Rheumatoid arthritis

Question 1

what cell types are found within the synovium?

Answer 1

macrophages and fibroblasts

Question 2

what type of tissue is the synovial membrane?

Answer 2

loose connective tissue

Question 3

what is RA synovitis characterised by?

Answer 3

inflammatory cell infiltration
neoangiogenesis
synoviocyte proliferation

Question 4

particularly during acute flares of RA, what cell type is present within the synovoial fluid?

Answer 4

neutrophils

Question 5

what antibodies are commonly associated with RA?

Answer 5

rheumatic factors

anti-citrullinated protein

Question 6

what is the difference between sero positive and seronegative RA?

Answer 6

seropositive RA will show positive RF and anti-cirrulated protein antibody (ACPA)
they are more likely to have a more severe form of RA and show a poorer prognosis

Question 7

how is seropositive RA diagnosed?

Answer 7

anti - CCP assay

Question 8

if one twin has RA, what is the likelihood the other twin will have it? (monozygotic twins)

Answer 8

15-30%

5% if dizygotic twins

Question 9

what environmental factors make you more susceptible to RA?

Answer 9

smoking and bronchial stress
infections;
- EBV, CMV
- E.coli
- mycoplasm
- periodontal disease
- microbiome (gut microbes)

Question 10

what is rheumatoid factor and what does rheumatoid factor target?

Answer 10

auto-antibody that has a high affinity against the Fc portion of Ig (IgG and IgM)

= autoimmunity

Question 11

describe the development of RA.

Answer 11

environmental factors + susceptibility genes + epigenetic modification
= self protein cirullation
= dendritic cells, T and B cells, autoantibodies ACPA production
= inflammation
= transition to arthritis

Question 12

what primarily mediates bone destruction in RA?

Answer 12

osteoclasts and fibroblast like synoviocytes

Question 13

what are the systemic consequences of RA?

Answer 13

vasculitis, nodules, scleritis, amyloidosis
CV disease
anaemia 
interstitial lung disease, fibrosis
sarcopoenia
osteoporosis
secondary sjogren's syndrome

Question 14

what are the orthopaedic complications of RA?

Answer 14

chronic synovitis
mechanical deformities
secondary osteoarthritis 
poor function
pain

Question 15

what clinical signs can you find in the hands of someone with rheumatoid arthritis?

Answer 15

Z shaped deformity of the thumb
ulnar deviation of the phalanges at the knuckles (MCP)
swan appearance - hyperextension of PIP with flexed DIP
boutonnières - hyperextension of DIP with flexed PIP

Question 16

what are the x-ray changes of rheumatoid arthritis?

Answer 16

Joint destruction and deformity
Soft tissue swelling
Periarticular osteopenia
Boney erosions

Question 17

what factors indicate a more severe form of rheumatoid arthritis?

Answer 17

male 
younger onset
more joints and organs affected
presence of RH and/or anti-CCP
erosions seen on x-ray

Question 18

how is rheumatoid arthritis diagnosed?

Answer 18

examination of joints affected (smaller and more joints have higher score)
serology (anti-CCP and RF)
inflammatory markers (CRP/ESR)
duration of symptoms (more or less than 6 weeks)

Question 19

what is the management algorithm of rheumatoid arthritis?

Answer 19

intra-articular steroid injections for flare ups
- NSAIDs and COX3 inhibitors can also be used

1st line: DMOARDS
- methotrexate, sulfazalazine, leflunomide or hydrocholoquine

2nd line:
- combine 2 of those

3rd line:
- methotrexate + biologics

4th line:
- methotrexate + rituximab

Question 20

how do you manage acute flare ups of rheumatoid arthritis?

Answer 20

intra articular steroid injections

or NSAIDS and COX3 inhibitors

Question 21

what is used to assess rheumatoid arthritis severity?

Answer 21

DAS82

disease activity score 28 (how many joints out of 28 are affected)

Question 22

what genes are involved in the development of rheumatoid arthritis?

Answer 22

HLA II and PTPN22

Question 23

what treatment can be given to a pregnant women for her rheumatoid arthritis?

Answer 23

anti-TNF alpha therapist i.e. Sulfasalazine