Associations among temporal and large artery abnormalities on vascular ultrasound in giant cell arteritis.

Objectives: Giant cell arteritis (GCA) can manifest in cranial and/or extracranial arteries. We investigated the distribution of affected arteries on vascular ultrasound (VUS) among patients with new-onset or prior-onset GCA.Method: We retrospectively studied patients with either new-onset or prior-onset GCA and an abnormal VUS, from 2013 to 2017. Trained vascular technologists imaged the bilateral temporal arteries and carotid, axillary, and subclavian arteries. Vascular medicine physicians interpreted the images. Vasculitis-related abnormalities in individual vessels and their distribution (temporal artery, large artery, or both) were evaluated. Phi coefficients (φ) and Fisher's exact test were used to assess correlations among individual abnormal arteries.Results: Among 66 GCA patients, 28.8% had prior-onset GCA (median duration 17.8 months). Acute arteritis on VUS was observed in the majority of patients with both new-onset (72.3%) and prior-onset GCA (68.4%); the remainder had hyperechoic wall thickening without acute arteritis. Involvement of the temporal arteries only (45.5%) or large arteries only (34.8%) was more common than involvement of both (19.7%); this finding was similar in new-onset and prior-onset GCA. There were moderate positive correlations among temporal artery branches (φ = 0.51-0.58, p < 0.003) and among axillary and subclavian arteries (φ = 0.51-0.77, p < 0.003), and moderate negative correlations between abnormalities in the temporal and large arteries (φ = -0.46 to -0.58, p < 0.003).Conclusion: On VUS, vasculitis-related abnormalities in the temporal arteries only or large arteries only were more common than concurrent temporal and large artery abnormalities in patients with both new-onset GCA and prior-onset GCA.

2015 Recommendations for the management of polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative

Therapy for polymyalgia rheumatica (PMR) varies widely in clinical practice as international recommendations for PMR treatment are not currently available. In this paper, we report the 2015 European League Against Rheumatism (EULAR)/American College of Rheumatology (ACR) recommendations for the management of PMR. We used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology as a framework for the project. Accordingly, the direction and strength of the recommendations are based on the quality of evidence, the balance between desirable and undesirable effects, patients' and clinicians' values and preferences, and resource use. Eight overarching principles and nine specific recommendations were developed covering several aspects of PMR, including basic and follow-up investigations of patients under treatment, risk factor assessment, medical access for patients and specialist referral, treatment strategies such as initial glucocorticoid (GC) doses and subsequent tapering regimens, use of intramuscular GCs and disease modifying anti-rheumatic drugs (DMARDs), as well as the roles of non-steroidal anti-rheumatic drugs and non-pharmacological interventions. These recommendations will inform primary, secondary and tertiary care physicians about an international consensus on the management of PMR. These recommendations should serve to inform clinicians about best practices in the care of patients with PMR.(AU)

Polymyalgia rheumatica can recur years after discontinuation of corticosteroid therapy.

OBJECTIVE: To describe disease recurrence in polymyalgia rheumatica. METHODS: I present 12 patients with recurring PMR from a single clinical practice with long-term clinical follow-up (mean 14.3 years). RESULTS: Despite a disease-free interval off corticosteroids of 2 years or longer, these patients experienced 1 overt recurrence (or more) of PMR. CONCLUSION: The course of PMR is not uniformly monophasic, and patient and physician should remain alert to the possibility of recurring disease.

Low-dose prednisone therapy.

Low doses of corticosteroids are beneficial in the management of certain patients with rheumatoid arthritis, and provide definitive symptomatic relief for patients with polymyalgia rheumatica. They are probably of similar value in the treatment of older adults with acute seronegative polyarthritis, a condition that may bear close resemblance to polymyalgia rheumatica.

Clinical features and medical management of osteoarthritis at the hand and wrist.

The epidemiology of osteoarthritis (OA) in the hand and wrist is reviewed. Clinical characteristics of primary and secondary OA are discussed, and differential diagnosis is outlined. Nonoperative management is detailed, including use of the nonsteroidal anti-inflammatory agents.

Esophageal motor dysfunction in systemic lupus erythematosus. Two cases with unusual features.

Two patients with systemic lupus erythematosus had intermittent episodes of dysphagia associated with severe nonpleuritic chest pain. Esophageal manometry disclosed abnormalities characteristic of diffuse esophageal spasm. The findings suggest that diffuse spasm should be considered in the differential diagnosis of unexplained chest pain and dysphagia in patients with lupus.

Medical management of rheumatoid arthritis.

The overall management of RA is multifaceted. It includes rest, both systemic and articular; physical therapy; utilization of the techniques and appliances of occupational therapy; drugs, both those that suppress inflammation and those that are capable of altering the disease course itself; a knowledge of specific articular and nonarticular complications; and the ability to refer for appropriate surgical management. Judicious, energetic application of these principles can favorably affect the outcome of rheumatoid disease in most patients.