Rheumatology: Psoriatic arthritis

Psoriatic arthritis (PSA) is severe autoimmune disease with typical presentation of a seronegative inflammatory arthritis along with features of psoriasis. It has variable presentation and can cause erosive changes and joint deformities.

Epidemiology:
2-3% of population have Psoriasis, one third of psoriasis patients will develop PSA
Male and female frequency are the same (M=F)
Bimodal, two peaks of occurence approx 25yrs and 55years. (also juvenile PSA presenting 9-12yrs)
Caucasians effected more than black or asian ethnicities
2/3 will have mild disease while 1/3 will develop severe manifestations of the disease.
Genetic and environmental factors contribute to disease
25-60% HLA-B27 positive
Link with obesity, strep pharyngitis (infections may trigger disease in those with inherited tendency) and trauma before onset.

Presentation:
Psoriasis preceded the arthritis by 8-10yrs on average
Many different presentations of psoriasis (dry itchy, sometimes painful desquamating plaques on the skin), check elbows, knees and hands. If not obvious check the scalp, behind the ear, umbilicus and nails for signs of psoriasis.
Often nail changes; nail pitting or onycholysis (loose nail), nails often thickened and discoloured.
Dactylitis is common (a sausage like swelling of toe or finger)
Often presents as an asymmetric oligoarthritis (2-4 joints effected)
there may be enthesitis (particulary the plantar fascia and achilles), fatigue, conjunctivtis (20%) and iritis (7%) also.
50% have spondyloarthropathy, presenting with lower back pain and stiffness. 20% sacroilitis
Will be Rheumatoid factor negative, and negative to most autoantibodies.
The joints will present with typical inflammatory features; swelling, effusion, erythema and heat, and will effect both small and large joints (see the different patterns below).

Diagnosis:
Seronegative arthritis and psoriasis
CASPAR criteria, 3 or more of folowing (99%sp 92%sn);
-evidence of psoriasis (current or family)
-psoriatic nail dystrophy
-negative RhF
-dactylitis
-radiographic evidence of juxtarticular new bone formation
XR can show pencil-in-cup deformity of phalanges (practically pathognomonic).
Think PSA if: involvemnet of DIPs without osteoarthritis, significant nail pitting, family history of PSA, absence of RhF positivity with polyarthritis.

Classification:
Most patients will have mild disease (2/3)
Five main presentations or subtypes:
-Asymmetric oligoarticular disease
-predominent DIP disease
-Arthritis mutilans (osteolysis of joints, mainly DIPs and PIPs with telescoping of digits)
-rheumatoid like polyarthritis (60% patients, MCPs, PIPs and wrists)
-isolated axial involvement (asymmetric sacrolilitis and jug handle syndesmophytes)

Prognosis:
Similar effect on quality of life and prognosis as rheumatoid arthritis
40-60% have erosive joint disease (deforming arthritis)
20% will develop ACR class 3 or 4 functional impairment
factors linked with poorer prognosis are; younger onset, female, acute onset, polyarticular disease and elevated CRP/ESR.
It is a lifelong disease that can flare at any point, with variable periods of remission.
Some many be clear for over 30years before a relapse.
Significant effect on quality of life.
overall mortality ratio 1.36

Treatment:
Patient should also be under the care of a dermatologist
Intial treatment with an NSAID, with addition of a DMARD if inflammation and joint pain persist.
DMARDS; sulfasalazine, azathioprine and methotrexate (most commonly used)
Steriods shuold be avoided
Treatment with biologic drugs if: peripheral arthritis with 3 or more joints tender and swollen AND have not responded to at least two standard DMARDs.
Etanercept, Infliximab, adalimumab are NICE approved. (be aware of immunosuppressive side effects and infections)
diet should be changed to a healthy diet focusing on foods that may lower inflammation; fresh fruit and veg, omega 3 acids.

Pearls and extras:

• Concordance for monozygomatic twins 35-75%, dizygomatic 12-20%
• trauma to joint is reported in 25% before onset
• arthritis and psoriasis occur simultaneously inj 33%
• no real relationshiup between tyep or pattenr of psorirasis and development of arthritis. more extensive psoriasis is linked with more deformity to a certain extent
• men tend to have a more DIP only presentation while women tend to resent iwt the polyarthritis subtype more
• pateints with DIP involvement are likely to have worse nail changes. 
• consider a concurrent HIV infection
• low titre RhF and CCA antibodies in 5% of patients
• hyperuricemia seen in 20%
• there have been anecdotable reports of 'flares' of arthritis with  hydroxychloroquine

#rheumatology #arthritis #psoriasis #medED #FOAMed #psoriaticarthritis #immunology

Public Service announcement from Deadpool

Testicular cancer is the most common form of cancer in men aged 15-35years, check those man berries!



#touchyourselftonight haha

Medical Apps: Touch Surgery

Touch surgery is an awesome new app I found available for both Android and Appstore. The app simulates many different surgical operations in an easy step by step manner, so you can learn to perform the procedures. Its actually pretty damn cool, ideal for budding surgeons or trainee warming up before surgery.
BBC video about it; http://www.bbc.com/news/technology-32844630

JiuJitsu(Nogi): Guillotine escapes! (featuring Braulio Estima's ANTI-guilliotine)

Excellent lesson by the great Braulio Estima, and some more videos below describing how to escape the guillotine from various positions, remember the best defense/escape is to avoid the position entirely of course!



More videos below....

Happy Australia Day!

Rheumatology: Fibromyalgia

Fibromyalgia AKA fibromyalgic syndrome (FMS) is one of the most common causes of chronic pain. It is characterised by allodynia, hyperalgesia and a wide range of other symptoms.
On average a FMS patient will have seen three or four different doctors before being diagnosed (taking an average of 2-3 years)!

Epidemiology
Prevalence 2-4%
Female (9:1)
35-60yrs (working age)
increased incidence in patients with autoimmune disorders

Symptoms/Signs
Widespread pain with tender points (pain elicited with palpation of these specific points)
Fatigue (doesn't improve with rest, number one complaint after pain)
Morning stiffness
Sleep disturbances (pt sleeps well but wakes up more tired)
variety of other disturbances; Headaches (tension-type and migraine), paresthesias, trouble concentrating, variable bowel habits, depression, mood and affective disorders, temporomandibular joint syndrome,  idiopathic back pain, non cardiac chest pain, vestibular complaints, ENT symptoms...

Diagnosis
Diagnosis is entirely clinical, by exclusion generally.
Rule out differentials, be vigilant of common co-existing conditions like irritable bowel syndrome
ACR 2010 diagnostic criteria
Reasonable diagnosis:
>Chronic widespread pain for greater than 3 months
>pain at 10 or more tender points (see image linked for specific locations, there are 18 defined areas)
(> also aiding in diagnosis; presence of Fatigue/stiffness and sleep disturbances)

Treatment
Centred towards the pain, but be aware that many FMS patients have concomitant psychiatric problems, so psychiatry referral suggested. Reassure patient its a physical diagnosis and warn them in some cases the symptoms will never resolve completely.

>Non pharmacological treatment
Exercise, CBT, homeopathy, physiotherapy, acupuncture, diet changes, relaxation techniques
all safe in the long term and may have potential benefits (small % of acupuncture pts had increased pain though)
Graded exercise showed benefits in many patients

>Pharmacological treatment
simple analgesics, tramadol,
tricyclic antidepressants
serotonin noradrenaline reuptake inhibitors (SNRIs)
alpha2 agonists (gabapentin, pregabalin)

Differential dx
Chronic fatigue syndrome (fatigue much more prevalent and severe, more an issue than pain)
Multiple bursitis/tendonitis (good response to local inection treatment, tender points absent)
Rheamatoid arthritis/Osteoarthritis (joint swelling, hands affected)
SLE (rash, systemic sx, ANA)
Ankylosing spondylitis (young male, lower back pain)
Polymyalgia rheumatica (older pt, acute onset, steroid responsive)
Hypothyroidism (weight gain, goitre)
Myositis (weakness more than pain)

Random pearls

• Although the etiology is unknown it is believed to be a central sensitization disorder, fitting in with the considerable overlap of IBS and dysmenorrhea with FM. A kind of abnormal response of the nervous system.
• RA and SLE often present as well. 
• FMS is increased in patients that have suffered a physical of psychiatric trauma (perhaps a starting point of the disease)
• increase in metabolic syndrome in FMS patients
• There are three subgroups to further classify FMS patients based on pain control, tenderness and associated symptoms
• In USMLE exam 'steroids' or 'NSAIDS' will not be the correct answer answer to treatment options
• 12th May is Fibromyalgia awareness day
• One third of FMS patients experience major depression or significant anxiety. 

Resources and Sources:
Medscape Fibromyalgia
Paul Bolin CRASH USMLE video on Fibromyalgia
ArthritisUK Great site for patients
More detailed look at diagnostic criteria

 #MEDed #FOAMed #Fibromyalgia #Rheumatology #Chronicpain #widespreadpain

Orthopedics: Fractures and Bone Healing

There is a lot of things to consider when a pt comes into the ER with a fracture. Do you know when you to treat with an OPEN or CLOSED reduction?

Bones can heal either by 'Healing Per Primam' or secondary healing with callus formation (much more common).
Healing per primam is direct healing of bone with tunneling of osteoclasts and migration/colonization of the tunnel with osteoblasts (no callus formation).

Secondary healing/callus formation stages:

1. Hematoma 
2. Granulation tissue 
3. (Soft callus) Cartilaginous callus formation 
4. (Hard Callus) Bony callus and cartilaginous remnants (lammellar bone deposition)
5. Remodelling to original bone contour 

Stephen Pearson strain theory, classification of fracture with regards to healing:

> Narrow simple line  > OPEN reduction

Requires absolute stability, usually a surgical fix with plates and screw so there is zero movement of bone fragments. healing per primam

e.g. this type of healing is ideal for fractures where we don't want a callus for example, joint fractures, fractures of the epiphysis (a callus would restrict movement). 

> Wide complex line  > CLOSED reduction

Requires relative stability, fix fracture with plaster cast or erfix etc. healing is by secondary bone healing with callus formation.

e.g. comminuted fractures, fractures with gaps and mutiple fragments.

JiuJitsu(Nogi):The Jail break side control escape to butterfly sweep options

Needs a little flexibility mind you, A very simple escape from side control,



Some butterfly guard sweep options below.....

5 4 3 2 1... MIGRAINE

Neat trick to remember the features of migraine: (5, 4, 3, 2, 1)

• >5 attacks a day
• lasting 4 hours to 3 days
• 2 or more features: Unilateral, Pulsating, Moderate/severe intensity, Aggravated or causing avoidance of routine physical activity
• 1 of either Nausea and vomiting or sensitivity to light (photophobia) and sound (phonophobia)

The precise diagnostic criteria can be found here for details: International Headache Society

Treatment: 

• Avoid and control triggers; e.g. foods containing tyramine (cheese, chocolate, wine), 
• Mild-moderate: paracetomol, NSAIDS, 
• Moderate-severe: Triptans (NO OPIATES!)
• Refractory: try combinations Triptans + NSAIDS
• Prophylaxis if more than 3 episodes a month, if it interferes with daily life or acute treatment is ineffective: AEDs, BBs, CCBs, Triptans, 

Some migraines have a characteristic 'Aura' before. Typically visual symptoms, a brilliant scintillating scotoma, lasting between 5-60 minutes. 

There are also many different types of Migraine, some worth noting;

Basilar type Migraine: accompanying brainstem symptoms e.g. dysarthria, vertigo, diplopia, ataxia. 

Familial hemiplegic Migraine: aura of fully reversible motor weakness, aura lasts unusually long 5 mins to 24 hours, pt has at least one affected relative.

Chronic Migraine: Migraine for greater than 15 days a month, for at least three months. Basically a migraine every other day, very disturbing.

WTF if a Triptan?
5-HT1B/1D receptor agonist, causes constriction of cranial blood vessels and inhibits production of inflammatory neuropeptides. Side effects include: Serotonin syndrome and coronary spasm. also used to altitude sickness.

#Migraine #Neurology #FOAMed #MedED

Epic Tea Time

RIP Alan Rickman and David Bowie.

Currently studying super hard for my upcoming neurology exam, burying my head in the books and ignoring those tempting invites for a drink or extra training session. So while my consumption of tea and highlighter pen use is going up, my social life is suffering. This latest study from PLOS medicine shows that being unsociable makes you 50% more likely to die earlier yikes, I really should get out more then.

I also discovered today that you can most definitely study AND exercise. Learning is actually improved by light exercise immediately before revising or reading, as long as the exercise was kept light. See link to blog post below from NY times (2013) for a good breakdown. Going to try wedge my copy of Harrison's internal medicine on the exercise bike handles.

Epic tea time with Alan Rickman (below)

NY times link

Link to the study

(original article posted on 1/15/2016,  I moved site today)

First post the post that hurts the most

My  life at the moment seems to be centered around two places; the hospital and the gym (dont worry I study and work in hospital, I'm a fifth year medical student). Having always had the desire to write a blog and having never really had any good ideas, I finally settled on this, a combination of jiujitsu and medicine...so, my new blog.... cue fanfare.....

Armlocks and Emergency!

I hope to provide some medical advice for common jiujitsu injuries, a modgepodge of general life hacks and some stories from the emergency room, perheps even a jiujitsu lesson every now and then ha. 

Quote: credit to author Karen Lamb, hopefully it will inspire you start that project you have been putting off for so long.
(Original blog post on 1/12/2016, I moved site today)

Interesting article for underground commuters

Why people are not walking up escalators, the tube at a standstill

New year resolutions

People who explicitly make resolutions are 10 times more likely to attain their goals than people who don't explicitly make resolutions

That is even if only 8% actually achieve their goals

This site has all the facts: http://www.statisticbrain.com/new-years-resolution-statistics/

                         Prof Wiseman's top 10 tips to achieving your New Year's resolution:

1. Make only one resolution. Your chances of success are greater when you channel energy into changing just one aspect of your behaviour.

2. Don’t wait until New Year’s Eve to think about your resolution and instead take some time out a few days before and reflect upon what you really want to achieve.

3. Avoid previous resolutions. Deciding to revisit a past resolution sets you up for frustration and disappointment.

4. Don’t run with the crowd and go with the usual resolutions. Instead think about what you really want out of life.

5. Break your goal into a series of steps, focusing on creating sub-goals that are concrete, measurable and time-based.

6. Tell your friends and family about your goals. You're more likely to get support and want to avoid failure.

7. Regularly remind yourself of the benefits associated with achieving your goals by creating a checklist of how life would be better once you obtain your aim.

8. Give yourself a small reward whenever you achieve a sub-goal, thus maintaining motivation and a sense of progress.

9. Make your plans and progress concrete by keeping a handwritten journal, completing a computer spreadsheet or covering a notice board with graphs or pictures.

10. Expect to revert to your old habits from time to time. Treat any failure as a temporary setback rather than a reason to give up altogether.