Progressive Multifocal Leukoencephalopathy Following Combined Rituximab-Based Immune-Chemotherapy for Post-transplant Lymphoproliferative Disorder in a Renal Transplant Recipient: A Case Report.

BACKGROUND: Transplant recipients are at risk of developing progressive multifocal leukoencephalopathy (PML), an opportunistic infection due to reactivation of JC virus. Post-transplant lymphoproliferative disorders (PTLDs) represent a common malignancy in this population, and antiCD20-therapy has become an established component of its treatment. CASE PRESENTATION: We describe the first case of a renal allograft transplant recipient with PTLD who received rituximab-based immune-chemotherapy and developed PML shortly thereafter. Despite early suspicion and diagnosis, the disease ran a relentlessly progressive course, and the patient succumbed to his illness shortly thereafter. CONCLUSION: PML should be strongly suspected whenever unusual neurologic symptoms appear in the context of immunosuppression. Clinicians and patients should be aware of the potential for PML after rituximab therapy.

Improving patient flow of people with rheumatoid arthritis has the potential to simultaneously improve health outcomes and reduce direct costs.

BACKGROUND: In our current economic climate of scarce resources there is a lot of debate around the best - and most efficient - way of delivering care, which points patients towards the right physician at the earliest opportunity. The aim of the study was to assess whether an improvement in the interdisciplinary management of rheumatoid arthritis (RA) has the potential to simultaneously improve health outcomes and reduce costs. METHODS: In a first step, we modelled the ways which lead patients with RA to the correct diagnosis, and the relevant specialist, respectively. On average, a patient experiences 3 GP visits before referral to a specialist. We compared this situation against a reconfiguration of current practice towards a more proactive identification and referral method with initiation of care by a rheumatologist early in the disease. We evaluated the impact of this reconfiguration on the number of RA patients diagnosed and the costs associated with the diagnostic process. RESULT: Using data on epidemiology and Austrian practice patterns, we estimate a total of 5294 people with undifferentiated arthritis per year, of which 1765 suffer from RA. Modelling for diagnostic accuracy, we found that 1200 of these patients are initially misdiagnosed in a primary care setting and 95 at a rheumatologist. Our model found that a reconfiguration of current practice towards an approach of more integrated care has the potential to be not only cost-effective, but cost-saving: EUR 100,188 could be saved annually by exclusively adopting the new approach. CONCLUSIONS: Our results show that by better directing the flow of people with RA, simultaneous clinical and economic benefits may be reaped:.

[Why rheumatoid arthritis needs cardiologists]. / Warum die rheumatoide Arthritis den Kardiologen braucht.

Rheumatoid arthritis (RA) is associated with a shortened life expectancy. Most premature deaths are caused by cardiovascular (CV) events; therefore it is of importance to consider the increased CV risk when treating RA patients. Traditional CV risk factors cannot fully explain the increased risk but the common understanding is that inflammation significantly contributes to the excess risk observed. Without the use of correction factors commonly used risk calculators underestimate the true CV risk in RA patients. Methotrexate and TNF inhibitors appear to be beneficial with regard to the CV risk. To date there are only few recommendations for interventions in the CV system of RA patients which go beyond those formulated for the general population. The present manuscript summarizes the published evidence concerning the increased CV risk in RA patients.

What is causing my arthritis, doctor? A glimpse beyond the usual suspects in the pathogenesis of rheumatoid arthritis.

Rheumatoid arthritis (RA) is a common, but heterogeneous, disease. Usually, when it comes to the pathogenesis of RA the physician faces a complex network of cytokines and cells of the immune system-the so-called effector level. However, is this network 'the cause' of the disease? Or is this rather the level most physicians are somewhat familiar with, as modern anti-rheumatic medications are having their targets there? In this review, we are looking beyond the usual culprits from the physician's perspective and discuss how other factors, such as genes, epigenetics, environmental factors, local joint characteristics or processes of aging might influence the clinical phenomenon RA.

Clinical versus histological diagnosis of diabetic nephropathy--is renal biopsy required in type 2 diabetic patients with renal disease?

OBJECIVES: The clinical and histological diagnosis (gold standard) of diabetic nephropathy (dNP) and vascular nephropathy (vNP) were compared in type 2 diabetic patients with end-stage renal disease (ESRD). AIM: The aim of the study was to investigate indication for renal biopsy in type 2 diabetic patients with renal disease. DESIGN: Retrospective study in diabetic patients with clinical and histological diagnosis of renal disease. PATIENTS AND METHODS: Eighty-four patients with type 2 diabetes and ESRD were investigated. Histological findings of the kidneys were available in all patients, 14 had undergone a renal biopsy before their first dialysis while a post-mortem kidney investigation was performed in 70 subjects. According to the histological findings, 66 patients had dNP and 18 subjects had vNP. The histological diagnosis was compared with the clinical diagnosis, and the sensitivity as well as the specificity of the clinical diagnosis of dNP and vNP were calculated. RESULTS: The clinical diagnosis was not identical with the histological diagnosis in 10 cases. In the dNP group the diagnosis was 4 false positive and 3 false negative as in the vNP group 1 false positive and 2 false negative. The sensitivity of clinical diagnosis was 95% for dNP and 89% for vNP. Specificity was 78% for dNP and 97% for vNP. CONCLUSION: The sensitivity of the clinical diagnosis is very high for dNP as well as vNP. A renal biopsy is not required in the majority of type 2 diabetic patients with ESRD, especially in patients who exhibit all criteria for clinical diagnosis.

Cardiovascular morbidity and mortality in patients with rheumatoid arthritis: vascular alterations and possible clinical implications.

Mortality in patients with rheumatoid arthritis (RA) is higher than in the general population, which is due mainly to premature cardiovascular disease. Traditional cardiovascular risk factors cannot entirely explain the higher level of cardiovascular complications, and there is growing evidence that chronic inflammation is the main culprit. The aims of this review of the literature are to (i) summarize aspects of vascular alterations found in the cardiovascular system of RA patients and to relate them to the clinically relevant cardiovascular morbidity and mortality and (ii) evaluate what these abnormalities and complications might in the end imply for clinical management. A number of abnormalities in the cardiovascular system of RA patients have been identified, on the molecular level, in endothelial function, arterial stiffness, arterial morphology and, finally, in the clinical presentation of cardiovascular disease. Cardiovascular risk assessment should be part of the care of RA patients. While a great deal of data is published demonstrating abnormalities in the cardiovascular system of these patients, it is much less clear what specific interventions should be performed to reduce the incidence of cardiovascular complications. Cardiovascular care should be delivered in accordance with recommendations for the general population. Whether specific drugs (e.g. statins, aspirin) are of particular benefit in RA patients needs further investigation. Control of inflammation appears to be of benefit. Methotrexate and tumor necrosis factor-α blocking agents might reduce the number of cardiovascular events. Leflunomide, cyclosporine, non-steroidal anti-inflammatory drugs and cyclo-oxygenase-2 inhibitors may worsen cardiovascular outcome. The role of glucocorticoids in active RA remains to be determined.

Nephrogenic systemic fibrosis. A debilitating disease causing fibrosis of the skin and inner organs in patients with kidney failure.

Nephrogenic systemic fibrosis (NSF) is a rare and debilitating disease which affects patients with kidney failure. The most obvious manifestation is fibrosis of the skin, but it also frequently involves the locomotor system and the inner organs. An association has been found with the administration of gadolinium-containing contrast agents, which are given to provide enhanced contrast during magnetic resonance imaging. It is thought that unstable chelate complexes release toxic gadolinium. Other triggers or co-triggers may also be relevant. No effective treatment currently exists for NSF, so prevention of the disease is of the utmost importance. If gadolinium-containing contrast agents need to be administered to patients who have kidney failure, a cyclic agent should be used, and the dosage should be as low as possible. Although no proof is yet available that hemodialysis prevents NSF, it is effective in the clearance of gadolinium and should therefore be considered as a treatment immediately after the imaging.

Comparable outcomes in type 2 diabetic patients with diabetic or vascular nephropathy treated by hemodialysis.

AIM: The aim of the present study was to find out any differences in the progression of macroangiopathic diseases and patient survival in diabetic patients with diabetic nephropathy (DN) or diabetic renal vasculopathy (DV) under hemodialysis therapy. METHODS: We compared 24 type 2 diabetic patients under hemodialysis with DV and 102 type 2 diabetic patients under hemodialysis with DN. Observation period was the first 3 years after initiating dialysis therapy. RESULTS: Patients with DN were younger and their diabetes duration was longer (p < 0.05) than in the DV patients. The prevalence of vascular diseases at the start of dialysis treatment as well as after 3 years was not significantly different between both groups. The 3-year mortality was 50% in the DN group and 46% in the DV patients. CONCLUSION: Patients with DN and DV show a similar poor outcome during the first 3 years of hemodialysis therapy.

Exercise program for older patients with insulin-treated type 2 diabetes: long-term effects on metabolic control and BMI.

BACKGROUND: Exercise is an important treatment for diabetes. In our study, we evaluated the acceptance of an exercise program and investigated the long-term effects of exercise on metabolic control and body mass index in older, insulin-treated type 2-diabetic patients. PATIENTS AND METHODS: A total of 72 type 2 diabetic patients, aged >or=50 years, participated in an exercise program. At the beginning of the study and after 3 and 12 months, patients completed a questionnaire concerning current activity. Finally, the patients were divided into two groups: those with and without regular exercise. Metabolic control was compared in both groups. RESULTS: Even during the first workout, blood glucose levels fell. No patient suffered from severe hypoglycemia. Motivation for regular exercise increased from 33 to 77%, decreasing slightly to 65% at 12 months. The mean HbA 1c levels were similar in both groups. However, in the exercise group no weight gain was observed in contrast to 2.5% weight gain in the other group. Moreover, insulin requirements were considerably lower in the exercise group. CONCLUSION: The acceptance of regular exercise is also high in older patients with newly insulin-treated type 2 diabetes. Metabolic control was significantly improved in patients with and without regular exercise; however, in the exercise group, body weight did not increase and insulin requirements were significantly lower.

[Radiological appearance of the cementless ALLOCLASSIC SL-stem implanted in very old patients with primary hip osteoarthritis]. / Radiologisches Erscheinungsbild des zementfreien ALLOCLASSIC SL-Schaftes bei sehr alten Patienten mit primärer Coxarthrose.

AIM: The radiological appearance of the cementless ALLOCLASSIC SL-stem, implanted in patients with primary osteoarthritis of the hip and aged at least 80 years at time of surgery, was investigated. METHOD: 66 hips in 58 patients were analysed. 17 patients (19 hips) died in the interim, 5 patients (5 hips) were not available for follow-up because of health reasons (4) or lack of co-operation (1). 1 stem had to be explanted after a periprosthetic fracture of the femur. Finally, 41 total hip arthroplasties in 35 patients could be analysed after an average of 67.9 months (39.2-93.4). RESULTS: Bone atrophy - especially in the proximal Gruen zones - was frequently found. In contrast, radiolucent lines and osteolyses were rare occurrences. The Harris Hip score was preoperatively on average 33.0 points, at time of follow-up 81.7 points. The survival rate (endpoint aseptic loosening) was 100 % after a mean follow-up of 5.7 years. CONCLUSION: Also in very old patients the implantation of a cementless stem is possible and provides very good results.

Cementless total hip arthroplasty in patients older than 80 years of age.

We reviewed 80 patients (87 hips) who were older than 80 years of age at the time of cementless total hip arthroplasty. An Alloclassic SL stem had been implanted in all patients. A variety of cementless acetabular components was used. After a mean follow-up of 69.3 months (39.2 to 94.1) 48 hips in 43 patients were analysed clinically and radiologically. One patient had sustained a traumatic periprosthetic fracture of the femur with subsequent exchange of the stem 73 months after operation. Thirty-two patients (34 hips) had died and five patients (five hips) were unavailable for follow-up because of health reasons (four patients) or lack of co-operation (one patient). If the endpoint is defined as removal of the prosthesis because of aseptic loosening, the survival rate was 100% for the cup and stem after 78 months. The mean Harris hip score was 81.9 points. Radiolucent lines and osteolysis were seldom found.