Outpatient Use of Antimicrobials in Patients With Rheumatoid Arthritis Before and After Treatment With Tumor Necrosis Factor Inhibitors: A Nationwide Retrospective Cohort Study.

OBJECTIVE: The objective of this study was to investigate the effect of tumor necrosis factor α inhibitor (TNFi) initiation on the use of antimicrobials among biologic-naïve patients with rheumatoid arthritis (RA). METHODS: Information on all biologic-naïve patients with RA was extracted from ICEBIO, a nationwide registry. Each patient was matched on age, sex, and calendar time to five randomly selected individuals from the general population. All filled antimicrobial and glucocorticoid prescriptions in the 2 years before and after initiation of the first TNFi were extracted from the Prescription Medicines Register. Prescriptions were quantified by using the number of filled prescriptions (NP) and defined daily doses. RESULTS: We extracted information on 359 patients with RA and 1795 comparators. During the 24 months before initiating treatment with TNFi, patients with RA received more prescriptions for antimicrobials than their matched general population comparators (mean ± SD: 2.8 ± 3.4 vs 1.6 ± 2.7; P < 0.001). The 24-month mean NP for patients with RA increased to 3.5 ± 3.9 (P < 0.001) after initiating TNFi: antibiotics, 2.6 ± 3.2 to 3.2 ± 3.5 (P < 0.001); antivirals, 0.06 ± 0.5 to 0.16 ± 0.7 (P = 0.004); and antimycotics, 0.14 ± 0.5 to 0.22 ± 0.9 (P = 0.06). The 12-month mean NP was highest in the second year after TNFi initiation (1.9 ± 2.4). No association was found between NP and glucocorticoids, age, body mass index, or pre-TNFi Disease Activity Score 28-joint count and C-reactive protein. CONCLUSION: Patients with RA on TNFi are more commonly treated for infections in the outpatient settings than previously reported. Patients are prescribed more antimicrobials in the 2 years preceding TNFi initiation than the general population, and this use further increases after initiation of TNFi. In contrast to what is reported for infections requiring hospitalization, outpatient antimicrobial use remained elevated for at least 2 years.

[Opioid Induced Pituitary Dysfunction].

A 77-year-old woman with a history of anal squamous cell carcinoma was admitted because of malaise, diarrhea and nausea, in addition to back pain related to a verte- bral compression fracture. During the course of treatment, opioid therapy was initiated, following which the patient became progressively hypotensive and hyponatraemic and respiratory drive progressively decreased. Serum levels of cortisol, TSH and LH were decreased and prolactin slightly elevated, but a Synacthen test and brain MRI turned out normal, suggesting a diagnosis of opioid-induced pituitary dysfunction. The patient was given glucocorticoid replacement therapy with good results. Here we present a case of this serious but less well recognised side-effect of opioids.

[Intensive care patients with influenza A (H1N1) infection in Iceland 2009]. / Gjörgaeslusjúklingar med inflúensu A (H1N1) á Islandi 2009.

BACKGROUND: We describe the main characteristics of patients that required intensive care due to the influenza (H1N1) outbreak in 2009. METHODS: Retrospective and prospective analysis of medical records from patients admitted to ICU with positive RT-PCR for (H1N1). RESULTS: During a six week period in the fall of 2009, 16 patients were admitted to intensive care in Iceland with confirmed H1N1 infection. Mean age was 48 years (range 1-81). Most patients were considered quite healthy but the majority had risk factors such as smoking, obesity or hypertension. All but one had fever, cough, dyspnea and bilateral infiltrates on chest x-ray and developed any organ failures (mean SOFA score 7). 12 needed mechanical ventilation and two extra corporeal membrane oxygenation (ECMO). Mean APACHE II score was 20. No patient died in the ICU but one elderly patient with multiple underlying diseases died a few days after being discharged from the ICU. CONCLUSIONS: (1) The incidence of severe influenza A (H1N1) that leads to ICU admission appears to be high in Iceland. (2) Many patients developed acute respiratory distress syndrome in addition to other organ failures, and required additional measures for oxygenation such as prone position, nitric oxide inhalation and ECMO. (3) 28 day mortality was low. (4) This study will aid in future outbreak planning in Iceland. Key words: influenza A, pneumonia, multiple organ failure, death rate, intensive care, ventilator therapy, ECMO.

[An unusual case of pneumocystis pneumonia--case report and review]. / Ovenjuleg pneumocystis lungnabólga--tilfelli og yfirlitsgrein.

A 63 year old woman seeks medical attention for symptoms of fever, headache and increasing dyspnoea. She has a history of psoriatic-arthritis and uses 10 mg/week of methotrexate as arthritic treatment. There is also a history of severe alcohol abuse. She is in respiratory failure, with basal pulmonary crackles and increased serum inflammatory markers, a normal white-cell count but with a lowered lymphocyte count. A CT-scan reveals ground-glass lung changes. Bronchial biopsy reveals the fungus P. jiroveci which infects immunodeficient hosts. After extensive testing it was concluded that the patient's immunodeficiency was attributed to the combination of methotrexate, ethanol and psoriatic-arthritis. In this article, a case of pneumocystis pneumonia is reviewed as well as the infective mechanism of P. jiroveci and host-defence against the fungus. Additionally, symptoms and signs of the infection, diagnostic approach and treatment are reviewed. Because the combination of methotrexate and ethanol played a significant role in the immunodeficiency of the patient, their effect on the immune system is addressed.