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Inflammation is a trigger of coronary artery disease in patients with rheumatoid arthritis Patients with rheumatoid arthritis are characterized by an increased risk of ischemic heart disease, compared with the general population. This elevated risk is occurred at the very early stages of the disease. By the time patients seek medical attention for their arthritis, they already have a several-times greater prevalence of prior hospitalization for acute heart attacks and electrocardiogram evidence of silent infarctions than arthritis-free matched controls, stated Dr. Gabriel, professor of medicine and epidemiology at the Mayo Clinic, Rochester, Minn. The retrospective postmortem study was performed by Dr. Gabriel and colleagues as a part of the Rochester Epidemiology Project. It included 41 rheumatoid arthritis patients who died at a mean age of 79 years, 25 with known cardiovascular disease. They were matched by age, gender, and history of heart diseases to 82 controls. Dr. Gabriel also presented highlights of a Rochester Epidemiology Project study demonstrating that the increased risk of ischemic heart disease in patients with RA precedes a diagnosis of the rheumatologic disease. The retrospective study involved 603 patients diagnosed with rheumatoid arthritis at a mean age of 58 years, and 603 matched non-arthritic controls. A detail analysis of all medical records from age 18 years on demonstrated that the rheumatoid arthritis group already had a threefold greater history of acute heart attacks by the time their joint disease was diagnosed. Coronary disease among patients with rheumatoid arthritis quite frequently presented atypically, with less chest pain. During a mean of about 15 years follow-up post rheumatoid arthritis diagnosis, the rate of sudden cardiac death was 35 cases per 10,000 person-years in the arthritis group, and 18 per 10,000 in arthritis-free controls. The rate of silent heart attacks was also greater in the rheumatoid arthritis group. Of interest to report, that seven other population-based studies published in the last 5 years have consistently shown an approximately two-times increased risk of coronary artery disease in association with rheumatoid arthritis. Celiac disease is undiagnosed in over 95% From Rheumatology News Celiac disease affects over 1% of people in the United States, but only about 3% of sufferers of this disease are being diagnosed. A shift to the silent form of celiac disease. “The patients and the doctors are on the wrong pages in the [medical] textbooks,” said Dr. Green, a professor of medicine from Columbia's Celiac Disease Center. “The patients got it wrong in that they forgot to get diarrhea, and the doctors got it wrong in that they thought that all patients with celiac disease had to have diarrhea.” In fact, he explained, only about half of celiac disease patients present with diarrhea. So-called silent modes of presentation include bone disease, anemia including iron-deficiency anemia, weight loss, dermatitis herpetiformis, psoriasis, and chronic urticaria. “There are increased rates of allergic reactions and there are oral manifestations [in the form of] dental enamel defects such as yellow spots, white spots, and brown spots,” he added. High-risk groups include patients with a family history of celiac disease, patients with type 1 diabetes, and those with primary biliary sclerosis and Sjögren's syndrome. Physicians are failing to recognize celiac disease. Physicians “are taught that it's a rare condition,” he said, when in fact it is not and the clinical manifestations vary widely. “That's one of the reasons why there is such a low rate of diagnosis, because no one set of doctors [is] looking at all of those patients.” Lack of support from the pharmaceutical industry. “We know that over 80% of medical research is financed by the pharmaceutical industry, and by far the bulk of postgraduate education is financed by the pharmaceutical industry,” said Dr. Green, who is also a professor of medicine at Columbia. Social phobia in celiac disease Patients with celiac disease have a high prevalence of anxiety and depression. Although social phobia is included among the anxiety disorders, its presence in celiac disease has never been investigated. Dr. Addolorato and his co-workers from Catholic University of Rome, Italy, have evaluated social phobia among celiac patients. A total of 40 celiac patients were consecutively enrolled in the study. Fifty healthy subjects were studied as controls. Results of the study showed that percentage of subjects with social phobia was significantly higher in celiac patients than in controls (70% versus 16%; p<0.0001), and also when the more severe generalized form was considered (15.0% versus 0%; p=0.006). The percentage of subjects with social phobia was not statistically different between newly diagnosed subjects and patients on a gluten free diet (73.3% versus 68%; p: NS), nor considering its generalized form (7.0% versus 20%; p: NS). Current depression was present in a significantly higher percentage of celiac patients in comparison with controls (52.5% versus 8%; p<0.0001). A direct correlation between social phobia and current depression was found in celiac patients (r=0.582; p<0.0001). Despite the limited number of cases evaluated, the present study showed a significantly higher prevalence of social phobia in celiac patients compared with in healthy subjects. Future studies are needed to clarify the possible social phobia-induced risks such as school and/or work failure in celiac patients. Long term effects of intra-articular botulinum toxin A for refractory joint pain From Neurotoxicity Research The pilot clinical trial from University of Minnesota Department of Medicine was focused on potential use of Botulinim toxin type A known as BOTOX™ in patients with refractory joint pain who had failed treatment with oral and/or intra-articular medications. Eleven patients with chronic arthritis and moderate to severe refractory joint pain in 15 joints were enrolled into the trial. The use of BoNT/A to treat joint pain is considered as a non-FDA approved "off label" treatment with potential side effects. After a detailed explanation of the joint injection procedure, signed informed consent was obtained for the procedure. Fifteen joints were injected with BOTOX™ (Allergan, Inc): six lower extremity joints (3 knees, 3 ankles) with 25-50 units and nine shoulders with 50-100 units. Patients were followed for one year or longer. Maximum relief of pain was measured by comparing baseline pain on a numeric rating scale (0-10) to pain at the time of maximum relief (paired t-test). Maximum improvement in function was assessed using paired t-tests for improvement in active flexion and abduction for the shoulder joint, and by the time to perform sit to stand ten times (the timed stands test, TST) for the lower extremity joints. Two patients were female and nine were male, aged 42-82 years. Five had osteoarthritis, five had rheumatoid arthritis and one had psoriatic arthritis. All patients were on analgesic and/or anti-inflammatory medications and all joints had previous intra-articular steroid or viscosupplement injections with inadequate or unsatisfactory benefit. A clinically and statistically significant improvement was noted after BOTOX™ injections. The mean maximum decrease in lower extremity joint pain was 55% (p =0.02) and the 36% (p =0.044) improvement in the Timed Stands Test was noted at four to ten weeks after injection. There was a 71% mean maximum reduction in shoulder pain severity from 8.2 +/- 1.1 to 2.4 +/- 1.9 (p <0.001). Active range of motion increased 67% in flexion (from 67.8 +/- 27.6 to 113.3 +/- 46.6 degrees, p =0.001) and 42% in abduction (from 50 +/- 18.5 degrees to 71.1 +/- 23.1 degrees p =0.01). No immediate or delayed adverse effects related to BOTOX™ were noted after the injection. Duration of pain relief was variable and ranged from 3 to 12 months. Five joints were re-injected with BOTOX™ and had a similar decrease in joint pain that lasted 3 to 12 months. This is the first report of the long term effects of intra-articular BOTOX™ injections to treat chronic joint pain and the efficacy of repeated injections. Although this study was small, and uncontrolled the results suggest that BOTOX™ injections are an effective and safe treatment for chronic joint pain disorders. Sjögren's syndrome is overlooked, undertreated From Rheumatology News Sjögren's syndrome presents is the second most common autoimmune disease in the United States, said several experts. “It is not a benign disease, which is a perception that many physicians have,” said Dr. Frederick B. Vivino, director of the Sjögren's syndrome center at Penn Presbyterian Medical Center, Philadelphia. “It has significant morbidity, and even mortality, when people develop internal organ manifestations or complications like lymphomas.” Dr. Arthur Weinstein, director of the section of rheumatology at the Washington Hospital Center, said that among internists and family physicians, Sjögren's syndrome is “grossly underrecognized.” Whether or not physicians follow the diagnostic criteria for the disease is a matter of debate. “My colleagues in rheumatology don't do as good a job diagnosing and treating Sjögren's as they do rheumatoid arthritis,” said Dr. Vivino. “Most physicians, including rheumatologists, aren't really aware of the current diagnostic criteria for the disease. Or if they are aware, they don't follow them.” For now, misdiagnosis of Sjögren's syndrome is common. Dr. Weinstein said, “Many of the SS patients are misdiagnosed as having RA because they have rheumatoid factor, or lupus, or because of a positive [antinuclear antibody test]. … Early on, it could look like those, but ultimately [these patients] have different problems. So it takes an awareness to ask the right questions.” Dr. Vivino said many women regard dryness, the primary symptom in Sjögren's syndrome, as a part of menopause, which is the approximate age of disease onset. On average, the mean time between symptom onset and diagnosis is 7 years, he added. Mouth burning or oral ulcers from the dryness can make eating difficult, leading to weight loss. Many patients develop dental caries, yeast infections of the mouth, or bacterial infections of the salivary glands. Ocular dryness can cause infections. “In some cases, the cornea can perforate,” said Dr. Vivino. Vaginal dryness also occurs. More seriously, Sjögren's syndrome is tied to fatigue, muscle pain, joint pain, liver and kidney dysfunction, and non-Hodgkin's lymphoma. The drug of choice for Sjögren's syndrome is hydroxychloroquine (Plaquenil), which came on the market in 1955. Dr. Weinstein said one new therapy that shows promise is B-cell-targeted rituximab. “There is this [fascinating] link between Sjögren's and the development of B-cell lymphomas,” he said; one study put the incidence of lymphoma in this cohort at more than 40 times higher than in the general population. In a study of 16 patients, rituximab was tied to remission in SS-associated lymphomas, but did little to lessen symptoms of dryness. Another investigational B-cell-targeted drug, epratuzumab, showed efficacy in a 16 patient-, open-label, phase I/II study. More than half of patients had a greater than 20% improvement in the Schirmer test of tear production, unstimulated whole salivary flow, fatigue, erythrocyte sedimentation rate, and IgG levels. Headache in primary Sjögren's syndrome: a prevalence study. The study has analyzed the prevalence of headache in patients with primary Sjögren's syndrome and examined the relationship between headache types and clinical, serologic features of the disease. The study enclosed 133 patients with the diagnoses of primary Sjögren's syndrome and 97 healthy controls. A questionnaire designed to assess the presence of headache and if present to classify it according to the criteria of the International Headache Society was used. In 133 of the primary Sjögren's syndrome patients evaluated, 104 had headache. No association was present between types of headache and the clinical and laboratory manifestations of the disease. Both migraine and tension-type headache were more common in patients with primary Sjögren's syndrome when compared with healthy controls (P < 0.001). The high prevalence of migraine in pSS patients might be explained by a vascular headache triggered by immuno-mediated disease activity without an obvious clinic or laboratory marker. Height loss over 3 Years predicts osteoporosis in patients over 50 From Rheumatology News Measuring a patient's height during routine primary care visits may be one of the simplest and least expensive ways to predict osteoporosis risk and to guide screening, according to a study at Virginia Commonwealth University, Richmond. Height loss of 1.5 inches (about 4 cm) or more over 3 years was associated with almost a doubling of osteoporosis risk in patients aged 50 years or older in the study of 1,039 primary care patients, reported Dr. Emmeline Gasink at the annual meeting of the North American Primary Care Research Group. Mean height loss in the study population was 0.596 inches. Among the 16% of patients who had a height loss of at least 1.5 inches, 3% had a diagnosis of osteoporosis (odds ratio, 1.8) of developing the disease. Some patients (13%) had significant height loss but were not diagnosed with osteoporosis. Another 8% did not have significant height loss but had osteoporosis, perhaps representing osteoporosis in a nonvertebral site. Nonetheless, a height loss of 1.5 inches or greater over 3 years provided a positive predictive value of 21% for osteoporosis. The study population was 71% female, so the risk may be slightly less for males. Also, people with low bone density tend to lose height more rapidly than do those with greater bone density. “Height measurement should definitely be a part of a yearly physical for patients 50 and older, as recommended by the U.S. Preventive Health Task Force,” noted Dr. Gasink after the meeting. For aching seniors: step away from the NSAIDs From Rheumatology News A variety of practical and psychological approaches may be the best medicine for highly active seniors suffering from osteoarthritis and overuse syndromes, speakers said at a multidisciplinary forum at the annual meeting of the American Association for Hand Surgery. The panel was asked to recommend nonsteroidal anti-inflammatory drugs (NSAIDs) that are safe for seniors aged 80 and older who flock to sunny locales each winter to play golf and tennis four times a week, but come in with aching joints. “There are no safe nonsteroidals,” replied panelist Steven R. Ytterberg, a rheumatologist at the Mayo Clinic, Rochester, Minn. “In our practice, we're trying to get away from using those drugs as much as we can.” Dr. Ytterberg said physicians need to consider “hierarchies” of risk according to side-effect threats. For example, he would rate aspirin as riskiest to the gut, with cyclooxygenase-2 inhibitors “maybe a little safer for the gut, but not nearly as safe for the gut as they were promoted to be.” Cyclooxygenase-2 inhibitors have cardiac risks of their own, he noted, but may be safer than aspirin for heart-healthy patients with a history of peptic ulcer disease. When patients absolutely require an NSAID, Dr. Ytterberg said he tends to favor “regular” nonsteroidals. “For some reason a lot of rheumatologists like naproxen, twice a day,” he said. At this dose, the drug has a “relatively good safety profile … but none are absolutely safe.” Attention then turned to several certified hand therapists (CHTs), who suggested that active elderly patients can benefit from education about ergonomics and joint protection principles. They also may need to readjust their expectations and realize they might not be able to match the performance goals they had when they were 20, said Ann Lund, an occupational therapist and CHT at the Mayo Clinic in Rochester. “A better life balance can help these people,” she said. Paul Brach, a physical therapist, CHT, and director of The Hand Center of Pittsburgh, said referral for an analysis of a patient's grip and/or sporting equipment may be very useful in these patients. Joint support devices and custom-designed grips can alleviate unnecessary aggravation of osteoarthritis, he said. |
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