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Arthritis, general [keywords]
- Recurrent DKA in a Previously Healthy 26-Year-Old Navajo Male Leading to a Diagnosis of Acromegaly. [JOURNAL ARTICLE]
- Chest 2014 Oct 1; 146(4_MeetingAbstracts):277A.
Critical Care Global Case ReportsSESSION TYPE: Global Case ReportPRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PMINTRODUCTION: Acromegaly, a clinical disorder caused by excess growth hormone (GH) secretion, is an uncommon adult condition with an estimated annual incidence of 3 per million. It is an often missed diagnosis, and delay in diagnosis leads to increased morbidity and mortality. We report a case of a 26 year old previously healthy Navajo male who was admitted to the intensive care unit (ICU) in an Indian Health Service (IHS) hospital 3 times in 6 months for diabetic ketoacidosis (DKA) before the diagnosis of acromegaly was made.CASE PRESENTATION: A 26 year old athletic Navajo male had no previous medical history until his first of 3 admissions within 6 months to an IHS hospital ICU for DKA. Each admission his presented with fatigue, headache, polyuria and polydipsia. His lab studies were notable for blood sugar > 500, severe anion-gap metabolic acidosis and ketones in his urine and blood. His DKA resolved each admission with IV insulin, IV fluids and electrolyte repletion. At each hospital discharge, his outpatient insulin dosage was increased. In 6 months his insulin needs went from 0 to 120 units/day. Acromegaly was clinically suspected due to the patients facial features including a wide nose, prognathism, frontal bossing and macroglossia. In the preceding 6 months the patient also noted an increase in shoe and hat size, decrease in libido and enlarging hands. Left homonymous hemionopsia was present. Insulin Growth Factor 1 (IGF-1) level was 539 ng/mL (upper limit of normal is 373 ng/mL ). Given his acromegalic physical features and IGF-1 level, an oral glucose tolerance test (testing for GH suppression) was not obtained and an MRI revealed a 3.3 x 3 CM lobulated pituitary mass displacing the optic chiasm. Further testing revealed central hypothyroidism and hypogonadism. He was referred to a tertiary center for surgery.DISCUSSION: Acromegaly is an uncommon disorder of GH excess most often arising from a pituitary tumor. The diagnosis is often missed because clinical features of the disease, such as fatigue, hypertension, insulin resistance, sleep apnea and arthritis, are common in the general population.1 In addition, the disease is difficult to detect because the condition usually develops insidiously, with a mean time from symptom onset to diagnosis of 7.7 years.2 Even in the presented patient, with acromegalic signs and symptoms developing relatively rapidly, it took 3 separate hospitalizations before the diagnosis was suspected. Specific history such as slowly increased hat and shoe sizes are unlikely to be volunteered by a patient. Facial features of the disease often occur over years and may not be noticed by patients themselves. Untreated disease leads to decrease in life expectancy by ten years, with increasing morbidity and mortality seen with delays in diagnosis.3 Clinicians should investigate further when any clinical suspicion for the disease arises, regardless of the reason for patient presentation.CONCLUSIONS: Acromegaly is an easily missed diagnosis with nonspecific clinical features that often present insidiously. Clinicians should consider testing patients for the disease when any clinical suspicion arises, regardless of the patient presentation. By reducing the time from symptom onset to diagnosis, significant morbidity and mortality from the disease can be mitigated.Reference #1: Reddy R, Hope S and Wass J. Acromegaly: Easily Missed? BMJ 2010; 341:c4189. Reference #2: Holiday, IM, Rajasoorya RC and Gamble GD. Factors influencing mortality in acromegaly. J Clin Endocrinol Metab 89 (2): 667-674. Reference #3: Rajasoorya C, Holdaway IM, Wrightson P, Scott DJ, Ibbertson HK. Determinants of clinical outcome and survival in acromegaly. Clin Endocrinol 1994;41:95-102.DISCLOSURE: The following authors have nothing to disclose: Drew Harris, Sharon DrakeNo Product/Research Disclosure Information.
- Cardiovascular risk factors and cardiovascular diseases in patients with moderate to severe psoriasis under systemic treatment. PSO-RISK, descriptive study. [JOURNAL ARTICLE]
- Eur J Dermatol 2014 Oct 21.
Background: The prevalence of cardiovascular risk factors (CVRF) in psoriasis has not been studied in large Spanish samples. Objective: To assess the prevalence of major CVRFs in psoriasis patients requiring systemic treatments. Material and Methods: Cross-sectional study in psoriasis patients from 33 hospital dermatology offices throughout Spain. Blood pressure (BP) was measured and a fasting lab test was performed. Each CVRF was diagnosed according to the recommendations of international societies. Results: In 368 patients (mean age 48 years old, 36% women), 80.2% had at least one CVRF. The prevalence of each CVRF was similar in men and women and slightly higher in patients with psoriatic arthritis and in patients with a history of more severe disease. The percentage of patients treated with drugs to control CVRF was low (∼50% of those with each CVRF). A total of 20.7% had experienced some cardiovascular disease (CVD) episode. Conclusion: The prevalence of CVRF was high, higher than in the general Spanish population, and 20% had already suffered CVD. However, the percentage with drug treatments for CVRF was low.
- Pelvic peritonitis during biologic therapy for rheumatoid arthritis: a case report and review of the literature. [Journal Article]
- Springerplus 2014.:567.
Infections are recognized as major complications during therapy with biologics and other immunosuppressant drugs. The respiratory tract, bone, joint, skin, and soft tissues are well known sites of infection in patients with rheumatoid arthritis (RA) treated by biologics or other immunosuppressants. It is known that patients with intra-abdominal infections may develop tuberculous peritonitis during biologic therapy. However, non-tuberculous pelvic peritonitis is rare.A case of a 46-year-old patient with RA developed pelvic peritonitis during therapy with MTX, tacrolimus (TAC), and golimumab (GLM). The patient visited our hospital due to a fever and general malaise. Physical findings included lower abdominal tenderness and rebound tenderness. Abdominal computed tomography (CT) images showed an intrauterine foreign body and ascites. The contraceptive ring was removed. Streptococcus agalactiae and Streptococcus constellatus were cultured from the removed contraceptive ring. She was started on an antimicrobial agent, flomoxef (FMOX), at 2 g/day. The FMOX dosage was increased to 3 g/day from the 3rd day of disease and continued for 10 days. Her fever disappeared from the 4th disease day, and her inflammatory response then gradually decreased. No exacerbation of symptoms occurred even after the FMOX treatment was stopped, and the patient was discharged on the 14th disease day.MTX and biologics were being administered at the time of onset of peritonitis. The peritonitis was diagnosed on the basis of the gynecological evaluation and CT imaging findings that were typical of peritonitis. The patient was in an immunosuppressed state during administration of anti-rheumatic drugs, and the peritonitis was thought to have developed due to an ascending infection via the long-term presence of the intrauterine contraceptive ring which had an attached string.Before starting biological agents, patients must be questioned regarding the presence of an intrauterine foreign body.
- Differential regulation of c-Met signaling pathways for synovial cell function. [Journal Article]
- Springerplus 2014.:554.
We previously demonstrated that blocking the hepatocyte growth factor (HGF) receptor, c-Met, using a HGF antagonist, NK4, inhibited arthritis in a rheumatoid arthritis (RA) model mice. In the present study, we investigated the role of c-Met signaling in synovial cell function. We demonstrated that synovial tissues from RA patients and MH7A cells, a human RA synovial cell line, expressed HGF and c-Met. HGF and c-Met expression in RA synovium was increased compared to osteoarthritis synovium suggesting increased c-Met signaling in RA synovial cells. The c-Met inhibitor, SU11274, inhibited ERK1/2 and AKT phosphorylation in HGF-stimulated MH7A cells. MEK and PI3K inhibitors suppressed production of matrix metalloproteinase-3 (MMP-3), vascular endothelial growth factor (VEGF) and prostaglandin E2 (PGE2) by MH7A cells, suggesting that c-Met-MEK-ERK and c-Met-PI3K-AKT pathways are involved positively regulating MH7A cell function. Although SU11274 suppressed MMP-3 and VEGF production it enhanced PGE2 production by MH7A cells suggesting that negative regulation by c-Met signaling, independent of the MEK-ERK and PI3K-AKT pathways, is involved in PGE2 production. Blocking c-Met signaling may be therapeutically useful to inhibit angiogenesis and cartilage and bone destruction by inhibiting VEGF and MMP-3 production, while enhancing PGE2 production in synovial cells in RA.
- An evaluation of risk factors for major adverse cardiovascular events during tocilizumab therapy. [JOURNAL ARTICLE]
- Arthritis Rheumatol 2014 Oct 20.
Objective. To explore associations of baseline and on-treatment lipid levels, inflammation, and rheumatoid arthritis (RA) disease activity with risk for major adverse cardiovascular events (MACE) in tocilizumab-treated RA patients. Methods. In retrospective post hoc analyses, data were pooled from 3986 adults with moderate to severe RA administered ≥1 dose of tocilizumab 4 or 8 mg/kg intravenously every 4 weeks in randomized controlled trials and extension studies. Cox proportional hazards modeling was used to evaluate associations among baseline characteristics and posttreatment initiation variables (week 24) and change from baseline to week 24 disease activity and laboratory values, with risk for future MACE during extended follow-up. Results. There were 50 independently adjudicated cases of MACE during 14,683 patient-years (PY) of follow-up (0.34 MACE/100 PY). At baseline, age, history of cardiac disorders, disease activity score using 28 joints (DAS28), and total cholesterol/high-density lipoprotein ratio were independently (P<0.05 for all) associated with MACE in multivariable models. On treatment, higher DAS28 scores and swollen and tender joint counts at week 24 were associated with future MACE. In separate models, greater reductions in DAS28 score and joint counts from baseline to week 24 were inversely associated with future MACE; changes in lipid parameters were not statistically significantly associated with risk for MACE. Conclusion. As in the general population, an association was observed between baseline total cholesterol/high-density lipoprotein ratio and increased risk for MACE. Risk for on-treatment MACE, however, was found to be associated with control of disease activity but not lipid changes. Larger studies are needed to confirm these findings. © 2014 American College of Rheumatology.
- Peripheral CD5(+) B-cells in ANCA-associated vasculitis. [JOURNAL ARTICLE]
- Arthritis Rheumatol 2014 Oct 20.
Objectives: Conceptualized as possible surrogates for regulatory B-cells (Bregs), we aimed to determine the utility of CD5(+) B-cells as biomarkers in ANCA-associated vasculitis (AAV) Methods: Absolute and relative (%) numbers of CD5(+) B-cells (explanatory variables) were measured longitudinally during 18 months in 197 patients randomized to receive rituximab (RTX) or cyclophosphamide followed by azathioprine (CYC/AZA) for the treatment of AAV (RAVE trial). Outcome variables included disease activity, responsiveness to induction therapy, relapse, disease severity, and in RTX-treated patients, relapse-free survival according to % CD5(+) B-cells upon B-cell repopulation. Results: CD5(+) B-cell measures were comparable between groups at baseline. After an initial decline, absolute CD5(+) B-cell numbers progressively increased in the RTX arm, but remained low in CYC/AZA-treated patients. In both groups, % CD5(+) B-cells increased during remission induction and slowly declined thereafter. During relapse, % CD5(+) B-cells correlated inversely with disease activity in RTX-treated patients, but not in subjects who received CYC/AZA. No significant association was observed between CD5(+) B-cells and induction treatment failure or disease severity. The dynamics of the CD5(+) B-cell compartment did not anticipate relapse. Following B-cell repopulation, % CD5(+) B-cells did not predict time to flare in RTX-treated patients. Conclusions: Peripheral % CD5(+) B-cells might reflect disease activity in RTX-treated patients. However, the sole staining for CD5 as a putative surrogate marker for Bregs did not identify a subpopulation of B-cells with clear potential for meaningful clinical use. Adequate phenotyping of Bregs is required to further explore the value of these cells as biomarkers in AAV. © 2014 American College of Rheumatology.
- Infection is the leading cause of hospital mortality in patients with dermatomyositis/polymyositis: Data from a population-based study. [JOURNAL ARTICLE]
- Arthritis Care Res (Hoboken) 2014 Oct 20.
Dermatomyositis (DM) and polymyositis (PM) are debilitating inflammatory myopathies associated with significant mortality. We evaluated the relative contribution of infection to hospital mortality in a large population-based study of individuals with DM/PM.Data derive from the 2007 to 2011 Healthcare Cost and Utilization Project National Inpatient Samples and included all hospital discharges that met a validated administrative definition of DM/PM. The primary outcome was hospital mortality. Variables for infections and comorbidities were generated from discharge diagnoses using validated administrative definitions. Logistic regression was used to investigate the relationship between infection and mortality in individuals with DM/PM, adjusting for sociodemographics, utilization variables, and comorbidities. Relative risks were calculated to compare the overall prevalence of specific infections and associated mortality in DM/PM hospitalizations with those seen in the general hospitalized population.15,407 hospitalizations with DM/PM met inclusion criteria for this study and inpatient mortality was 4.5% (700 deaths). In adjusted logistic regression analyses, infection (OR 3.4, 95% CI 2.9-4.0) was the strongest predictor of hospital mortality among individuals with DM/PM. Bacterial infection (OR 3.5, 95% CI 3.0-4.1), comprised primarily of pneumonia and bacteremia, and opportunistic fungal infections (OR 2.5, 95% CI 1.5-4.0) were independently associated with hospital mortality. The overall burden of infection in hospitalizations with DM/PM was significantly increased in comparison with the general hospitalized population (RR 1.5, 95% CI 1.4-1.6).Among hospitalized individuals with DM/PM, infection is the leading cause of mortality. Strategies to mitigate infection risk in both the clinic and hospital settings should be evaluated to improve disease outcomes. © 2014 American College of Rheumatology.
- [Septic arthritis in adult patients in a general hospital in Chile]. [English Abstract, Journal Article]
- Rev Chilena Infectol 2014 Aug; 31(4):435-43.
Septic arthritis is an infrequent condition of prolonged morbidity and there is no previous publications in Chile that allow orientate therapy.To characterize a group of adult patients with septic arthritis confirmed by culture.Descriptive study of a case series.From 2003 to august 2013, 24 patients with 25 events of septic arthritis were identified in a general hospital. Mean age was 68.3 years old (range 24-94). Predisposing conditions were harbored by 91.7%. Predominant clinical manifestations were pain (92%) and impaired joint movement (95.7%). Fever was present in 64%, hypotension in 28% of events, and C-reactive protein > 100 mg/L in 90.6%. Gram positive cocci were the most frequently isolated microorganisms (81.5%), predominating S. aureus (48.1%), and with 4 isolates methicillin resistant isolates (26.7%). Resistant isolates trend to be associated with previous surgery (p = 0.055) and all cases caused by non-fermentative Gram negative bacilli had recent hospitalization or surgery, a feature that did not reach a significant difference. Nine events were associated to bacteremia (36%). Outcome analysis indicated 32% of events with full recovery, 28% with a favorable evolution, 20% with therapy failure and 16.7% patients that died. A total of 24% of the series remained with significant sequels.Septic arthritis is an infrequent disease that affects in most cases patients with predisposing conditions. Associated symptoms include pain and impaired joint movement, sometimes fever, hypotension, positive blood cultures and frequently a C-reactive protein > 100 mg/L. Predominant agents are Gram positive cocci, specially S. aureus, including methicillin resistant isolates. Case-fatality ratio, treatment failure and sequels are important.
- Acute Gout in Hospitalized patients in Sarawak General Hospital. [JOURNAL ARTICLE]
- Med J Malaysia 2014 Jun; 69(3):126-128.
we performed a prospective study of all hospitalized patients with a diagnosis of Gout in Sarawak General hospital from 1st July 2011 to 1st July 2012. There were a total of 126 patients in our study of which 112 (88.9%) were males. The majority of our patients were from the indigenous populations (71.7%). They have a mean age of 60.0 ± 14.2 years. Most of our patients were overweight (68%) with comorbities of hypertension (78.6%), Chronic Kidney Failure (48.4%), Type II diabetes Mellitus (30.2%), dyslipidemia (27.8%) and Ischaemic heart disease (11.9%). Polyarticular gouty arthritis was the main presenting pattern during hospitalization (88.1%). The mean length of stay for our patients was 9.8 ± 6.0 days which was significantly longer than the mean length of stay for other patients without gout (p<0.05). Only 17 patients had gout on admission and the majority developed gout during hospitalizations. Our patients were admitted respectively for medical problems (45.4%), surgical problems (28.6%) and orthopaedic problems (9.2%). Colchicine (73.8%) and steroid (40.5%) were the main stays of treatment for our patients. Our hospitalized gout patients were complicated patients with multiple comorbidities.
- The prevalence of fibromyalgia in the general population - a comparison of the American College of Rheumatology 1990, 2010 and modified 2010 classification criteria. [JOURNAL ARTICLE]
- Arthritis Rheumatol 2014 Oct 16.
Background The ACR 1990 fibromyalgia classification criteria are based on widespread pain and tenderness. In 2010 new criteria were proposed, focusing more on multiple symptoms and these, latterly, were modified to require only self-report. The current study aimed to determine the population prevalence of fibromyalgia, and to compare differences in prevalence, using the alternative criteria. Methods A cross-sectional survey was conducted. Questionnaires, including items on pain, symptoms, and rheumatological diagnoses, were mailed to 4600 adults in northeast Scotland. Participants with chronic widespread pain, or who met the modified 2010 criteria, plus a sub-sample of other participants were invited to a research clinic. Attendees completed an additional questionnaire, and a rheumatological examination, and were classified according to the ACR 1990, 2010 and modified 2010 criteria. The prevalence of each was calculated, weighting back to the target population by age, sex and area of residence. Results Of 1604 questionnaire participants, 269 were invited and 104 (39%) attended the research clinic, of whom 32 (31%) met ≥1 of the fibromyalgia criteria. The prevalence of fibromyalgia using the 1990, 2010 and modified 2010 criteria was 1.7% (95%CI: 0.7-2.8%); 1.2% (0.3-2.1%); and 5.4% (4.7-6.1%), respectively. The female/male ratio was 13.7 to 4.8 and 2.3, respectively. Conclusion Fibromyalgia prevalence varies with the different classification criteria - specifically, prevalence is higher, and a greater proportion of men are identified, with the modified 2010 criteria, compared to those requiring clinician input. This has important implications for the use of the new criteria both in research and in clinical practice. © 2014 American College of Rheumatology.