This document discusses rheumatoid arthritis (RA), including its etiology, classification criteria, clinical features, diagnostic testing, complications, and treatment approaches. RA is a chronic inflammatory disorder that primarily involves synovial joints, with symmetric involvement of hands/feet typically seen. Diagnosis relies on clinical exam showing inflamed joints and laboratory tests like rheumatoid factor and anti-CCP antibodies. If left untreated, RA can cause long-term joint damage and functional disability. Treatment involves medications like NSAIDs, DMARDs, steroids, and biologics to reduce inflammation and prevent structural damage.
Living with rheumatoid arthritis is challenging. Besides the benefit of getting shortly on medication after diagnosis, lifestyle modifications play an important role in rheumatoid arthritis management. Diet, exercise, sleep, medication can be very helpful.
Living with rheumatoid arthritis is challenging. Besides the benefit of getting shortly on medication after diagnosis, lifestyle modifications play an important role in rheumatoid arthritis management. Diet, exercise, sleep, medication can be very helpful.
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Ponencia presentada por el Dr. Domingo Pascual Figal en el directo ‘Estudio AFFIRM-AHF: manejo del déficit de hierro en insuficiencia cardiaca aguda’, realizado el 23 de marzo de 2021
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Ponencia presentada por el Dr. Domingo Pascual Figal en el directo ‘Estudio AFFIRM-AHF: manejo del déficit de hierro en insuficiencia cardiaca aguda’, realizado el 23 de marzo de 2021
SOAP NOTE
Name: C.M.
Date: 04/08/2016
Time: 10:55
Pt. Encounter #
Age: 52
Sex: Female
SUBJECTIVE
CC:
“My hands are swollen and painful”
HPI:
This is a 51-year-old female who comes to the office with complains of fatigue, general malaise, and pain and swelling in her hands that has gradually worsened over the last few weeks. She reports that pain, stiffness, and swelling of her hands are most severe in the morning. Also, she report weight loss, anorexia, aching, and stiffness. Morning stiffness lasts for as long as 1 to 2 hours.
Medications:
1. Diovan 80mg po daily
2. Singular 10mg po at bed time
3. Tylenol 500mg 1 tab po every 6 hours x pain
4. Albuterol 2 puff every 6 hours as needed
PMH
Allergies: NKA
Medication Intolerances: None
Chronic Illnesses/Major traumas: Hypertension, Asthma.
Hospitalizations/Surgeries: Hysterectomy 5 years ago.
Family History
Mother diagnosed with: Asthma, Hypothyroidism, Rheumatoid Arthritis
Father diagnosed with: HTN, Dementia
Sister diagnosed with: HTN
Social History
Patient has a high school education. She works as a mail carrier for the post office for 15 years. She has been widowed for the last two years. Currently, she lives alone in a rented apartment. She has two living children, who all live close by and have families of their own. She reports her family is supportive and denies any needs at this time. She has adequate shelter and food. She denies any leisure activities. She refuses to practice exercises. She just goes to the local church on Sunday. She eats a diet low sodium. She denies substance use, ETOH, tobacco, marijuana or illicit drugs.
ROS
General
Weight loss and fatigue
Decreased energy level
Cardiovascular
Denies chest pain, palpitations, PND, orthopnea, edema
Skin
Denies delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles
Respiratory
Denies cough, wheezing, dyspnea at this time
Eyes
Corrective lenses
Gastrointestinal
Denies abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools
Ears
Denies ear pain, hearing loss, ringing in ears, discharge
Genitourinary/Gynecological
Denies urgency, frequency burning, change in color of urine, vaginal discharge or STDS. Hysterectomy 5 years ago. Last mammography 1 years ago.
G2, P2, A0
Nose/Mouth/Throat
Denies sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, and throat pain
Musculoskeletal
Localized symptoms in hand joints: pain, tender, swollen, and decrease range of motion.
Breast
SBE every month, denies lumps, bumps or changes
Neurological
Denies syncope, seizures, transient paralysis, weakness, paresthesias, black out spells
Heme/Lymph/Endo
Denies HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance
Psychiatric
Denies depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx
OBJECTIVE
.
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According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
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Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
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4. • Inflammatory synovitis
• Palpable synovial swelling or tenderness
• Morning stiffness >1 hour
• Symmetrical and polyarticular
• Typically involves wrists, MCP, and PIP joints
• Typically spares certain joints
▪ Thoracolumbar spine
▪ DIPs of the fingers and IPs of the toes
5. 2010 ACR-EULAR
Classification
Criteria for RA
A score of ≥6/10 is
needed for
classification of a
patient as having
definite RA
6. Prominent ulnar
deviation in the right
hand
MCP and PIP
swelling in both
hands
Synovitis of left wrist
7. Soft synovial swelling
Synovitis and volar
subluxation at the
MCP joints
Synovitis of the wrists
Early swan neck
deformities
9. • RF (IgM against the Fc portion of IgG)
• Specificity approx. 80%
• 45% positive in first 6 months
• 85% positive with established disease
• Not specific for RA
• Hep C (mixed cryoglobulinemia)
• Sjögren syndrome
• SLE
• May be present in up to 10% of healthy persons
• Anti-CCP antibodies
• more specific – 95%
10. Xrays
Periarticular
osteopenia
Erosions
Symmetric
joint-space
narrowing
MRI & US are more
sensitive to dx
synovitis &
erosions.
11. • Long-standing rheumatoid arthritis
• May have NO symptoms
• Manipulation under anesthesia can cause
spinal cord injury
• Flexion and extension X-rays of the C spine
Klippel. Primer on Rheum Dis. 13th edition. 2008:114
12. • Damage occurs early in most patients
• 50% show joint space narrowing or erosions in the
first 2 years
• By 10 years, 50% of young working patients are
disabled
13. • Assess current activity
• Morning stiffness, synovitis, ESR/CRP
• Degree of damage
• X-rays: Joint space narrowing and erosions
• Functional status
• Assess prior Rx responses and side effects
14. • Education
• Educating the patient about their disease
• Exercise/Physical Therapy
• Vaccination
• Influenza and pneumococcal vaccines are advised.
• Live vaccines
• should be avoided in patients on biologic therapies
• considered safe with nonbiologic DMARDs and low-dose
prednisone
2012 Update of the 2008 American College of Rheumatology recommendations for the use of disease-modifying antirheumatic
drugs and biologic agents in the treatment of rheumatoid arthritis. Arthritis Care Res, 64: 625–639.
15. • NSAIDs
• Not DMARDs
• Low-dose prednisone (10 mg qd)
• May substitute for NSAID
• Used as bridge therapy
• Intra-articular steroids
• Useful for flares
16. • Disease modifying drugs (DMARDs)
• Sulfasalazine, hydroxychloroquine
▪ May use in patients with low dz activity
• Methotrexate/Leflunamide
▪ MTX is the gold standard therapy
• Triple Therapy
• HCQ, SSZ & MTX
• Cyclophosphamide
▪ Effective for vasculitis, less so for arthritis
Klippel. Primer on Rheum Dis. 13th edition. 2008:133.
17. • Anti-TNF drugs (First line biologics)
• Infliximab
• Etanercept
• Adalimumab
• Golimumab
• Certolizumab pegol
• Side Effects of anti-TNF agents.
• Infections (Hep B/TB reactivation)
• CHF exacerbation
• Demyelinating dz
• Drug induced lupus
18. • Tocilizumab – IL6 inhibitor
• Increase lipids, GI perforation, HZ reactivation,
improve anemia.
• Abatacept – inhibits T cell co-stimulation
• COPD exacerbation
• Tofacitinib – interferes with JAK-STAT
pathway
• Increase lipids, HZ reactivation
• Rituximab – anti CD 20
• Risk for developing PML
19. Most women demonstrate clinical improvement
during pregnancy
Flares are common during the postpartum period
MTX must be discontinued 3 mths prior to
conception.
Leflunomide must be discontinued 2 yrs prior to
conception
cholestyramine may be used to hasten the elimination.
SSZ can cause reversible oligospermia; men should
discontinue it for 3 months prior to conception
HCQ & SSZ are often used during pregnancy.
20.
21. A 32 YO woman seeks preconception counseling. She
was diagnosed with RA 1 year ago. She has no other
pertinent personal or family medical history. Disease
activity is controlled with methotrexate. She also
takes FA.
On PE, vital signs are normal. On MSK examination,
there is no synovitis or bony abnormalities. The
remainder of the examination is normal.
Laboratory studies, including ESR and CRP level, are
normal; RF and anti-CCP antibodies are positive.
Urine pregnancy test results are negative.
Radiographs of the hands, feet, & C spine are normal.
22. Which of the following is the most appropriate
management?
A. Discontinue methotrexate before conception
B. Discontinue methotrexate when conception is
confirmed
C. Maintain methotrexate through pregnancy at
current dose
D. Maintain methotrexate through pregnancy
with dose adjustment
Women with RA who are taking MTX must
discontinue it 3 months before conception.
23. A 52 YO man is evaluated for an 8-week history of
pain and 2 hours of morning stiffness of the hands
that improves with activity. The patient has no
pertinent personal or FH. He takes no medications.
On PE, vital signs are normal. Synovitis is noted at the
MCP joints of the second through fifth digits
bilaterally with swelling, tenderness, and pain on
range of motion. The remainder of the examination is
normal.
Laboratory studies, including CBC, chemistries, LFTs,
TSH, CRP, and UA, are normal; ESR is 13 mm/h, and
RF is negative. Parvovirus serology results are
negative.
Radiographs of the hands are normal.
24. Which of the following antibody assays is
most helpful in establishing this patient's
diagnosis?
A. Anti–cyclic citrullinated peptide antibodies
B. Antimitochondrial antibodies
C. Antineutrophil cytoplasmic antibodies
D. Antinuclear antibodies
RF may be negative in early RA. Anti–CCP
antibodies are a highly specific marker for RA.
25. A 64YO man is evaluated during a routine f/u visit for a 5-year h/o RA.
Four months ago, he began IV tocilizumab to manage synovitis that was
not responding to treatment with etanercept; his last infusion was
administered 2 weeks ago. The patient also has hypertension. FH is
notable for his father, brother, and uncle with coronary artery disease.
Other medications are enalapril, HCTZ, methotrexate, prednisone, and
naproxen as needed.
On PE, temperature is 37.0 °C (98.6 °F), BP is 130/84 mm Hg, pulse rate is
80/min and regular, and RR is 16/min. Auscultation of the heart and lungs
is normal, and no edema is present. No synovitis is present on MSK
examination. The remainder of the examination is unremarkable.
Laboratory studies performed before each infusion reveal normal CBC,
LFTs, and serum creatinine levels. A lipid profile obtained 6 months ago
revealed a total cholesterol level of 180 mg/dL (4.7 mmol/L) and a LDL
cholesterol level of 98 mg/dL (2.5 mmol/L).
Results from a tuberculin skin test obtained before starting tocilizumab
treatment were negative.
26. Which of the following is the most
appropriate test to perform next?
A. Echocardiography
B. Electrocardiography
C. Lipid profile
D. Serum aminotransferase levels
E. Serum immunoglobulin levels
Periodic monitoring for changes in lipid status
is indicated for patients receiving
tocilizumab.
27. A 42 YO man is evaluated for morning stiffness of the
wrists lasting up to 1 hour. He was diagnosed with RA
4 months ago and was started on methotrexate and
titrated to maximum dose 3 months ago with partial
response. He also takes prednisone as needed for joint
pain and FA daily.
On PE, vital signs are normal. MSK examination
reveals swelling, tenderness, and pain on range of
motion of the wrists. No rash or joint deformities are
noted. The remainder of the examination is normal.
Laboratory studies reveal a CRP of 3.1 mg/dL; anti–
CCP antibodies are positive.
28. Which of the following is the most
appropriate treatment?
A. Add adalimumab
B. Discontinue folic acid
C. Discontinue methotrexate; begin infliximab
D. Discontinue methotrexate; begin
sulfasalazine
E. Maintain current regimen
Use of methotrexate with a TNF α inhibitor is
associated with further reductions in disease
activity and radiographic progression
29.
30. Age: 75% of persons over age 70 have OA
Female sex
Obesity (most important modifiable risk
factor)
Hereditary
Trauma
Neuromuscular dysfunction
Metabolic disorders
31. Pain is related to use
Pain gets worse during
the day
Minimal morning
stiffness (<20 min) and
after inactivity
Range of motion
decreases
Joint instability
Bony enlargement
Crepitus
Variable swelling
and/or instability
32. Primary OA typically
involves variable
number of joints in
characteristic
locations, as shown
35. No specific tests
No associated laboratory abnormalities;
eg, sedimentation rate
36. Joint space
narrowing (medial is
more common)
Marginal
osteophytes
Subchondral cysts
Bony sclerosis
Malalignment
37. Radiograph shows
severe changes
Most common
location in hand
May cause
significant loss of
function
38. X-ray shows
osteophytes,
subchondral
sclerosis, and
complete loss of
joint space
Patients often
present with deep
groin pain that
radiates into the
medial thigh
39. • Consider secondary causes of OA
• Previous trauma and/or overuse
• Neuromuscular disease, especially diabetic or
other neuropathies
• Metabolic disorders,
• CPPD (calcium pyrophosphate deposition disease)
• Hemochromatosis
• MCPs with hook like osteophytes
• Order iron studies
• Genetic tests: HFEmutations (C282Y)
41. Flares of joint
inflammation involve
PIP & DIP joints
Associated with
erythema, swelling, &
severe pain.
Radiographs reveal
erosions of these joints
(Sea gull appearance)
42. • Goal: decrease pain to increase function
• Progressive exercise to
• Increase function
• Increase endurance and strength
• Reduce fall risk
• Patient education:
• Weight loss
• Heat/cold modalities
43. Use of a cane can significantly unload a knee /hip
& improve gait, mobility, & pain.
Proper Positioning
Placed in the hand contralateral to the symptomatic
joint.
The top of your cane should reach to the crease in
your wrist when you stand up straight.
Elbow should bend a bit (10-15 deg.) when holding the
cane.
Walking
Cane & injured leg swing & strike the ground at the
same time.
45. • Surgery
• Arthroscopy
• Osteotomy
• Total joint replacement
• Decision is based on the patient's sx & quality
of life, rather than the radiographic severity
46.
47. A 76 YO woman is evaluated for a 3-month history of left knee pain
of moderate intensity that worsens with ambulation. She reports
minimal pain at rest & no nocturnal pain. There are no clicking or
locking symptoms. She has tried naproxen and ibuprofen but
developed dyspepsia; acetaminophen provides mild to moderate
relief. The patient has HTN, HLD, and chronic stable angina.
Medications are lisinopril, metoprolol, simvastatin, low-dose
aspirin, and nitroglycerin as needed.
On PE, VS are normal. BMI is 32. ROM of the left knee elicits
crepitus. There is a small effusion without redness or warmth &
tenderness to palpation along the medial joint line. Testing for
meniscal or ligamentous injury is negative.
Lab studies, including CBC & ESR, are normal.
Radiographs of the knee reveal medial tibiofemoral compartment
joint-space narrowing and sclerosis; small medial osteophytes are
present.
48. Which of the following is the next best step in
management?
A. Add celecoxib
B. Add glucosamine sulfate
C. MRI of the knee
D. Weight loss and exercise
Obesity is the most important modifiable risk
factor for knee OA.
49. A 58 YO man is evaluated for a 6-year history of
hand pain accompanied by morning stiffness
lasting 30 minutes & a 2-year history of bilateral
hip pain. He takes naproxen, which moderately
relieves the pain.
On PE, VS are normal. There is tenderness of
both wrists and the MCP joints and pain on
flexion and internal rotation of the hips. The
wrists and hips have limited range of motion.
Radiographs reveal joint-space narrowing at the
hips, MCP joints, and proximal interphalangeal
joints; osteophytes are seen at the MCP and hip
joints.
50. Which of the following tests is likely to
confirm diagnosis?
A. Antinuclear antibody assay
B. Rheumatoid factor
C. Serum transferrin saturation
D. Serum uric acid level
Secondary OA involving the MCP joints
should specifically raise suspicion for
hemochromatosis.
51. A 72 YO woman is evaluated for a 6-month history of increasing
pain and swelling of the hands and fingers associated with a 20-
year history of OA. The pain is worse with activity, and she now
has difficulty opening jars and buttoning her shirt. She states
that diclofenac no longer provides relief.
On PE, temperature is 37.0 °C (98.6 °F), BP is 148/78 mm Hg,
PR is 88/min, and RR is 18/min. MSK exam reveals bilateral firm
swelling and tenderness of the second and third proximal IP
joints. The left third distal IP joint is swollen and red. The
remainder of the examination is unremarkable.
Laboratory studies reveal an ESR of 36 mm/h.
Radiographs of the hands reveal joint-space narrowing of the
proximal and distal IP joints with multiple osteophytes; erosive
changes of the distal IP joints are noted.
52. Which of the following is the most likely
diagnosis?
A. Erosive hand osteoarthritis
B. Psoriatic arthritis
C. Rheumatoid arthritis
D. Tophaceous gout
Erosive hand OA involves proximal and distal
IP joints that are associated with erythema,
swelling, and severe pain. Erosions in DIPs
should raise suspicion for erosive OA or PsA.
53. American College of Rheumatology (ACR)
ACR: Image Bank
ACR: Rheum2Learn
https://www.rheumatology.org/education/tra
ining/Rheum2Learn.asp
Primer on Rheumatic Diseases
ACP – MKSAP 16