The Prevalence of Hypermobility in Children with Irritable Bowel Syndrome and Functional Abdominal Pain Is Similar to that in Healthy Children.

OBJECTIVES: To test the hypothesis that the prevalence of joint hypermobility is greater in children with irritable bowel syndrome and functional abdominal pain than in healthy control children and is related to gastrointestinal symptoms and psychosocial distress (anxiety, depression, and somatization). STUDY DESIGN: Children (irritable bowel syndrome, n = 109; functional abdominal pain, n = 31; healthy control, n = 69), 7-12 years of age completed prospective 2-week pain and stooling diaries and child- and parent-reported measures of anxiety, depression, and somatization. Joint hypermobility was determined using Beighton criteria (score of ≥4 or 6). We also examined possible relationships between Beighton score, race, body mass index, gastrointestinal symptoms, and psychosocial distress. RESULTS: Beighton scores were similar between groups, as was the proportion with joint hypermobility. Scores were higher in girls (3.1 ± 2.4) than boys (2.3 ± 1.8; P = .004) and decreased with age (P < .001; r = -0.25). Race and body mass index did not impact joint hypermobility prevalence. Beighton scores were not related to abdominal pain or stooling characteristics. Participants with a score of ≥4 and ≥6 had greater somatization and depression by child report (P = .017 and P = .048, respectively). No association was seen for anxiety. There was no significant association between joint hypermobility and psychosocial distress measures per parent report. CONCLUSIONS: Contrary to the adult literature, the prevalence of joint hypermobility does not differ among children with irritable bowel syndrome, functional abdominal pain, or healthy control children. The presence or severity of joint hypermobility does not correlate with abdominal pain or stooling characteristics. Somatization and depression by child report appear to have a relationship with joint hypermobility.

Rare Case of Vasculitis of the Hepatic Artery.

Vasculitis is an accumulation of inflammatory leucocytes in the blood vessels with reactive damage to mural structures. Isolated vasculitis of the gastrointestinal tract without systemic involvement is rare. We report a unique case of a female patient who presented with abdominal pain, and was found, on serology, to have elevated inflammatory markers without autoantibodies. A computed tomography scan of the abdomen and pelvis was suggestive of vasculitis of the hepatic artery. To the best of our knowledge, this is the first case, to date, of vasculitis of hepatic artery.

Antiphospholipid antibodies-associated diffuse alveolar hemorrhage.

OBJECTIVES: To describe the clinical features and outcomes of 17 patients with primary antiphospholipid syndrome (PAPS) or antiphospholipid antibodies (aPL) and diffuse alveolar hemorrhage (DAH). METHODS: We reviewed the medical records of all patients diagnosed with PAPS-associated DAH and aPL-associated DAH between January 1, 1997, and December 31, 2013, for clinical features, laboratory and radiographic findings, management, and outcomes. RESULTS: A total of 17 patients met the criteria for DAH and had aPL and 10 patients met the criteria for PAPS. The mean age at DAH diagnosis was 57.6 years. Secondary causes of DAH were ruled out. Surgical lung biopsy was performed in 6 cases, 5 of whom had bland hemorrhage. Pulmonary capillaritis was present in only 1 case. Four patients (3 with aPLs and 1 with PAPS) achieved complete remission despite receiving no treatment. The majority of patients treated received initial corticosteroids. Additionally, cyclophosphamide (2 cases), rituximab (1 case), plasma exchange (2 cases), methotrexate (1 case), azathioprine (1 case), and hydroxychloroquine (2 cases) were used. In total, 10 patients (59%) achieved complete and sustained remission with a median length of follow-up of 48 months. Four patients (23%) died (2 with PAPS and 2 with aPLs), all from uncontrolled DAH. Three patients (18%) relapsed after achieving complete remission. CONCLUSIONS: DAH is a rare complication of PAPS that can also arise de novo in aPL-positive individuals. Lung pathology shows either bland hemorrhage or capillaritis. Recognition of this unusual but known complication is important, since early diagnosis and therapy could potentially affect outcomes.

Infectious and healing complications after elective orthopaedic foot and ankle surgery during tumor necrosis factor-alpha inhibition therapy.

BACKGROUND: Biologic response modifiers are assuming a larger role in the management of patients with rheumatoid arthritis. The tumor necrosis factor-alpha (TNF-alpha) inhibitors etanercept and infliximab improve patient symptoms and function. However, these agents have been associated with a risk for healing and infectious complications due to systemic blockade of TNF-alpha, a ubiquitous mediator required in the normal inflammatory response in tissue healing and infection surveillance. This study analyzed the risk of healing/infectious complications in patients undergoing elective foot and ankle surgery while being treated with TNF-alpha inhibitors etanercept and infliximab. METHODS: Patients with rheumatoid arthritis undergoing elective foot and ankle surgery over a 12-month period were prospectively followed for the development of complications in the postoperative period. All patients continued their antirheumatic medication schedule unaltered in the perioperative period. Data collected included sex, age, all medications used to treat rheumatoid arthritis, smoking history, and number of orthopaedic foot and ankle procedures performed. Patients were then stratified into two groups based on the use of immunomodulation via TNF-alpha inhibition (group 1) versus patients who did not receive TNF-alpha inhibition therapy (group 2). Groups 1 and 2 were followed and compared for the development of infectious/healing complications. RESULTS: Thirty-one patients were enrolled in the study. Group 1 (n = 16) and group 2 (n = 15) patients were comparable for sex distribution, number of orthopaedic procedures performed, and use of steroids, methotrexate, leflunamide, and nonsteroidal anti-inflammatory drugs. Group 1 contained six times the number of smokers in group 2. At mean follow-up of 10.6 months (group 1) and 9.7 months (group 2), healing or infectious complications were similar in both groups. However, when total complications (healing + infection) were analyzed, group 1 (TNF-alpha inhibition, "higher risk") patients demonstrated a lower complication rate (p =.033). CONCLUSIONS: The data suggest that in patients with rheumatoid arthritis undergoing elective foot and ankle surgery, the use of TNF-alpha inhibition agents may be safely undertaken in the perioperative period without increasing the risk of healing or infectious complications.

Mortality and cardiovascular burden of systemic lupus erythematosus in a US population-based cohort.

OBJECTIVE: To examine the mortality and cardiovascular disease (CVD) burden among a population-based cohort of patients with systemic lupus erythematosus (SLE) with previously described late mean onset and low rates of organ-threatening disease. METHODS: This retrospective population-based cohort study investigated incident cases of SLE diagnosed from 1991-2008 and followed through March 2009 to examine rates of death and CVD events: myocardial infarction, stroke, or congestive heart failure hospitalization. Cases were identified using the 1997 update of the 1982 American College of Rheumatology SLE criteria. Searches included electronic records, chart audits, and state death matches, with physician review. Age-matched and sex-matched population comparisons facilitated relative event rate calculations. RESULTS: Seventy incident SLE cases had late mean onset (52 years), with an incidence of 5 cases per 100,000/year. Matched comparisons showed similar baseline rates of hypertension, hyperlipidemia, and diabetes. However, patients with SLE experienced more CVD in the 2 years preceding SLE diagnosis (OR 3.8, 95% CI 1.8, 8.0). The estimated 10-year mortality rates were 26% for SLE subjects versus 19% for comparisons, hazard ratio (HR) 2.1, p<0.01. Adjusted for prior CVD, SLE cases still demonstrated increased hazards of mortality (HR 1.9, p=0.01) and CVD event or death (HR 1.8, p=0.01). CONCLUSION: This incident SLE cohort demonstrated nearly doubled mortality and CVD event hazards compared to age-matched and sex-matched comparisons, even after accounting for higher CVD events in the 2 years preceding SLE diagnosis. This raises research questions regarding delayed SLE diagnosis versus accelerated CVD prior to SLE, particularly in older-onset SLE.

Bilateral prosthetic knee infection by Campylobacter fetus.

We present the first documented case of a bilateral prosthetic knee joint infection with Campylobacter fetus. Our patient's risk factors included age, the presence of prosthetic joints, and potential exposure through his contact with farm animals. It is important to be aware of the possibility of C fetus joint infections in high-risk patients who present with pain after total joint arthroplasty.

Artritis reumatoidea precoz / Early rheumatoid arthritis

El diagnostico de artritis reumatoidea precoz se basa generalmente en la anamnesis y el examen fisico y suele establecerse por exclusion. El diagnostico diferencial puede plantear dificultades debido a las grandes variaciones en cuanto edad, sexo, sintomas sistemicos, hallazgos del examen fisico y distribucion de la artropatia. La terapia intensiva inicial debe incluir educacion del paciente, reposo, ejercicios graduados, consejeria y tratamiento farmacologico apropiado. La ausencia de nodulos subcutaneos y de erosion articular puede significar un mejor pronostico en la artritis reumatoidea. La presencia de factor reumatoide, eosinofilia, trombocitosis o vasculitis indica una evolucion menos favorable