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2 RHEUMATOLOGY UPDATE 2016– Part IOverview and Differential Diagnosis Mark A. McQuillan MD FACP SFHM June 15, 2016

3 DISCLOSURES None

4 Acknowledgements Blake Roessler MD David A. Fox, Division ChiefW. Joseph McCune Ruba Kado MD Josef Holoshitz MD UMHS Rheumatology William Repaskey MD MFH Brian Mandell MD CCF and SHM UpToDate UM Pharmacy Drug Information Service

5 Some Shared Goals Support you in providing optimal care What is new in 2016? Audience engagement Who and when to refer Timely access to “Musculoskeletal professional” Affordability You know a LOT of Rheumatology & MusculoSkeletal Differential Diagnosis— mono vs polyarth. regional patterns IgG4 subclass disorder Anti-synthetase disorder (Nomenclature) Hard Cases Controversies: Opiates March 2016 unproven therapies Others?

6 This Audience: Providers of varied backgroundsOutstanding skill and, experience, & motivation Care passionately for your patients and families and community Seek balance and meaning and resilience Lifelong learners Striving Therefore DESERVES CURRENT info & updates Take home points “Top Ten” Flexibility Agility Terrific references

7 Sessions in five parts I-overview and Differential Diagnosis and What’s New in 2016!? II-Laboratory Testing, Interpretation, news! III-News for Gout, Pseudogout, Crystalline arthropathy IV-News for Knee Disorders: “The Bum Knee Revisited” (a la James Peggs MD) V-News for Shoulder Disorders: “Doc my wing is killing me every night!” --

8 TOP TEN topics from five sessions…Opiate guidelines 3/2016 Unproven therapies Costs and affordability IgG4 subclass disorder Anti-synthetase disorder Gout treatment news Knee surgery evidence Preventing ACL injuries Shoulder surgery evidence Shoulder sleep position

9 #1--Opiate prescribing guidelines March 2016?pendulum Role of ketorolac, tramadol, gabapentin vs pregabalin 3 days vs 7 days Naloxone Buprenorphine Naltrexone Naltrexone long acting injection Direct marketing Local experiences and future?

10 #2-Unproven therapies Examples Kinesio-tapeSham arthroscopy/meniscectomy Prolotherapy Platelet-rich plasma Stem cell therapies (more on these in Knee and Shoulder sessions) Again, direct marketing

11 #3-Cost Information UM Pharmacy Drug Information Service 734-936-8200Specific inquiries on Lidoderm patches, Febuxostat, colchicine, Lesinurad, Etanercept, Adalumimab, Anakinra, Updated Subject to insurance coverages, prior authorization, local factors, in or out of network, Explanation of tiers etc. University of Mich HR website hr.umich.edu/prescription-drug- plan Also Effective June 1, 2016

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13 “Musculoskeletal Professional”Best fit for needs and access ? Local trends: Primary Care SportsMed Orthopedics Rheumatology Transitions (inpatient to outpatient) Costs for patients

14 Physical Findings From Latin: Looking for obvious inflammation CalorDolor Rubor Tumor Functio Lasse (Loss of function)/ decr. ROM Looking for obvious inflammation

15 Diagnostic CategoriesEtiology Location (exercise/ audience participation) Number of joints Mono-arthritis Poly-arthritis Pauci/oligo-arthritis Symmetry

16 Diagnosis by Etiology Crystalline Infectious Degenerative TraumaRepetitive Trauma/cumulative Inflammatory Metabolic Neoplastic

17 Diagnosis by Location Cranial Vertex to the Big Toe (1st MTP)List (exercise) List 2-3 most common or important afflictions for each joint region Don’t forget TMJ, S-C joint, cricoarytenoid, others… Peculiar predilections in addition to above: Pinna, thyroid cartilage, nasion Elbow, ulna, Symphysis pubis, Sacro-iliac (and unreliability of physical findings) Trochanteric bursitis, ilio-tibial band, TFL, pyriformis Anserine bursitis

18 Rheumatologist’s View of the UniverseWhiteboard Algorithmic approach STR OA Degen Crystalline Infectious Degenerative Inflammatory Symmetry Oligo SSA RA SLE SD/PSS MCTD Muscle Vasculitis Misc.

19 STR Soft Tissue RheumatismFM RMFPS RSD CTS Overuse Athletic Industrial PMR GCA OA Degen Endocrine

20 Seronegative SpondyloarthropathyAnkylosing Spondylitis Psoriatic Arthritis (5 subtypes) Enteropathic arthritis Reactive Arthritis Behcet’s Whipple’s Disease

21 Miscellaneous Rheum Diagnoses“Great Imitators” Sarcoidosis FMF FUO Septic Arthritis “Great Imitators” SBE TB Syphilis Lymphoma Lyme Disease HIV/AIDS

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