Use and Utility of Patient After-Visit Instructions at a University Rheumatology Outpatient Clinic: Status and Randomized Prospective Pilot Intervention Study.

OBJECTIVE: The aim of this study was to evaluate the use of after-visit instructions (AVIs) in an academic rheumatology clinic and assess the impact of standardized AVIs (sAVIs) and teach-back (TB) on comprehension of health information. METHODS: A retrospective review of adult patients seen between October 1 and 8, 2021, at the rheumatology clinic collected data on patient demographics, clinical features, and the presence, content, and readability of AVIs. During a subsequent prospective proof-of-concept study, routinely scheduled patients seen at the rheumatology clinic were randomized into three groups: control (received standard of care), received sAVIs only, and received sAVIs plus TB. Patients completed a health literacy questionnaire, satisfaction survey, and a one- to two-week postvisit telephone survey to assess AVI comprehension. RESULTS: Out of 316 retrospective patient visits, 82 (25.9%) received AVIs. Among 210 of 316 patients (66.5%) with management changes, 76 (36.1%) received AVI, with 74.2% of the instructions considered concordant with the provider's note. Use of AVIs was higher with management changes, new patient visits, and medical trainee/teaching clinics. AVIs were written at a median 6.8 grade level. A total of 75 patients completed the prospective study: 31 (41.3%) were in the control group, 19 (25.3%) were in the group that received sAVIs only, and 25 (33.3%) were in the group that received AVIs with TB. There were no differences in overall postvisit survey comprehension/retention scores among the three patient groups evaluated. CONCLUSION: Although a lack of AVI use was identified, implementation of sAVIs did not appear to impact patient retention or comprehension of discharge health information.

Comparison of Efficacy of Lidocaine and Articaine as Inferior Alveolar Nerve Blocking Agents in Patients with Symptomatic Irreversible Pulpitis: Randomized Controlled Trial.

Background and Objectives: Lidocaine Hydrochloride has been the standard choice for local anesthesia in dentistry and Articaine's unique structure and growing popularity make it a viable alternative. Due to contradictory results in prior research and a scarcity of trials conducted in the Pakistani population, this study aims to compare the anesthetic efficacy of Lidocaine with Articaine for inferior alveolar nerve blocks in patients with symptomatic irreversible pulpitis. Materials and Methods: This double-blinded, randomized controlled trial included 152 patients who were selected by consecutive non-probability sampling. The participants included patients who presented with symptomatic irreversible pulpitis in mandibular posterior teeth (molars and premolars) and depicted normal apical tissue radiographically. The patients were equally and randomly divided into two groups. The control group received 2% Lidocaine Hydrochloride injections, and the experiment group received 4% Articaine Hydrochloride injections. Participants scored their pain on the HP-VAS both before and after the administration of anesthesia. A value of 54 mm or less on the scale indicated effective anesthesia. The data obtained were analyzed using SPSS. Chi-square test was applied to analyze data for statistical significance. Results: There was no statistically significant difference in the efficacy of the two anesthetic agents. During access cavity preparation, Lidocaine demonstrated a success rate of 93%, whereas Articaine exhibited a slightly higher success rate of 97%. During initial instrumentation, the success rates for Lidocaine and Articaine were 72% and 71%, respectively. This suggests that both Lidocaine and Articaine were effective in achieving anesthesia during the dental procedure in patients with symptomatic irreversible pulpitis, with Articaine showing a slightly better success rate, although the difference was not statistically significant. Conclusions: The anesthetic efficacy of Articaine is similar to that of lidocaine in subjects with symptomatic irreversible pulpitis. Hence, Articaine can serve as an alternative to Lidocaine for local anesthesia administration in dentistry.

Analysis Of Common Somatic Mutations In Colorectal Carcinoma And Associated Dysregulated Pathwaysarts.

BACKGROUND: Identification of gene targets and biological pathways involved in colorectal carcinoma (CRC) is essential for better management of patients. Our study aims to highlight common somatic mutations in colorectal carcinoma and to identify dysregulated pathways and gene enrichment based on KRAS and BRAF interaction network analysis. METHODS: By using cancer browser tool in COSMIC database, mutation frequencies of the top 20 mutated genes listed for colorectal adenocarcinoma were identified. The most frequent variants of selected genes were explored with ClinVar database which led to identification of protein change along with its cytogenic location, variant type, variant length and the associated single nucleotide polymorphism (SNP). These identified SNPs were searched in Pakistani database using 1000genome in an attempt to identify common polymorphisms. Using the database ClinicalTrial.gov the number of clinical trials based upon these selected mutations was explored. Enrichment and protein interaction (PI) analysis of KRAS and BRAF was carried out to reveal significant biological pathways associated with these genes. RESULTS: In cumulative data, among all variants about 57% of substitution mutations are observed to be G>A including mutations in KRAS, Tp53, SMAD4, PI3K and NRAS. The mutations of KRAS (c.35G>A), TP53 (c.524G>A) and APC (c.4348C>T) were found to be pathogenic with single nucleotide variation and variant length of 1bp. Searching 1000genome database revealed that 100 % of alleles found in East Asian population studied are 'C'(frequency=1). Significant biological pathways (<0.05) identified by our search include Trk receptor signalling mediated by the MAPK pathway, signalling to p38 via RIT and RIN, signalling to ERKs, Frs2-mediated activation, ARMS-mediated activation and prolonged ERK activation events. CONCLUSIONS: Our study highlights the role of genetic profiling in CRC, with emphasis on mutations which may define treatment outcome. Targeting several collateral pathways simultaneously may be further explored to improve colorectal cancer therapeutics.

The association between adult-onset Still's disease and collapsing glomerulopathy: a case report.

BACKGROUND: Collapsing glomerulopathy, characterized by marked hypertrophy and hyperplasia of the podocytes with eventual collapse of the glomerular tuft, is an important cause of end-stage renal disease. Among the many causes of collapsing glomerulopathy, autoimmune diseases, such as systemic lupus erythematosus, have been implicated. There are also rare reports of adult-onset Still's disease, an autoinflammatory condition characterized by fever, rash, and inflammatory arthritis being associated with collapsing glomerulopathy. CASE PRESENTATION: Herein, we present a review of three published cases, and present a new case of a 15-year-old African American female patient with collapsing glomerulopathy who was diagnosed with adult-onset Still's disease 12 years later when she presented with fevers, arthralgias, sore throat, lymphadenopathy, hepatocellular injury, and elevated serum ferritin. Her collapsing glomerulopathy was initially well controlled following induction therapy with cyclosporine and prednisone and maintenance therapy with losartan. However, after developing adult-onset Still's disease, she had multiple flare-ups despite various immunosuppressive therapies and developed worsening renal function, eventually progressing to end-stage renal disease. CONCLUSIONS: Our case-based review highlights a rare but important association between adult-onset Still's disease and collapsing glomerulopathy, and postulates a possible pathophysiological link.

An assessment of unstimulated salivary flow rate, IgA and clinical oral dryness among active and passive smokers.

OBJECTIVES: The aim of this study was to assess the impact of smoking on the whole salivary flow rate (SFR), IgA levels and clinical oral dryness (COD) among active and passive smokers. MATERIAL AND METHODS: The participants were categorized as active smokers (N = 54) or passive smokers (N = 163). Saliva was collected in tubes and placed in ice storage at -70°C. Salivary IgA levels were assessed in duplication using the enzyme linked immunosorbent assay (ELISA) method. Following the saliva sample collection, the subjects were assessed for COD using the COD score, SFR and caries. Chi-square test, the t-test and ANOVA were employed to compare the clinical impact of the smoking status associated with specific variables (smoking status, number of cigarettes, active caries, gender, age, COD score, IgA level and SFR). A p-value of <0.05 was considered significant. RESULTS: Two hundred and seventeen subjects with the mean age of 32.86±6.30 years, with 145 males (66.8%) and 72 females (33.2%), were included in the study. Among the active smokers, 88.8% were males compared to 11.2% females. The active smokers had the mean age of 32.52 years, a COD score of 1.43, an IgA level of 1.39 g/l, and a SFR of 0.37 ml/min. Among the passive smokers, 59.5% were males and 40.5% were females, with the mean age of 32.97 years, a COD score of 0.87 g/l, an IgA level of 1.47, and a SFR of 0.42 ml/min. Active caries showed a positive correlation with the number of cigarettes, with significance in the >35 years age group (p < 0.05). CONCLUSIONS: The study demonstrated significant differences in SFR, IgA and COD scores among the active and passive smokers. The number of cigarettes had a negative impact on saliva production, IgA levels, the oral health status, and the progression of caries with respect to age and gender. Smoking potentially leads to xerostomia associated with active caries. Int J Occup Med Environ Health. 2022;35(1):39-51.

The Psychological Impact Analysis of Novel COVID-19 Pandemic in Health Sciences Students: A Global Survey.

OBJECTIVE: To evaluate the anxiety and depression amid novel coronavirus disease-19 (COVID-19) pandemic in health sciences students around the globe. MATERIALS AND METHODS: This cross-sectional observational study comprised 523 health science students. A well-structured online questionnaire consisting of closed-ended questions based on student's general information, Patient Heath Questionnaire (PHQ)-9 and Generalized Anxiety Disorder (GAD)-7 scales were used to assess the psychological impact of COVID-19. STATISTICAL ANALYSIS: SPSS-25 was used to analyze the outcome of this study. Multiple linear regression analysis test was used to assess variables which had impact on PHQ-9 and GAD-7 scores among the participants. A p-value of ≤ 0.05 was considered as statistically significant. RESULTS: Among the 523 participants, 365 (69.55%) students were from developing countries and 158 (30.21%) from developed countries; 424 (81.1%) students were tested negative for COVID-19 and 99 (18.9%) had suffered from severe acute respiratory syndrome coronavirus 2 infection during pandemic. The mean GAD-7 and PHQ-9 scores were 7.16 ± 5.755 and 7.30 ± 6.166, respectively. Significant impact on anxiety levels was associated with age, gender, education status, and COVID-19 positive patient, while depression was not significantly associated with gender, COVID-19, and its reported symptoms in participants. CONCLUSION: As the world is trying to contain the health effects of COVID-19, the psychological effects might take a longer time to be addressed. Our study highlights the dire need to identify mental well-being of health science students as this may have a direct impact on their professional commitments and future responsibilities.

Dysregulated epidermal growth factor and tumor growth factor-beta receptor signaling through GFAP-ACTA2 protein interaction in liver fibrosis.

OBJECTIVE: Viral hepatitis is associated with high morbidity and mortality. Identification of biological pathways involved in hepatic fibrosis resulting from chronic hepatitis C are essential for better management of patients. Constructing the HCV-human protein interaction network through bioinformatics may enable us to discover diagnostic biological pathways. We investigated to identify dysregulated pathways and gene enrichment based on actin alpha 2 (ACTA2) and glial fibrillar acidic protein (GFAP) interaction network analysis in hepatic fibrosis. METHODS: This is an in-silico study conducted at Ziauddin University from March,2019 to September 2019. Enrichment and protein-protein interaction (PPI) network analysis of the identified proteins: GFAP and ACTA2 along with their mapped gene data sets was performed using FunRich version 3.1.3. RESULTS: Biological pathway grouping showed enrichment of proteins (85.7%) in signalling pathway by epidermal growth factor receptor (EGFR) and Tumor growth factor (TGF)-beta Receptor followed by signaling by PDGF, FGFR and NGF (71.4%) (p < 0.001). SRC, PRKACA, PRKCA and PRKCD were enriched in both EGFR and TGF-beta Signalling pathways. CONCLUSION: EGFR and TGF-beta signalling pathways were enriched in liver fibrosis. SRC, PRKACA, PRKCA and PRKCD were enriched and differentially expressed in both EGFR and TGF-beta signalling pathways.

Health Disparities Among Hispanics With Rheumatoid Arthritis: Delay in Presentation to Rheumatologists Contributes to Later Diagnosis and Treatment.

OBJECTIVE: The aim of this study was to evaluate referral and treatment delays by ethnicity/race in patients with rheumatoid arthritis (RA) treated at an academic rheumatology center. METHODS: We reviewed the medical records of all RA patients evaluated at an outpatient clinic between 2011 and 2016 to identify newly diagnosed and naive-to-treatment patients. We determined the durations between symptom onset and first rheumatology visit and time to initiate treatment. Data extraction included referral source, demographics, treatment, and laboratory tests. Routine use of a multidimensional health assessment questionnaire allowed us to calculate baseline RAPID3 (routine assessment of patient index data 3) scores. Comparisons between self-reported ethnicity/race groups were performed. We used logistic regression models to analyze associations between baseline variables and early referral. RESULTS: Data from 152 disease-modifying antirheumatic drug-naive RA patients were included in the study; 35% were white, 37% black, 20% Hispanic, and 8% other. The range in median time to first rheumatology visit was 6 to 8 months for all patient groups, except Hispanic. This group had a median time of 22.7 months (p = 0.01). The referral pattern was considerably variable between-groups; 40% of Hispanic patients were self-referred (p = 0.01). There were no statistically significant between-group differences for time to treatment initiation according to ethnicity/race. RAPID3 scores (p = 0.04) and erythrocyte sedimentation rates (p = 0.01) were significantly higher in the black and Hispanic groups. A high C-reactive protein value at baseline was associated with earlier referral. CONCLUSIONS: There is significant delay in initial presentation to a rheumatologist that was associated with a higher disease severity at presentation, especially for Hispanic patients.

Retinal vasculitis the first clue in the diagnosis of progressive hemifacial atrophy.

Retinal vasculitis is a sight-threatening condition that can occur as an isolated ocular disorder or in association with a number of systemic diseases. Parry-Romberg syndrome, also known as progressive hemifacial atrophy (PHA), is a rare disorder of unknown etiology characterized by unilateral facial atrophy and is associated with multiple ophthalmologic and neurologic manifestations. Here we report the case of a 17-year-old man with no prior diagnosis of PHA, who presented with a sudden onset of floaters and decreased vision in the right eye; he was found to have retinal vasculitis and uveitis in the right eye. Routine workup did not reveal the cause of retinal vasculitis. However, thorough physical examination demonstrated features of PHA overlapping with linear scleroderma en coup de sabre. The patient was started on treatment with systemic steroids with a later addition of methotrexate; he responded to treatment with considerable improvement in his symptoms and ophthalmologic examination.

Multiple cutaneous and mucosal lesions in a patient with cocaine-levamisole-induced vasculopathy syndrome.

Levamisole is an adulterant found in nearly 70% of cocaine in the United States. The concomitant use of levamisole and cocaine leads to a distinct clinical syndrome that typically manifests as agranulocytosis, leukocytoclastic vasculitis, and elevated antineutrophil cytoplasmic antibody (ANCA) levels. Systemic involvement has also been rarely reported with this syndrome. This is a case of a 51-year-old woman with chronic cocaine use who initially presented with multiple cutaneous ulcerations and was later found to have pulmonary and renal involvement. Infectious workup was unrevealing and autoimmune workup revealed highly elevated levels of perinuclear ANCA. Due to continuous cocaine use despite counseling, the patient was readmitted with worsening pulmonary and renal manifestations requiring initiation of immunosuppressive therapy.

Challenges to Practicing Rheumatology in an Academic Center.

Rheumatologists working in academics participate in patient care, teaching, and research. There are several challenges associated with the pursuit of these academic missions, and these are the focus of this article. Additionally, how financial pressures faced by academic institutions have led to greater emphasis on the generation of revenue from clinical activities to the detriment of other academic pursuits is discussed. In an era of greater physical burnout and with the looming shortages of the rheumatology workforce, the importance of addressing these issues is stressed and potential solutions discussed.

Overview of musculoskeletal ultrasound for the clinical rheumatologist.

Within the realm of rheumatology, the field of musculoskeletal ultrasound (MSUS) has grown exponentially over the last few decades. This review, aimed at the clinical rheumatologist, provides a basic overview of the principles of image generation and the commonly used clinical applications of MSUS, while also highlighting its advantages and limitations. In particular, the role of MSUS in the assessment of early and established rheumatoid arthritis, crystalline disease, the spondyloarthropathies and Sjögren's disease is discussed in more detail and by reviewing the pertinent literature.

Bariatric Surgery: What the Rheumatologist Needs to Know.

A staggering 76 million adults are obese in the United States. It is known that obesity contributes to increased incidence and worse disease outcomes in many rheumatic conditions. Bariatric surgery has emerged as the most effective treatment modality for the morbidly obese, leading to substantial and sustained weight loss. The purpose of this review article is to summarize the findings of studies investigating the effect of substantial weight loss achieved through bariatric surgery on rheumatic disease and outcomes. Second, with an increasing number of patients undergoing bariatric surgery, it is important for the rheumatologist to have a basic understanding of the commonly performed bariatric procedures and to be aware of important nutritional deficiencies and medication restrictions that apply to this patient population.

Red cell distribution width: a measure of cardiovascular risk in rheumatoid arthritis patients?

This study aims to evaluate if myocardial infarction (MI) is more frequent in rheumatoid arthritis (RA) patients with elevated levels of red cell distribution width (RDW). Utilizing a secure cloud based platform, Explorys, we searched de-identified US patient data between 1999 and 2014. RA patients were identified by serologic positivity and ICD9 diagnosis code. Patients were stratified into high (≥15.6 %) RDW and low (<13.5 %) RDW groups (and excluding any patient with prior episode of RDW >15.6 %). The proportion of patients with diagnosis of MI in each RDW group was collected. For comparison, patients were divided into high and low CRP groups (≥2.5 and ≤0.8 mg/dL) and high and low ESR groups (≥50 and ≤30 mm/h), and MI data were collected. Statistical comparison between high and low laboratory test groups was performed with chi-square test, and odds ratios were calculated. The patient population included 20,810 patients with RA. The proportion of RA patients with MI was significantly increased in the high compared to low RDW, ESR, and CRP groups (p < 0.001 for each). The odds ratios of MI were greater in the high than in the low group for each parameter: RDW (OR1.5, 95 % CI 1.3 to 1.6); ESR (OR2.0, 95 % CI 1.8-2.3); and CRP (OR1.9, 95 % CI 1.7 to 2.2). These data from a large unselected population suggest that elevated RDW levels in RA patients should prompt physicians to aggressively screen and treat their patients for modifiable cardiovascular (CVS) risk factors, in addition to treating RA inflammation.

Review of diagnostic techniques of hepatic fibrosis.

With increasing innovations aimed at the treatment of chronic liver disease (CLD), the precise staging of liver fibrosis is important to help establish efficacious management of disease activity in each patient. The development of biomarkers capable of non-invasive staging of fibrosis in the liver is challenging as fibrogenesis is a part of the normal wound healing response. There is an array of non-invasive methods, including serum biomarker assays, and imaging techniques such as transient elastography. The degree of implementation of non-invasive diagnostic tests for liver fibrosis differs all over the world, and still remains limited. Liver biopsy so far is the mainstay of diagnosing hepatic fibrosis. Precise staging of liver fibrosis is essential in management of patients. This review provides a systematic overview of various techniques, as well as both approaches based on direct and indirect biomarkers to stage fibrosis, and covers recent studies related to hepatic fibrosis.

Glial Fibrillary Acidic Protein (GFAP) as a Mesenchymal marker of Early Hepatic Stellate Cells Activation in Liver Fibrosis in Chronic Hepatitis C Infection.

OBJECTIVE: This study aims to determine expression of Glial Fibrillary Acidic Protein and of Alpha Smooth Muscle Actin (α-SMA) in hepatic stellate cells of CHC cases and their association with stage of fibrosis. METHODS: The study was conducted at Ziauddin University, Clifton Campus during the year 2010-2012. Sixty Chronic Hepatitis C cases were immmunostained using anti α-SMA antibody and anti-GFAP antibody. Semi quantitative scoring in pericentral, periportal and perisinusoidal area of each case was done to assess immunoexpression of each marker. Results : Immunoexpression of GFAP showed significant association with α-SMA. GFAP expression was inversely correlated with progression of fibrosis. Conclusion : GFAP could represent a useful marker for early hepatic stellate cells activation. Follow up biopsies showing decline in GFAP levels may help identify the target group requiring aggressive therapy.

Spondyloarthritis associated with acne conglobata, hidradenitis suppurativa and dissecting cellulitis of the scalp: a review with illustrative cases.

To review and highlight the association of acne conglobata, hidradenitis suppurativa, and dissecting cellulitis of the scalp with inflammatory arthritic conditions, we report five illustrative patients with this association, and a review of the literature. All our patients were African-American males, and their skin disease present before the onset of arthritis. Both asymmetric peripheral arthritis and axial disease can occur. The arthritis is usually insidious and lacks association with rheumatoid factor and HLA-B27. Imaging of peripheral joints can reveal erosions, periosteal bone reaction and new bone formation. When the axial skeleton is involved, imaging can reveal sacroiliitis, syndesmophyte formation. NSAIDs, oral and intra-articular steroids, DMARDs and TNF alpha antagonists have all been used with success. Controlled trials with larger numbers of patients are needed to assess which treatment options are the most effective for this group of patients.