MSK

• Reactive arthritis is a post-infectious autoimmune condition that classically presents with the triad of urethritis, conjunctivitis, and arthritis following a STI/GI infection Hans Reiter, a nazi physician first described the condition
• Reactive arthritis is the triad of urethritis, conjunctivitis, and arthritis after a sexually transmitted infection (STI) """Can't see, pee or climb a tree"" STI or GI infection"
• Reactive arthritis is more common in men 3:1 Typically younger men
• Reactive arthritis is associated with sexually transmitted infections and GI infections Post-urethritis: Chlamydia Post-enteritis: Shigella, Salmonella, Campylobacter, or Yersinia
• What is the most common organism that causes reactive arthritis? Chlamydia
• What is the symptomatic treatment of reactive arthritis? NSAIDs or intra-articular steroids
• What is the management for persistent/severe reactive arthritis? DMARDs e.g. sulfasalazine >6 months
• Reactive arthritis resolves spontaneously within ~12 months
• Reactive arthritis is a HLA-B27 associated seronegative spondyloarthropathy
• Reactive arthritis typically onsets ~4 weeks from infection Symptoms last ~5 months
• Dactylitis, and asymmetric involvement of DIP's and nails suggests reactive or psoriatic arthritis
• Reactive arthritis typically presents with asymmetrical oligoarthritis of the lower limbs
• Which seronegative spondyloarthropathy is associated with keratoderma blennorhagicum (waxy yellow), a skin lesion that resembles pustular psoriasis? Reactive arthritis
• Osteoporosis is a skeletal disorder characterised by low bone mass and structural deterioration of bone tissue [© NICE [07 February 2017] Osteoporosis: assessing the risk of fragility fracture [CG146]. Available from https://www.nice.org.uk/guidance/cg146/chapter/Introduction All rights reserved. Subject to Notice of rights NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication]
• Osteoporosis is important because it can cause fragility fractures
• Women have ↑ risk of osteoporosis, partly due to loss of oestrogen post-menopause
• Osteoporosis risk factors: - Age - Female (postmenopausal) - Family history - Chronic corticosteroids use - Low BMI update 02/12/24
• BMI less than 19kg/m2 increases the risk of osteoporosis [https://www.osteoporosis.foundation/sites/iofbonehealth/files/2021-09/OsteoporosisRiskCheck_Leaflet_english_QR_0.pdf ]
• For osteoporosis, it is recommended to use FRAX or QFracture screening tool to assess for 10-year risk of fragility fractures [© NICE [07 February 2017] Osteoporosis: assessing the risk of fragility fracture [CG146]. Available from https://www.nice.org.uk/guidance/cg146/chapter/Introduction All rights reserved. Subject to Notice of rights NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication]
• What DEXA (DXA) T score is diagnostic of osteoporosis? ≤ -2.5
• What autoimmune MSK condition is a risk factor for osteoporosis? Rheumatoid arthritis
• What medication poses the BIGGEST risk factor for osteoporosis? Glucocorticoids!
• Myeloma can mimic osteoporosis and should be ruled out Sometimes multiple myeloma symptoms can mimic those of age-related osteoporosis
• A history + physical examination & FBC should be done to investigate secondary causes of osteoporosis FBC + urea & electrolytes, LFT, bone profile, CRP, thyroid function tests
• Patients who are likely to be on steroids for at least 3 months should be offered bisphosphonates Consider risk of osteoporosis https://www.derbyshiremedicinesmanagement.nhs.uk/assets/Clinical_Guidelines/Formulary_by_BNF_chapter_prescribing_guidelines/BNF_chapter_6/Osteoporosis_Guideline.pdf
• NICE advise all women aged ≥ 65 years old & men aged ≥ 75 years old should be considered for assessment of osteoporosis fragility fractures Using FRAX or QFracture tools [© NICE [07 February 2017] Osteoporosis: assessing the risk of fragility fracture [CG146]. Available from https://www.nice.org.uk/guidance/cg146/chapter/Introduction All rights reserved. Subject to Notice of rights NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of i...
• FRAX assessment for 10-year risk of fragility fractures Low risk = reassure & give lifestyle advice Intermediate risk = offer DEXA scan High risk = offer bisphosphonates vitamin D + calcium https://www.derbyshiremedicinesmanagement.nhs.uk/assets/Clinical_Guidelines/Formulary_by_BNF_chapter_prescribing_guidelines/BNF_chapter_6/Osteoporosis_Guideline.pdf
• DEXA scan T score > -1.0 = normal -1.0 to -2.5 = osteopenia < -2.5 = osteoporosis
• DEXA scan T score is based on bone mass of a young reference population & measured with standard deviations
• DEXA scan Z score is adjusted for age, gender, & ethnic factors! Factors that cannot be changed → NOT BMI!
• What supplements are given to patients with osteoporosis? Calcium & vitamin D unless they have adequate levels
• What is the first-line management of osteoporosis? Alendronate (bisphosphonate) In geriatrics placement, lots were give, IV zoledronic acid that can last up to 3 years plus calcium & vitamin D supplements
• What is the second-line management of osteoporosis if they cannot tolerate alendronate? Risedronate or IV zoledronate In placement, lots were give IV zoledronic acid that can last up to 3 years update 02/12/24 as zoledronate is used [https://www.nogg.org.uk/full-guideline/section-6-pharmacological-treatment-options]
• ~1/4th of patients do not tolerate alendronate because of indigestion Give risedoronate or etidronate instead In placement, lots were given IV zoledronic acid that can last up to 3 years
• A fragility fracture is a low impact fracture from standing height or lower
• "The most common fragility fractures are - Vertebral crush fractures - Hip fractures (NOF#) - Colles fracture"
• How do the following laboratory values typically change in patients with osteoporosis? Calcium: normal Phosphate: normal Alkaline phosphatase: normal
• Weight-bearing exercise can increase bone mineral density for osteoporosis
• Ankylosing spondylitis is associated with the HLA-B27 gene
• Ankylosing spondylitis usually affects males aged 15-30 years old 2.2:1 - Male:Female update 02/12/24 to change age range to 15-30 [Anne Boel, Clementina López-Medina, Désirée M F M van der Heijde, Floris Alexander van Gaalen, Age at onset in axial spondyloarthritis around the world: data from the Assessment in SpondyloArthritis international Society Peripheral Involvement in Spondyloarthritis study, Rheumatology, Volume 61, Issue 4, April 2022, Pages 1468–1475, https://doi.org/10.1093/rheumatology/keab544]