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OK. Hello everyone. Thank you for joining our first session of our mind, the Bleep Rheumatology Series. So today we'll be going through all things arthritis, which um Lucy and Doctor Miller will be presenting. Um And before we start, we have a talk by Daniel from BMA. So I'll hand over to you Daniel. Thank you. Yeah, I'll be super quick guys. Um So yeah, you'll see on the screen. Um There's a bit of an offer today if you wanted to join. Um good time to join, obviously with F one sort of looming. Um So, yeah, if you go on our website, you don't get any of this. So, so hopefully you want to take the much of it. Um But if you use that link, I put in the chat, you'll get your first month free. Um You'll also get a 10 lb a, a voucher for joining as well. Um Membership finally is 3 lbs 50 a month. So it's basically like getting three months free plus the extra month. So it's four months. So it's pretty good if you're, if you're considering joining the BMA soon anyway, so just choose that link and then when you're, when you've done. So um when you've joined, just drop me an email and I'll get that um Amazon voucher sorted for you as well. So all the details are in that side chat bar. So don't, don't worry if you, if you missed this, this um this slide. Um So I'm done. II work in the BMA. I work in sort of the membership side of things. I and I'm based in London, so I cover a few med schools um around London, maybe you've seen some of my um colleagues um around, around your areas and your med schools. Um I won't go too much into this cos I don't want to take too much time. Everyone knows what the BMA is, what the BMA um does. Um So we're essentially your trade union. So we cover you. Um Now, not, not just um sort of when you become a doctor, but now you can actually use a lot of our services. Um But yeah, it's three ways of looking at how we, how we help you individually locally and nationally. So obviously on a national basis, um we, we, we negotiate and um pay so for or just resident doctors, consultants and a as well. Um So it's been quite successful, obviously the past couple of years. Um then on a local level, um if, if you want to start f one, if, if you're having sort of similar issues, F one you can get in touch with us and we can sort any issues out and then obviously individually, things like your contract stuff we can help you with as well. Um So, yeah, so, but like I said, it's not, it's not something that you need to wait to, to, to join and start using, you start using us. Now. Um We've got really good MLA tools that we, that we just created. So um on the B MJ on examination um MLA stuff. Um It's fantastic. Um loads of tools on there to help you revise and, and past your past your finals. Um Again, I won't take up too much time on it. But yeah, it's got, it's got an app um really, really good, easy to use um application. Um And you can customize things, things like dis difficulty levels and whatnot. Um B MJ um cos your final year, you should actually, if, if you're a member, you'll be getting the B MJ through the post. It's actually changed. Um As of, as of today, it's gonna be fortnightly not weekly anymore. Um So, so yeah, it, that's another benefit if you are a member in your final year, if you're already a member and you're not getting that, you just need to get in touch with us, just, just use the, the contact form on our website. Um And just say, look, I'm finally here and I, and I'd like to start getting it through the post and and we'll out for you um loads of other tools you can use. So BMA library, um we used to post books out, this was many years ago, sort of pre COVID. Um But now everything's just available um instantly. So you can just log in with, with your BMA login and, and access any book or journal you could, you could possibly think of. Um We've got a great specialty explorer tool as well. Um So it's an essentially a normal psychometric test. Takes about 20 minutes to complete, asks all sorts of life uh work life balance questions. Um And then at the end, it will give you a, a breakdown of what specialties suit you based on that you've given um B MJ learning. So I'm sure people have used B MJ learning. But yeah, there's some popular topics for, for incoming F ones on the screen. So with, with our learning tools, we don't just have clinical stuff. We have nonclinical tools as well. So, so we can help you in that sense. Uh So just a touch on the pay. Um a big point, obviously, we've recently agreed uh a deal with the government um for now. Um um And, and F one pay has gone from what it was in 2022 29,000. This is, this is before any pay, uplift or anything like London Wing or any anything extra. So basic pay, it's gone from 29,384 to 36,616. So you guys are obviously a massive um benefactor of that and, and the work the BMA and, and members have been doing. Um So yeah, so I hope you're pleased and, and hope there's even more reason for you guys to join. Um That's obviously a pay up left of nearly 25% for, for F one and um and I wanna say we're not finished there, but I'll get onto that. Um So yeah, the, the idea with, with that offer from the government, it was no secret that we would just take it. Um Obviously we have a view still to, to pay restoration. So, um, pay restoration is still, you know, quite a lot off. So, so we've taken that and it's a massive step towards pay restoration. Um But many of you have seen maybe in December, um that the, that the government's recommended to DDR B and up close to 2.8% this year, which we think is, is miles off, what it should be. We, we think it should be around 12% if it's gonna be, um, if we're gonna get to pay restoration this year. So it's possible it's, I'm not saying this isn't anything official, but it's possible that that things are sort of moving towards another ballot and obviously you guys as incoming F ones will be, will be part of this. Um So, yeah, So possibly, well, we'll see possibly more strikes, more, more on the table for, for this year. Um So yeah, I'll leave it there. Um Good time to join, effectively getting four months of membership, uh paid if, if you join today with the Amazon voucher and the, and the first month free. So use that link in the chat. This is a sort of a one off thing cos I'm cos I'm here. Um Yeah, that's it. I'll stop, try to do that as quickly as possible. Thanks for having me. Um And yeah, enjoy the session. Thank you, Daniel. Um And I'm sure many of the final years here will find it very useful to join before starting F one. I am just trying to share my screen and then I will start as it worked. Can you see my screen? Mhm Hang on. It's just ablating now. Sorry guys should have done this before. There we go. Can you see it now? Yeah. Fab. OK. So hi, my name is Lucy. I'm uh currently working in York. I've done a job in A&E and I've just started my job on gen um I've got a particular interest in rheumatology. So I thought I would start to do some talks about rheumatology because I find it quite interesting to um research that myself. So today's talk is about all things arthritis and what I'd like you to get from this is mainly how to distinguish between inflammatory forms and noninflammatory forms and how you can use different cues and M CQ questions to help you get to the right answer. Um So just to start with, because I can see the chat function. Can anybody list or like name any symptoms or anything that would make them think it was an inflammatory form of arthritis. What parts like what wording in a question would make you think it was inflammatory arthritis. So, inflammatory arthritis, when I think about inflammatory arthritis, I think about, yeah, tenderness. That's a good one. So the joints will be hot, they'll be tender and yeah, they'll be described as pain which is particularly worse with rest and better when with activity. So typically in the exam question, it will be a patient's had some say finger pain, um which gets better when they're playing sports, for example. And it's worse when they're just sat at home doing nothing. It's also often worse in the morning with inflammatory arthritis. So patients will often describe pain when they wake up. It might take over 30 minutes for this pain and stiffness to subside in the morning. They might be like, oh doctor, it takes me a long time to get going and those sorts of things point you towards an inflammatory form of arthritis. And there's lots of different types of inflammatory arthritis which we will go into. And then you've got your non inflammatory arthritis such as osteoarthritis, which is often worse with activity the activity makes the symptoms worse. Whereas when these patients rest, uh, they see an improvement in their symptoms. So, from those simple criteria, pretty much, one's worse with rest and one's better with rest that can help you distinguish between the two different types. I hope that makes sense. So, the first, um, form of arthritis that I'd like to talk about is rheumatoid arthritis. So I feel like it's said a lot. Uh, we talk about rheumatoid arthritis a lot. And it's probably the arthritis that comes to my mind when I think about arthritis. So it's an autoimmune condition which is caused by chronic inflammation of your synovial linings of your joints. So I pop the diagram in there, your tendon sheath and also your bursa which your fluid filled sacs which go around the joint. So it's not only a joint problem. Rheumatoid arthritis affects different parts in the joint. Um and around the joints, for example, tendons attached to bones and things like that is often described as pain, which is associated with stiffness and swelling of the joints. So those three things you normally have, you can have a gradual onset of rheumatoid arthritis or you can have sudden onset depending on the different types. Often when it's sudden onset, it's more severe type. It typically affects your small joints in your hands and your feet in a symmetrical fashion. So, in a question, if the the joints are affected are asymmetrical, for example, just one hand, it's less likely to be rheumatoid arthritis in particular. You've got your MCP joints which are here in your hand, you've got your PIP joints which are here in your hand, uh, your wrist and then your MTP joints in your feet. If it's your distal IP joints, which are the ones at the ends of your fingers, it's not likely to be rheumatoid arthritis. It doesn't affect those joints. What you also get with rheumatoid arthritis because it is a autoimmune condition. It causes systemic symptoms. So you've got things like fatigue, weight loss, flu like symptoms and then muscle aches and weakness as well. So it's a whole sy a whole syndrome of things, not just joint pain. Uh you also get extra articular manifestations. These are particularly, I think they love to test these on uh pass med. I remember this coming up a lot when I was doing my finals. So things like pulmonary fibrosis patients with rheumatoid arthritis can get pulmonary fibrosis Belti syndrome, which is rheumatoid arthritis with neutropenia and splenomegaly. You can get secondary Sjogren's as a result of rheumatoid arthritis. A anemia of chronic disease. You can get rheumatoid nodules which are harmless nodules on the skins or uh on your elbows or your fingers. And these can often be mistaken for things like Bouchard's nodes and things which we'll talk about in osteoarthritis also get a higher increase in carpal tunnel syndrome and then problems with your eyes like episcleritis and scleritis with episcleritis being painless and scleritis being painful. So I would recommend that you for your finals that you know some of these associations because they can be tested in M CQ questions and they can help you answer. So some of my um exam questions for uni the key to the question was knowing that pulmonary fibrosis was associated with rheumatoid arthritis. So you knew it was rheumatoid arthritis. So it just gives you more clues when you're answering questions. And then, so you get different hand signs with rheumatoid arthritis. So you get az deformity of the thumb. So the thumb can appear to be Z shaped like the diagram there. You can get a swan neck deformity where your P IP joints are hyperextended and then your D IP joints are flexed, you can get a butane deformity, which is a hyperextended D IP with a flexed P IP. And then you also get o own deviation of the fingers as well. Um I think it's important to know some of these hand signs because typically patients with osteoarthritis and rheumatoid arthritis are quite stable. So they might bring them in for things like osk. That was definitely the case in my medical school. Um So just having an awareness of how you would spot them as well going on to diagnosis. So, if you're, for example, in GP and you're expecting that your patient has rheumatoid arthritis, they need to have an urgent referral to the to a rheumatologist to be fully assessed. But there are things that you can do in the interim to help guide this assessment further on. So these patients typically have persistent joint pain, stiffness and swelling. So you can do blood test. First of all, you would check for your rheumatoid factor. So this is seen in about 70% of patients with rheumatoid arthritis. If that's positive, it could make you, it would lead you to think it was rheumatoid arthritis. But you also can check the anti CCP antibodies which are more sensitive and more specific to rheumatoid factor. Um by that, we mean that more people that don't have it. So rheumatoid factor is more likely to be seen in patients who don't have rheumatoid rheumatoid arthritis and anti CP because it's more specific for it. So you could do a ana um but it wouldn't be very specific for it. You would want to do particularly your rheumatoid factor and your anti CPI. Think ana is more for things like vasculitis is. But if you were unsure of the cause I would, I would think they would probably do them all. But if you're thinking, oh this is definitely an arthritis, they might just stick to your rheumatoid factor, an anti CCP definitely in primary care. They do that. They also you get um x rays of the hands and feet. So you can look for changes in the bones as well. So it's quite a small picture. Um So you can see you get periarticular osteopenia. So the, the above and below the joint, the joint, the bone is a lot weaker, which you can see on an X ray. You can also get bony erosions where the bones weaker or where the inflammation has eroded into the bones. You get joint destruction and deformity and you can also see soft tissue swelling on the x-ray. You're less likely now to see the x-ray changes where you were before because we've got much better at picking up arthritis earlier. So it becomes less common to see these things, but it's still really important that we do the X rays just to make sure um that they're not further on in the disease state. Some people think that ultrasounds and MRI S can be done to detect synovitis, but it's not always necessary and that would be guided by a, a rheumatologist. There's a monitoring score that I'd recommend being familiar with, which is D 28 and this is to monitor the disease activity for patients. As their score increases, the disease becomes more severe and it's called DS 28 because it assesses 28 joints, particularly looking at whether they're swollen, tender and also correlating that with their C RP or their E SR result. So it gives you an overall indication of the amount of inflammation that's going on and then of where that's um and what joints are affected management wise. So for most rheumatological conditions, da S are the mainstay of treatment now, which are disease modifying anti rheumatic agents. There's lots of different types of DA S and you've got. So first line is typically monotherapy with either methotrexate leflunomide or sulfalazine. Um and then second line would be a combination of those agents. So you could use methotrexate and sulfalazine or methotrexate and leflunomide depending on the patient. Third line is biological, the therapies and methotrexate. So your biological therapies are your TNFL for inhibitors, your anti CD 20 such as riTUXimab. Um but it's always important that biological therapies are, have more and more side effects that are coming out now. So these include, they can increase your risk of infection, increase your risk of certain cancers and they can reactivate latent TB and their, their side effects I think are tested quite a lot in multiple choice questions. So for acute flares of pain, we can use nsaids such as Ibuprofen and Naproxen for for short periods of time. And we can also give um intraarticular steroid injections for patients as well, but that will just help with symptoms and it won't help with the disease process. So for methotrexate, it's a, it's a type of chemotherapy. Originally, it's a folate dehydrogenase, it inhibitor, it, it messes with the metabolism of folate. So it suppresses the immune system and then that suppresses disease activity. Uh things to note for this is it's given once a week. You should co prescribe with five mgs of folic acid on a different day that they take the methotrexate. You cannot have trimethoprim with it because trimethoprim also in um does something to folate metabolism. So they are a no go. So that would be good for your PSA just to know that you should never co prescribe methotrexate with trimethoprim. Some of your key side effects. You've got mouth ulcers, liver toxicity, bone marrow suppression and it can cause really low white cells and then it's tetra IC. So we can't give it to um pregnant people of childbearing age, both men and women and you shouldn't have it for six months before or six months after it needs a washout period. It requires drug monitoring. I always remember these my ay because I thought methotrexate would be a good drug counseling station, but I never got given it, but I do think it's important to know them. So you have your FB CS using these and LFT S done every 1 to 2 weeks until you're on a stable dose. And then it comes to about then it's like monthly and they work you up to a point. But it's a big commitment for patients. Even when it is 2 to 3 monthly, they've still got to go and get a blood test done. So that's also important to know Liam. Um It interferes even with the production of pyrimidine. So it also causes immunosuppression. But in a different way, some of the side effects of no are that increases your BP. It also causes bone marrow suppression. It's also genic and it can cause peripheral neuropathy. So those things might come in, come up in multiple choice questions. The drug which is safe for pregnant women would be cefalo and the main side effect of note that will come up in your exams for that is it can cause your urine to go orange and it can also cause some reversible male infertility. It can lower the male sperm count. But when you stop taking it, it does, it increases again. So it's all right. Um So I would just make sure that you're fami familiar with three of the main ones and maybe knowing what kind of drugs some of the biologics are cause that might come up as well. So, moving on to another inflammatory arthritis. So we've talked about rheumatoid arthritis and now we're gonna talk about psoriatic arthritis. So this is another inflammatory arthritis which is associated with psoriasis. So it occurs in about 10 to 20% of all patients with psoriasis. So you're not definitely gonna get psoriatic arthritis if you have psoriasis, but it is 10 to 20%. So it's quite a lot of them. It's sero negative, which means that there aren't any associated antibodies with it. So we can't look for something in the blood to tell us it's psoriatic arthritis. We need to look for um patches of psoriasis on the skin. So when you're doing your hand exam in um your Rovs, it's really important to make sure that you're looking on the elbows to see if there are any plaques of psoriasis. And that'll be really, that will show an impression that you've thought you're not just looking for arthritis as a whole, you're looking for the different types of it. So with psoriatic arthritis, you again get swollen and tender joints like you would in rheumatoid arthritis, you also get some nail and some finger changes. So you get some nail pitting, which you can see the diagram of there. So that's why it's really important to look at the nails in the hand exam. You get ony sis, which is where the nail bed comes away from the fingernail itself. You get dactylitis, which is inflammation of the fingers and toes, often described as sausage fingers. So these patients will have, they'll appear to be really swollen all of the digits. And then you also get inflamma enthesitis. It's hard to say, which is inflammation at the points where your tendons insert into your bones. So similar to rheumatoid arthritis where you get the inflammation of where the tendons get to the bone, you also get that in psoriatic arthritis as well. Unlike rheumatoid arthritis, it can hurt, it can be asymmetrical or symmetrical. There's lots of different presentations, different types. So if the question is it sounded like rheumatoid arthritis. You've got your swollen tender joints. Um but it's asymmetrical and you, you can think uh psoriatic arthritis because rheumatoid arthritis is often symmetrical. So that's one of the big giveaways for the difference is also with psoriatic arthritis, it can affect your s your axial skeleton and your dis D I PS and your D I PS are not affected in rheumatoid arthritis. So, they're one of the main differences. It can be asymmetrical, it affects your D I PS and your axial skeleton. And then hopefully, in the question, it will tell you that they've got psoriasis and you can be like, ah I know what it is. There's a score that's been developed which can help screen for psoriatic arthritis in patients with psoriasis and that's called a pet score. So that's just important to be able to recognize in a question or we've done a pet score in a patient. And um if they score over three, this can trigger a rheumatology referral. Some of the extra articular manifestations are inflammatory bowel disease and uveitis as well. So lots of um eye pathology can be linked to some arthritis as well. So you also get X ray changes with psoriatic arthritis. You can get per oitis, which is inflammation of the periosteum, which cause a thick gain a thickened and irregular bone outline. You can get destruction of the bone like you do in rheumatoid arthritis and you can sometimes see fixation or fusion of the bones of the joint. But again, this would be at the late and later stages of the disease state. And you can see the the dactylitis, the swelling of the fat fingers on an X ray. So management, again, very similar to rheumatoid arthritis and it will be shared management with rheumatologists and dermatologists. So the dermatologist will provide treatment for the skin and the rheumatologist will help with the joint pain, but sometimes um what helps the skin will also help the joints. So they have to work together to make sure that the patients are on the best care. Nsaids again can be used such as Ibuprofen to help with the pains. It won't help with the disease state, but it will help with the symptoms. You can use DRS like methotrexate leflunomide or sulfalazine to target the disease process itself. Some anti TNF medications are used such as Etanercept and aim and they can be really good for the skin as well. And then I 17 inhibitors such as cum, I've never heard of this. But when I sent my presentation to a rheumatology consultant, they said that they do use this quite a lot. So I've added it in and then we've got reactive arthritis to finish off your inflammatory arthritis is. So this is um joint, a joint inflammation which typically happens in one or more joints and it's usually as a result of an infected trigger. So it's seronegative again, so we can't test for any antibodies for reactive arthritis. It's commonly triggered by gastroenteritis or a sexually transmitted infection. So, in your M CQ, for, you're looking, they've had like two weeks ago, three weeks ago, they've had a bout of food poisoning. So that would be giving you a clearer now, they've got a painful knee and then with sexually transmitted infection you just got a thing, younger adults are more at risk. So if you've got a 21 male or female, are they more likely to have um like an sti which is called the reactive arthritis or a gastroenteritis? So that's a decision you need to make by reading between the lines of the question. So chlamydia is the sr that most commonly causes reactive arthritis because gonorrhea is more associated with septic arthritis and then Campylobacter shigella and salmonella, just some of the types of bacteria which can trigger reactive arthritis. It will present often with a hot, swollen joint and it's usually only one joint. So most of the time with reactive arthritis, you need to make sure that it's not septic arthritis. So it needs to be managed in line with your hospital's hot hot joint policy. But once you've aspirated it and you see there's no active infection and because you can't from the aspirate, you wouldn't be able to grow any bacteria. So that would be what would help you distinguish between reactive arthritis and septic arthritis. Some of the common symptoms with it as well as you can get bilateral conjunctivitis, anterior UTIs, urethritis, and then dermatitis of the head of the penis. So I always remembered it as can't see pee or climb a tree. So they can't climb a tree because they've got painful joints. For example, their knee hurts, they can't see cause of conjunctivitis or anterior UTIs and then difficulty peeing. So urethritis will cause dysuria. So if any parts of the question link, any of those three things, it would make me think straight away about reactive arthritis is associated with the HLA B 27 gene. And this is also associated with some other um rheumatological conditions such as ankylosing spondylitis to associated with psoriasis and inflammatory bowel disease management. So you need to, first of all make sure that it's not septic arthritis because that's very dangerous. And these IV antibiotics straight away, you can treat the uh trigger an infection. For example, if it's chlamydia, you'd want to make sure that the patient has been treated for chlamydia, for example, Doxycycline for seven days. Um usually we don't treat gastroenteritis with uh antibiotics. So, if it was triggered by gastroenteritis, they're most likely better from that by now. So you wouldn't treat it. You can give nsaids such as Ibuprofen. If this isn't helping, you could consider a steroid joint infection, but most people's symptoms will be controlled with simple analgesia like Ibuprofen. Um Another thing to know is it's more common in people with HIV. So you need to make sure that you exclude HIV, in patients presenting with reactive arthritis, especially in different parts of the country, depending on where you work, the rates of HIV will be different. So if you work in an area where it's particularly high areas of HIV, this will be even more important to make sure that you've excluded it because early treatment would be better outcomes for those patients. Um For most people with reactive arthritis, their symptoms will completely resolve within six months and they'll forget that they've ever had it. Um So we've gone over rheumatoid arthritis, psoriatic arthritis and reactive arthritis and how we would distinguish them in a question. Um Does anyone have any questions before I move on? No. Ok. There's some MC Qs that we can work through at the end. I won't talk for the whole time, don't worry. So, moving on to osteoarthritis. So this is what we call the wear and repair now in the joints, not wear and tear as we did before. So it's where your cartilage is damaged from increased use. It can just be every day or you might, might have patients that have been particularly active and the cartilage becomes damaged to a larger extent than can be repaired by your chondrocytes, which are what create your cartilage. So when that balance is tipped towards more towards damage and less towards repair, you start to see symptoms of osteoarthritis, you typically see it more in your bigger joints. So your hips, your spine, your c spine, your lumbar spine, you can also see it in your thumb and your D IP joints. So it typically affects the ones closest to the tip of your finger. Whereas rheumatoid arthritis will be your P IP joints and also your knees. So you get lots of patients, older patients often with, um, knee trouble and that will be osteo osteoarthritis. So x-ray changes. Um so you can get subchondral cysts which are fluid filled, but holes in your bone, you can get osteophytes which are out for like extra growths of bone, like spiky bits of bone that you can see on the X ray. You get a loss of joint space, you can no longer see the gap in the joint in the X ray anymore. And then you get subchondral subarticular sclerosis where the bone density around the joint line becomes more dense to try and um compensate for the lack of cartilage. So you see it becomes more white at the joint edge. You can remember that I think with the acronym loss as well that I loved acronyms in medical school. So you've got loss of your joint space, osteopor, subarticular sclerosis and then sub chondrosis if you wanted an acronym for that. So it ty typically again, presents with joint pain and stiffness. But the difference here is it gets better with rest and gets worse with activity. It doesn't often have stiffness which lasts over 30 minutes in the morning. These patients can get up and get going a bit quicker. They might see they might have bulky bony enlargement. So your osteophytes on the hands or around the joint that's affected, they'll have restricted movement in that joint. You might hear crepitus. For example, if you bend a knee and you put your hand over it. So this is my knee and you extended the knee like that, you'll be able to hear the crepitus. So when you're doing a knee exam, I think that's part of the knee exam is to have a feel for crepitus. And then you also get effusions around the joint. So they'll, they'll look quite swollen hand signs, you get squaring of the thumb and that's different to rheumatoid arthritis where you get Z shaped thumb. So that can help you distinguish patients will often lose function. So they'll have a weak grip. So in the parts of the hand exam where you're testing function, can they pick up um a button? Can they squeeze around your hand? They will often be weaker when they do that. You can see Bouchard's nodes which are on your proximal joints. So you'll see um small nodules and then you've got herb's nodes which are on your distal joints. I tend to remember it because B shots and bone are very similar and I think they're the closer joints. And then herbs, nodes, other ones on the ends. So they can be mistaken for rheumatoid nodules. But you've got to use the other clues to help you come to the conclusion that they're associated with osteoarthritis. But I think most of the times that questions are quite clear, they're leading you down one ro road or the other. The difference with osteoarthritis is that nice? Doesn't recommend any investigations if a patient is over 45 of symptoms, such as joint pain and stiffness with no morning stiffness, I think they've done lots of research and they found that it's very unlikely that these patients have an inflammatory cause for their arthritis. So they don't, they don't need any more investigations to diagnose them with osteoarthritis. So, if you've got a patient who's 65 the, the knee has been hurting, they've got joint pain and stiffness, but it never la it lasts about 10 minutes in the morning, gets worse when they go on a long walk and it's better at rest. You can almost guarantee that it's gonna be osteoarthritis. So that gives the GPS a bit more power to be able to diagnose management wise. This has changed since I started revising for my, um, finals. So when I did it, paracetamol was still first line for it, but now it's changed. So, topical nsaids are first line. So you should try them with an Ibuprofen gel or a diclofenac gel to see if that works. If they've tried that for about 2 to 3 months and they've seen no improvement in their symptoms. We can give oral nsaids, so, such as Ibuprofen, but we must co prescribe that with a PPI such as omeprazole or lansoprazole for gastroprotection. So it's getting the balance right. We don't want patients to be in pain, but we don't want to give them any, um, gastric ulcers at the, at the, at the same time, especially as most patients with osteoarthritis will be older. So it's getting the balance, but that, that's something that GPS do quite regularly. Um So weak opiates and paracetamol are no longer recommended for symptom relief. Um by nice, we can offer things like intraarticular injections. So, steroid injections which go into the joint, which is most effective and these can improve your symptoms up to 10 weeks and then you can do joint replacements. So like knee replacement and hip replacements in very severe cases. But this um would be done by your orthopedic surgeons and not by your rheumatologist. One of the, the big things and the big pushes of osteoarthritis at the moment is the nonmedical treatment is optimizing a holistic management for these patients, making sure that they have the exercises to improve their strength and function with their, for example, with their hands, if they're overweight, encouraging weight loss and that can really help with symptoms, especially if it's like their knees and their hips that are affected and then utilizing occupational therapists to help support patients because they can give adaptations for the homes. You can get special gadgets for the kitchen things, open jars like that if weak um grip strength is weaker. Um So that was my whistle stop tour of arthritis. So hopefully now you'll be able to look at a question, decide one. Is it inflammatory or noninflammatory arthritis and then use the different parts of the question to help you narrow it down. So I've got a few multiple choice questions now to see if we can have a go at that. So before I go on to that, has anyone got any questions that they won't answer and just type them in the chat? I know I talk really quickly. Um So apologies for that. No. OK. So for this question, we've got a 53 year old man who presents to his GP with some joint issues. He has had joint pain and swelling with persistent morning stiffness which lasts for over. Uh Yes, reactive arthritis is also seronegative cause you don't, you can't test for a um antibody for that either. Um So this 53 year old gentleman has joint pain and swelling which is with persistent morning stiffness which lasts for two hours. His joint sys symptoms initially began with his M CPS. So these ones and his P IP joints and his P IP joints and now his wrists are involved. When you examine the patient, he has symmetrical joint, swelling on both sides, they're tender and he has restricted range of motion in his wrists. Also, when you have a look at the hands of some ulnar deviation, what would you expect to see on his X ray? So, to start with, do we think that this is inflammatory arthritis or do we think it's a noninflammatory arthritis if someone could put something in the chest? Yeah, I agree. I think it's an inflammatory arthritis and I think the clues in the question that tell us this is, it lasts more than two hours. Um, he's got persistent morning stiffness as well. So that makes me think straight away. So we've ruled out osteoarthritis. So we don't need to think about that. So, the next part of the question is, what would you expect to see on his X ray? So, for this, we need to decide, do we think it's rheumatoid arthritis? Do we think it's psoriatic arthritis or do we think it's reactive arthritis? So, has anyone got any ideas what they think it would be? Yeah. So, I think it's rheumatoid arthritis as well. So you've got the ulnar deviation and the fact that the M CPS and the P I PS are affected and also the risks. So, from that, then you've got to think, right. What will I see on an X ray? So, from that list, what would, um, what would your guess be if you put AC ABC theory? Ok. Yep. So it's not. Yeah, I agree. I think it's d as well. So, working through the options. So, subchondral cysts are seen in osteoarthritis. So we, we don't think it's that. Yeah, the fact that it's also symmetrical helps us think it's rheumatoid arthritis. If it was asymmetrical, I'd be thinking more psoriatic arthritis, osteoarthritis, um, osteo, I mean, osteophytes are also associated with osteoarthritis, scarring of the thumb as well. You get periarticular erosions in rheumatoid arthritis. And then for a bonus point, where would you see calcification at the joint line? Does anyone know I don't have any prizes but just out of interest? No. So it, it could be pseudo gout. So you can get um like a swollen hot joint with pseudo gout, but that'll be talked about in a different talk. But I just pop that in there to see. Yeah. Pseudogout perfect. So yeah, it was periarticular erosions. So we talked about the fact that it's inflammatory arthritis. The joints involved the examination findings that point us towards ra and then just having to remember the X ray changes which are specific to ra to help us answer the question. So next question is a six year old man presents to the GP with left sided knee pain. He has been diagnosed with osteoarthritis. He's got no past medical history or medications. He was trialed on a topical NSAID for three months, for example, like an ibuprofen gel, but this was not, this did not relieve his symptoms. He would like something to control his pain. Long term. What would the most appropriate next step be? So, for this question, we don't need to work out if it's inflammatory or noninflammatory because they've told us it's osteoarthritis. It's trying to test, do we know the management? So, they've already tried the first line agent, which is a topical NSAID. So, do you guys think it's a, a steroid injection? B Cocodamol? An oral NSAID paracetamol or top another topical NSAID? Yeah. C So yeah, I think it's c you would use a topical NSAID with PPI cover cause they don't use a weak opiate anymore like Cocodamol, we don't use paracetamol. They've already tried a topical NSAID. So trying diclofenac ibuprofen is not gonna make a difference. And before we move to a steroid injection, we should try a um NSAID. So yeah, first key is just knowing the management te um the management steps and when it would be appropriate. So for that question, I also wanted you to think that steroid injections only provide relief for 10 weeks. So it wouldn't be a long term option for him. That would be for more of an acute flare of his pain. I think this is the last question. So a 25 year old man presents the GP with one month history of joint pain. The stiffness is worse in the early morning and improves of use. He has no past medical history he has a family history of psoriasis and vertigo. He smokes around 10 a day and he's recently recovered from a viral throat infection. Two days ago. He has swelling in his left knee and his first and his second M CPS of his right foot and he has tenderness and reduced range of active and passive movement. So, it's a 25 year old man and he's got one month history of joint pain, which is worse in the early morning and improves with you. So, do we think uh last September? Ok. Um Do we think it's inflammatory or noninflammatory? Ok. So it's an inflammatory arthritis. So what? So we've worked that out. So there's lots of different clues in this question. So he has a history of psoriasis and vitiligo. So there's lots of different autoimmune conditions, the fact that he's had a viral infection two days ago, but it's not making us think about it's not a gastroenteritis or anything like that. So, d so yeah, psoriatic arthritis. So we know it was an inflammatory arthritis. He had a family history of vitiligo and psoriasis. So he's got a strong autoimmune history and the fact that the psoriasis in the family, he might develop psoriasis at some point, he um had an asymmetrical joint involvement. So that makes us think it's more likely psoriatic rather than rheumatoid. And then um just the point that the the skin lesions can appear after arthritis depending on the just depends on the patient. So that should never completely guide your answer in a question or when you see a patient. So I think that's everything I have to say about arthritis. If anyone has any more questions, just put them in the chart and I'll do my best to answer them um as well. Well, I hope it was helpful. Yeah. And if you guys fill in the form and you can get your certificate for your portfolios as well. So, thank you.