How to Monitor Disease Activity of Axial Spondyloarthritis in Clinical Practice.

PURPOSE OF REVIEW: Treatment guided by periodic and quantitative data assessment results in better outcomes compared to using clinical gestalt. While validated generic as well as specific disease activity measures for axial spondyloarthritis (axSpA) are available, there is vast scope to improve their actual utilization in routine clinical practice. In this review, we discuss available disease activity measures for axSpA, describe results from the survey conducted among general rheumatologists as well as Spondyloarthritis Research and Treatment Network (SPARTAN) members about disease activity measurement in daily practice, and discuss ways to improve axSpA disease activity using technological advances. We also discuss the definitions of active disease and target for the treatment of axSpA. RECENT FINDINGS: The 2019 American College of Rheumatology (ACR)/Spondylitis Association of America (SAA)/Spondyloarthritis Research and Treatment Network (SPARTAN) axSpA treatment guidelines conditionally recommend the regular monitoring of disease activity using a validated measure such as Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) or Ankylosing Spondylitis Disease Severity Index (ASDAS). Assessment of Spondyloarthritis International Society (ASAS)-European Alliance of Associations for Rheumatology (EULAR) guidelines recommend ASDAS as the most appropriate instrument for the assessment of disease activity, preferably calculated using C-reactive protein (CRP). ASAS has selected a core set of variables which were updated recently and have been endorsed by the Outcome Measures in Rheumatology Clinical Trials (OMERACT) group in order to bring homogeneity in assessment of axSpA. In a recent study, Patient-Reported Outcomes Measurement Information System (PROMIS®) measures were able to discriminate inactive, moderate, and high-very high ASDAS activity groups. A newly developed semi-objective index P4 (pain, physical function, patient global, and physician global) correlates well with BASDAI and ASDAS in axSpA and can also be used for other rheumatic diseases in busy clinical practices. Regular disease activity monitoring is critical for long-term management of axSpA and shared decision-making. The integration of electronic health records and smart devices provides a great opportunity to capture patient-reported data. Automated capture of electronic patient-reported outcome measures (ePROMs) is a highly efficient way and results in consistent regular monitoring and may improve the long-term outcomes. While currently used measures focus only on musculoskeletal symptoms of axSpA, a composite disease activity measure that can also incorporate extra-articular manifestations may provide a better assessment of disease activity.

Cardiovascular Manifestations in Rheumatoid Arthritis.

Rheumatoid arthritis (RA) is a systemic inflammatory disorder that characteristically affects the joints. RA has extra-articular manifestations that can impact multiple organ systems including the heart, lungs, eyes, skin, and brain. Cardiovascular involvement is a leading cause of mortality in RA. Cardiovascular manifestations of RA include accelerated atherosclerosis, heart failure, pericarditis, myocarditis, endocarditis, rheumatoid nodules, and amyloidosis. Inflammation is an important mediator of endothelial dysfunction and is a key driver of cardiovascular risk and complications in patients with RA. Prompt identification of cardiac pathologies in patients with RA is essential for appropriate management and treatment. Choosing the most appropriate treatment regimen is based on individual patient factors. In this article, we provide a comprehensive review of the epidemiology, pathophysiology, clinical manifestations, diagnosis, and medical management of cardiovascular manifestations of RA. We also discuss the relationship between anti-rheumatic medications, specifically non-steroidal anti-inflammatory drugs, corticosteroids, methotrexate, statins, tumor necrosis factor inhibitors, interleukin-6 inhibitors, Janus kinase inhibitors, and cardiovascular disease.

Clinical, histological features, and predictors of relapse in patients with idiopathic granulomatous mastitis.

Idiopathic granulomatous mastitis is a benign, inflammatory disease of breasts characterized by non-caseating granulomas. Our study aims to identify distinguishing clinical and histopathological features of relapsing disease compared to those in complete remission. We queried databases at our institution (1990-2021) to include females ≥18 years with biopsy-proven diagnosis of idiopathic granulomatous mastitis, excluding patients with breast cancer, lymphoproliferative disorders, solid organ malignancy, foreign body reaction in breast, plasma cell mastitis, and ductal ectasia. Remission was defined as a 3-month period without recurrence of symptoms or imaging findings. Relapse was defined as recurrence after 3 months of remission. Clinical and histopathological features were compared using 2-sample t tests and chi-squared tests. Of the 27 patients that met our inclusion criteria, the mean age at diagnosis was 35.8 years (± standard deviation 9.4 years) with a mean body mass index of 31.7 kg/m2 (± standard deviation 6.7 kg/m2). 11 (41%) were Hispanic, 25 (93%) had at least one previous full-term pregnancy prior to diagnosis and 8 (30%) were on oral contraceptives. Remission was seen in 18 patients (66%) and 9 (33%) had relapse. Six of these patients received steroids after antibiotics, while 5 patients received methotrexate. Three (33%) patients with relapse and 14 (77%) with remission, had abscess formation confirmed on histopathology (P = .04). Patients with remission had a higher number of abscesses on histopathology and history of oral contraceptive use was associated with more relapse. By identifying key clinical and histopathological findings in this population may guide prognosis and treatment of these patients.

Clinical Management of Patients With Stable Ischemic Heart Disease.

Ischemic heart disease is considered stable, if patients are asymptomatic or have well controlled symptoms. Based on the pretest probability, noninvasive imaging tests are performed to rule out the disease, and coronary computed tomography angiography being the first line. Invasive coronary angiography remains the gold standard method for diagnosing coronary artery disease. In patients with stable coronary artery disease, comorbidities such as hyperlipidemia, hypertension, and diabetes should be optimized. For patients with persistent anginal symptoms even with optimized medical therapy, coronary revascularization with percutaneous coronary intervention can be considered. Coronary artery bypass grafting may be more beneficial for patients who has stable coronary artery disease with left main disease and/or left ventricular dysfunction and/or multivessel disease; however, treatment should be individualized to the overall clinical picture.

Dual-Energy Computed Tomography (DECT) Resolves the Diagnostic Dilemma in an Atypically Presenting Case of Gout.

Gout is a common inflammatory arthropathy that presents as acute monoarthritis, most commonly of the first metatarsophalangeal (MTP) joint. Chronic polyarticular involvement may lead to confusion with other inflammatory arthropathies, including rheumatoid arthritis (RA). A thorough history, physical examination, synovial fluid analysis, and imaging are keys to establishing a correct diagnosis. Although a synovial fluid analysis remains the gold standard, the affected joints may be difficult to access by arthrocentesis. In cases where a large monosodium urate (MSU) crystal deposition is in the soft tissues - the ligaments, bursae, and tendons, it becomes a clinical impossibility. In such cases, dual-energy computed tomography (DECT) can assist in differentiating gout from other inflammatory arthropathies, including RA. Additionally, DECT can perform quantitative analysis of tophaceous deposits and, therefore, assess response to treatment.

Treatment of Pyoderma Gangrenosum With Mycophenolate and Hyperbaric Oxygen Therapy: A Case Report and Literature Review.

Pyoderma gangrenosum is an uncommon inflammatory ulcerative skin disorder with an unclear etiology. In many cases, it is associated with several underlying systemic diseases, with inflammatory bowel disease being the most common one. Since it does not have any specific clinical or laboratory findings, it is a diagnosis of exclusion. A multidisciplinary approach is vital in treating pyoderma gangrenosum. Its recurrence remains common, and it also has an unpredictable prognosis. Here, we report a case report of pyoderma gangrenosum, which was successfully treated with mycophenolate and hyperbaric oxygen therapy.

Coronary Artery Bypass Grafting in a Patient With Severe Factor VII Deficiency.

Factor VII deficiency is a rare bleeding disorder. Clinical presentation is highly variable and can range from mild symptoms like mucosal bleeding to life-threatening hemorrhages in early infancy. Some people remain asymptomatic and are only diagnosed incidentally on laboratory tests. Given the low incidence in the population and variable phenotypes, there are no official guidelines on the management of such patients perioperatively to minimize bleeding risk. We present a case of a man with inherited severe factor VII deficiency who underwent successful coronary artery bypass grafting.

A clinical study to assess feasibility, acceptance, and outcome of multifocal intraocular lens in patients with bilateral immature cataract at a tertiary eye care institute.

PURPOSE: : To assess feasibility, acceptability, and outcome of multifocal intraocular lenses (IOL) in patients with bilateral immature cataract. METHODS: 1691 patients with bilateral immature cataract were included in the study. The feasibility of these IOLs was calculated by studying ocular parameters using Visionix VX120 and subjective characteristics. A prospective study was then conducted in 148 eyes of 74 patients in which multifocal IOLs were implanted. Their visual outcome was assessed using LogMAR for distance and Snellen's chart for near vision, contrast sensitivity by Pelli-Robson chart, and satisfaction using visual function-7 questionnaire. RESULTS: Considering ocular and subjective characteristics, it was feasible to implant the lens in 920 patients (54.40%) and the acceptability rate was 8.04%, most common reason for decreased acceptability was cost (85%) of IOL. The median distance uncorrected visual acuity (UCVA) at day 7 and at 30 days was LogMAR 0.2 (0.1-0.3) and 0.15 (0.1-0.2), respectively, which was statistically significant compared to preoperative distance UCVA (P < 0.001). The median near UCVA at day 7 and 30 days was N6 for both and statistically significant (P < 0.001) compared to preoperative near UCVA. 77.02% patients had distance UCVA of LogMAR (0.0-0.2) and 91.8% had near UCVA of N6-N8 at 30 days. The contrast sensitivity was decreased in all patients. CONCLUSION: Appropriately selected patients can achieve spectacle independence and good visual satisfaction which begins with proper patient education, lifestyle and personality dynamics, and individualized weighing of benefits and side effects of multifocal IOLs.