The Effect of Medical Cannabis on Pain Level and Quality of Sleep among Rheumatology Clinic Outpatients.

Introduction: Medical cannabis (MC) is becoming increasingly popular for the treatment of chronic pain conditions. In this study, we evaluated the effect of MC treatment on pain level and quality of sleep of patients with different medical conditions at the rheumatology clinic. Methods: Patients licensed for the use of MC at the rheumatology clinics at different settings were located and contacted. Their demographic and clinical parameters were documented, including type of medical cannabis consumed, way of consumption, and current monthly consumed amount. These patients were contacted by phone and asked about the effect on pain level and quality of sleep. Results: A total of 351 patients were located, and 319 completed the questionnaire. Mean age was 46 ± 12 years, 76% were female, 82% had fibromyalgia, ∼9% had mechanical problems, ∼4% had inflammatory problems, ∼4% had neurological problems, and ∼1% had other problems. The average monthly consumed dose of MC was 31, 35, 36, and 32 g, with mean pain level reduction of 77%, 82%, 83%, and 57%, and mean sleep quality improvement of 78%, 71%, 87%, and 76% among patients with fibromyalgia, mechanical, neuropathic, and inflammatory problems, respectively. Mean THC and CBD contents were 18.38% ± 4.96 and 2.62% ± 4.87, respectively. The THC concentration, duration of MC consumption, and MC consumption dose had independent significant correlations with pain reduction while only the duration of MC consumption had an independent significant correlation with sleep quality improvement. Conclusions: MC had a favorable effect on pain level and quality of sleep among all spectrums of problems at the rheumatology clinic.

Initial Presentation of Pain in Patients with Fibromyalgia.

BACKGROUND: Fibromyalgia is characterized by diffuse musculoskeletal pain at the time of diagnosis, but many patients report their initial symptoms as being focal or local. OBJECTIVES: To evaluate, prospectively, the initial location of body pain in recently diagnosed patients with fibromyalgia. METHODS: Non-selected patients from the rheumatology clinic who were recently diagnosed with fibromyalgia (≤ 2 years) with symptoms of ≤ 4 years participated in our study. Demographic and clinical parameters were documented, as was the initial location of pain they had experienced. Sub-analysis of data according to gender and ethnicity was conducted using chi-squire test. RESULTS: The study comprised 155 patients. Mean age was 39.8 ± 11.7 years; 85% were female. Mean duration of symptoms was 2.11 years and of diagnosis was 0.78 years. Six patients (3.9%) reported initial symptoms of pain as being diffuse from the start, 10 (6.5%) could not remember the location of their initial symptoms, and 139 (90%) reported initial focal pain. Hands were reported as the initial area of pain for 25.2% of the patients, 19.4% reported the back, and 11% reported both trapezial areas as the initial area of pain. In 90% of the patients (excluding patients with back, abdominal, or chest pain) the initial symptoms were bilateral and symmetrical. No significant difference in initial presentation was found among different gender or ethnic groups. CONCLUSIONS: Pain in fibromyalgia patients usually presents as focal and symmetrical. Bilateral hand pain, followed by back pain, was the most common reported area of initial pain among fibromyalgia patients.

The Effect of Periarticular Injection of Methylprednisolone Acetate in Patients with Primary Osteoarthritis of the Proximal Interphalangeal Joints: A Case Controlled Study.

BACKGROUNDS: Primary osteoarthritis of the proximal interphalangeal joints (PIPJ) is a common entity. It could be associated with local pain that has no effective treatment. Local subcutaneous periarticular injection of methylprednisolone acetate (MPA) was evaluated in a prospective case-control study. METHODS: Patients with painful osteoarthritis of the PIPJ for more than 1 month not responding to nonsteroidal meds were prospectively recruited. Radiographic, demographic, clinical, and lab parameters were documented. Visual analogue scale (VAS) was documented regarding the level of PIPJ pain prior to the injection. Patients had local subcutaneous periarticular injection at the medial and lateral sides of each painful PIPJ of one hand, of 8 mg (0.2 ml) of MPA mixed with 0.1 ml of lidocaine 1% (group 1) at each side. Age- and sex-matched control group were given 0.3 ml of normal saline using the same approach (group 2) at each side. VAS was evaluated 1, 4, and 10 weeks following the injection and compared to baseline levels using Wilcoxon's ranks signed test. RESULTS: Eighteen and sixteen patients were recruited in group 1 and group 2, respectively. There were 11 females in group 1 with mean age of 52.7 ± 9.2 years. Mean VAS in group 1 at baseline was 67 and at weeks 1, 4, and 10 was 23 (p=0.001), 29 (p=0.001), and 55 (p=0.043), respectively. Mean VAS in group 2 at baseline was 65 and at weeks 1, 4, and 10 was 43 (p=0.005), 64 (p=0.534), and 69 (0.698), respectively. CONCLUSIONS: Subcutaneous periarticular injection of MPA + lidocaine at the PIP joints resulted in a small but significant improvement that gradually diminished with time across the week 10, among patients with primary OA of hands.

The impact of intra-articular injection of diprospan at the knee joint on blood glucose levels in diabetic patients.

OBJECTIVE: To evaluate the effect of intra-articular (IA) corticosteroid injection (IACI) of betamethasone dipropionate/betamethasone sodium phosphate (Diprospan) on blood glucose levels in diabetic patients METHODS: Patients with type 2 diabetes and symptomatic osteoarthritis of the knee (OAK) in whom medical therapy failed were administered 1 mL Diprospan IACI (5 mg of betamethasone dipropionate +2 mg of betamethasone sodium phosphate). Patients were asked to monitor blood glucose levels before and 2 h after meals for 1 week before and 12 days after the injection was administered. A control group was administered an IA injection of hyaluronic acid. RESULTS: Twelve patients from the Diprospan group and six from the control group were recruited for the study. Patients in the Diprospan group had significantly increased blood glucose levels with median initial and peak levels of 187.5 mg% and 310 mg%, respectively, at a median of 4 and 11.5 h following IACI, respectively. The last peak level was seen after a median of 45 h following IACI. There was no significant increase in blood glucose levels in the control group. CONCLUSION: Diprospan IACI is associated with significantly increased blood glucose levels in all diabetic patients with OAK.

The effect of local injection of methylprednisolone acetate on the hypothalamic-pituitary-adrenal axis among patients with greater trochanteric pain syndrome.

Greater trochanteric pain syndrome (GTPS) is a common clinical entity for which the most effective treatment is local corticosteroid injection (LCI). There are no studies on the effect of LCI among patients with GTPS on the hypothalamic-pituitary-adrenal axis. The present study recruited nonselected patients diagnosed with GTPS. After consenting, participants received low dose (1 µg) of adrenocorticotropin hormone (ACTH) stimulation test at 09:00. Immediately following the test, participants received a LCI of 80 mg of methylprednisolone acetate at the greater trochanteric region. The ACTH stimulation test was repeated 1, 2, 4, and 6 weeks following the LCI. Cortisol samples were obtained at just prior to (basal) and 30 min (post-stimulation) following every ACTH stimulation test. Serum cortisol levels of <500 µmol/l obtained 30 min following the ACTH stimulation test were considered evidence of secondary adrenal insufficiency. The study enrolled 22 patients, 21 of whom completed participation. There were 19 female participants (~90%), and mean age of all the participants was 55.2 ± 8.6 years. Four participants showed evidence of secondary adrenal insufficiency, which was observed only at weeks 1 and 2 following the LCI. Mean serum cortisol level among these four participants 30 min following the ACTH stimulation test was 354 µmol/l, with a range of 268-430 µmol/l. LCI of 80 mg of methylprednisolone acetate in the greater trochanteric area among patients with GTPS was associated with transient secondary adrenal insufficiency in ~20% of the patients, mainly 1 week following the injection.

The impact of intra-articular methylprednisolone acetate injection on fructosamine levels in diabetic patients with osteoarthritis of the knee, a case-control study.

Fructosamine is a glycated protein that reflects blood glucose control over the last 2-3 weeks. There are no studies that address the impact of intra-articular injection (IAI) of methylprednisolone acetate (MPA) on fructosamine levels among patients with type-2 diabetes and osteoarthritis of the knee (OAK). Non-selected patients attending the rheumatology or orthopedic clinic with type-2 diabetes and painful OAK, who failed non-steroidal anti-inflammatory drugs (NSAIDS) and physical therapy, were asked to participate in our study. After consent blood tests were drown for fructosamine, hemoglobin A1c (HbA1c) level, complete blood count, lipid profile, serum albumin, serum protein, c-reactive protein, and erythrocyte sedimentation rate. Demographic and different clinical parameters were also documented. Immediately after that, patients had IAI of 80 mg of MPA at the knee joint (group 1). Two to three weeks later, the same blood tests were repeated (except for HbA1c). Age- and sex-matched group of patients with type-2 diabetes and painful OAK attending the same clinics, but who were managed by NSAIDS were asked to participate as a control group (group 2) and had the same evaluation at enrollment and 2-3 weeks later, after consent. Eighteen patients from either group completed the study. Mean fructosamine level in group 1 patients was 263.7 ± 31.8 mg% prior to the IAI vs. 274.6 ± 39.3 mg% (p = 0.035), 2-3 weeks later, while mean fructosamine level in the control group (group 2) at enrollments was 274.2 ± 31.2 mg% vs. 269 ± 30.2 mg%, p = 0.509, 2-3 weeks later. There was no significant change in any other parameter tested at enrollment in either group, compared to those obtained 2-3 weeks afterwards. Body mass index was on the edge of significance as a predictor for a significant change in fructosamine level in group 1 patients. IAI of 80 mg of MPA in patients with type-2 diabetes and OAK had resulted in a significant, though mild increase in fructosamine levels 2-3 weeks later.

The impact of Ramadan fast on patients with gout.

BACKGROUNDS: Ramadan fast is a religious custom in Islam. Increased serum uric acid level during this month had been reported in past studies of nongout patients. OBJECTIVES: The objective of this study was to assess the impact of Ramadan fast on patients with gout. METHODS: All Moslem patients with gout from the registry of Nazareth Hospital, who intended to fast during Ramadan, were asked to participate in our study (group 1). Data regarding age, gender, income, education, duration of gout, meds, adherence to low-purine diet, and gouty attacks were documented. Age- and gender matched Moslem patients from the same registry, but who did not intend to fast during Ramadan, were asked to participate as a control group (group 2). Just prior to and at the end of Ramadan, blood for uric acid, creatinine, and urea levels were obtained as well as body mass index, from all the patients. During Ramadan, patients were monitored for gouty arthritis or renal calculi attacks, as well as low-purine diet and medicine adherence. RESULTS: Twenty-one and 22 patients from groups 1 and 2, respectively, completed the study. Mean serum uric acid, urea, creatinine, and body mass index levels at the end of Ramadan fasts in group 1 patients were 8.11 mg/dL, 26.38 mmol/L, 0.87 mg/dL, and 31.0 kg/m, respectively, as compared with 7.92 mg/dL (P = 0.707), 24.54 mmol/L (P = 0.769), 0.84 mg/dL (P = 0.180), and 30.5 kg/m (P = 0.907) respectively, obtained just prior to the fast. No significant change in any parameter was seen also in group 2 patients. There also was no significant change between the 2 groups in arthritis or renal calculi attacks and also in medication and low-purine diet adherence, during Ramadan. CONCLUSIONS: There was no risk for a significant increase in gouty arthritic/renal calculi attacks or serum uric acid in patients with gout during Ramadan fast.

Ultrasonographic findings in a large series of patients with knee pain.

BACKGROUND: Musculoskeletal ultrasound (MSKUS) is becoming more and more popular in the evaluation of different musculoskeletal abnormalities. The aim of this retrospective study was to document the prevalence and spectrum of MSKUS findings at the painful knee. MATERIALS AND METHODS: All the studies of MSKUS that were performed for the evaluation of knee pain during the previous 2 years at the Department of Radiology in Nazareth hospital were reviewed. Demographic and clinical parameters including age, gender, side, and MSKUS findings were documented. RESULTS: Two hundred and seventy-six patients were included in the review. In 21 of them, both knees were evaluated at the same setting (total number of knees evaluated was 297). One hundred and forty-four knees were of the left side. Thirty-three pathologies were identified. 34% of the studies were negative. The most common MSKUS findings were medial meniscal tear (MMT) (20%), Baker's cyst (BC) (16%), and osteoarthritis (OA) (11%). Only one knee of all the knees evaluated in our study showed synovitis. Fifty-three knees (18% of all the knees evaluated) had more than one imaging finding, mosty two and while some had three findings. The most common combination of findings was MMT and BC (8 knees), MMT with OA (8 knees), and MMT with fluid (6 knee). In 67% of the patients who had simultaneous bilateral knee evaluation, at least one knee had no abnormal findings and in 43%, both knees were negative. CONCLUSIONS: MSKUS has the potential for revealing huge spectrum of abnormalities. In nearly 90% of the positive studies, degenerative/mechanical abnormalities were reported, with MMT, BC, and osteoarthritic changes being the most common.

Simultaneous bilateral knee injection of methylprednisolone acetate and the hypothalamic-pituitary adrenal axis: a single-blind case-control study.

OBJECTIVE: The objective of this study was to evaluate the effect of simultaneous bilateral intra-articular injection (IAI) of methylprednisolone acetate (MPA) on the hypothalamic-pituitary-adrenal axis in patients with knee osteoarthritis. METHODS: Nonselected patients with symptomatic bilateral knee osteoarthritis had simultaneous IAI of 80 mg MPA at each knee (group 1). Just before the injection and on weeks 1, 2, 4, 6, and 8 after it, patients had 1 µg adrenocorticotropin hormone stimulation test. Age- and sex-matched patients had simultaneous IAI of 60 mg of hyaluronic acid in each knee (group 2) and the same protocol of adrenocorticotropin hormone stimulation tests. Demographic, clinical, and laboratory parameters were documented in all the patients. Secondary adrenal insufficiency (SAI) was defined as poststimulation serum cortisol levels of less than 18 µg/dL. RESULTS: Twenty patients were enrolled in each group. There were 15 women and 5 men in each group. Mean age of the patients in group 1 was 60.3 (SD, 7.6) years. Twelve patients (60%) from group 1 had evidence of SAI versus 3 patients in group 2 (P = 0.003). In all the patients who had SAI in group 1, it was observed in week 1 with decreasing frequency of SAI at the subsequent time points. Yet, 2 patients (10%) from group 1 had evidence of SAI 8 weeks after the IAI. Secondary adrenal insufficiency did not significantly correlate with any demographic, clinical, or laboratory parameter. CONCLUSIONS: Secondary adrenal insufficiency was very common following simultaneous bilateral IAI of 80 mg of MPA. Although it was transient, SAI could still be observed nearly 2 months after the IAI, in 10% of the patients.