Rheumatology & Orthopedics

Speeding is a major risk factor for road traffic injuries,

contributing to both crash risk and crash consequences.

As average traffic speed increases,
so too does the likelihood of a crash.

For instance,

an increase of 1 km/h in mean vehicle speed

results in an increase of 3% in the incidence of crashes resulting in injury

and an increase of 4–5% in the incidence of fatal crashes.

The higher the speed
the greater the stopping distance required,

and hence the increased risk of a road traffic crash.

MTX-Methotrexate is strongly recommended
over hydroxychloroquine
or sulfasalazine for

DMARD-naive patients
with moderate to high disease activity.

Oral methotrexate is conditionally recommended
over subcutaneous methotrexate for patients initiating MTX.

Methotrexate is conditionally recommended over
alternative DMARDs

for DMARD-naive patients
with
nonalcoholic fatty liver disease, normal liver enzyme levels
and findings on liver function tests,
and no evidence
of advanced liver fibrosis
who have moderate to high disease activity.

Initiation of a conventional synthetic DMARD
without longer-term (≥ 3 months) glucocorticoids

is strongly recommended over

initiation of a conventional synthetic DMARD
with longer-term glucocorticoids for
DMARD-naive patients
with moderate to high disease activity.

When should you not worry about Uric acid tests and its levels ?

https://youtu.be/P2yPOG80BCk

False positive Uric Acid blood test/ Dr Naeem Ashraf People worry a lot when they get high uric acid levels.This video guides you what to do if your uric acid is moderately high.Pass it on to your friends if yo...

A 25-year-old female
gives birth to a baby with complete heart block who subsequently requires pacemaker insertion.

Which of the following antibodies is most likely to be detected in the maternal serum?

a. Anti-double-stranded deoxyribonucleic acid
(dsDNA) antibodies

b. Anti-endomysial antibodies

c. Anti-Ro/SSA antibodies

d. Anti-SCL70 antibodies

e. Rheumatoid factor

Plantar fasciitis:

Is a disorder of the connective tissue which supports the arch of the foot.

It is usually unilateral.

Tenderness on palpation of the plantar aspect of the foot is a common finding.

Osteosarcoma usually develops at the edges of the long bone (i.e. femur) and is often unilateral at the onset.

Children with osteosarcoma often complain of bone pain that interferes with normal activities.

The lack of systemic symptoms such as fever, weight loss and fatigue makes this diagnosis unlikely.

Achilles tendinitis commonly follows an injury.

Patients with this condition often have pain and swelling over the Achilles or the ankle joints.

The lack of trauma in the history and examination findings make this diagnosis unlikely.

Osteomyelitis is an infection of the bone. The fact that the child is systemically well and has bilateral symptoms make this diagnosis very unlikely.

Calcaneal apophysitis (Sever disease)

Calcaneal apophysitis (Sever disease) is an overuse injury causing ankle pain in sporty children.

Sever's disease is an important differential diagnosis for heel pain in children and adolescents.

It is a swelling and irritation of the growth plate in the heel.

It usually occurs in kids who are in their growth spurt and are active in sports or activities that involve a lot of running or jumping.

Tenderness on squeezing the heels and the presence of swelling support this diagnosis.

A mother brings her 11-year-old son to the GP surgery with heel pain.

It started three-weeks ago on both heels.

The pain is localised to the heel and is worse following exercise and gets better on resting.

There is no reported swelling, stiffness or redness.

There are no other joint complaints.

He is well in himself with no temperature symptoms, night sweats or weight loss.

There is no history of trauma.

He is an active child and plays for the basketball team at school.

On examination,
his gait and range of movements of his ankle joints are normal.

His temperature is 37.1ºC.

Apart from mild swelling over both heels,
there is no redness on the heel or other swellings of the foot joints.

There is no tenderness on palpation of the Achilles tendon and the plantar aspect of the foot.

Pain is elicited on squeezing the sides of both heels.

What is the most likely diagnosis for this child?

A. Calcaneal apophysitis

B. Plantar fasciitis

C. Osteosarcoma

D. Achilles tendinitis

E. Osteomyelitis

A 67 years old lady was found to have serum Calcium of 3.7 mmol/l.

What is the most suitable treatment option for her from the following?

A. Pamidronate
B. Calcitonin
C. Decrease calcium in diet
D. No intervention needed

A 67 year old man
with a 20 year history of osteoarthritis
complains of sudden onset of sharp pain,
swelling and redness in his left calf muscles.

He says he used to have a long standing swelling at the back of his knee which is now no longer present.

His reflexes are normal and peripheral pulses are palpable.

What is the single most likely condition affecting him?

A. Deep vein thrombosis
B. Burger’s disease
C. Ruptured Baker’s cyst
D. Ruptured muscle tendon

A 40-year-old man fell onto outstretched hand.

X-ray confirms Scaphoid fracture.

What’s the most appropriate management?

A. Follow up in clinic in 6 weeks
B. Analgesia and follow in clinic
C. Broad arm sling
D. Above elbow cast
E. Cast for 6 weeks and review

A housewife develops pain on the anterior inferior part of the knee.

What’s the most likely bursa is involved?

Prepatella
Suprapatella
Inferior patella
Lateral patella
Medial patella

An 18-year-old lady with several tiny nodules for 2 days ,
she has cervical lymphadenopathy and rash on the shin.

She has 2 small children.

What is the most likely diagnosis?

A. Sarcoidosis
B. Reactive arthritis
C. Rheumatoid arthritis
D. SLE
E. Reiter’s syndrome

6/boy

brought to the A&E with pain in his left arm
following a fall from a tree on his outstretched hand.

There is a swelling around his left elbow
and a reduced radial pulse.

What is the most likely diagnosis?

a. Angulated fracture
b. Compound fracture
c. Epiphyseal fracture
d. No fracture
e. Spiral fracture
f. Supracondylar fracture

According to ACP guidelines,
high-quality evidence showed no difference between low-dose febuxostat and allopurinol for gout flares.

However, febuxostat is associated with higher costs than allopurinol.

The most common adverse effect associated with allopurinol is rash.

The most common adverse effects associated with febuxostat are abdominal pain, diarrhea, and musculoskeletal pain.

Also according to ACP guidance,
low-dose colchicine is recommended when using the medication to treat acute gout.

Evidence suggests that lower doses
(1.2 mg followed by 0.6 mg 1 hour later)
are as effective as higher doses
(1.2 mg followed by 0.6 mg/h for 6 hours)
for pain management, and are associated with fewer adverse gastrointestinal effects.

The ACP recommends against the use of long-term urate-lowering therapy in most patients
after an initial gout attack
and in patients with infrequent attacks.

Although urate-lowering therapy has shown efficacy in shorter durations,
the benefits of long-term use after a single or infrequent gout attacks remain unclear.

The ACP found insufficient evidence to recommend various dietary changes or supplements.

Diet modifications alone are rarely able to lower uric acid levels sufficiently to prevent accumulation of urate, although they may help lessen the triggers of acute gout attacks.

Which of the following statements is most accurate regarding the treatment of gout,according to guidelines?

1.High-dose colchicine is more effective in treating acute gout than low-dose colchicine

2.Long-term urate-lowering therapy should be initiated in all patients after an initial gout attack

3.Low-dose febuxostat and allopurinol are equally effective in reducing the incidence of gout flares, although allopurinol is associated with lower costs

4.In most patients, a purine-restricted diet is able to prevent future gout attacks

Pseudogout attacks can be triggered by many metabolic abnormalities.

Thus, patients who have an initial attack of arthritis with calcium pyrophosphate crystals
should have a workup that includes

a chemistry screen;
serum magnesium,
calcium,
and iron levels;
and thyroid function tests.

Gout is most often diagnosed clinically on the basis of the presence of monoarticular arthritis
that is marked by swelling and redness
and usually involves the first metatarsophalangeal joint.

The American College of Rheumatology criteria are the most widely used for diagnosis.

The most definitive studies for establishing the diagnosis of gout,
synovial fluid aspiration and polarizing microscopy,
are not commonly performed in these patients,
as most cases are managed in primary or acute care settings.

Moreover, in many cases, clinical criteria are sufficient to establish the diagnosis.

Ultrasonography, MRI, and CT scanning are not typically necessary for diagnosis.

Imaging may be useful to exclude fractures in patients with gout-like symptoms after a joint injury to identify chondrocalcinosis or for quantifying the extent of urate deposition.

Gouty attacks are not related to serum levels of uric acid. Thus, an elevated serum uric acid level does not prove the diagnosis of acute gout. Hyperuricemia is present in the vast majority of cases of gout; however, a normal level does not exclude the diagnosis.

Which of the following statements is most accurate regarding the diagnosis and workup of patients with gout and pseudogout?

1.Synovial fluid aspiration and polarizing microscopy are required for an initial diagnosis of gout

2.Patients with suspected pseudogout attacks should have a workup that includes a chemistry screen; serum magnesium, calcium, and iron levels; and thyroid function tests

3.Definitive diagnosis of gout requires use of imaging studies, such as ultrasonography, MRI, or CT scanning

4.Elevated serum uric acid levels definitively confirm the diagnosis of acute gout

Podagra is synonymous with gout/pseudo gout.

a.True
b. false

Untreated, the first attacks of gout resolve spontaneously within weeks.

A history of intermittent inflammatory arthritis,
in which the joints return to normal between attacks,
is typical of crystalline disorders
and is characteristic of gouty arthritis early in its course.

The pattern of symptoms in untreated gout changes over time.

The attacks can become more polyarticular,
more proximal
and upper-extremity joints become involved,
and attacks tend to occur more frequently and last longer.

The spontaneous onset of excruciating pain,
edema,
and inflammation in the metatarsal-phalangeal joint of the great toe is highly suggestive of acute gouty arthritis.

Podagra is the initial joint manifestation in around half of all gout cases and is eventually involved in the vast majority of cases.

However, podagra is not synonymous with gout or pseudogout.

It may also be observed in patients with many other types of arthritis,
including sarcoidosis,
gonococcal arthritis,
psoriatic arthritis,
and reactive arthritis.

Fever, chills, and malaise do not distinguish cellulitis or septic arthritis from crystal-induced arthritis

because these illnesses can all produce these signs and symptoms.

A careful history may uncover risk factors for cellulitis or septic arthritis,
such as possible exposure to gonorrhea,
a recent puncture wound over the joint,
or systemic signs of disseminated infection.

Gout initially presents as polyarticular arthritis in a minority of patients.

Although crystal-induced arthritis is most commonly monoarticular,
polyarticular acute flares are not rare,
and many different joints may be involved simultaneously or in rapid succession.

Multiple joints in the same limb often are involved,
as when inflammation begins in the great toe and then progresses to involve the midfoot and ankle.

Elderly women, particularly women with renal insufficiency who are taking a thiazide diuretic, can develop polyarticular arthritis as the first manifestation of gout.

Which of the following statements is most accurate regarding the presentation
and physical examination of patients with gout or pseudogout?

1.A history of joints returning to normal between attacks is characteristic of gouty arthritis early in its course

2.The presence of podagra indicates either gout or pseudogout and excludes other conditions

3.Fever, chills, and malaise distinguish cellulitis or septic arthritis from crystal-induced arthritis, such as gout and pseudogout

4.Gout and pseudogout both more commonly present as polyarticular arthritis, as opposed to monoarticular arthritis

Gout has an increased prevalence in some populations but is rare in others.

However, racial differences may at least in part reflect differences in diet.

Black Americans have an increased risk for incident gout compared with white Americans;

these differences are demonstrable beyond known racial differences in serum urate level.

In the United States, attacks of gout have been noted to occur more frequently in the spring
and less frequently in the winter.

Acute pseudogout attacks have not shown the same seasonal variation.

Gout also has a male predominance.

This difference is largely a consequence of age at onset;

estrogenic hormones have a mild uricosuric effect,
and gout is unusual in premenopausal women.

For pseudogout, the male-to-female ratio is more even.

Earlier onset of gout occurs in patients with renal insufficiency or a genetic abnormality of purine metabolism

(eg, hypoxanthine-guanine phosphoribosyltransferase deficiency
or phosphoribosylpyrophosphate synthetase superactivity).

Cyclosporine A can cause an accelerated form of gout, even in premenopausal women.

Gout can present after only a few years of hyperuricemia, particularly if the patient is also receiving diuretics.

Individual gout flares
are often triggered by

acute increases or decreases in urate levels

that may lead to the production, exposure,
or shedding of crystals.

Many factors can result in urate level changes,

including acute alcohol ingestion,

acute overindulgence in foods high in purines,

rapid weight loss,

dehydration,

or trauma.

Similarly,
flares can be precipitated by additions of or changes in dosage of medications
that raise or lower uric acid levels.

Medications that increase uric acid levels via effects on renal tubular transport include:

Loop and thiazide diuretics (eg, hydrochlorothiazide)

Niacin

Low-dose aspirin

Cyclosporine

Pembrolizumab

Agents that lower levels of uric acid include:

Radiocontrast dyes

Xanthine oxidase inhibitors (eg, allopurinol, febuxostat)

Uricosurics (eg, probenecid)

Which of the following medications is most commonly recognized as a trigger for gout flares?

1.Metformin

2.Ibuprofen

3.Prednisone

4.Hydrochlorothiazide

Gout is one of the oldest diseases in the medical literature, known since the time of the ancient Greeks.

Pseudogout may be clinically indistinguishable from gout.

If untreated, these disorders can lead to joint destruction and renal damage.

Worldwide, incidence has been steadily increasing.

Gout is now the most common type of inflammatory arthropathy seen in adults.

Identification and treatment of gout and pseudogout are important to relieve pain,
to prevent disease progression,
and to prevent deposition of urate crystals in the renal medulla or uric acid crystals in the renal collecting system,

which may produce kidney stones or urate nephropathy.

Guidelines recommend methotrexate (MTX) as first-line therapy for the majority of patients with rheumatoid arthritis, based on long-term data on its safety and efficacy, as well as low cost.

MTX is a folic acid antagonist
disease-modifying antirheumatic drug (DMARD)
that was originally used in the early 1950s as a treatment for childhood leukemia and psoriasis.

MTX is approved for use as a monotherapy or in combination with other drugs.

Abatacept,
etanercept,
and sarilumab are not recommended as first-line treatments for rheumatoid arthritis
but are approved treatments for patients with rheumatoid arthritis.

Abatacept is a non-tumor necrosis factor (non-TNF) inhibitor approved by the FDA and EMA for use as monotherapy

or in combination with a non-TNF antagonist DMARD for adult patients with moderate to severe rheumatoid arthritis

who demonstrated inadequate response to one or more DMARDs.

Etanercept is a non-TNF inhibitor approved by the FDA and EMA for the treatment of adult patients with moderate to severe rheumatoid arthritis who have demonstrated inadequate response or intolerance to MTX
or other DMARDs. Etanercept may be given as monotherapy or in combination with MTX.

Sarilumab is a monoclonal antibody
(interleukin-6 receptor antagonist) approved by the FDA and EMA for the treatment of adult patients
with moderate to severe rheumatoid arthritis who have demonstrated inadequate response or intolerance to MTX or other DMARDs.