Where do the large hepatic cells come from and how does the material get inside?
Response: Those hepatics cells come from mice but nowadays they are cloned and synthetized in labs. The material is pushed inside by the technician.

Why does the Rheum referral form ask for an ANA? It kinda forces a family physician to feel that it is needed.
Response: Normally we ask for it only for Raynaud and vasculitis. It doesn’t appear in the pre-requisite tests for arthritis suspicion.

In a patient who complains of polyarthralgia (ex: right shoulder, left knee, neck, back, fingers, toes) that appears most likely to be OA, do you recommend to Xray all those joints?
Response: Not necessarily, I do mostly the hands because that is where we find most specifics findings of OA vs other kind of suspicion findings. In that case I would probably do the hands, cervical and lumbar spine and if everything points to OA tell the patients that the other joints are most probably OA too.

Can you explain why my patient with lupus gets ANA every year ordered by specialist?
Response: Shouldn’t be done. It is not appropriate. However, we check for dsDNA, complement levels and sometimes other auto-antibodies levels quite regularly, but not the ANA. If it is positive once, it is going to stay that way. Same for RF and antiCCP in RA. We test once (sometimes twice at a couple of years intervals when we want to see if becomes + over time) and then we’re done.

Lots of people think they have Raynaud’s but have only mild symptoms. At what point is it useful to do an ANA, and at what point is it not even Raynaud’s?
Response: I agree. Patient are really difficult to questions sometimes. I really insist on the changing of colors and the clear delimitation of the color changes on the fingers especially. Not pain or cold in the cold, really objectifiable changes of color than even other people see. If just mild blueish discoloration = acrocyanosis and I close the case. Clear white discoloration of some or all fingers: I do an ANA and if neg I stop there.

I received an ANA result ( I did not order it!) on a woman with unclear arthralgia, myalgia and the result came back positive 1/640 and the comment was " possible AC-18 : cytoplasmic discrete dots". What does this mean?
Response: Hi! There are a myriad of reasons why a patient might have cytoplasmic antibodies, most of those aren’t rheum diseases. This situation is the perfect example as to why we don’t ask for an ANA in a patient with non specific sx :) Unfortunately will have to be sent in rheum to investigate further and make sure it isn’t a mild form of myositis. Please check CK beforehand it is going to help to exclude that dx.

Why an ANA in Reynaud's when only symptom is whitening of fingers in cold winters without arthritis?
Response: Only to make sure it is a primary Raynaud.

What’s overlap syndrome? What’s positive in this?
Response: The overlap syndrome means a combo of multiple auto-immune disease in the rheum setting, for example a patient with lupus and scleroderma (has + antibodies for both diseases and have sx of both too…). Happens with lupus and RA (we call that Rhupus), Scleroderma and DM/PM is another classical overlap syndrome.

How do you make a diagnostic of sero-negative arthritis? is it a real arthritis?
Response: Clinical exam et compatible sx. 60% of RA patients are seronegative patients and those patients most of the time have normal blood tests and radiographs. To have a dx of seronegative RA the patient must have synovitis at the physical exam.

If Raynaud and ANA + but low titer, homogenous or speckled -> does it need to be repeated down the road?
Response: No.

Should you work up raynaud’s even in a young healthy patients?
Response: You do an ANA, if negative we stop there and reassure patient. Some doc prefer a wait and see approach and I think it is adequate too (ex 20 yo female with family history of primary Raynaud, no sx of CTD whatsoever…)

Which Raynaud should be referred to rheum? If we have Raynaud with ANA positive but NOT centromere pattern, should we still refer to rheum?
Response: Yes :) Raynaud with ANA+ = rheum consult

Do you suggest doing a workup for chillblains?
Response: If classic in the young female patient then no. Chillblains is not associated with CTDs.

Do you ever do vascular testing for Raynaud?
Response: If we think the cause of Raynaud for a given patient is vascular we refer them to internal medicine vascular clinics.

Where to refer for capillary testing?
Response: Send in standard rheum via CRDS and the rheum is going to send for the capillaroscopy at his referral place of choice.

When you refer to Raynaud's is it just of fingers, or also of toes (chillblains)?
Response: Raynaud can affect fingers, toes, tip of the nose, etc. Chillblains (perniosis) is a blue/burgundy decoloration usually of only the toes.

How can you differentiate Raynaud vs acrocyanosis?
Response: Raynaud - at least 2 different change of colors - white/red/blue with clear delimitation. Acrocyanosis - blueish discoloration of fingers, usually not clearly defined.

When do we start secondary osteoporosis workup?
Response: https://osteoporosis.ca/2023-clinical-practice-guideline/

Fibromyalgie with persistent elected CRP
Response: Make sure that there isn’t another cause for elevated CRP (ex overweight or obesity, concommitant hematologic disease, NASH, liver disease, etc).

For GCA, if CRP or ESR elevated, should be referred for possible GCA, what increase is considered significant under what level can r/o GCA if slightly elevated?
Response: In the presence of characteristics symptoms, even a mild elevation can be suspicious, however most of the PMR and GCA patients will have a really elevated ESR and CRP, sometimes even over 100.