Rheumatology

Question 1

Common symptoms people present to rheumatology with

Answer 1

pain 
stiffness 
swelling 
functional impairment 
systemic symptoms

Question 2

Signs of RA

Answer 2

tenderness 
swelling 
restricted movements 
heat and redness 
systemic features

Question 3

List some rheumatic diseases

Answer 3

RA 
connective tissue diseases 
sero negative arthritis 
bone disease 
crystal arthritis 
systemic vasculitis

Question 4

Functions of synovium

Answer 4

maintain intact tissue surface
lubrication of cartilage
control of synovial fluid volume and composition - hyaluronic acid and lubricin
nutrition of chondrocytes within joints

Question 5

Describe the rheumatoid joint

Answer 5

inflamed synovium and tendon sheath

erosion into corner of the bone and thinning of cartilage

Question 6

Define RA

Answer 6

chronic, symmetric, autoimmune, inflammatory

small joints in hands and feet

Question 7

pannus

Answer 7

rheumatoid synovitis

inflammatory cell infiltration, synoviocyte proliferation and neoangiogenesis

Question 8

What is found in synovial fluid in acute RA flares?

Answer 8

neutrophils

Question 9

Autoantibodies

Answer 9

RF and ACPA

Question 10

What can the autoantibodies recognise?

Answer 10

joint eg type 2 collagen or systemic antigens

Question 11

How can autoantibodies contribute to inflammation?

Answer 11

activation of complement

Question 12

What does RF do?

Answer 12

autoantibody to self IgG Fc

Question 13

does sero negative or positive RA have a better prognosis?

Answer 13

negative

Question 14

Genes in RA

Answer 14

susceptibility and severity
monozygotic twins: 15-30%
HLA-DR4, PTPN22
promote autoimmunity and molecular mimicry

Question 15

Environmental factors

Answer 15

smoking and bronchial stress

infectious agents eg viruses and periodontal disease

Question 16

What happens after repeated insults in a susceptible person?

Answer 16

form immune complexes and RF

altered citrullination of proteins and breakdown of tolerance with resulting ACPA response

Question 17

citrullination

Answer 17

converting the amino acid arginine to citrulline

Question 18

Very briefly describe the synovitis with inflammatory cells

Answer 18

CD4+ T cells, macrophages and B cells
local hypoxia and cytokines –> neoangiogenesis
insufficient lymphangiogenesis for clearance

Question 19

What T cell cytokines do Th1 and 17 produce?

Answer 19

IFN- alpha and IL-17

Question 20

What are ectopic lymphoid follicles?

Answer 20

synovial B cells mainly in Tcell-B cell aggregates

Question 21

What produce chemokines?

Answer 21

macrophages and fibroblasts

Question 22

IL-6 systemic effects

Answer 22

acute phase response
anaemia
cognitive dysfunction
lipid metabolism dysregulation

Question 23

Purpose of neoangiogenesis in RA

Answer 23

provide nutrients to hyperplastic synovium

Question 24

Why does neoangiogenesis occur?

Answer 24

hypoxic conditions and angiogenic factors eg IL-8, VEGF

Question 25

What produces metalloproteinases and aggrecanases and what do these proteases do?

Answer 25

fibroblasts

can attach and invade cartilage

Question 26

What activates osteoclasts and where is it produced?

Answer 26

RANKL

synovium

Question 27

Systemic consequences of RA

Answer 27

vasculitis, nodules, scleritis, amyloidis
CVD
fatigue and reduced cognitive function
liver, lungs - fibrosis, ILD
sarcopenia, osteoporosis, sjogrens syndrome

Question 28

List some classification criteria for RA

Answer 28

morning stiffness for atleast 1 hour 
arthritis of more than 3 joints, hand joints 
symmetric 
nodules 
serum RF 
radiology changes

Question 29

Most commonly affected people with RA

Answer 29

women, 1%, can happen anytime after 16 but usually in 4th or 5th decade

Question 30

Immunology for RA

Answer 30

anti CCP, ACPA

RF - IgG, IgM

Question 31

investigations for RA

Answer 31

x-rays

doppler USS

Question 32

symptoms of RA

Answer 32

pain, stiffness, immobility, poor function, systemic symptoms

Question 33

signs of RA

Answer 33

swelling - tenderness - heat - red - limited movement

Question 34

non specific systemic features

Answer 34

fatigue, weight loss and anaemia

Question 35

Specific systemic symptoms

Answer 35

eyes, lungs, nerves, skin and kidneys

Question 36

long term features

Answer 36

CVS and malignancy

Question 37

What does the disease activity score help determine?

Answer 37

time for biologics or if in remission

Question 38

Therapies for RA

Answer 38

NSAIDS, DMARD, biologics, steroids

Question 39

DMARD in use

Answer 39

methotrexate and hydroxychloroquine

Question 40

positives of methotrexate

Answer 40

cheap - well tolerated - effective - combination treatment - well concordance

Question 41

treatment strategies

Answer 41

monotherapy (sequential)
combination: step up, step down, parallel
treat to target

Question 42

briefly describe pros and cons of biologics

Answer 42

target inflammatory cascade, work rapidly ad well tolerated

toxic, expensive, infections, malignancy

Question 43

name some biologics

Answer 43

TNF alpha inhibitors
Anti B and T cell therapies
IL6 inhibitors

Question 44

how can CCS be given?

Answer 44

im, ia, IV

Question 45

Are CCS appropriate for monotherapy?

Answer 45

no

Question 46

MDT for RA

Answer 46

orthotics 
podiatrist 
rheumatology specialist nurse 
rheumatology physio
rheumatology OT 
pharmacist 
clinical psychologist

Question 47

3 assessments when starting biologics

Answer 47

TB scar/chest X-ray
chronic blood borne viral screen
VZV serology