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Sunday, August 27

  1. page Systemic Lupus Erythematosus edited ... Weight loss Oral ulcers Seizures Pathophysiology Like many autoimmune diseases the initi…
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    Weight loss
    Oral ulcers
    Seizures
    Pathophysiology
    Like many autoimmune diseases the initiating process of SLE is not well understood. One theory suggests that there is T-cell dysregulation of B cells which allows autoimmunity to occur. In most cases the disease is driven by high affinity IgG antibodies to double-stranded DNA (dsDNA) and nuclear proteins (anti-nuclear antigens). Another theory suggests that defects in apoptosis lead to increased apoptosis, a failed clearance apototic debris, antibodies that target the debris and immune complex formation (type III Hypersensitivity). These Immune complexes deposit in vessels and organs which mediates many of the symptoms and complications of SLE. Other symptoms are caused by circulating inflammatory cytokines such as IL-1.
    (view changes)
    6:55 pm

Tuesday, August 22

  1. page Giant Cell Arteritis edited ... Giant Cell Arteritis, also GCA, is a vasculitis that affects large and medium-sized arteries. …
    ...
    Giant Cell Arteritis, also GCA, is a vasculitis that affects large and medium-sized arteries. It usually affects branches of the external carotid artery.
    Incidence
    ...
    of 50 per year
    Age
    >50, highest incidence 70-80
    (view changes)
    6:06 pm
  2. page Vasculitis edited ... Oxford Handbook of Clinical Medicine - "Vasculitis" http://link.springer.com/articl…
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    Oxford Handbook of Clinical Medicine - "Vasculitis"
    http://link.springer.com/article/10.1007%2Fs11926-005-0036-5
    http://bestpractice.bmj.com.ezp.lib.unimelb.edu.au/best-practice/monograph/520.html
    http://www.medscape.com/viewarticle/407580_3

    http://bestpractice.bmj.com.ezp.lib.unimelb.edu.au/best-practice/monograph/520.html
    http://bestpractice.bmj.com.ezp.lib.unimelb.edu.au/best-practice/monograph/520.html
    (view changes)
    4:14 am
  3. page Vasculitis edited ... Oxford Handbook of Clinical Medicine - "Vasculitis" http://link.springer.com/articl…
    ...
    Oxford Handbook of Clinical Medicine - "Vasculitis"
    http://link.springer.com/article/10.1007%2Fs11926-005-0036-5
    http://bestpractice.bmj.com.ezp.lib.unimelb.edu.au/best-practice/monograph/520.html
    http://www.medscape.com/viewarticle/407580_3

    http://bestpractice.bmj.com.ezp.lib.unimelb.edu.au/best-practice/monograph/520.html
    http://bestpractice.bmj.com.ezp.lib.unimelb.edu.au/best-practice/monograph/520.html
    (view changes)
    4:12 am
  4. page Giant Cell Arteritis edited Definition Giant Cell Arteritis, also GCA, is a vasculitis that affects large and medium-sized …

    Definition
    Giant Cell Arteritis, also GCA, is a vasculitis that affects large and medium-sized arteries. It usually affects branches of the external carotid artery.
    Incidence
    7-20 per 100 000 people over the age of 50
    Age
    >50, highest incidence 70-80
    Gender
    2-4 times more common in women
    Aetiology
    Exact cause unknown
    Risk Factors
    Age
    Female
    Smoking
    Atherosclerosis
    B1*0401 or B1*0404/8 variant of the HLA-DR4 genotype
    Polymyalgia rheumatica (association rather than causation)
    Signs and Symptoms
    Local
    Headache (temporal or occipital)
    Scalp tenderness
    Polymyalgia rheumatica symptoms
    Neck pain
    Shoulder pain
    Hip Pain
    Shoulder and Hip stiffness
    Claudication of arms (and rarely legs) in patients who have large vessel stenosis
    Amaurosis fugax (painless and temporary loss of vision in one eye)
    Jaw claudication
    Systemic
    Low-grade fever
    Malaise
    Fatigue
    Weight loss
    History
    Where is the headache?
    Do you have pain when you chew? Does it get worse the more you chew?
    Have you had any changes in vision?
    Examination
    Scalp tenderness
    Temporal (rarely facial and occipital) artery tenderness, thickening, nodularity
    Fundoscopy - Possible optic disc pallor and oedema
    Auscultation of carotid arteries, subclavian arteries - possible bruits
    Blood pressure - may be asymmetric
    Pathophysiology
    The exact underlying cause is not understood. CD4 T cells enter arteries and proliferate within the vessel wall. The release of interferon-gamma promotes macrophage infiltration and giant cell formation. In response to vessel injury growth factors that cause angiogenesis are released. This leads to thickening of arteries which can cause stenosis and ischaemia.
    GCA usually affects the branches of the common carotid artery.
    Investigations
    Bloods
    ESR - raised (>50)
    CRP - elevated
    LFTs - AST, ALT, ALP slightly raised
    FBE - normocytic anaemia, normal white cell count, raised platelets
    Imaging
    Temporal artery ultrasound - may show thickening, stenosis
    Other
    Temporal artery biopsy - Granulomatous inflammation, multinucleated giant cells may be present in about 50%
    Diagnosis
    3 of 5 to suggest GCA over another vasculitis:
    Age >50
    New headache
    Temporal artery abnormality: tenderness or reduced pulse
    Elevated ESR >50
    Abnormal artery biopsy - granulomatous inflammation, usually with multinucleated giant cells
    Differentials to rule out
    Polymyalgia Rheumatica
    Takayasu's Arteritis
    Haematological Malignancy or Solid Organ Cancer
    Chronic Infection
    Rheumatoid Arthritis
    Systemic Lupus Erythematosus
    Amyloidosis
    Management
    Pharmacological
    Prednisolone 1mg/kg (max 80mg) for 4 weeks, gradually reduce
    Methylprednisolone 1mg for 3 days (if visual or neurological symptoms)
    Aspirin (reduces risk of vision loss)
    Calcium + Vitamin D (Osteoporosis prevention)
    Methotrexate (if relapsing)
    Follow-up
    Monitor inflammatory markers during initial steroid treatment
    Monitor blood sugar, blood pressure, bone density during ongoing steroid treatment
    Monitor FBE for anaemia
    Yearly Aortic ultrasound due to aneurysm risk (6 monthly CT once dilation is detected)
    Complications
    Glucocorticoid complications
    Vision Loss
    Aortic Aneurysm
    Large-vessel stenosis
    Prognosis
    Up to 50% of patients experience relapses. GCA does not seem to be associated with increased mortality.
    See Also
    BMJ Best Practice - Giant Cell Arteritis
    http://bestpractice.bmj.com.ezp.lib.unimelb.edu.au/best-practice/monograph/177.html
    http://bestpractice.bmj.com.ezp.lib.unimelb.edu.au/best-practice/monograph/177.html
    http://bestpractice.bmj.com.ezp.lib.unimelb.edu.au/best-practice/monograph/177.html
    http://bestpractice.bmj.com.ezp.lib.unimelb.edu.au/best-practice/monograph/177.html
    http://bestpractice.bmj.com.ezp.lib.unimelb.edu.au/best-practice/monograph/177.html
    http://bestpractice.bmj.com.ezp.lib.unimelb.edu.au/best-practice/monograph/177.html
    http://bestpractice.bmj.com.ezp.lib.unimelb.edu.au/best-practice/monograph/177.html
    http://bestpractice.bmj.com.ezp.lib.unimelb.edu.au/best-practice/monograph/177.html
    http://bestpractice.bmj.com.ezp.lib.unimelb.edu.au/best-practice/monograph/177.html
    http://bestpractice.bmj.com.ezp.lib.unimelb.edu.au/best-practice/monograph/177.html
    http://bestpractice.bmj.com.ezp.lib.unimelb.edu.au/best-practice/monograph/177.html
    http://bestpractice.bmj.com.ezp.lib.unimelb.edu.au/best-practice/monograph/177.html
    http://bestpractice.bmj.com.ezp.lib.unimelb.edu.au/best-practice/monograph/177.html

    (view changes)
    4:10 am

Thursday, August 17

  1. page Gout edited ... Age Male ... and alcohol (particularly beer) Use of diuretics Chronic Kidney Disease …
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    Age
    Male
    ...
    and alcohol (particularly beer)
    Use of diuretics
    Chronic Kidney Disease
    ...
    Tophi
    Pathophysiology
    ...
    chance of delevopingdeveloping the condition
    Gout more commonly affects the first metatarsophalangeal joint (ie the great toe) due to it's relative coolness. Gout may also be common in osteoarthritic joints. Urate crystals trigger an immune response which can result in synovitis.
    Gout usually resolves spontaneously after urate crystal clearance by phagocytes. Urate crystals may also induce chronic inflammation causing synovitis, cartilage loss, and bone erosions.
    ...
    Joint X-ray - periarticular erosions
    Other
    ...
    cell count, negative-birefringent crystals under polarised light
    Diagnosis
    Diagnosis of gout is confirmed with synovial fluid analysis showing urate crystal deposition.
    ...
    Psoriatic arthritis
    Management
    Non-Pharmacological
    Weight Loss
    Restrict alcohol consumption
    Restrict meat and seafood consumption
    Drink water to prevent dehydration

    Pharmacological
    Acute
    NSAID (1st line)
    Colchicine (acute)(1st line acute)
    Corticosteroids (acute)(2nd line acute)
    Ongoing
    NSAID (1st line)

    Allopurinol (not during attack)(1st line) - reduces
    ...
    acid production
    Benzbromarone

    Probenecid or sulfinpyrazone
    - increases
    ...
    acid excretion (2nd line)
    Febuxostat - reduces uric acid production
    Follow-up
    ...
    6 months. Patients starting allopurinol should be monitored for allergy.
    Complications
    Renal Stones
    ...
    http://bestpractice.bmj.com.ezp.lib.unimelb.edu.au/best-practice/monograph/13.html
    http://bestpractice.bmj.com.ezp.lib.unimelb.edu.au/best-practice/monograph/13.html
    https://www.racgp.org.au/afp/2016/may/the-management-of-gout-much-has-changed/
    http://bestpractice.bmj.com.ezp.lib.unimelb.edu.au/best-practice/monograph/13.html
    http://bestpractice.bmj.com.ezp.lib.unimelb.edu.au/best-practice/monograph/13.html
    (view changes)
    12:43 am

Wednesday, August 16

  1. page Rheumatoid Arthritis edited ... Progression of disease leads to: Join erosion Loss of cartialage cartilage Juxta-articul…
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    Progression of disease leads to:
    Join erosion
    Loss of cartialagecartilage
    Juxta-articular ostroporosisosteoporosis
    Ulnar deviation of metacarpal-phalangeal joints
    Rheumatoid Nodules
    ...
    Anti-Citrullinated Protein Antibody (ACPA) - >30
    X-Ray - joint erosion, swelling, deformities, juxta-articular osteoporosis, uniform joint space narrowing
    For treatment:
    Urea and Electrolytes
    Liver Function Tests
    Chest X-ray - for baseline
    Hepatitis B, C status
    Quantiferon Gold - Tuberculosis
    HIV status

    Diagnosis
    Diagnosis is made based on a list of Criteria (see image on right)
    ...
    Coronary Artery Disease
    Pulmonary Fibrosis
    Follow-up
    Patients should be monitored every 4-8 weeks for treatment toxicity to the liver, kidney and lungs. Once stable patients should be checked every 3-4 months.

    Prognosis
    Patients who are treated aggressively at an early stage have a good prognosis. If there is a delay then many patients become disabled within 10 years. There is also an increase in mortality in patients with Rheumatoid Arthritis. This is mainly due to Coronary Artery Disease.
    (view changes)
    11:47 pm

Wednesday, August 9

  1. page Gout edited ... Few affected joints Joint swelling Tophi History Have you had this pain before? What med…
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    Few affected joints
    Joint swelling
    Tophi
    History
    Have you had this pain before?
    What medications are you taking?
    What do you diet like? (high protein, meat, seafood)
    Do you drink alcohol?
    Has anybody in your family had gout?
    Examination
    Examine all joints of limbs
    Red, swollen, tender joints

    Tophi
    Pathophysiology
    ...
    Rheumatoid arthritis
    Psoriatic arthritis
    TreatmentManagement
    Pharmacological
    NSAID (1st line)
    ...
    Benzbromarone - increases uric acid excretion
    Febuxostat - reduces uric acid production
    ManagementFollow-up
    Patients should be monitored for recurrent attacks, formation of tophi and radiological changes. Patient on uric acid lowering treatment should have their uric acid monitored at least every 6 months.
    Complications
    (view changes)
    10:09 pm

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