Elevated DAS28-ESR in patients with rheumatoid arthritis who have comorbid fibromyalgia is associated more with tender joint counts than with patient global assessment or swollen joint counts: implications for assessment of inflammatory activity.

OBJECTIVES: More than 20% of rheumatoid arthritis (RA) patients have comorbid fibromyalgia (FM+), which may elevate DAS28-ESR (disease activity score 28-erythrocyte sedimentation rate) and other indices, resulting in challenges to assess inflammatory disease activity. Although several reports indicate that elevated patient global assessment (PATGL) may elevate DAS28 in the absence of inflammatory activity, less information is available concerning the other three components, tender joint count (TJC), swollen joint count (SJC), and erythrocyte sedimentation rate (ESR), to possibly elevate DAS28 in FM+ vs. FM- RA patients. METHODS: A PubMed search identified 14 reports which presented comparisons of DAS28-ESR and its four components in RA FM+ vs. FM- groups. Median DAS28, component arithmetic differences, pooled effect sizes and 95% confidence intervals were analysed in the FM+ vs. FM- groups. RESULTS: In FM+ vs. FM- groups, median DAS28 was 5.3 vs. 4.2, SJC 4.0 vs. 3.0, TJC 13.2 vs. 5.3, PATGL 61.6 vs. 39.9, ESR 26.3 vs. 26.5. DAS28-ESR was classified as "high" (>5.1) in 11/14 FM+ groups and "moderate" (3.2-5.1) in all 14 FM- groups. Effect sizes in FM+ vs. FM- groups for DAS28-ESR, SJC, TJC, PATGL, and ESR were large (≥0.8) in 10/14, 1/13, 12/13, 7/13, and 1/13 comparisons, respectively, and pooled effect sizes 0.84 (0.3, 1.4), 0.33 (-0.4, 1.0), 1.27 (0.01, 2.5), 0.91 (-0.6, 2.4), and 0.07 (-0.6, 0.7), respectively. CONCLUSIONS: DAS28-ESR is elevated significantly in FM+ vs. FM- RA patients; pooled effect sizes were highest for TJC, followed by PATGL, SJC and ESR. The findings appear relevant to response and remission criteria, treat-to-target, and general management of RA.

Clinical and Liver Biochemistry Phenotypes, and Outcome in 133 Patients with Anti-seizure Drug-Induced Liver Injury.

AIMS AND OBJECTIVE: Anti-seizure drugs that cause idiosyncratic drug-induced liver injury (DILI) are an important cause of morbidity and mortality in individuals exposed to these drugs. The clinical and demographic characteristics, the liver injury pattern, the outcome, and the agents responsible for hepatotoxicity have not been thoroughly studied. We investigated the aforementioned characteristics in a large cohort of DILI registry patients. METHODS: Patients with anti-seizure DILI were studied from a large single-center DILI registry between 1998 and 2021. DILI was defined by international working group criteria with at least a probable relation with RUCAM. Immunoallergic features and organ-specific contribution to outcome were investigated. RESULTS: Anti-seizure drugs accounted for 133 patients (12.5%) among 1067 patients with idiosyncratic DILI. Compared to other agents, patients with anti-seizure DILI were younger (31 vs 41 years; p = 0.31), were more often females (52% vs 46%; p = 0.19) and had a lower frequency of jaundice (41% vs 59%, p = 0.001), MELD score (14.5 vs 16.5; p = 0.02) and mortality (9.8% vs 15.7%, p = 0.03). Anti-seizure DILI exhibited a greater frequency of hypersensitivity skin rashes (75% vs 22%, p < 0.001), including DRESS (51% vs 13%, p < 0.001) and SJS/TEN (19% vs1%, p < 0.001). A total of 18 different anti-seizure agents were responsible for DILI, largely contributed by carbamazepine (n = 36), phenytoin (n = 71), phenobarbitone (n = 8) and valproate (n = 14) which accounted for 89% of cases and 85% of 13 deaths. CONCLUSIONS: Anti-seizure DILI are caused predominantly by first generation drugs. Newer agents account for < 10% of cases. Hypersensitivity reaction is the most common phenotypic presentation. Both severity and mortality are lower with anti-seizure DILI.

Potential therapeutic effects of adjunct osteopathic manipulative treatments in SARS-CoV-2 patients.

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) affects various human organ systems, including the lymphatic, pulmonary, gastrointestinal, and neurologic systems. The utilization of osteopathic manipulative treatment (OMT) techniques has been clinically effective in the alleviation of various upper respiratory infection symptoms. Consequently, the use of osteopathic manipulative medicine (OMM) in SARS-CoV-2 patients as adjunct treatment can be beneficial in promoting overall recovery. This paper attempts to address the pathophysiology of SARS-CoV-2 infection at the cellular level and its downstream effects. Subsequently, osteopathic principles were investigated to evaluate potential therapeutic effects, providing a holistic approach in the SARS-CoV-2 treatment. Although the association between the benefits of OMT on clinical improvement during the 1918 Spanish influenza pandemic can be seen, further investigation is required to establish a direct correlation between OMT and symptom management in SARS-CoV-2.

Thrombotic Thrombocytopenia Masquerading As COVID-19 Infection.

Thrombotic thrombocytopenic purpura (TTP) is a rare and challenging diagnosis that consists of thrombotic microangiopathy due to complete or severe deficiency of ADAMTS13 protease that can present at any age. It is very important to have a suspicion concerning this disease as mortality can be very high if it goes unnoticed. This case describes a patient that presented with gastrointestinal symptoms and hematuria and was found to have COVID-19 and TTP.  We present a case of a 40-year-old female with no past medical history who presented to the Emergency Department with complaints of abdominal pain, nausea, vomiting, and dark urine. The patient workup revealed a platelet count of 4000. The patient was also noted to be COVID-19 positive. Upon further workup, the TTP diagnosis was confirmed. She responded appropriately to plasmapheresis and steroids. COVID-19 seems to be linked to a wide range of hematologic conditions including but not limited to TTP. In view that TTP can have significant mortality if untreated, we must be suspicious about this condition in COVID-19 cases. The aim of this case report is to highlight the importance of having a low threshold for making a diagnosis of TTP if labs are significant for hemolytic anemia. Our aim is also to emphasize that the treatment should be initiated if schistocytes are seen on the peripheral smear without awaiting laboratory results confirming low levels of ADAMTS13, given the fatal nature of the condition if left untreated.

From bathymetry to bioshields: a review of post-tsunami ecological research in India and its implications for policy.

More than half a decade has passed since the December 26th 2004 tsunami hit the Indian coast leaving a trail of ecological, economic and human destruction in its wake. We reviewed the coastal ecological research carried out in India in the light of the tsunami. In addition, we also briefly reviewed the ecological research in other tsunami affected countries in Asia namely Sri Lanka, Indonesia, Thailand and Maldives in order to provide a broader perspective of ecological research after tsunami. A basic search in ISI Web of Knowledge using keywords "tsunami" and "India" resulted in 127 peer reviewed journal articles, of which 39 articles were pertaining to ecological sciences. In comparison, Sri Lanka, Indonesia, Thailand and Maldives had, respectively, eight, four, 21 and two articles pertaining to ecology. In India, bioshields received the major share of scientific interest (14 out of 39) while only one study (each) was dedicated to corals, seagrasses, seaweeds and meiofauna, pointing to the paucity of research attention dedicated to these critical ecosystems. We noted that very few interdisciplinary studies looked at linkages between pure/applied sciences and the social sciences in India. In addition, there appears to be little correlation between the limited research that was done and its influence on policy in India. This review points to gap areas in ecological research in India and highlights the lessons learnt from research in other tsunami-affected countries. It also provides guidance on the links between science and policy that are required for effective coastal zone management.

Chemokine receptor 2b inhibition provides renal protection in angiotensin II - salt hypertension.

The present study was designed to determine whether chemokine receptor 2b (CCR2b) contributes to the development of renal injury in salt-sensitive angiotensin II (ANG) hypertension. Rats were infused with ANG and fed a high-salt diet (HS) for 14 days. Rats were divided into 4 groups: HS; HS administered the CCR2b antagonist, RS102895; Ang/HS hypertensive; and Ang/HS hypertensive administered RS102895. CCR2b inhibition slowed the progression of blood pressure elevation during the first week of ANG/HS hypertension; however, it did not alter blood pressure in the HS group. At 2 weeks, arterial pressure was not significantly different between ANG/HS and ANG/HS hypertensive rats administered RS102895. Renal cortical nuclear factor kappaB activity increased in ANG/HS hypertension compared with the HS group (0.11+/-0.006 versus 0.08+/-0.003 ng of activated nuclear factor kappaB per microgram of protein), and RS102895 treatment lowered nuclear factor kappaB activity in ANG/HS hypertension (0.08+/-0.005 ng of activated nuclear factor kappaB per microgram of protein). Renal tumor necrosis factor-alpha and intercellular adhesion molecule-1 expression increased, and Cyp2c23 expression decreased in ANG/HS hypertension compared with the HS group, and CCR2b inhibition reduced tumor necrosis factor-alpha and intercellular adhesion molecule-1 and increased Cyp2c23 expression. Histological immunostaining revealed increased renal monocyte and macrophage infiltration in ANG/HS hypertensive rats with decreased infiltration in rats receiving RS102895 treatment. Albuminuria and cortical collagen staining also increased in ANG/HS hypertensive rats, and RS102895 treatment lowered these effects. Afferent arteriolar autoregulatory responses to increasing renal perfusion pressure were blunted in ANG/HS hypertension, and RS102895 treatment improved this response. These data suggest that CCR2b inhibition protects the kidney in hypertension by reducing inflammation and delaying the progression of hypertension.