(Regrettably, our local university is the main reason that county STD rates are the second-highest in the state (the highest-ranking county is home to a naval base). Outbreaks are common and rather a grim joke with local healthcare providers. The county has purchased a new emergency radio system and one of their officers has arrived to train our staff on how to use the equipment.)
Instructor: “The great thing about this system is that it is linked to over two hundred towers, state-wide. This means that if you need to, you can communicate not only throughout the county, but with other jurisdictions as well. For example; let’s say you have to set up some kind of emergency clinic at the University for… I don’t know, what’s an epidemic that the students might experience there?”
Me: *without thinking* “Probably chlamydia.”
(My boss shushed me, but our director of nursing almost fell off her chair from laughing so hard.)
Stress hormone helps control the circadian rhythm of brain cells
University of Copenhagen The Faculty of Health and Medical Sciences
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IMAGE: Cross-section of rat brain. To make sure that the suprachiasmatic nucleus had been properly deactivated, the researchers subsequently examined several histologies such as this one. view more
Credit: Department of Neuroscience, University of Copenhagen
As day turns into night, and night turns into day, the vast majority of living organisms follow a fixed circadian rhythm that controls everything from sleep needs to body temperature.
This internal clock is found in everything from bacteria to humans and is controlled by some very distinct hereditary genes, known as clock genes.
In the brain, clock genes are particularly active in the so-called suprachiasmatic nucleus. It sits just above the point where the optic nerves cross and sends signals to the brain about the surrounding light level. From here, the suprachiasmatic nucleus regulates the rhythm of a number of other areas of the body, including the cerebellum and the cerebral cortex.
However, these three areas of the brain are not directly linked by neurons, and this made researchers at the University of Copenhagen curious. Using test rats, they have now demonstrated that the circadian rhythm is controlled by means of signalling agents in the blood, such as the stress hormone corticosterone.
'In humans, the hormone is known as cortisol, and although the sleep rhythm in rats is the opposite of ours, we basically have the same hormonal system', says Associate Professor Martin Fredensborg Rath of the Department of Neuroscience.
He explains that recent years have seen an increasing, scientific focus on research on clock genes, one reason being that previous research on clock genes have found a correlation between depression and irregularities in the body's circadian rhythms.
New Method with Medical Micropumps
In the study with the stress hormone corticosterone, the researchers removed the suprachiasmatic nucleus in a number of rats. As expected, this removed the circadian rhythm of the animals.
Among other things, the body temperature and activity level of the rats went from circadian oscillations to a more constant state. The same was true of the otherwise rhythmic hormone production.
However, the circadian rhythm of the cerebellum was restored when the rats were subsequently implanted with a special programmable micropump, normally used to dose medication in specific quantities.
In this case, however, the researchers used the pump to emit carefully metered doses of corticosterone at different times of the day and night, similar to the animals' natural rhythm.
'Nobody has used these pumps for anything like this before. So technically, we were onto something completely new', says Martin Fredensborg Rath.
For that reason, the researchers spent the best part of a year carrying out a large number of control tests to ensure that the new method was valid.
Interaction Between Neurons and Hormones
As mentioned, the new method paid off. With the artificial corticosterone supplement, researchers were again able to read a rhythmic activity of clock genes in the cerebellum of the rats, even though their suprachiasmatic nucleus had been removed.
'This is hugely interesting from a scientific point of view, because it means that we have two systems - the nervous system and the hormonal system - that communicate perfectly and influence one another. All in the course of a reasonably tight 24-hour programme', says Martin Fredensborg Rath.
With the test results and the new method in the toolbox, the researchers' next step is to study other rhythmic hormones in a similar manner, including hormones from the thyroid gland.
New X-ray technology could revolutionize how doctors identify abnormalities
University of Maryland Baltimore County
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Using ground-breaking technology, researchers at the University of Maryland, Baltimore County (UMBC) and University of Baltimore (UMB) are testing a new method of X-ray imaging that uses color to identify microfractures in bones. Microfractures were previously impossible to see using standard X-ray imaging. The findings associated with this advancement in color (spectral) CT (computed tomography) imaging are published in Advanced Functional Materials.
Since the discovery of X-rays in 1895, the basics of the technology have remained consistent. Doctors and scientists use them to see dense materials, like bones, but the technology's capabilities have been limited. Dipanjan Pan, professor of chemical, biochemical and environmental engineering UMBC, and professor of radiology at UMB, is the corresponding author of this new study. Looking ahead to the next generation of X-ray technology, he asks, "How can we detect a bone microcrack, something that is not visible using X-ray imaging?"
Pan explains that to examine this question, his lab developed nanoparticles that navigate and attach specifically to areas where microcracks exist. He likes to call them "GPS particles." They started conducting this research at the University of Illinois Urbana-Champaign. The researchers have programmed the particles to latch onto the correct area of the microcrack. Once the particles attach to microcracks, they remain there, which is crucial to the imaging process.
The particles contain the element hafnium. A new X-ray-based technique developed by a New Zealand-based company MARS then take CT images of the body and the hafnium particles appear in color. This provides a very clear image of where the bone microcracks are located.
Hafnium is used because its composition makes it detectable to X-rays, generating a signal that can then be used to image the cracks. Pan's lab showed that hafnium is stable enough to be used in testing involving living creatures, and can be excreted safely from the body. The lab has not yet begun testing on humans, but the technology to do so may be available as soon as 2020.
As for other applications for spectral CT imaging with this hafnium breakthrough, the research suggests that this methodology could be used to detect much more serious problems. For example, in order to determine whether a person has a blockage in their heart, doctors often will perform a stress test to detect abnormalities, which comes with a significant amount of risk. One day in the near future, doctors may be able to use spectral CT to determine whether there is a blockage in organs.
"Regular CT does not have a soft-tissue contrast. It cannot tell you where your blood vessels are. Spectral CT can help solve that problem," Pan explains. He notes that although more research is needed to begin using spectral CT in this way, he anticipates that it will be a "tremendous" new tool for radiologists. Dr. Fatemeh Ostadhossein, a recent graduate of the Pan lab, was first author on this study.
Research team from Graz, Austria, develops biological methods to improve the shelf life of fruit and vegetables
The crops have been harvested. Now it is important to store the various crops well and to preserve them as long and as carefully as possible. Post-harvest losses due to spoilage, however, represent a significant problem along the supply chain and lead to profit losses in the millions. According to the FAO (Food and Agriculture Organization of the UN) statistics, almost half of the world's harvest (45 percent) of fruits and vegetables are lost on their way to the end consumer. The main causes of these losses are pest or disease infestation and incorrect storage conditions, which lead to rotting or loss of fresh mass due to respiration and evaporation. The only remedy is often the excessive use of chemicals. Researchers from the Institute of Environmental Biotechnology at TU Graz in cooperation with the Austrian Centre of Industrial Biotechnology (acib) and industrial partners have successfully tested ecological methods that improve the storage of apples and sugar beet - representative examples for other types of fruit and vegetables.
Shelf life of apples significantly increased
Hot water treatment (HWT) has proven to be a sustainable method for reducing fungal fruit decay after harvest in a large number of crops. In this treatment, apples are briefly dipped into a hot water bath. This "heat shock" stimulates the apple's natural defence mechanisms, the principle of action has not yet been fully clarified. Nevertheless, there are always outbreaks of pathogens in storage and apples spoil.
In a laboratory experiment, the head of the Institute of Environmental Biotechnology, Gabriele Berg, PhD student Birgit Wassermann and PhD student Peter Kusstatscher, have now successfully tested a method that significantly improves the shelf life of organic apples through the combined use of HWT and biocontrol organisms. Birgit Wassermann explains the experimental setup: "We infected organic apples with two of the most important putrefactive agents, then treated them with hot water and a biocontrol agent designed by us. This combined approach enabled us to either kill the post-harvest pathogens completely or to reduce the infection diameter to a maximum in about 60 percent of the apples treated in this way." Compared to the control group - apples that were only treated with HWT - the combi-method showed 20 percent better results in the resistance of the apples to storage rot. The additive protective effect of the biocontrol agent obtained from the apple microbiome of native organic apples for the control of the storage moulds could be clearly demonstrated. The results of the study were published in the journal Frontiers in Microbiology.
"This combined approach is a sustainable and ecologically sound way to reduce apple blight. On the basis of this method, we can optimize apple storage together with industrial project partners," summarizes Gabriele Berg, head of the institute.
The apple microbiome remains intact
At the same time, Gabriele Berg and her team have investigated for the first time how the hot water treatment affects the microbiome of the apple, i.e. the entirety of all microorganisms. Together with an Austrian organic fruit company, the researchers were able to show in a trial on an industrial scale that the natural microbiome of apples remains unchanged through HWT treatment, whereas harmful fungi are almost completely contained. This proves that HWT leads to the release of certain plant defence metabolites that kill pathogens without affecting the natural apple-associated microbiome. The close connection between the plant and its microbial symbionts is thus confirmed once again. Just a few weeks ago, the same team of researchers at Graz University of Technology, led by Gabriele Berg and Birgit Wassermann, caused a stir with their study on the composition of the apple microbiome. With every apple we eat about 100 million bacteria, but the microbiome of an organic apple differs considerably from that of a conventional apple. Stored apples with rotten spots also contain a fundamentally different microbiome, which consists of 99 percent fungi and only one percent bacteria.
Biological crop protection also effective for sugar beet
Not only apple farmers, but also the sugar beet industry suffers millions in losses every year due to storage rot. In cooperation with the Austrian Centre of Industrial Biotechnology (acib), the research team has also devoted itself to this topic and developed an environmentally friendly crop protection agent together with one of the largest European sugar producers and the Graz start-up Roombiotic. acib researcher Peter Kusstatscher designed his own biocontrol agent for this purpose and tested it under industrial conditions. "The treatment of the beets leads to significantly higher sugar levels after storage," explains Peter Kusstatscher. In addition, a process was developed that shows which beets from which fields are particularly susceptible to storage rot even before the beets are harvested and therefore must be processed quickly. The research results could considerably minimize economic losses in the future, especially since the sugar losses occurring in Germany alone currently cause more than half a million euros of damage per day.
Researchers at Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences developed a model of myocardial infarction using cardiomyocytes differentiated from human induced pluripotent stem cells.
The journal Biochemical and Biophysical Research Communications published the study, with Ken Takahashi, Ph.D., as corresponding author, and Wei Heng, MSc., a graduate student in the Naruse Lab, as first author.
To date, laboratory animals such as mouse have been used to model diseases including myocardial infarction. However, there have been concerns about difference in characteristics of cardiomyocytes e.g. heart rate and action of drugs, based on the difference of gene expression between laboratory animals and human.
Using this model, researchers can evaluate the extent of myocardial tissue damage by microscope morphologically, and by measuring injury-marker proteins and analyzing contractility and its synchroneity from recorded movie quantitatively. Further analysis revealed that gene expression of interleukin-8, an inflammation marker known to increase in acute myocardial infarction, increased in this model.
"This myocardial infarction model will contribute to the development of preventive/therapeutic medicine more effective to human even without sacrificing animals," said Ken Takahashi, Ph.D., assistant professor in the university and lead author of the study
Mated female mosquitoes are more likely to transmit malaria parasites
PLOS
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IMAGE: Anopheles gambiae view more
Credit: Jim Gathany-CDC, Flickr (CC-BY)
Female mosquitoes that have mated are more likely to transmit malaria parasites than virgin females, according to a study published November 7 in the open-access journal PLOS Pathogens by Farah Dahalan of Imperial College London, Mara Lawniczak from the Wellcome Sanger Institute, and colleagues. The results of this study imply that efforts to target male mosquitoes might not only suppress mosquito populations, but also act to decrease vector competence among residual females.
Malaria is a mosquito-transmitted disease, caused by the parasite Plasmodium falciparum, that kills more than 400,000 people and infects more than 200 million people worldwide annually. Existing vector control measures rely on continued mosquito susceptibility to various insecticides, but resistance has evolved to all four insecticide classes currently in use, and new vector control strategies, including strategies that target reproduction, are sorely needed. Several species of Anopheles are responsible for the majority of transmission in Africa, where the disease causes the most morbidity. In Anopheles mosquitoes, levels of the hormone 20-hydroxyecdysone (20E) in females can be influenced by two major factors: blood-feeding and mating. In the new study, Dahalan and colleagues investigate the impact of both mating and 20E on female mosquito susceptibility to P. falciparum.
Farah Dahalan says "If male-derived 20E enhances vector competence of mated females in nature, then male mosquitoes may be contributing to malaria transmission in previously unappreciated ways. It is possible that vector control strategies that target males may have additional benefits toward reducing transmission."
Methotrexate reduces joint damage progression over placebo in erosive hand OA
American College of Rheumatology
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ATLANTA -- According to new research findings presented at the 2019 ACR/ARP Annual Meeting, methotrexate did not demonstrate superior efficacy over placebo for pain relief and function evolution at three and 12 months in patients with erosive hand osteoarthritis, but did significantly reduce the progression of joint damage over placebo and seems to facilitate bone remodeling in these patients (Abstract #1759 ).
Osteoarthritis (OA) is a common joint disease that most often affects middle-age to elderly people. OA is a disease of the entire joint, involving the cartilage, joint lining, ligaments, and bone. It is characterized by breakdown of the cartilage (the tissue that cushions the ends of the bones between joints), bony changes of the joints, deterioration of tendons and ligaments, and various degrees of inflammation of the joint lining (called the synovium).
No studies so far have evaluated the effect of methotrexate (MTX), a disease-modifying antirheumatic drug, in hand osteoarthritis. Researchers conducted this one-year prospective, monocentric, randomized, double-blind, placebo-controlled study to examine the drug's effect on pain and structural progression in patients with symptomatic erosive hand osteoarthritis.
"Erosive hand OA poses problems in terms of pain, function and disability, but especially given the lack of truly effective therapies. The natural evolution of erosive hand OA is characterized by a succession of erosive phases and remodeling. These rearrangements suggest the involvement of pro-inflammatory cytokine cascades known to cause cartilage degradation and bone resorption," says Prof. Christian Roux, head of the joint unit in the rheumatology department at Cote d'Azur University in France, and the study's lead author. "In recent years, imaging data have confirmed the presence of inflammation in the joints of these patients. The clinical presentation and imaging data bring this entity closer to inflammatory rheumatism, such as rheumatoid arthritis and psoriatic arthritis. These similarities have justified for some the use of treatments used in inflammatory rheumatism."
Sixty-four patients with erosive hand OA in the study were randomized into two groups: taking a dose of 10 mg of MTX per week or a placebo. The study's primary endpoint was pain assessment at three months. Secondary endpoints were clinical features, including pain measured on a Visual Analogue Scale (VAS), radiographic features and magnetic resonance imaging (MRI) at 12 months.
At three months, there was no significant difference in the evolution in VAS pain score between both groups: the MTX group's mean decrease was 17.5 (from 28.4) and the placebo's mean decrease was 8.4 (from 25.2). Erosive joints progressed significantly more to a remodeling phase in the MTX group than the placebo group, or 27 percent to 15 percent. Joints with joint space loss appeared to be eroding less in the MTX group than in the placebo group, or eight percent to 29 percent. Interleukin-6 level and synovitis findings on MRI scans at baseline were found to be predictive factors for erosive structural evolution of non-erosive joints.
According to the study's findings, while MTX did not demonstrate superior efficacy over placebo for improvement of pain and functional evolution at three and 12 months in people with EHOA, it did significantly reduce joint damage progression compared to placebo and seems to facilitate bone remodeling. The presence of systemic and local inflammation at baseline predicted erosive progression.
"The study does not demonstrate superior efficacy of MTX over placebo on pain and function in subjects with erosive hand OA. But probably it will be linked to a multifactorial origin of pain in these subjects such as mechanical or inflammatory pain," says Prof. Roux. "It is possible that we have to treat earlier if we want to have an effect on pain. However, our results show a structural effect of the treatment that facilitates bone remodeling and seems to slow the erosive structural progression of digital osteoarthritis with a seemingly more pronounced effect in patients with early lesions. I think this is a major point. The main complaint for people is the deformity linked to structural evolution in this disease. Our study's results should encourage new studies to be conducted."
ADA2 is a specific biomarker for MAS in systemic JIA
American College of Rheumatology
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ADA2 is a Sensitive, Specific Biomarker for Life-Threatening Macrophage Activation Syndrome in Systemic JIA
ATLANTA -- According to new research findings presented at the 2019 ACR/ARP Annual Meeting, adenosine deaminase 2 (ADA2) in the peripheral blood is a sensitive, specific biomarker for macrophage activation syndrome, a potentially life-threatening complication of systemic juvenile idiopathic arthritis (systemic JIA) (Abstract #920 ).
About one child in every 1,000 develops some type of chronic arthritis. These disorders can affect children at any age, although rarely in the first six months of life. It is estimated that around 300,000 children in the United States have been diagnosed with the condition.
Macrophage activation syndrome (MAS) is characterized by a vicious cycle of immune cell activation and dysregulated cytokine production that can result in multi-organ failure and is a life-threatening complication in systemic JIA. Clear biomarkers are needed for prompt diagnosis of MAS to initiate treatment and better understand the pathogenesis of the disease. To address this, a group of researchers conducted a study of peripheral blood ADA2 activity levels to determine if it is a useful biomarker for MAS.
"Children with deficiency of ADA2 are known to develop early onset vasculitis and stroke, but the function of ADA2 and how it is regulated is not entirely clear," said Pui Y. Lee, MD, PhD, attending physician at Boston Children's Hospital and one the study's lead authors. "We conducted this observational study to understand whether ADA2 enzyme levels are different in various childhood rheumatologic diseases. To our surprise, the levels were very high in children with systemic JIA complicated by MAS. It is important to find useful biomarkers for MAS, because many of the existing markers are not very effective in distinguishing MAS from systemic inflammation. Early detection of MAS is extremely important, because mortality of the condition remains quite high and treatment should be started as soon as possible."
Researchers established normal levels of peripheral blood ADA2 levels in 175 healthy children and compared these values with 25 children with Kawasaki's disease, 13 with systemic lupus erythematosus (SLE), 13 with juvenile dermatomyositis and 120 with various forms of JIA. While they found mild elevation of ADA2 in some patients with SLE and juvenile dermatomyositis, ADA2 levels that were above the upper limit of normal were largely restricted to children with systemic JIA who had clinically diagnosed MAS.
The study's results show that in children with active systemic JIA, ADA2 activity beyond the upper limit of normal is strong evidence for concomitant MAS.
"Our findings show that ADA2 is a valuable diagnostic marker to distinguish MAS from other forms of systemic inflammation," said Dr. Lee. "While there are many markers currently used for evaluation of MAS, many of them lack specificity unless the cut-off is raised significantly to distinguish MAS from general inflammation. In contrast, elevation of ADA2 levels above the normal limit of healthy individuals has good sensitivity and specificity for diagnosing MAS. This is likely related to the biology of ADA2 as a direct product of activated macrophages. It is our hope that ADA2 testing will be become more available as a clinical test to help diagnose MAS rapidly, which will in turn facilitate treatment initiation and improve patient outcomes
Children with Down syndrome at increased risk for inflammatory, erosive arthritis
American College of Rheumatology
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ATLANTA --A new study finds that children with Down syndrome are at an increased risk of an associated form of arthritis. Additionally, researchers recommend changing the name to Down syndrome-associated arthritis to more accurately reflect the inflammatory and erosive nature of the condition. Details of this study will be presented at the 2019 ACR/ARP Annual Meeting (Abstract #1817 ).
About one child in every 1,000 develops some type of chronic arthritis. These disorders can affect children at any age, although rarely in the first six months of life. It is estimated that around 300,000 children in the United States have been diagnosed with the condition. Down syndrome is a condition in which a person has an extra chromosome number 21, which affects how the body and brain develop.
Arthropathy of Down syndrome has an increased incidence and prevalence compared to Juvenile Idiopathic Arthritis (JIA). However, the disease is rarely recognized at onset and remains under-diagnosed. Children with arthropathy of Down syndrome often present with significant joint damage and disability at diagnosis. A group of researchers from Ireland conducted a cross-sectional, observational study to identify undiagnosed cases of arthropathy of Down syndrome, document the time to diagnosis among these patients, and describe the clinical, laboratory and radiological features of the condition at diagnosis.
"Given the paucity of information in the literature with regards to arthritis in children with Down syndrome, our initial aims were to identify whether arthritis in Down syndrome is missed leading to a delay in diagnosis, describe the clinical and radiological features of inflammatory arthritis in children with Down syndrome, and estimate the prevalence of inflammatory arthritis in children with Down syndrome," said Charlene M. Foley, MBBS, BSc, PhD, a clinical researcher at the National Centre for Pediatric Rheumatology at Our Lady's Children's Hospital in Crumlin, Ireland, and the study's lead author. "If we know there is increased risk in children with Down syndrome, we are more likely to consider it as a possible diagnosis. Early recognition leads to earlier instigation of appropriate treatment and, therefore, better clinical outcomes and quality of life for a population of children already at risk of a number of co-morbidities that can impact their lives."
Researchers invited children (zero to 21 years old) with Down syndrome to participate in a musculoskeletal screening clinic where they received a detailed examination from a pediatric rheumatologist. A subsequent clinical visit with a different physician confirmed all suspected cases of arthropathy of Down syndrome. Physicians instigated investigations and treatment following normal clinical practice for JIA. The researchers collected data on a convenience sample of 21 newly diagnosed children with JIA to create a comparison group.
Over an 18-month period, 503 children with Down syndrome were screened for arthritis, with 18 new cases diagnosed. In total, the study identified 33 children with arthropathy of Down syndrome, combining cases that predated the study's commencement and those children referred to the center during the study period. The study's results suggest that prevalence of arthropathy Down syndrome is 20 per 1,000 children with Down syndrome.
The researchers also observed significant delays in diagnosis of arthritis in children with Down syndrome. The majority of children presented with polyarticular, RF-negative arthritis, with a predominance of arthritis in the small joints of the hands and wrists. No children with arthropathy of Down syndrome in the study were ANA positive. Erosive changes were reported on X-ray in more children with arthropathy Down syndrome (42 percent) than the JIA group (14 percent). Future research in this patient population may help accurately define disease pathogenesis, identify disease biomarkers and establish best practices for treatment, the researchers concluded. They also suggest that "Down syndrome-associated arthritis" would be a more accurate term than "arthropathy of Down syndrome."
"To our knowledge, this is the first study to consider screening children with Down syndrome for arthritis. Through this simple, non-invasive process we detected a number of undiagnosed cases of Down syndrome associated arthritis (DA)" said Dr. Foley. "We observed a high degree of methotrexate-associated side effects in children with DA. With this knowledge, clinicians may consider altering their treatment choices in favor of biological therapy for this cohort of children. Our study highlighted that the clinical phenotype of the condition is inflammatory and erosive in nature. Our proposal to rename the condition Down syndrome-associated arthritis is to reflect the inflammatory, erosive nature of the disease."
Children with Down syndrome at increased risk for inflammatory, erosive arthritis
American College of Rheumatology
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ATLANTA --A new study finds that children with Down syndrome are at an increased risk of an associated form of arthritis. Additionally, researchers recommend changing the name to Down syndrome-associated arthritis to more accurately reflect the inflammatory and erosive nature of the condition. Details of this study will be presented at the 2019 ACR/ARP Annual Meeting (Abstract #1817 ).
About one child in every 1,000 develops some type of chronic arthritis. These disorders can affect children at any age, although rarely in the first six months of life. It is estimated that around 300,000 children in the United States have been diagnosed with the condition. Down syndrome is a condition in which a person has an extra chromosome number 21, which affects how the body and brain develop.
Arthropathy of Down syndrome has an increased incidence and prevalence compared to Juvenile Idiopathic Arthritis (JIA). However, the disease is rarely recognized at onset and remains under-diagnosed. Children with arthropathy of Down syndrome often present with significant joint damage and disability at diagnosis. A group of researchers from Ireland conducted a cross-sectional, observational study to identify undiagnosed cases of arthropathy of Down syndrome, document the time to diagnosis among these patients, and describe the clinical, laboratory and radiological features of the condition at diagnosis.
"Given the paucity of information in the literature with regards to arthritis in children with Down syndrome, our initial aims were to identify whether arthritis in Down syndrome is missed leading to a delay in diagnosis, describe the clinical and radiological features of inflammatory arthritis in children with Down syndrome, and estimate the prevalence of inflammatory arthritis in children with Down syndrome," said Charlene M. Foley, MBBS, BSc, PhD, a clinical researcher at the National Centre for Pediatric Rheumatology at Our Lady's Children's Hospital in Crumlin, Ireland, and the study's lead author. "If we know there is increased risk in children with Down syndrome, we are more likely to consider it as a possible diagnosis. Early recognition leads to earlier instigation of appropriate treatment and, therefore, better clinical outcomes and quality of life for a population of children already at risk of a number of co-morbidities that can impact their lives."
Researchers invited children (zero to 21 years old) with Down syndrome to participate in a musculoskeletal screening clinic where they received a detailed examination from a pediatric rheumatologist. A subsequent clinical visit with a different physician confirmed all suspected cases of arthropathy of Down syndrome. Physicians instigated investigations and treatment following normal clinical practice for JIA. The researchers collected data on a convenience sample of 21 newly diagnosed children with JIA to create a comparison group.
Over an 18-month period, 503 children with Down syndrome were screened for arthritis, with 18 new cases diagnosed. In total, the study identified 33 children with arthropathy of Down syndrome, combining cases that predated the study's commencement and those children referred to the center during the study period. The study's results suggest that prevalence of arthropathy Down syndrome is 20 per 1,000 children with Down syndrome.
The researchers also observed significant delays in diagnosis of arthritis in children with Down syndrome. The majority of children presented with polyarticular, RF-negative arthritis, with a predominance of arthritis in the small joints of the hands and wrists. No children with arthropathy of Down syndrome in the study were ANA positive. Erosive changes were reported on X-ray in more children with arthropathy Down syndrome (42 percent) than the JIA group (14 percent). Future research in this patient population may help accurately define disease pathogenesis, identify disease biomarkers and establish best practices for treatment, the researchers concluded. They also suggest that "Down syndrome-associated arthritis" would be a more accurate term than "arthropathy of Down syndrome."
"To our knowledge, this is the first study to consider screening children with Down syndrome for arthritis. Through this simple, non-invasive process we detected a number of undiagnosed cases of Down syndrome associated arthritis (DA)" said Dr. Foley. "We observed a high degree of methotrexate-associated side effects in children with DA. With this knowledge, clinicians may consider altering their treatment choices in favor of biological therapy for this cohort of children. Our study highlighted that the clinical phenotype of the condition is inflammatory and erosive in nature. Our proposal to rename the condition Down syndrome-associated arthritis is to reflect the inflammatory, erosive nature of the disease."
Low-dose oral prednisolone substantially improves pain and function in hand OA
American College of Rheumatology
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ATLANTA -- Research presented at the 2019 ACR/ARP Annual Meeting found that a six-week treatment with low-dose oral prednisolone substantially improves pain and decreases signs of inflammation in patients with painful hand osteoarthritis (Abstract #1760).
Osteoarthritis (also known as OA) is a common joint disease that most often affects middle-age to elderly people. It is commonly referred to as "wear and tear" of the joints; it is now known that OA is a disease of the entire joint, involving the cartilage, joint lining, ligaments, and bone. OA is characterized by breakdown of the cartilage, bony changes of the joints, deterioration of tendons and ligaments, and various degrees of inflammation of the joint lining (called the synovium).
While studies have previously shown that synovial inflammation is often present in people with hand OA and is a main determinant of both pain and disease progression, there is still some uncertainty about how to effectively treat it. This randomized, double-blind, placebo-controlled trial looked at both efficacy and safety for short-term, low-dose prednisolone used to treat hand OA.
"Hand OA is a common musculoskeletal disease, with a substantial disease-burden in the form of hand pain, functional disability, reduced grip strength and a reduced quality of life. Currently, there is an unmet need for effective therapies for this disease. While several therapeutic options for hand OA are available to alleviate symptoms, the efficacy of these treatments is modest at best," says Féline Kroon, MD, a rheumatologist in training at Leiden University Medical Centre in the Netherlands and the study's lead author. "In this trial, we set out to investigate the efficacy and safety of prednisolone based on observations from previous research that local inflammation seems to play a role in the disease and may be a potential target for treatment."
The trial enrolled patients with signs of synovial inflammation and who met the American College of Rheumatology criteria for painful hand OA. Patients with four or more osteoarthritic nodes involving interphalangeal joints, one or more interphalangeal joint with soft tissue swelling or erythema, and one or more positive power Doppler signal or synovitis of grade two or higher were eligible. Key exclusion criteria for the trial were patients who had chronic inflammatory rheumatic diseases, psoriasis, use of immune-modulating drugs within 90 days before baseline or predominant thumb-based pain.
The researchers randomized eligible patients who had visual analogue scale evidence of finger pain (30 mm or more), and patients who flared upon nonsteroidal anti-inflammatory drug washout (20 mm or more) to receive either prednisolone 10 mg daily for six weeks or a placebo. This was followed by a two-week prednisolone taper, then six weeks without study medications. Outcomes were assessed at two, four, six, eight and 14 weeks.
The trial's primary endpoint was visual analogue scale finger pain at week six in intention-to-treat analysis. The secondary clinical endpoints included fulfillment of the Osteoarthritis Research Society International (OARSI) responder criteria, Australian/Canadian Hand OA Index (AUSCAN) pain and function, Functional Index for Hand OA (FIHOA), visual analogue scale patient global assessment, the Medical Outcomes Study's Short-Form 36 and grip strength. Imaging endpoints for the trial included both ultrasound evidence of synovitis and positive power Doppler signal. Ninety-two people were enrolled in the trial. The average age was 63 years, and 79 percent of the participants were women. The enrolled group were split evenly with half receiving prednisolone and the other half receiving placebo. In each of these two groups, 42 completed the trial. At week six, 33 patients in the prednisolone group and 15 in the placebo group fulfilled the OARSI responder criteria, and prednisolone was superior to placebo in most other secondary clinical endpoints. Additionally, ultrasound synovitis significantly improved at week six in the prednisolone group and there was no difference in the power Doppler signal. After drug tapering, between-group differences disappeared. Adverse events were mostly mild for patients in the study, and they were comparable between the two groups.
"Substantial improvements in pain and function, exceeding effects of currently available therapies, were seen in the trial. Therefore, a short course of 10 mg of prednisolone could be considered a new treatment option for people suffering with hand OA, especially those who experience a flare," says Dr. Kroon. "However, it is important to realize that patients included in this study had pain and signs of inflammation and experienced a flare after withdrawal of pain medication, and therefore, these results only pertain to this group of patients. Future studies to investigate the optimal dosage and duration of treatment are warranted."
Limited access to SLE lab tests in developing nations affects usefulness
American College of Rheumatology
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ATLANTA -- According to new research findings presented this week at the 2019 ACR/ARP Annual Meeting, supportive laboratory assays to diagnose lupus, specifically the antinuclear antibody (ANA) test, are less often offered in developing nations due to a relative lack of resources. This greatly reduced the diagnostic utility of ANA as an entry criterion for lupus classification in Ghanaian and Nigerian cohorts compared to African American cohorts in the United States. This emphasizes an urgent need for broader clinical trials and ANA testing to participants in developing countries (Abstract #705 ).
Systemic lupus erythematosus, referred to as SLE or lupus, is a chronic (long-term) disease that causes systemic inflammation which affects multiple organs and can be deadly. In addition to affecting the skin and joints, it can affect other organs in the body such as the kidneys, brain, the tissue lining the lungs (pleura) and/or heart (pericardium). Many patients experience fatigue, weight loss, and fever.
Diagnostic criteria for SLE are important to generate reliable epidemiologic data. Prevalence of SLE in West Africa is falsely low because of barriers to accurate diagnostic testing, including lack of resources and the labor-intensive nature of these tests. The newly developed 2019 ACR/EULAR SLE classification criteria tool may improve diagnostic sensitivity and specificity compared to the previously established ACR and SLICC criteria. This new study investigated the performance of each set of criteria in two West African lupus cohorts from Korle bu Teaching Hospital in Ghana and Lagos University Teaching Hospital in Nigeria and compared it to an African American cohort at New York University/Langone Medical Center in New York City.
"African SLE patients throughout the diaspora are undertreated and understudied. This is in part due to the tendency for these individuals to hail from resource-limited areas of the world. In vetting diagnostic criteria, it is important to consider how more sophisticated testing may exacerbate existing disparities in diagnosis, treatment, and research," says Ashira D. Blazer, MD, MSCI, assistant professor of medicine, Division of Rheumatology, at New York University Langone Medical Center and the study's lead author. "Lack of widely available testing for ANA, the entry criterion to classify SLE using the 2019 ACR/EULAR classification criteria, throughout sub-Saharan Africa could impact SLE clinical care and slow down research", she adds. "We aimed to test the diagnostic efficiencies of each criteria in the USA compared to two low- or middle-income countries."
The researchers collected data on 355 patients with SLE for the study, including 151 African American patients in the United States, 110 patients in Ghana and 94 patients in Nigeria. All were diagnosed with lupus by expert clinicians. They gathered clinical information including demographics, SLE criteria, SLEDAI scores, SLICC damage indexes, vital signs and laboratory values that were available at the initial patient encounter. Longitudinal data was collected, at six-month intervals, over the course of at least one year during routine clinical visits. When necessary, the researchers also retrospectively reviewed clinical charts. They calculated the proportion of patients in each of the three cohorts who met each of the systems for classifying patients with lupus: (1) ACR, (2) SLICC and the (3) 2019 ACR/EULAR Classification Criteria for SLE.
The African American cohort's demographics included an average age of 43 years, 90 percent were women, mean SLE disease duration of 14.3 years; and 96 percent met the ACR criteria, 96 percent met the SLICC criteria and 95 percent met the ACR/EULAR criteria. In the Ghanaian cohort, the average age was 32 years, all were women, the mean SLE disease duration was 2.2 years; and 85 percent met the ACR criteria, 84 percent met the SLICC criteria and 62 percent met the ACR/EULAR criteria. In the Nigerian cohort, the average age was 35, 97 percent were women, the mean SLE disease duration was 4.4 years, and 90 percent met the ACR criteria, 87 percent met the SLICC criteria and 61 percent met the ACR/EULAR criteria.
Researchers found discrepancies in the data due largely to missing laboratory data, particularly immunologic and hematologic studies. While none of the African-American cohort were missing ANA test results, 26 percent of the Ghanaian cohort and 33 percent of the Nigerian cohort were missing ANA results. Compared to both the Ghanaian and Nigerian cohorts, the African-American cohort was more likely to meet ACR, SLICC and ACR/EULAR criteria. While the ANA entry criterion greatly diminished the diagnostic utility of the ACR/EULAR classification criteria in both the Ghanaian and Nigerian cohorts, the criteria's weighted point system performed better than either the ACR or SLICC criteria, with 96 percent of the African-American, 92 percent of the Ghanaian and 95 percent of the Nigerian cohorts earning a sufficient number of diagnostic points.
"The new clinical indices provided better diagnostic efficiency in the developing world than either the ACR or SLICC criteria. These findings were enlightening, and they solidified an important concept: that SLE is a clinical diagnosis first," says Dr. Blazer. "While research partnerships across the international economic divides might provide ANA testing, it is imperative that no new barriers be created for regional investigators who might struggle to disseminate data lacking the international community's required laboratory results."
Low-dose oral prednisolone substantially improves pain and function in hand OA
American College of Rheumatology
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ATLANTA -- Research presented at the 2019 ACR/ARP Annual Meeting found that a six-week treatment with low-dose oral prednisolone substantially improves pain and decreases signs of inflammation in patients with painful hand osteoarthritis (Abstract #1760).
Osteoarthritis (also known as OA) is a common joint disease that most often affects middle-age to elderly people. It is commonly referred to as "wear and tear" of the joints; it is now known that OA is a disease of the entire joint, involving the cartilage, joint lining, ligaments, and bone. OA is characterized by breakdown of the cartilage, bony changes of the joints, deterioration of tendons and ligaments, and various degrees of inflammation of the joint lining (called the synovium).
While studies have previously shown that synovial inflammation is often present in people with hand OA and is a main determinant of both pain and disease progression, there is still some uncertainty about how to effectively treat it. This randomized, double-blind, placebo-controlled trial looked at both efficacy and safety for short-term, low-dose prednisolone used to treat hand OA.
"Hand OA is a common musculoskeletal disease, with a substantial disease-burden in the form of hand pain, functional disability, reduced grip strength and a reduced quality of life. Currently, there is an unmet need for effective therapies for this disease. While several therapeutic options for hand OA are available to alleviate symptoms, the efficacy of these treatments is modest at best," says Féline Kroon, MD, a rheumatologist in training at Leiden University Medical Centre in the Netherlands and the study's lead author. "In this trial, we set out to investigate the efficacy and safety of prednisolone based on observations from previous research that local inflammation seems to play a role in the disease and may be a potential target for treatment."
The trial enrolled patients with signs of synovial inflammation and who met the American College of Rheumatology criteria for painful hand OA. Patients with four or more osteoarthritic nodes involving interphalangeal joints, one or more interphalangeal joint with soft tissue swelling or erythema, and one or more positive power Doppler signal or synovitis of grade two or higher were eligible. Key exclusion criteria for the trial were patients who had chronic inflammatory rheumatic diseases, psoriasis, use of immune-modulating drugs within 90 days before baseline or predominant thumb-based pain.
The researchers randomized eligible patients who had visual analogue scale evidence of finger pain (30 mm or more), and patients who flared upon nonsteroidal anti-inflammatory drug washout (20 mm or more) to receive either prednisolone 10 mg daily for six weeks or a placebo. This was followed by a two-week prednisolone taper, then six weeks without study medications. Outcomes were assessed at two, four, six, eight and 14 weeks.
The trial's primary endpoint was visual analogue scale finger pain at week six in intention-to-treat analysis. The secondary clinical endpoints included fulfillment of the Osteoarthritis Research Society International (OARSI) responder criteria, Australian/Canadian Hand OA Index (AUSCAN) pain and function, Functional Index for Hand OA (FIHOA), visual analogue scale patient global assessment, the Medical Outcomes Study's Short-Form 36 and grip strength. Imaging endpoints for the trial included both ultrasound evidence of synovitis and positive power Doppler signal. Ninety-two people were enrolled in the trial. The average age was 63 years, and 79 percent of the participants were women. The enrolled group were split evenly with half receiving prednisolone and the other half receiving placebo. In each of these two groups, 42 completed the trial. At week six, 33 patients in the prednisolone group and 15 in the placebo group fulfilled the OARSI responder criteria, and prednisolone was superior to placebo in most other secondary clinical endpoints. Additionally, ultrasound synovitis significantly improved at week six in the prednisolone group and there was no difference in the power Doppler signal. After drug tapering, between-group differences disappeared. Adverse events were mostly mild for patients in the study, and they were comparable between the two groups.
"Substantial improvements in pain and function, exceeding effects of currently available therapies, were seen in the trial. Therefore, a short course of 10 mg of prednisolone could be considered a new treatment option for people suffering with hand OA, especially those who experience a flare," says Dr. Kroon. "However, it is important to realize that patients included in this study had pain and signs of inflammation and experienced a flare after withdrawal of pain medication, and therefore, these results only pertain to this group of patients. Future studies to investigate the optimal dosage and duration of treatment are warranted
Limited access to SLE lab tests in developing nations affects usefulness
American College of Rheumatology
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ATLANTA -- According to new research findings presented this week at the 2019 ACR/ARP Annual Meeting, supportive laboratory assays to diagnose lupus, specifically the antinuclear antibody (ANA) test, are less often offered in developing nations due to a relative lack of resources. This greatly reduced the diagnostic utility of ANA as an entry criterion for lupus classification in Ghanaian and Nigerian cohorts compared to African American cohorts in the United States. This emphasizes an urgent need for broader clinical trials and ANA testing to participants in developing countries (Abstract #705 ).
Systemic lupus erythematosus, referred to as SLE or lupus, is a chronic (long-term) disease that causes systemic inflammation which affects multiple organs and can be deadly. In addition to affecting the skin and joints, it can affect other organs in the body such as the kidneys, brain, the tissue lining the lungs (pleura) and/or heart (pericardium). Many patients experience fatigue, weight loss, and fever.
Diagnostic criteria for SLE are important to generate reliable epidemiologic data. Prevalence of SLE in West Africa is falsely low because of barriers to accurate diagnostic testing, including lack of resources and the labor-intensive nature of these tests. The newly developed 2019 ACR/EULAR SLE classification criteria tool may improve diagnostic sensitivity and specificity compared to the previously established ACR and SLICC criteria. This new study investigated the performance of each set of criteria in two West African lupus cohorts from Korle bu Teaching Hospital in Ghana and Lagos University Teaching Hospital in Nigeria and compared it to an African American cohort at New York University/Langone Medical Center in New York City.
"African SLE patients throughout the diaspora are undertreated and understudied. This is in part due to the tendency for these individuals to hail from resource-limited areas of the world. In vetting diagnostic criteria, it is important to consider how more sophisticated testing may exacerbate existing disparities in diagnosis, treatment, and research," says Ashira D. Blazer, MD, MSCI, assistant professor of medicine, Division of Rheumatology, at New York University Langone Medical Center and the study's lead author. "Lack of widely available testing for ANA, the entry criterion to classify SLE using the 2019 ACR/EULAR classification criteria, throughout sub-Saharan Africa could impact SLE clinical care and slow down research", she adds. "We aimed to test the diagnostic efficiencies of each criteria in the USA compared to two low- or middle-income countries."
The researchers collected data on 355 patients with SLE for the study, including 151 African American patients in the United States, 110 patients in Ghana and 94 patients in Nigeria. All were diagnosed with lupus by expert clinicians. They gathered clinical information including demographics, SLE criteria, SLEDAI scores, SLICC damage indexes, vital signs and laboratory values that were available at the initial patient encounter. Longitudinal data was collected, at six-month intervals, over the course of at least one year during routine clinical visits. When necessary, the researchers also retrospectively reviewed clinical charts. They calculated the proportion of patients in each of the three cohorts who met each of the systems for classifying patients with lupus: (1) ACR, (2) SLICC and the (3) 2019 ACR/EULAR Classification Criteria for SLE.
The African American cohort's demographics included an average age of 43 years, 90 percent were women, mean SLE disease duration of 14.3 years; and 96 percent met the ACR criteria, 96 percent met the SLICC criteria and 95 percent met the ACR/EULAR criteria. In the Ghanaian cohort, the average age was 32 years, all were women, the mean SLE disease duration was 2.2 years; and 85 percent met the ACR criteria, 84 percent met the SLICC criteria and 62 percent met the ACR/EULAR criteria. In the Nigerian cohort, the average age was 35, 97 percent were women, the mean SLE disease duration was 4.4 years, and 90 percent met the ACR criteria, 87 percent met the SLICC criteria and 61 percent met the ACR/EULAR criteria.
Researchers found discrepancies in the data due largely to missing laboratory data, particularly immunologic and hematologic studies. While none of the African-American cohort were missing ANA test results, 26 percent of the Ghanaian cohort and 33 percent of the Nigerian cohort were missing ANA results. Compared to both the Ghanaian and Nigerian cohorts, the African-American cohort was more likely to meet ACR, SLICC and ACR/EULAR criteria. While the ANA entry criterion greatly diminished the diagnostic utility of the ACR/EULAR classification criteria in both the Ghanaian and Nigerian cohorts, the criteria's weighted point system performed better than either the ACR or SLICC criteria, with 96 percent of the African-American, 92 percent of the Ghanaian and 95 percent of the Nigerian cohorts earning a sufficient number of diagnostic points.
"The new clinical indices provided better diagnostic efficiency in the developing world than either the ACR or SLICC criteria. These findings were enlightening, and they solidified an important concept: that SLE is a clinical diagnosis first," says Dr. Blazer. "While research partnerships across the international economic divides might provide ANA testing, it is imperative that no new barriers be created for regional investigators who might struggle to disseminate data lacking the international community's required laboratory results."
Additional medications to treat children with JIA are urgently needed
American College of Rheumatology
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ATLANTA -- According to new research findings presented this week at the 2019 ACR/ARP Annual Meeting, there is a profound ongoing need for additional medications to control the signs and symptoms of juvenile idiopathic arthritis (JIA), despite the availability of several approved biologic disease-modifying antirheumatic drugs (biologics) (Abstract #1813 ).
There are several biologics used for JIA treatment in the United States including etanercept, adalimumab, abatacept, tocilizumab and canakinumab. Nevertheless, many children with JIA continue to have active arthritis despite the available medications and are treated with other medications off-label. Medications that have been proven to be safe and effective in adults with chronic inflammatory arthritis are not being universally studied in children with JIA. This study's goal was to document the continuing medical need for additional, newly approved medications to treat children with JIA.
"The approved treatment options for JIA have expanded tremendously, but there are still significant proportions of children who do not respond to available therapies or who are receiving medications that have not been approved for JIA. We must demand that newly developed medications are studied for safety and effectiveness in children," says Timothy Beukelman, MD, MSCE, associate professor, Division of Pediatric Rheumatology, at the University of Alabama at Birmingham, and the study's co-author.
For the study, the researchers reviewed electronic medical record data for 1,599 JIA patients treated at Cincinnati Children's Hospital Medical Center (CCHMC) since 2008 for medication use and disease activity over time. In addition, they assessed 7,379 JIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) registry for medication use and disease activity at their most recent registry visit. The researchers defined ongoing medication need as active JIA despite sequential use of two or more biologics. They defined active JIA as either physician global assessment of JIA activity (on a scale of zero to 10 with zero as inactive disease) of three or higher, or three or more active joints, or a patient global assessment score (on a scale of zero to 10 with zero meaning very well) of three or higher. They only assessed medication failure for patients with complete data.
Use of biologics was common in both data sources (53 percent in CCHMC; 65 percent in CARRA registry), and ongoing medication need was assessed in 487 CCHMC patients and 1,159 CARRA patients. Approximately 52 percent of CCHMC patients and 45 percent of CARRA patients had ongoing active JIA despite treatment with two or more biologics. Among all patients who received any biologic treatments, there was frequent use of medications that are not approved for JIA (37 percent CCHMC patients and 24 percent CARRA patients).
"There is clearly a need to increase the number and types of therapies available for the treatment of children with JIA. Only if FDA demands studies from the pharmaceutical companies as part of their drug development program, will pediatric rheumatologists have valid information about the proper dosing, efficacy and preliminary safety of new medications. Further, FDA approval greatly increases access of JIA patients to new medications," says Hermine I. Brunner, MD, MSc, MBA, chief of rheumatology and director Lupus Center at Cincinnati Children's Hospital Medical Center, and scientific director of the Pediatric Rheumatology Collaborative Study Group (PRCSG) and the study's lead- author.
SLE Medicaid patients have higher 30-day death rate compared to those with diabetes
American College of Rheumatology
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ATLANTA --New research found that the 30-day death rate for Medicaid patients with systemic lupus erythematosus (SLE) who underwent coronary revascularization procedures for cardiovascular disease was double that of patients with diabetes mellitus who underwent the same procedures. This study will be presented at the 2019 ACR/ARP Annual Meeting (Abstract # 897).
Systemic lupus erythematosus, referred to as SLE or lupus, is a chronic (long-term) disease that causes systemic inflammation which affects multiple organs and can be deadly. In addition to affecting the skin and joints, it can affect other organs in the body such as the kidneys, brain, the tissue lining the lungs (pleura) and/or heart (pericardium). Many patients experience fatigue, weight loss, and fever.
This research group previously found that although there were similar myocardial infarction risks in patients with SLE or diabetes mellitus (DM), for unknown reasons the rates of coronary revascularization procedures among SLE patients enrolled in Medicaid were 18 percent higher than age- and sex-matched diabetes patients. Although DM patients are known to have an elevated absolute risk of death after coronary revascularization procedures, little is known about mortality after these heart procedures in lupus patients. The researchers conducted a study to determine the outcomes in SLE patients compared to patients with DM as well as patients in the general population. Patients in each cohort were enrolled in Medicaid.
The researchers used Medicaid Analytic eXtract data containing billing claims from the 29 most populated states in the United States from 2007 to 2010. They identified adults 18 to 65 years old with prevalent SLE or DM based on the ninth edition of the International Classification of Diseases (ICD-9) codes. They also included patients without SLE or DM for the general population cohort.
Researchers identified coronary revascularization procedures among 608 SLE patients, 1,185 DM patients and 628 general population patients. Each group had a similar follow-up period of approximately two years (1.7). SLE patients had the highest 30-day post-revascularization mortality rate (351.35) per 1,000 person years of observation compared to 210.4 in the DM group and 189.9 in the general population. The analysis showed that lupus patients had double the odds of death within 30 days after a coronary revascularization compared to patients with DM. They also found a similar, but non-significant trend for SLE patients compared to the general population, although this was limited by very few deaths in the general population group.
"The results suggest that Medicaid SLE patients undergoing coronary revascularization procedures had an increased risk of death compared to similar diabetes mellitus patients having the same procedures. This may be due to severity of cardiovascular disease and overall health status in SLE patients selected for these procedures," said Medha Barbhaiya, MD, a rheumatologist and clinical researcher the Hospital for Special Surgery and the study's lead author. "Future studies accounting for the complexity and indications of the procedures performed, SLE and cardiac disease severity, and investigating causes of post-procedure deaths are required. Given the small number of deaths observed, this study needs to be replicated in a larger cohort."
Although based on a small number of post-procedural deaths, this study found that the SLE patients had 1.7 times higher 30-day mortality rates post-coronary revascularization compared to DM and general population patients, despite being comparatively much younger on average.
No matter what job you hold in pharmacy, you’re likely to run into some funny situations.
Recently, I was reminiscing about my time as a pharmacy intern and student on PharmD rotations. Here are some of my favorite stories.
Price Check
As an intern at a retail pharmacy chain, I often spent time price matching prescription drugs at other stores.
One time, a customer brought in more than 10 prescriptions and asked me to price match every possible competitor for each drug. I think it took me about 90 minutes to make all the calls.
I was checking the customer out at the register when he suddenly flew into a rage. He angrily shouted, “This is 25 cents more than last time!”
I interrupted the man’s rant with, “Are you really going to hassle me over 25 cents?” I then reached into my pocket and handed the man a quarter.
We never saw him again.
Itchy Leg Aid
Another time as an intern, a man asked me to help him pick out some cream for an itchy insect bite.
We were in the OTC aisle looking at hydrocortisone cream when he rolled up his pant leg and revealed a red, swollen leg with red streaking in the vein from his ankle all the way up past where I could see. The patient obviously had an advanced case of cellulitis.
I told him, “There’s no OTC cream that can fix that,” and then I quickly walked him out of the pharmacy, pointed to an urgent care center across the street, and said, “If you want to keep that leg, you’ll go seek medical treatment right now.”
Thankfully, he took my advice.
Inappropriate Exam
As a Pharm D student, I spent a month working with an internal medicine physician. This physician believed that students should be actively involved, so I ended up participating in patient care rather than observing it.
One day, a patient came in with classic symptoms of benign prostatic hyperplasia. Without warning or asking me to leave the room, the physician had the patient drop his pants for a digital rectal examination.
After the test was completed, the physician asked if I would like to feel the enlarged prostate. I quickly declined, saying, “If you go to a pharmacy that does that, you're in the wrong pharmacy.” It was the only time I ever saw the physician laugh.
Jailhouse Script
Here’s a bonus story courtesy of my wife, who is also a pharmacist.
As an intern, my wife was working at a retail store when a man pulled up to the drive-thru window. He presented a script for Percocet and said, “I need this in a hurry because I’m on my way to jail.”
The pharmacist overheard him and said, “I don’t think they’re going to let you take those pills with you to jail!”
Don’t accidentally overlook these trending pharmacy stories!
5. Does Insulin Syringe Needle Length Matter?
When it comes to diabetes therapy, insulin is pharmacists’ most valuable weapon. Although oral therapies can offer convenience and reduce hypoglycemia risk, the glucose-lowering effects of insulin remain unrivaled.
Unfortunately, patients may resist starting insulin for many reasons, one of which is a fear of needles. Injecting insulin can be painful, especially when using longer needles. Painful injections are not only unpleasant for patients, but can also lead to medication noncompliance and poorer health outcomes.
Although longer needles are often prescribed for patients with increased body fat, this practice actually has no clinical basis. Insulin is meant to be injected into subcutaneous tissue; human skin is only 1.6 mm to 2.4 mm thick, on average. Because skin thickness doesn’t increase significantly in overweight and obese patients, a 4-mm needle is sufficient to deliver insulin to subcutaneous tissue in patients of all sizes.
Furthermore, choosing longer needles can negatively impact therapy in thinner patients. If patients inject insulin intramuscularly because their needle is too long, the drug’s absorption will be accelerated, while it’s duration of action will be shortened.
4. Cystic Fibrosis Patients Could Soon Take a Deep Breath of Ibuprofen
For patients with cystic fibrosis (CF), ibuprofen can help slow down lung function decline. The only problem is that consistent, high-dose ibuprofen use can lead to gastrointestinal bleeding, as well as kidney injury if taken with nephrotoxic intravenous antibiotics, which are commonly taken among CF patients.
The solution to this problem could be breathable ibuprofen.
The idea for developing inhaled ibuprofen originally came from Michael Konstan, MD, the pediatric department chair at Case Western University School of Medicine, who showed that patients with CF who received oral, high-dose ibuprofen (20 mg/kg, or 6 of the 200-mg tablets for a 60-kg person) were able to retain lung function and needed fewer courses of antibiotics. He also found that rats who took high-dose ibuprofen slowed the influx of the neutrophil into the lung, which provided an anti-inflammatory effect.
Carolyn L. Cannon, MD, PhD, associate professor of microbial pathogenesis and immunology at Texas A&M Health Science Center, is working in the preclinical phase of some nanoparticle formulations of this proposed therapy. She explained that Dr. Konstan’s Cystic Fibrosis Care Center at Rainbow Babies and Children’s Hospital still provides high-dose ibuprofen as a treatment option, but few other places do so because of potential adverse effects.
3. Common Medications Can Trigger Heart Failure
The American Heart Association (AHA) has released a scientific statement cautioning against the use of some common drugs and supplements in patients with heart failure (HF).
The statement published this month in Circulation said certain medications can cause heart-related problems by:
• Being toxic to heart muscle cells or changing how the heart muscle contracts.
• Interacting with HF medications, which means some of their benefits are lost.
• Containing more sodium than advised for patients with HF.
For example, commonly used nonsteroidal anti-inflammatory drugs, such as ibuprofen, can trigger or worsen HF by causing sodium and fluid retention and rendering diuretic medications less effective. Meanwhile, OTC heartburn medications and cold treatments may also contain significant amounts of sodium, which is normally restricted in patients with HF.
The AHA advised that many supplements can be dangerous for HF patients, including products containing ephedra, which is known to increase blood pressure, and others that interfere with one or more commonly used HF medications, such as St. John’s wort, ginseng, hawthorn, danshen, and green tea.
2. Pharmacist Reprimanded for Poor Professional Practice
The Pharmaceutical Society of Ireland is censuring a pharmacist for poor professional performance. Pharmacist Jeremiah Blake, owner of Blake’s Pharmacy, will be “mentored” for a year by a superintendent pharmacist, and he will have to meet with that mentor at least 3 times during the 12-month period.
The Pharmaceutical Society of Ireland council found that Blake had poorly maintained a controlled drug register, prescription register, and pharmacy records, including records of medications dispensed. Blake was also rebuked for the lack of appropriate storage of human and veterinary medicinal products. For example, out-of-date products were not segregated from other items and were also not removed for disposal or destruction.
Medications that needed to be kept in cool temperatures were also not stored properly in the fridge. In addition, Blake did not keep medications stored in a clean or appropriate environment. The pharmacist also did not ensure that standard operating procedures were followed, and he did not provide a patient consultation area.
The pharmacist mentor will file reports on Blake’s solutions to these problems, and then the council will review all the reports at the end of the year to ensure that his behavior is satisfactory. If any of the reports do not satisfy the council, then Blake will continue to be monitored until the council is appeased.
1. 3 Federal Regulatory Changes Affecting Pharmacy
In recent years, federal agencies have introduced significant regulatory proposals impacting different facets of the pharmaceutical industry, from drug manufacturing, to reimbursement, to disposal.
Here are 3 major proposals handed down from federal agencies that pharmacists should know:
1. CMS Final Rule on Outpatient Drug Reimbursement
2. FDA Draft Compounding Guidance
3. EPA Proposed Rule on Hazardous Waste Pharmaceuticals
We’re In Our Thirties And That’s When His Attitude Is Stuck
Bigotry, Crazy Requests, Germany, Great Stuff, Pharmacy | Right | October 28, 2019
(I work at a pharmacy. My coworkers and I are female, all in our thirties. One day, an old man walks in. He carries a dirty bag. He has a pair of trousers in there, which he grabs and puts on the counter.)
Old Man: “Please fix it. The zipper is broken.”
Coworker: “Sir, you’re at a pharmacy.”
Old Man: “So?”
Coworker: “We sell prescriptions. We don’t fix clothes here.”
Old Man: *angry now* “But you all are young women in here! You have to be able to fix my pants!”
Extra Stupid, Pharmacy, USA | Healthy | October 23, 2019
(One of my medications is delivered to my home through a specialty pharmacy. Every month they call to verify my information and see if anything has changed. At the end of our conversation, the Home Delivery Pharmacist — HDP — reverifies my medical history before finalizing the order.)
Home Delivery Pharmacist: “Okay… I see here this is from [Hospital Doctor]. Did you see him recently?”
Me: “Yes, while I was in-patient at [Hospital] last month.”
Home Delivery Pharmacist: “Okay. Have you been to the ER, had an infection, or been hospitalized in the last 90 days?”
Me: “Yes, all three.”
Home Delivery Pharmacist: “Which one?”
Me: “All of them.”
Home Delivery Pharmacist: “No. ER, infection, or hospital. Which one?”
Me: “Um… all of the above. All three.”
Home Delivery Pharmacist: *annoyed* “No, ma’am. Were you in the ER, did you have an infection, or were you hospitalized in the last 90 days?”
Me: “Yes! I went to the ER because I couldn’t breathe. I found out I had a lung infection and I was hospitalized for 21 days.”
Home Delivery Pharmacist: “Oh.” *sour tone* “You could have just said yes. We’ll ship this tomorrow.” *hangs up*
Columbus, Ohio, Pharmacy, USA | Unfiltered | October 22, 2019
(Note: I’m the bad customer here)
Recently, I got sick with a very bad cold that among other things, caused me to lose my voice for an extended period. My mother then proceeded to catch this cold, along with a pneumonia, and had to be hospitalized in the ICU with a tube down her throat. My dad has been by her side the whole time and left his phone charger at home, so I go out to get him a new one. It’s Halloween when this happens, which happens to be my mother’s favorite holiday, and I’m very aware of her condition on her favorite day of the year, so I’m not in the best of moods. I eventually find a CVS and buy a phone charger, in the process ruining the night of the cashier.
Me: (hands cashier items)
Cashier: “How are you tonight?”
Me: *Raspy and irritable* “Not great”
Cashier: “Is it because everyone else is ‘too cool for school’?”
(Note: We’re right next to a major university on Halloween, he probably thought I was having a bad night for more normal reasons.)
Me: ” No, it’s because my mother is intubated in the ICU.”
Cashier: (says something about how the ICU here is very good, but is clearly not expecting my response)
(That was a bad night for me, and as I walked out, I felt really bad about ruining that guy’s night as well. If you’re reading this, I’m sorry.)
Diễn Đàn Người Việt Hải Ngoại. Tự do ngôn luận, an toàn và uy tín. V́ một tương lai tươi đẹp cho các thế hệ Việt Nam hăy ghé thăm chúng tôi, hăy tâm sự với chúng tôi mỗi ngày, mỗi giờ và mỗi giây phút có thể. VietBF.Com Xin cám ơn các bạn, chúc tất cả các bạn vui vẻ và gặp nhiều may mắn.
Welcome to Vietnamese American Community, Vietnamese European, Canadian, Australian Forum, Vietnamese Overseas Forum. Freedom of speech, safety and prestige. For a beautiful future for Vietnamese generations, please visit us, talk to us every day, every hour and every moment possible. VietBF.Com Thank you all and good luck.
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