Spontaneous Spinal Epidural Hematoma During Simultaneous Tocilizumab and Warfarin Use in a Patient With Rheumatoid Arthritis: Is There a Drug Interaction Between Tocilizumab and Oral Anticoagulants?

Interleukin 6 (IL-6) plays a main role in the immunopathogenesis of rheumatoid arthritis (RA). Tocilizumab (TCZ) is a humanized immunoglobulin G1 monoclonal antibody against the human IL-6. Warfarin sodium is an oral anticoagulant that is primarily metabolized by cytochrome P450 2C9 (CYP2C9). Impaired metabolism of this low therapeutic index drug is important as it may result in serious bleeding. In this article, we present a 56-year-old female patient with RA, treated with TCZ and warfarin sodium and presented spontaneous spinal epidural hematoma (SSEH) of thoracic spine although international normalized ratio levels were in normal ranges. One week after decompressive surgery for hematoma, a cervical spine abscess developed which resulted in her death. To the best of our knowledge, this is the first case of RA developing SSEH while taking TCZ and warfarin sodium together. Although it is difficult to attribute the severe bleeding to TCZ treatment, clinicians should be aware that concomitant use of oral anticoagulants and TCZ might result in potentially fatal complications in patients with RA.

Complete Decongestive Therapy Is an Option for the Treatment of Rosacea Lymphedema (Morbihan Disease): Two Cases.

BACKGROUND AND PURPOSE: Morbihan disease, also known as rosacea lymphedema, is a rare persistent form of lymphedema that is associated with the disease rosacea. Even though acne rosacea responds well to standard medical treatment, the lymphedema component of the disease is resistant to both medical and surgical therapy. Complete decongestive therapy (CDT) can be considered as a conservative alternative option for treatment of rosacea lymphedema. To date, there is no report on the use of CDT in treating facial lymphedema secondary to acne rosacea. CASE DESCRIPTION: We present 2 cases of women with a diagnosis of Morbihan disease and chronic facial lymphedema that remained resistant to drug treatment for many years before CDT was offered. The treatment program included 4 components: manual lymphatic drainage, compression bandaging, exercises to enhance lymphatic drainage, and patient education. OUTCOMES: Following 10 to 15 sessions of CDT, the first patient's facial edema had almost completely resolved. The second patient's response to treatment was assessed as moderate. DISCUSSION: To the best of our knowledge, these 2 cases of Morbihan disease treated with CDT are the first of their kind to be presented in the literature. As the treatment options for Morbihan disease remain inadequate, we believe that CDT should be considered as a treatment option in those patients who do not benefit from or refuse drug treatment, before moving on to more invasive procedures. Prospective studies should be designed to demonstrate the efficacy of CDT and provide management details.

Treatment of ankylosing spondylitis by extracorporeal photochemotherapy given for mycosis fungoides: a potential treatment option?

We describe a patient with cutaneous T-cell lymphoma (CTCL), in association with concurrent ankylosing spondylitis (AS), who achieved a long-lasting complete remission of both diseases after 3 cycles of extracorporeal photochemotherapy (ECP). The combination of CTCL with AS is very rare. In our patient, the CTCL was refractory to psoralen-UVA. He was unable to continue with administration of interferon α because of exacerbation of his back, anterior chest, and bilateral heel pain. The Bath AS Functional Index and Bath AS Disease Activity Index scores were determined to be 2.2 and 5.8, respectively. Extracorporeal photochemotherapy has been shown to be effective in the treatment of CTCL consisting of reinfusion of 3 to 9 × 10 leukocytes, taken from the patient by leukopheresis and treated in an extracorporeal system with 8-methoxypsoralen and UVA. There is a strong suggestion that ECP as a monotherapy can provide a significant benefit for other T-cell-mediated diseases including rheumatoid arthritis and psoriatic arthritis. This is the first report describing an effective treatment of AS in which pain, inflammatory response, Bath AS Disease Activity Index, and Bath AS Functional Index improved after initiation of ECP.

Validation of the Middlesex Elderly Assessment of Mental State (MEAMS) as a cognitive screening test in patients with acquired brain injury in Turkey.

PURPOSE: Assessment of cognitive impairment with a valid cognitive screening tool is essential in neurorehabilitation. The aim of this study was to test the reliability and validity of the Turkish-adapted version of the Middlesex Elderly Assessment of Mental State (MEAMS) among acquired brain injury patients in Turkey. METHODS: Some 155 patients with acquired brain injury admitted for rehabilitation were assessed by the adapted version of MEAMS at admission and discharge. Reliability was tested by internal consistency, intra-class correlation coefficient (ICC) and person separation index; internal construct validity by Rasch analysis; external construct validity by associations with physical and cognitive disability (FIM); and responsiveness by Effect Size. RESULTS: Reliability was found to be good with Cronbach's alpha of 0.82 at both admission and discharge; and likewise an ICC of 0.80. Person separation index was 0.813. Internal construct validity was good by fit of the data to the Rasch model (mean item fit -0.178; SD 1.019). Items were substantially free of differential item functioning. External construct validity was confirmed by expected associations with physical and cognitive disability. Effect size was 0.42 compared with 0.22 for cognitive FIM. CONCLUSION: The reliability and validity of the Turkish version of MEAMS as a cognitive impairment screening tool in acquired brain injury has been demonstrated.

Assessing normative cut points through differential item functioning analysis: an example from the adaptation of the Middlesex Elderly Assessment of Mental State (MEAMS) for use as a cognitive screening test in Turkey.

BACKGROUND: The Middlesex Elderly Assessment of Mental State (MEAMS) was developed as a screening test to detect cognitive impairment in the elderly. It includes 12 subtests, each having a 'pass score'. A series of tasks were undertaken to adapt the measure for use in the adult population in Turkey and to determine the validity of existing cut points for passing subtests, given the wide range of educational level in the Turkish population. This study focuses on identifying and validating the scoring system of the MEAMS for Turkish adult population. METHODS: After the translation procedure, 350 normal subjects and 158 acquired brain injury patients were assessed by the Turkish version of MEAMS. Initially, appropriate pass scores for the normal population were determined through ANOVA post-hoc tests according to age, gender and education. Rasch analysis was then used to test the internal construct validity of the scale and the validity of the cut points for pass scores on the pooled data by using Differential Item Functioning (DIF) analysis within the framework of the Rasch model. RESULTS: Data with the initially modified pass scores were analyzed. DIF was found for certain subtests by age and education, but not for gender. Following this, pass scores were further adjusted and data re-fitted to the model. All subtests were found to fit the Rasch model (mean item fit 0.184, SD 0.319; person fit -0.224, SD 0.557) and DIF was then found to be absent. Thus the final pass scores for all subtests were determined. CONCLUSION: The MEAMS offers a valid assessment of cognitive state for the adult Turkish population, and the revised cut points accommodate for age and education. Further studies are required to ascertain the validity in different diagnostic groups.

Exercise and cognitive-behavioural treatment in fibromyalgia syndrome.

Fibromyalgia syndrome is a nonarticular rheumatic disorder characterised by diffuse musculoskeletal pain, stiffness, fatigue, disturbed sleep and tender points. The pathophysiology is not well understood and treatment remains a challenge. Although pharmacological therapy is still the primary treatment choice, a long-term effective intervention has not been demonstrated yet. Thus, besides pharmacotherapy, other multimodal interventions are often used. Exercise and cognitive-behavioural treatments which exist in the multimodal approach and encompass largely self-managed strategy, are reviewed in this article. Although, there is a great number of exercise studies, the large diversity of outcome measures and measurement instruments that have been used in studies, varying intensity and types of exercises, small sample sizes, high attrition rates, large variability in baseline function, symptom severity and psychosocial status limit to come to a conclusion about the efficacy of exercise in the treatment of fibromyalgia syndrome. There are also inconclusive results about the efficacy of cognitive-behavioural treatment because of limited number of studies with small sample sizes of patients with fibromyalgia syndrome. However, the results of the trials overall demonstrate the beneficial effects of both different types of exercise and cognitive-behavioural treatment, on the other hand, there is still a need for larger, more systematic and randomised controlled trials to evaluate the effectiveness.

Metastatic vertebral tumor misdiagnosed in magnetic resonance imaging as benign degenerative bone marrow changes: a case report.

Many disorders including congenital, degenerative, inflammatory, and neoplastic lesions are associated with low back pain. It is essential to differentiate between malignant disease and the more common causes of back pain. We report a man with low back and right groin pain as a result of metastatic breast carcinoma which was misdiagnosed in magnetic resonance imaging as benign degenerative changes.