Bone mineral density in patients diagnosed with giant cell arteritis taking glucocorticoids: a case-control study.

Objective: The standard treatment for GCA is high-dose glucocorticoids (GCs). It is unknown whether GCs are more detrimental to BMD at the spine or the hip. The aim of this study was to investigate the effect of GCs on BMD at the lumbar spine and hip in patients with GCA being treated with GCs. Methods: Patients who were referred for DXA at a hospital in the north-west of England between 2010 and 2019 were included. Two patient groups were identified: patients with GCA on current GC (cases) were matched 1:4 based on age and biological sex to those referred to the scanner with no indication for scanning (controls). Logistic models were fitted looking at the spine and hip BMD, unadjusted and adjusted for height and weight. Results: As would be expected, this gave an adjusted odds ratio (OR) of 0.280 (95% CI 0.071, 1.110) at the lumbar spine, OR of 0.238 (95% CI 0.033, 1.719) at the left femoral neck, OR of 0.187 (95% CI 0.037, 0.948) at the right femoral neck, OR of 0.005 (95% CI 0.001, 0.021) at the left total hip and OR of 0.003 (95% CI 0.001, 0.015) at the right total hip. Conclusion: The study has shown that patients diagnosed with GCA receiving GC treatment have a lower BMD at the right femoral neck, left total hip and right total hip compared with controls in patients of the same age and biological sex after adjusting for height and weight.

The role of HIV/hepatitis B virus/hepatitis C virus RNA+ triple infection in end-stage liver disease and all-cause mortality in Europe.

BACKGROUND: There are limited data on end-stage liver disease (ESLD) and mortality in people with HIV (PWH) coinfected with both hepatitis B virus (HBV) and hepatitis C virus (HCV). METHODS: All PWH aged greater than 18 under follow-up in EuroSIDA positive for HBsAg (HBV), and/or HCVRNA+, were followed from baseline (latest of 1 January 2001, EuroSIDA recruitment, known HBV/HCV status) to ESLD, death, last visit, or 31 December 2020. Follow-up while HCVRNA- was excluded. In two separate models, Poisson regression compared three groups updated over time; HIV/HBV, HIV/HCV, and HIV/HBV/HCV. RESULTS: Among 5733 included individuals, 4476 (78.1%) had HIV/HCV, 953 (16.6%) had HIV/HBV and 304 (5.3%) had HIV/HBV/HCV. In total, 289 (5%) developed ESLD during 34 178 person-years of follow-up (PYFU), incidence 8.5/1000 PYFU [95% confidence interval (CI) 7.5-9.4] and 707 deaths occurred during 34671 PYFU (incidence 20.4/1000 PYFU; 95% CI 18.9-21.9). After adjustment, compared with those with HIV/HCV, persons with HIV/HBV had significantly lower rates of ESLD [adjusted incidence rate ratio (aIRR) 0.53; 95% CI 0.34-0.81]. Those with HIV/HBV/HCV had marginally significantly higher rates of ESLD (aIRR 1.49; 95% CI 0.98-2.26). Those under follow-up in 2014 or later had significantly lower rates of ESLD compared with 2007-2013 (aIRR 0.65; 95% CI 0.47-0.89). Differences in ESLD between the three groups were most pronounced in those aged at least 40. After adjustment, there were no significant differences in all-cause mortality across the three groups. CONCLUSION: HIV/HBV-coinfected individuals had lower rates of ESLD and HIV/HBV/HCV had higher rates of ESLD compared with those with HIV/HCV, especially in those aged more than 40. ESLD decreased over time across all groups. CLINICALTRIALSGOV IDENTIFIER: NCT02699736.

Acute Abducens Nerve Palsy in a Patient who Sustained Mechanical Trauma to the Orbit.

BACKGROUND: Abducens nerve (Cranial Nerve VI) innervates the lateral rectus (LR) muscle. Head trauma is one of the most common causes of abducens nerve palsy. Orbital and/or facial injuries could also affect the LR muscle directly or the orbital course of abducens nerve and lead to palsy. We present a case of a young man with multiple orbital fractures and an impingement of the LR muscle resulting in a complete loss of abduction. CASE REPORT: A 29-year-old male reported falling 15 feet. He presented with diplopia and had complete abduction deficit of the left eye. Orbital CT imaging revealed a bony spur from his left zygomatic bone impinging on the lateral rectus muscle. In view of -4 abduction deficit, he was operated upon to remove the bony spur. This led to a gradual, but complete recovery of his abduction. DISCUSSION: The abducens nerve has a tortuous course and as a result is commonly injured during head trauma, in particular due to its vulnerability as it passes into Dorello's canal, or its journey through the cavernous sinus. The case report highlights orbital causes such as direct muscle avulsion or injury to the orbital portion of the abducens nerve, as reasons for how LR weakness could be easily overlooked, unless specifically examined with high-resolution orbital imaging. CONCLUSION: Orbital mechanical causes can be overlooked in LR palsy. We emphasise the role of orbital imaging in any patient with abducens nerve or LR Palsy and reaffirm that not all cases are associated with an intracranial cause.

The predictors of pain extent in people living with HIV.

OBJECTIVE: To investigate the prevalence of widespread pain among people with HIV (PWH) and describe associations with antiretroviral therapy (ART) and markers of HIV disease stage. DESIGN: Cross-sectional analysis of cohort study in the United Kingdom and Ireland. METHODS: Pain information was collected during the baseline visit (conducted from 2013 to 2015) through a self-completed manikin identifying pain at 15 sites from five body regions. Pain was classified as widespread if reported at at least four regions and at least seven sites, or regional otherwise. Chi-squared tests, Kruskal-Wallis tests and ordinal logistic regression were used to consider associations between pain extent and sociodemographic and HIV-related factors. RESULTS: Among the 1207 participants (614 PWH ≥ 50 years, 330 PWH < 50 years, 263 HIV-negative controls ≥50 years), pain was most commonly reported at the upper (left: 28.9%, right: 28.0%) and lower (left: 25.7%; right: 24.5%) leg, upper (18.6%) and lower (29.7%) back and shoulders (left: 16.0%; right: 16.8%). Widespread pain was more commonly reported in PWH than in HIV-negative controls (PWH ≥ 50 years: 18.7%; PWH < 50 years: 12.7%; HIV-negative ≥50 years: 9.5%) with regional pain reported in 47.6, 44.8 and 49.8%, respectively (global P = 0.001). In multivariable analyses, pain extent was greater in those with lower educational attainment, those exposed to more ART drugs, and those with a higher current CD4 cell count but longer exposure to immunosuppression. CONCLUSION: Widespread pain is commonly reported in PWH and is associated with longer duration of exposure to HIV, immunosuppression and ART. Our findings call for greater awareness, and interventions to support the management, of pain in PWH.

Associations Between Widespread Pain and Sleep Quality in People With HIV.

BACKGROUND: We investigate the association of widespread pain with sleep quality among people with HIV and HIV-negative controls. SETTING: UK-based cohort. METHODS: Pain information was collected through a pain mannikin identifying affected body sites; pain was classified as widespread if pain was reported in ≥4 of 5 body regions and in ≥7 of 15 body sites, and as regional otherwise. Sleep was assessed a median of 3.2 years later through 7-night actigraphy and through self-reported assessments of sleep quality. Chi-squared tests, Kruskal-Wallis tests, and linear/logistic regression considered associations between pain extent and sleep quality. RESULTS: Of the 414 participants, 74 (17.9%) reported widespread and 189 (45.7%) regional pain. Although there were few clear associations between actigraphy outcomes and pain extent, those with widespread and regional pain consistently reported poorer sleep quality on all self-reported measures than those with no pain. Median (interquartile range) insomnia severity index and Patient-reported Outcomes Measurement Information System (PROMIS) for sleep disturbance and sleep-related impairment scores were 12 (7-16), 55.3 (48.0-58.9), and 57.2 (48.9-61.3), respectively, for those with widespread pain, 8 (4-13), 51.2 (45.5-58.3), and 50.3 (43.6-56.1) for those with regional pain, and 5 (2-9), 47.9 (42.9-54.3), and 45.5 (41.4-50.3) for those with no pain (all P values 0.0001). Associations remained strong after adjustment for HIV status and other confounders, and were reduced but remained significant, after adjustment for depressive symptoms. CONCLUSIONS: Widespread pain was not associated with objective measures of sleep but was strongly associated with self-reported assessments of sleep quality in people with HIV.