medaites anti-inflammatory effects by stimulating A2a and A3 receptors
Promotes macrophages to transform to M2 phenotype - release less TNF-a and IL-2 (proinflammtory mediators) than M1, and increase IL-10, IL-13 and VEGF to promote fibrosis and angiogenesis for resolution of inflammation

59
Q

What happens in the early inflammatory arthritis clinic?

A

Designed to diagnose and treat arthritis in early stages
GP referral > 6 weeks
Diagnosis from blood tests and x-rays, prescribed DMARDs >
Referral to early inflammatory arthritis clinic, nurse led - ask about medications and symptoms > 2 months
MDT early arthritis clinic with review meetings

60
Q

What is versus arthritis?

A

Charity that supports patients
- Support services
- Research funding
- Advocacy and awareness
- Education
- Campaigns

61
Q

What are national audits?

A

National audits: collect and analyse data supplied by local clinicians to provide picture of care standards for the specific condition

62
Q

What are the stages of medication counselling?

A
  • Clarifying with the patient what the medication is for
  • State how and when to take them
  • State how long the medication takes to work
  • State the potential side effects of the medication
  • Provide lifestyle advice and suggest support groups
  • Offer written information to take home
63
Q

What is DAS28?

A

Disease activity score
Measure of disease in RA
28 refers to 28 joints that are examined in the assessment
Mathematical formula takes into account:
No of tender and swollen joints
Blood test to measure inflammation via ESR
Personal assessment of overall disease activity
Score greater than 5.1 suggests high disease activity
Score less than 2.6 suggests disease remission

64
Q

What joints are assessed in DAS28?

A

Hands, wrists, elbows, shoulders, knees

Unit 11 PBL cases (4 decks)

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