American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network 2015: recommendations for the treatment of ankylosing spondylitis and nonradiographic axial spondyloarthritis

OBJECTIVE: To provide evidence-based recommendations for the treatment of patients with ankylosing spondylitis (AS) and nonradiographic axial spondyloarthritis (SpA). METHODS: A core group led the development of the recommendations, starting with the treatment questions. A literature review group conducted systematic literature reviews of studies that addressed 57 specific treatment questions, based on searches conducted in OVID Medline (1946-2014), PubMed (1966-2014), and the Cochrane Library. We assessed the quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) method. A separate voting group reviewed the evidence and voted on recommendations for each question using the GRADE framework. RESULTS: In patients with active AS, the strong recommendations included use of nonsteroidal antiinflammatory drugs (NSAIDs), use of tumor necrosis factor inhibitors (TNFi) when activity persists despite NSAID treatment, not to use systemic glucocorticoids, use of physical therapy, and use of hip arthroplasty for patients with advanced hip arthritis. Among the conditional recommendations was that no particular TNFi was preferred except in patients with concomitant inflammatory bowel disease or recurrent iritis, in whom TNFi monoclonal antibodies should be used. In patients with active nonradiographic axial SpA despite treatment with NSAIDs, we conditionally recommend treatment with TNFi. Other recommendations for patients with nonradiographic axial SpA were based on indirect evidence and were the same as for patients with AS. CONCLUSION: These recommendations provide guidance for the management of common clinical questions in AS and nonradiographic axial SpA. Additional research on optimal medication management over time, disease monitoring, and preventive care is needed to help establish best practices in these areas.(AU)

Travel-related disseminated Penicillium marneffei infection in a renal transplant patient.

Penicillium marneffei is a thermally dimorphic fungus that causes severe human immunodeficiency virus-related opportunistic infection in endemic areas of Southeast Asia and has rarely been reported in solid organ transplant (SOT) recipients. We report here the case of an Australian renal transplant patient who presented with disseminated P. marneffei infection shortly after a 10-day holiday to Vietnam, and review all previously published cases of penicilliosis associated with renal transplantation. This is the first reported case, to our knowledge, of P. marneffei infection in an SOT recipient acquired during travel to an endemic country, and highlights the importance of an accurate travel history when opportunistic infection is suspected, as well as giving appropriate health advice to transplant patients who travel.

The clinical application of a urine albumin:creatinine ratio point-of-care device.

INTRODUCTION: Microalbuminuria is an accepted predictive marker for the early detection of renal disease and the identification of patients at high risk of developing complications of diabetes and hypertension. The Bayer Clinitek 50 is a urine chemistry point-of-care analyser for the semi-quantitative measurement of albumin and creatinine and calculation of albumin:creatinine ratio (ACR). METHOD: Urine samples were obtained from 252 consecutive patients attending a city center diabetic clinic, and from 40 patients on admission to the ICU. Albumin and creatinine measurements were carried out using the Clinitek 50 and by the central laboratory. RESULTS: The Clinitek 50 results agreed with the central laboratory results in 89% of the diabetic patient samples and 80% of the ICU patient samples. Excluding samples defined as normal by the Clinitek 50 (ACR<3.4 mg/mmol) would have resulted in an 80% reduction in samples sent to the lab for further quantification. The average length of stay in the group of ICU patients with normal ACR was significantly less than for those patients with an abnormal ACR (p<0.005). CONCLUSIONS: The Clinitek 50 provides useful, immediate clinical information regarding the microalbuminuria status for use in the diabetic clinic setting or as a potential immediate risk management tool in intensive care.

Characterization of mycobiont adaptations in the foliose lichen Xanthoparmelia chlorochroa (Parmeliaceae).

A cross section of the vagrant soil lichen Xanthoparmelia chlorochroa was analyzed using proton microprobe PIXE. Data were used to generate quantitative, two-dimensional element distribution maps for Al, Si, P, S, Cl, K, Ca, Ti, Cr, Mn, Fe, Ni, Cu, Zn, As, and Sr. Element maps show differential element partitioning between the stratified layers of the thallus. These data document transfer of inorganic nutrients across the thallus to the algal layer. Inorganic particle entrapment was also evident in the element maps. Dense accumulations of calcium oxalate at the junction of the medulla and the algal layer on the order of 10% by dry mass were discovered. Scanning electron microscopy and thermogravimetric analyses were used to characterize the calcium oxalate region. These data provide evidence for possible functional roles of the calcium oxalate layer, including regulation of water and light. Data also provide support for a mutualistic interpretation of the lichen association.

Guidelines for the medical management of osteoarthritis. Part I. Osteoarthritis of the hip. American College of Rheumatology.

Treatment of patients with OA of the hip should be individualized and tailored to the severity of the disease. In individuals with mildly symptomatic disease, treatment may be limited to patient education, physical and occupational therapy, other nonpharmacologic modalities, and drug therapy with a non-opioid oral analgesic. In patients who are unresponsive to this treatment regimen, the use of an NSAID in addition to nonpharmacologic therapy is appropriate unless it is medically contraindicated. Patients with severe symptomatic OA of the hip require an aggressive approach to decreasing pain, increasing mobility, and improving function; such patients may benefit from orthopedic consultation and evaluation for osteotomy or total joint arthroplasty.

Guidelines for the medical management of osteoarthritis. Part II. Osteoarthritis of the knee. American College of Rheumatology.

Treatment of patients with OA of the knee should be individualized and tailored to the severity of the symptoms. In individuals with mild symptomatic OA, treatment may be limited to patient education, physical and occupational therapy and other nonpharmacologic modalities, and pharmacologic therapy including non-opioid oral and topical analgesics. In patients who are unresponsive to this treatment regimen, the use of NSAIDs in addition to nonpharmacologic therapy is appropriate unless medically contraindicated. Judicious use of intraarticular steroid injections has a role either as monotherapy or an adjunct to systemic therapy in patients with knee OA who have symptomatic effusions. The role of joint lavage and arthroscopic debridement in patients with OA of the knee who are unresponsive to conservative medical therapy needs further study, and these procedures cannot be routinely recommended for all patients at this time. Patients with severe symptomatic OA of the knee require an aggressive approach to decreasing pain, increasing mobility, and decreasing functional impairment; such patients may benefit from orthopedic consultation and evaluation for osteotomy or total joint arthroplasty.

Effects of social anxiety and facial expression on habituation of the electrodermal orienting response.

The present research examined electrodermal orienting to happy and angry faces as a function of social anxiety and threat of shock. A preliminary study using 569 undergraduate participants developed an adequate set of normative data of social anxiety for the Willoughby questionnaire (WQ) for use in subject selection. Electrodermal activity was measured in both high and low socially anxious subjects (N = 85) during exposure to 10 presentations of an angry face intermixed with 10 presentations of a happy face. Threat of shock (no-shock, shock work-up only, and shock work-up plus threat) was also manipulated. Skin conductance responses (SCRs) which occurred within 1-4 s of stimulus onset and trials-to-habituation constituted the data of primary interest. Although trials-to-habituation did not differ between angry and happy facial expressions, SCRs were larger to the angry face than to the happy face in both high and low socially anxious subjects. No differences in SCR magnitude were found as a function of threat of shock. The implications of these results for Ohman's functional-evolutionary model of social phobia are discussed, and alternative explanations in terms of prepotency and prior learning are examined.

Hemiplegic gait: analysis of temporal variables.

The objective of this study was to determine key quantitative variables in hemiplegic gait, and to correlate them with clinical abnormality, eg, degree of motor recovery. In 23 hemiplegic patients, clinical and locomotion laboratory assessments gave the following results. Two temporal gait variables, walking speed and symmetry of the swing/phase, showed a good correlation with the stage of motor recovery. Patients with greater degrees of motor recovery walked faster and more symmetrically than those with less motor recovery. None of the other temporal variables analyzed showed a significant relationship with the stage of motor recovery.