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Ridgeview and the Ridgeview Continuing Medical Education Program are proud to present the Ridgeview Podcast: CME Series. Quality, portable and on-demand continuing medical education, featuring a variety of our exceptional physicians, providers and other staff from Ridgeview and it's affiliates. Hosting the program are Fred Demeuse, PA-C and Jason Hicks, PA-C. Thanks for tuning-in, downloading and listening! 

 

DISCLOSURE ANNOUNCEMENT 

The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview & Ridgeview Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws. 

It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.

Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.

Dec 4, 2020

This podcast presents, Dr. Michael Edwards, a rheumatologist with Ridgeview Specialty Clinics, who provides a discussion some unique arthritis cases.

Enjoy the podcast!

Objectives:  
  Upon completion of this podcast, participants should be able to:

  • Identify various causes of monoarthritis.
  • Review the evaluation and management of monoarthritis.
  • Recognize that lower back pain may be inflammatory in nature, and how to further evaluate and manage the inflammation/pain.

CME credit is only offered to Ridgeview Providers & Allied Health Staff for this podcast activity. Complete and submit the online evaluation form, after viewing the activity.  Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks.  You may contact the accredited provider with questions regarding this program at  rmccredentialing@ridgeviewmedical.org.

To receive continuing education credit for this activity - click the link below, to complete the activity's evaluation.

 CME Evaluation

(**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) 

DISCLOSURE ANNOUNCEMENT 

The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics.  Any re-reproduction of any of the materials presented would be infringement of copyright laws. 

It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.

Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.

SHOW NOTES:

CASE 1 - Psoriatic Arthritis: 
For our first case, our 77 year old male ended up with psoriatic arthritis. Key points of the work up include ruling out a septic joint, looking for articulation problems or soft tissue concerns like chronic infections, skin lesions, or breakdown and assessing for polyarthritis. Further work up includes sedimentation rate, C-reactive protein, and imaging, starting with x-rays.

Key points of the work up include ruling out a septic joint, looking for articulation problems or soft tissue concerrns like chronic infections, skin lesions or breakdown and assessing for polyarthritis. Further work up includes sedimentation rate, C-reactive protein, and imaging - starting with x-rays.

To tap or not to tap? That is the question for joint complaints. Arthrocentesis through an area of cellulitis or inflamed soft tissue is generally contraindicated. However, if a tap is feasible, the three C's:  culture, WBC count, and crystals should be send. A cell count greater than 10,000 would be indicative of an inflammatory effusion. In the acute setting, the pros and cons should be weighted as to whether or not to inject steroids. If you suspect infection, though, do NOT inject corticosteroids.

Long-term treatment of psoriatic arthritis is individualized to the patient. Some patients manage with methotrexate, while others might need a biologic. Cost is a barrier in prescribing biologics, requiring referrals, and prior insurance authorization. Biologics target a specific part of the immune system. Contraindications would be patients who are already immunosuppressed, have TB, hepatitis or multiple sclerosis, or are in late stages of CHF. Other contraindications include breast, lung or melanoma cancer with a high risk of recurrence. When running a fever or prior to surgery, biologic doses should be delayed or paused.

CASE 2 - Ankylosing Spondylitis: 
In case number 2, a young man with a long history of back pain ended up with ankylosing spondylitis. Again, the history becomes important in the diagnosis, keying us to be suspicious of this patient's chronic pain. For this case, though lab work was normal, an AP x-ray of the pelvis showed narrow and sclerotic sacroiliac joints with erosion.

Like psoriatic arthritis, this diagnosis falls under the category of seronegative spondylarthropathy. When tested, the patient will not have antibodies or positive rheumatoid factor. It is a reactive condition: sacroiliitis causes inflammatory changes and therefore pain. Inflammatory bowel conditions like Crohns and Ulcerative colitis fall into this same family of reactive conditions.

First line treatment for ankylosing spondylitis is NSAIDS taken on a scheduled basis to protect the joints. Long term management includes physical therapy and back education. Biologics can be used for pain refractory to NSAIDS.

This pain can go undiagnosed for years, and cause irreparable fusion of the spine, otherwise known as a bamboo sign as seen on x-ray. Again, a thorough history is key to catching and diagnosing these patients early, and preventing long-term complications.

CASE 3 - Gout: 
Out last patient is a woman with a swollen knee, normal wbc, and elevated sed rate. Due to her history, and RA flare up would be considered in the differential, but unlikely due to a monoarthritic presentation. Following a similar work up as the first two cases, labs and imaging are obtained and the knee is tapped. The three C's mentioned earlier:  culture, WBC count  and  crystals are sent and the results are positive for needle-like crystals which are negative birefringent when examined with polarizing microscopy. The patient has gout.

Treatment includes NSAIDS like Naprosyn or indomethacin. In an acute setting, oral steroids can be prescribed. Dosing for gouty monoarthritis is 20-30mg for 3-5 days. For patients already on baseline steroids, include a steroid taper back to baseline.

Additional work up could include uric acid levels. While not diagnostic, a uric acid greater than 9 may help identify patients at risk for future episodes. If the patient has 2 or more gout attacks a year. Allopurinol can be prescribed.

CONCLUSION: 
To sum up all our cases today; a thorough history and exam are critical, keep the differential broad, and management is weighing the pros and cons of NSAIDS, steroids and whether or not to tap that joint. Septic arthritis can not be overlooked. Early recognition and diagnosis is key.

Thanks for listening.