Long-term treatment with tenofovir in Asian-American chronic hepatitis B patients is associated with abnormal renal phosphate handling.

BACKGROUND: Increased risk of defective urinary phosphate reabsorption and osteoporosis has been reported in HIV and chronic hepatitis B (CHB) patients treated with tenofovir disoproxil fumarate (TDF). AIMS: Goals of this study were to evaluate the prevalence of renal phosphate wasting and abnormal bone mineral density in CHB patients taking TDF compared to CHB patients treated with entecavir (ETV) and untreated CHB patients. METHODS: This is a cross-sectional study of 146 consecutive Asian-American CHB patients who were treatment naïve (n = 60) or treated with either TDF (n = 42) or ETV (n = 44). Proximal tubular handling of phosphate was assessed by the maximal rate of tubular reabsorption of phosphate (TmPO4) divided by glomerular filtration rate (GFR) (TmPO4/GFR). Bone mineral density (BMD) was measured using dual X-ray absorptiometry. RESULTS: TmPO4/GFR was similar among CHB patients treated with TDF compared to untreated patients and patients taking ETV. However, among patients treated with ≥18 months of TDF or ETV, prevalence of abnormal TmPO4/GFR was higher among patients treated with TDF compared to ETV (48.5 % (16/33) vs. 12.5 % (3/24), p = 0.005). Overall prevalence of osteoporosis in this cohort of CHB patients was 14 %, with no significant difference between the three groups. Renal phosphate handling did not correlate with osteoporosis. CONCLUSIONS: Chronic hepatitis B patients treated with ≥18 months of TDF experienced an increased risk of proximal tubular dysfunction. TDF did not increase the risk of osteoporosis. Longitudinal studies are needed to confirm these findings.

Reflecting on pain management for patients with osteoarthritis and other rheumatic disorders: there's more to pain management than managing pain.

SUMMARY Medical progress is measured by advances in science and technology. The pace of discovery will surely accelerate. We are increasingly challenged not only to assimilate new information, but also to reconcile our learning with our art. We present the common clinical problem of managing pain in osteoarthritis as a paradigm for this dilemma in contemporary patient care. We do not yet have the understanding and interventions to do this optimally for all with osteoarthritis, leaving us with uncertainties as we struggle to care for these patients. In a world of growing complexity and sophistication we must not overlook the person who is our patient. It is easy to be seduced by electronic and informational advances, to be entranced by machinery, and to forget the unique individuality and needs of each patient. Osler taught that "the practice of medicine is an art, based on science". This doesn't change.

Evolution of classification criteria for rheumatoid arthritis: how do the 2010 criteria perform?

Classification criteria are created in an attempt to produce a homogenous group of subjects with rheumatoid arthritis (RA) who can be used for clinical and basic research. The 1987 revised criteria lead to improved performance and more confidence in correct classification compared with the 1958 criteria. As therapies were introduced and early, aggressive approaches to RA management became common, there was a growing need for clinical trials focusing on early RA. The 2010 criteria were created to facilitate study of subjects at earlier stages in the disease. This article reviews the diagnostic performance of the 2010 criteria.

Management of Corneal Graft Rejection - A Case Series Report and Review of the Literature.

PURPOSE: To report long-term results in a case series of patients treated with systemic immune suppression for prevention of penetrating keratoplasty (PKP) graft rejection. DESIGN: Retrospective noncomparative chart review. PARTICIPANTS: Three patients presented with PKP graft failure. METHODS: Patients received oral prednisone, azathioprine and cyclosporine to prevent rejection of repeat corneal transplant. Patients received repeat PKP and graft outcome was reported. MAIN OUTCOME MEASURES: Visual acuity and graft survival were recorded. RESULTS: Mean age was 55 years, two male and one female. Mean follow-up period was 37 months (range 24-46). All three patients completed the treatment protocol with minimal adverse effects. All grafts remained clear over observational period. CONCLUSION: Our study suggests that systemic immune suppression with 2 or more agents may be helpful to prevent corneal graft rejection in high-risk patients.

Successful rituximab therapy of acquired factor VIII inhibitor in a patient with rheumatoid arthritis.

Acquired factor VIII deficiency due to antibody inhibition can result in life-threatening hemorrhage. Rarely such antibody inhibition of factor VIII can be associated with other autoimmune disorders including rheumatoid arthritis. We present the first case of a patient with active rheumatoid arthritis and refractory bleeding diatheses due to a factor VIII inhibitor who was successfully treated with rituximab. A 61-year-old Caucasian female with rheumatoid arthritis unresponsive to multiple therapies developed an acute hematoma while having a peripheral catheter placed. Her aPTT was prolonged at 61.4 with low factor VIII activity and an inhibitor level for factor VIII of 2.0 Bethesda Units. She received rituximab 375 mg/m in 4 weekly doses. Normalization of the aPTT and resolution of the bleeding occurred in 2 weeks. After 45 days, the levels of factor VIII inhibitor and factor VIII activity were <0.4 BU/mL and 130%, respectively. After 1 year, the aPTT remained normal and there was no further bleeding. An added benefit was the substantial improvement in her rheumatoid arthritis. Treatment of acquired factor VIII inhibitors in rheumatoid arthritis should be guided by the levels of the inhibitor. Patients with low levels of the inhibitor may respond to rituximab monotherapy, whereas higher levels may necessitate combination therapies. The dual benefit of RA disease control and resolution of bleeding makes rituximab therapy compelling in the rare patient who presents with these 2 disorders.

Rituximab treatment for resistant antiphospholipid syndrome.

Antiphospholipid syndrome (APS) and catastrophic antiphospholipid syndrome (CAPS) can be challenging to treat. As they are rare, clinicians are not often exposed to these complex diseases. For the patient resistant to standard treatments new therapeutic directions can be perplexing, especially in the context of ongoing thromboses and bleeding episodes. We describe 3 patients, 2 with APS and one with CAPS, resistant to conventional medications, who responded to treatment with rituximab, an anti-CD20 monoclonal antibody. Since rituximab infusion, all the patients have had stable platelet counts and no further episodes of bleeding or thromboses.