By Karen Law, Aliza Lipson
The box encompassed through rheumatology has advanced swiftly during the last decade to incorporate a number of immune-modulating and biologic drugs, new class standards, major updates on bone metabolism, and entirely new paradigms of therapy in accordance with groundbreaking reviews released in the final five years. even if a lot has been followed as average of care in line with new facts, such a lot textbooks don't replicate those perform changes.
Rheumatology Board Review highlights the most recent advances within the box and new criteria of care, together with references to present citations within the clinical literature. It presents overseas criteria and instructions and is designed to show a greatest volume of data fast and successfully, with many beneficial schematics, radiographs, and tables.
Rheumatology Board Review bargains bankruptcy assurance of:
• Non-inflammatory joint and gentle tissue disorders
• chosen themes in rheumatoid arthritis
• chosen issues in systemic lupus erythematosus
• Antiphospholipid antibody syndrome
• IgG4-related disease
• Myopathies
• chosen themes in pediatric rheumatology
• HIV and rheumatic diseases
• Miscellaneous arthropathies
• Osteoporosis
• assessment of musculoskeletal radiology
• learn layout, size, and easy statistical analysis
• replace on vasculitis
Rheumatology Board Review is a must have reference for rheumatology fellows and execs looking a concise but thorough evaluation of state of the art rheumatology.
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Extra resources for Rheumatology Board Review
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Comparison of the 1987 American College of Rheumatology Criteria and the 2010 American College of rheumatology/European League Against Rheumatism Criteria. Arthritis and Rheumatism 63: 37–42. CHAPTER 3 Selected topics in systemic lupus erythematosus: B cells in lupus and lupus nephritis Iñaki Sanz, S. Sam Lim Emory University School of Medicine, Atlanta, GA, USA Introduction B cells contribute to the pathogenesis of systemic lupus erythematosus (SLE) through multiple actions, including primary autoantibody production as well as antigen presentation, T cell induction, and the secretion of proinflammatory cytokines.
In fact, Myasoedova et al. demonstrated that total cholesterol and LDH levels significantly decreased in the 5 years prior to the diagnosis of RA ○ Diabetes mellitus (DM) and metabolic syndrome ■ In a 2011 meta-analysis, Boyer et al. found that there was an increased prevalence of DM in patients with RA when compared to controls ■ Multiple studies have shown an increased prevalence of the metabolic syndrome in patients with RA Treatment advances in rheumatoid arthritis New medications for the treatment of RA have undergone rapid expansion in the last decade, primarily in the group of drugs known as biologics, or biologic response modifiers.
18 Rheumatology Board Review • Rheumatoid arthritis ○ Typically involves MCPs and PIPs, sparing DIPs ○ Joint erosions are also typically more marginal Treatment • To date, there is no definitive therapeutic approach to IE-HOA • Treatments recommended for non-erosive hand osteoarthritis are frequently ineffective ○ Acetaminophen frequently inadequate, NSAIDs with limited efficacy • Intra-articular steroid injections can provide symptomatic relief • Hydroxychloroquine ○ Small pilot studies suggest symptomatic improvement • Anakinra ○ Small case series with three patients suggests improvement Diffuse idiopathic skeletal hyperostosis (DISH) Introduction • A non-inflammatory disorder, also known as Forestier’s disease or ankylosing hyperostosis • Characterized by calcification and ossification of soft tissues, mainly ligaments and where tendons and ligaments attach to bones (entheses) ○ Hallmark of the disease – calcification of the anterolateral aspect of the thoracic spine • More common in people over 50 years old and men • Etiology unknown Metabolic conditions associated with DISH: Hyperinsulinemia with or without diabetes Obesity, especially with large waist circumference Hyperuricemia Dyslipidemia Hypertension Coronary artery disease Clinical findings • Asymptomatic condition in many individuals • Most common symptoms are stiffness and decreased range of spinal motion • Mild back pain (commonly in thoracic region) Non-inflammatory joint and soft tissue disorders 19 • Painful enthesopathy • Increased susceptibility to unstable spinal fractures after trivial trauma • Cervical spine ○ Dysphagia ○ Odynophagia and otalgia ○ Hoarseness ○ Atlantoaxial complications ○ Stridor – rare, results from large anterior osteophytes at C2–C3 ○ Myelopathy – due to spinal cord compression from the posterior longitudinal ligament • Lumbar spine ○ Radiculopathy ○ Spinal stenosis Radiologic findings (see also Chapter 11, Review of musculoskeletal radiology) • Preference for axial skeleton ○ Classically involves the thoracic spine (especially the middle and lower part), but can be seen in cervical and lumbosacral spine ○ “Flowing” ossification along the anterolateral margins of vertebral bodies over four contiguous levels ■ Radiolucent line usually separates the ossified anterior longitudinal ligament from the anterior aspect of the adjacent vertebral bodies ■ Findings more prominent on right side of thoracic spine → Pulsation of the aorta may influence location of ossification ○ Cervical spine ■ Hyperostosis initially occurs along the anterior surface of the vertebral body ■ More common in the lower cervical spine ■ Ossification of the posterior longitudinal ligament less common, but occurs almost exclusively in the cervical spine • Extraspinal involvement is less common, but can occur ○ Radiographic changes are often symmetric ○ Pelvis radiographs ■ Hypertrophic whiskering (bone proliferation) can involve the iliac crest, ischial tuberosity, trochanter ■ Ligament ossification ■ Periarticular osteophytes ○ Peripheral joints ■ New bone formation is prominent in the entheseal areas, particularly around the heels, knees, and elbows 20 Rheumatology Board Review ■ Hand – phalangeal tufting, increased cortical thickness of tubular bones of the hand, increase in the size of sesamoid bones Diagnosis • Resnick and Niwayama diagnostic criteria ○ Presence of flowing calcification and ossification along the anterolateral aspects of at least four contiguous vertebral bodies ○ Preservation of the intervertebral disc spaces ○ Absence of apophyseal joint space narrowing or sacroiliac inflammatory changes Differential diagnosis • Ankylosing spondylitis (AS) ○ Shared features between DISH and AS ■ Involvement of the axial skeleton and peripheral entheses ■ Bone proliferations in the latter phases of their courses ■ Both can have severe limitation of spinal mobility and postural abnormalities ○ Sacroiliac joint involvement in DISH is typically the upper, ligamentous portion ■ In AS the lower, synovial portion of the sacroiliac joint is involved ○ Peripheral enthesopathy in DISH is not as painful as in AS ○ AS begins at a younger age; it is rare for DISH to occur in patients <40 years old ○ AS is associated with inflammatory back pain symptoms ○ No SI joint erosions or bony ankylosis are noted in DISH ○ DISH has not been associated with HLA-B27 • Osteoarthritis ○ Both seen in similar age groups – both conditions may coexist ○ Distinctive features that differentiate DISH ■ Involvement of joints usually unaffected by primary OA (elbows, wrists, ankles, shoulders) ■ Increased hypertrophic changes compared with primary OA ■ Prominent enthesopathies at sites adjacent to peripheral joints ■ Calcification and ossification of entheses in sites other than joints Treatment • Aimed at symptomatic relief of pain and stiffness • Similar to OA ○ Acetaminophen ○ NSAIDs Non-inflammatory joint and soft tissue disorders 21 ○ Local applications ○ Physiotherapy ○ Weight loss • Control of associated constitutional and metabolic disorders • Surgery is rarely needed but can be helpful in the following settings: ○ When dysphagia results from large anterior cervical osteophytes ○ When progressive myelopathy results from the ossification of posterior longitudinal ligament ○ In the setting of nerve root compression and thoracic outlet syndrome Gout Gout is a relatively common crystalline arthropathy that causes episodic flares of arthritis that over time may become debilitating.