Retraction: Mesenteric Panniculitis: A Rare Condition in a Patient With Rheumatoid Arthritis.

[This retracts the article DOI: 10.7759/cureus.20136.].

Mesenteric Panniculitis: A Rare Condition in a Patient With Rheumatoid Arthritis.

Rheumatoid arthritis is a relatively common chronic inflammatory disorder affecting the synovial joints. Extra-articular manifestations of rheumatoid arthritis are not uncommon and include a wide range of cardiovascular, pulmonary, and neurological complications. Gastrointestinal involvement in rheumatoid arthritis is rare, but it can be impactful on the quality of life of patients. We present the case of a 45-year-old woman, with rheumatoid arthritis on methotrexate, who presented with a one-week history of abdominal pain. The patient visited the outpatient clinic earlier and was diagnosed with indigestion and was offered symptomatic treatment which failed to provide any improvement. Abdominal examination revealed a distended abdomen with generalized tenderness and rebound. However, the abdomen was soft with no palpable masses. Initial laboratory examination, including inflammatory parameters, was normal. The patient underwent a computed tomography scan of the abdomen with intravenous contrast which demonstrated inhomogeneous hyperdense mesenteric fat giving a mass-like lesion with a displacement of adjacent bowel loops. Such findings conferred the diagnosis of mesenteric panniculitis. The patient was started on corticosteroid therapy with oral prednisolone 40 mg daily with close follow-up. She developed gradual improvement in her condition and the pain resolved completely after six days. The patient was re-evaluated after six months from discharge and she had no recurrence. The case highlighted a rare association of mesenteric panniculitis and rheumatoid arthritis. Physicians should keep this mesenteric panniculitis in mind when they encounter patients with the autoimmune disorders who presented with abdominal symptoms.

Significant cardiac disease complicating Graves' disease in previously healthy young adults.

SUMMARY: Graves' disease is associated with tachydysrythmia, cardiac ischaemia and cardiomyopathy - all uncommon in young adults without previous cardiac disease. We present three young individuals who developed cardiac complications after periods of uncontrolled Graves' disease. Subject 1: A 34-year-old female had severe thyrotoxic symptoms for weeks. Investigations showed fT4: 98.4 (11-25 pmol/L), fT3: 46.9 (3.1-6.8 pmol/L), TSH <0.01 (0.27-4.2 mU/L) and thyrotrophin receptor antibody (TRAb): 34.8 (<0.9 U//l). She had appropriate treatment but several weeks later she became breathless despite improving thyroid function. Echocardiography showed a pericardial effusion of 2.9 cm. She responded well to steroids and NSAIDs but developed active severe Graves' orbitopathy after early total thyroidectomy. Subject 2: A 28-year-old male developed thyrotoxic symptoms (fT4: 38 pmol/L, fT3: 13.9 pmol/L, TSH <0.01 (for over 6 months) and TRAb: 9.3 U/L). One month after starting carbimazole, he developed acute heart failure (HF) due to severe dilated cardiomyopathy - EF 10-15%. He partially recovered after treatment - EF 28% and had early radioiodine treatment. Subject 3: A 42-year-old woman who had been thyrotoxic for several months (fT4: 54.3; fT3 >46.1; TSH <0.01; TRAb: 4.5) developed atrial fibrillation (AF) and heart failure. Echocardiography showed cardiomegaly - EF 29%. She maintains sinus rhythm following early total thyroidectomy (EF 50%). Significant cardiac complications may occur in previously fit young adults, who have had uncontrolled Graves' disease for weeks to months. Cardiac function recovers in the majority, but early definitive treatment should be discussed to avoid Graves' disease relapse and further cardiac decompensation. LEARNING POINTS: Cardiac complications of Graves' disease are uncommon in young adults without previous cardiac disease. These complications may however occur if Graves' disease had been poorly controlled for several weeks or months prior to presentation. Persistent symptoms after adequate control should alert clinicians to the possibility of cardiac disease. Specific treatment of Graves' disease and appropriate cardiac intervention results in complete recovery in the majority and carries a good prognosis. Early definitive treatment should be offered to them to prevent cardiac decompensation at times of further relapse.

Prevalence of subclinical cardiac abnormalities in patients with metal-on-metal hip replacements.

BACKGROUND: Metal-on-metal (MOM) hip prostheses have a higher failure rate than conventional prostheses and leaching of cobalt and chromium has been linked to cardiomyopathy. We screened MOM subjects to evaluate if cobalt and chromium are related to subclinical cardiac dysfunction. METHODS: A single centre, non-randomised, observational study using echocardiography in 95 patients who had undergone MOM hip prostheses, and 15 age matched controls with non-MOM hip replacement. Serial plasma cobalt and chromium levels were recorded, and data compared by tertiles of cobalt exposure. RESULTS: Indexed left ventricular (LV) end-diastolic and end-systolic volumes (EDVi and ESVi) increased with tertile of cobalt (omnibus p = 0.003 for EDVi and ESVi), as did indexed left atrial (LA) volumes (p = 0.003). MOM subjects had 25% larger EDVi than controls, 32% larger ESVi (40 ml vs. 32 ml, and 15 ml vs. 11 ml, p = 0.003 for both) and 28% larger indexed LA (23 ml vs. 18 ml, p = 0.002). There were no differences in LV systolic or diastolic function, including ejection fraction, tissue velocity and mitral E/e'. Estimated glomerular filtration rate was 18% lower in the highest tertile compared with the lowest (p = 0.01) and correlated inversely with LA volume (r = -0.36, p < 0.001) and LV EDV (r = -0.24, p = 0.02). CONCLUSIONS: No correlations between sensitive measures of systolic or diastolic cardiac function or serum cobalt/chromium levels were observed in this study. However, there was a relationship between increasing left ventricular and left atrial volumes and declining renal function with high cobalt levels which requires further evaluation in MOM patients.

Remote monitoring of cardiovascular disease: great promise, but do not forget the patient!

After more than 20 years, the conflict of interest (COI) movement has failed to substantiate its central claim that interactions between physicians, researchers and the medical products industry cause physicians to make clinical decisions that are adverse to the best interests of their patients. The COI movement's instigators have produced no solid evidence of harm commensurate with their extravagant allegations. At the same time, they have diverted resources away from more worthwhile pursuits, such as basic and applied medical research, clinical care and medical education towards onerous compliance exercises and obtrusive laws. Perhaps worst of all, they have made it respectable to ignore the epistemological foundations of medical science, diverting attention away from the scientific merit of the information presented and focusing it instead on the identity and motives of those who present the information.

A national audit of current cardiac device policies from radiotherapy centres across the UK.

AIMS: The number of patients with cardiac implantable electronic devices (permanent pacemakers and implantable cardioverter defibrillators) undergoing radiotherapy treatment is increasing. The aims of this audit were to establish current UK practice regarding the management of patients with implanted cardiac devices undergoing radiotherapy and to compare this practice with current 'gold standard' evidence-based guidelines. MATERIALS AND METHODS: All UK radiotherapy departments were contacted and asked to provide their current cardiac implantable electronic device policy or to indicate if there was no current policy. A proforma was created to analyse these policies and to compare with current best practice. RESULTS: In total, 47/67 (70%) radiotherapy departments responded and 45 departmental policies were submitted; 31/45 (69%) policies defined the radiotherapy tolerance dose to permanent pacemakers and 14/45 (31%) defined the monitoring procedure for patients in line with current best practice. Only 5/45 (11%) policies defined the radiotherapy tolerance dose to implantable cardioverter defibrillators and 12/45 (27%) defined the monitoring procedure in line with current best practice. CONCLUSION: Most UK cardiac device policies do not reflect current best evidence. Policies are based on research carried out in 1994 by the American Association of Physicists in Medicine. This evidence does not account for advances in cardiac implantable electronic device technology. Further research is urgently needed to establish the effect of radiotherapy on these devices.

Novel Pharmacological Interventions to Maintain Sinus Rhythm after DC Cardioversion.

Despite the availability of potentially curative interventions for atrial fibrillation, there remains an important role for conventional anti-arrhythmic therapy and anti-coagulation combined with direct current cardioversion. Unfortunately, the latter approach is disturbed by high recurrence rates of atrial fibrillation. In recent years, several adjunctive therapies have emerged which may facilitate the maintenance of sinus rhythm. These novel therapies and their potential mechanisms of action are reviewed in this article.

Heart rate deceleration after exercise predicts patients most likely to respond to cardiac resynchronisation therapy.

OBJECTIVE: This study examines the relationship between heart rate recovery following exercise and subsequent response to cardiac resynchronisation therapy (CRT). BACKGROUND: Blunted heart rate recovery is an adverse prognostic marker in heart failure and has been shown to correlate with disease severity. METHODS: 37 patients receiving biventricular pacemakers for conventional indications underwent functional assessments; cardiopulmonary exercise test, 6-min walk test and quality-of-life assessment, together with echo analyses, before and at 3 months following implant. Heart rate deceleration (HRD) gradients were calculated at 30-, 60-, 90- and 120-s intervals following cessation of the baseline exercise test and compared with subsequent markers of response to CRT. Functional response was defined as > or =20% improvement in any two of the three functional assessments, and echo response defined as > or =5% increase in ejection fraction. RESULTS: Functional responders demonstrated steeper HRD gradients than non-responders at 30, 60 and 90 s. Echo responders also demonstrated steeper HRD at 30 and 60 s from the cessation of exercise. Receiver-operating curve analysis demonstrates area under the curve of 0.87 and 0.82, respectively, for HRD30 to predict functional and echo response to CRT. A cut-off value of 3 for HRD30, equating to a 5% reduction in HR between peak exercise and 30 s into recovery, demonstrates the optimal sensitivity/specificity profile to perform this function. CONCLUSIONS: HRD following exercise correlates with functional and echocardiographic response to CRT. Application of this parameter in addition to standard criteria may provide valuable supplementary information in the evaluation of prospective CRT candidates.

Late opening of the infarct related artery: an open or shut case?

Is there a place for the late opening of infarct related arteries, beyond the time window for myocardial salvage?

Infarct zone viability influences ventricular remodelling after late recanalisation of an occluded infarct related artery.

OBJECTIVE: To investigate the influence of infarct zone viability on remodelling after late recanalisation of an occluded infarct related artery. METHODS: A subgroup of 26 volunteers from TOAT (the open artery trial) underwent dobutamine stress cardiovascular magnetic resonance at baseline to assess the amount of viable myocardium present with follow up to assess remodelling at one year. TOAT studied patients with left ventricular dysfunction after anterior myocardial infarction (MI) associated with isolated proximal occlusion of the left anterior descending coronary artery with randomisation to percutaneous coronary intervention (PCI) with stent at 3.6 weeks after MI (PCI group) or to medical treatment alone (medical group). RESULTS: In the PCI group there was a significant relation between the number of viable segments within the infarct zone and improvement in end systolic volume index (-7.7 ml/m2, p = 0.02) and increased ejection fraction (4.1%, p = 0.03). The relation between viability and improvements in end diastolic volume index (-8.8 ml/m2, p = 0.08) and mass index (-6.3 g/m2, p = 0.01) did not reach significance (p = 0.27 and p = 0.8, respectively). In the medical group, there was no significant relation between the number of viable segments in the infarct zone and the subsequent changes in end diastolic (p = 0.84) and end systolic volume indices (p = 0.34), ejection fraction (p = 0.1), and mass index (p = 0.24). CONCLUSION: The extent of viable myocardium in the infarct zone is related to improvements in left ventricular remodelling in patients who undergo late recanalisation of an occluded infarct related artery.

Warfarin for non-rheumatic atrial fibrillation: five year experience in a district general hospital.

OBJECTIVES: To assess the long term efficacy of and risks associated with computer aided oral anticoagulation for non-rheumatic atrial fibrillation (NRAF) in a district hospital setting. DESIGN: Retrospective, age stratified, event driven clinical database analysis. SETTING: District general hospital. PARTICIPANTS: 739 patients receiving warfarin for NRAF between 1996 and 2001. Patients were selected from an anticoagulation database through appropriate filter settings. MAIN OUTCOME MEASURES: Anticoagulation control (international normalised ratio (INR)) and hospitalisations for bleeding complications, thromboembolic events, and stroke. RESULTS: Over 1484 patient-years, computer assisted anticoagulation was uncontrolled in 38.3% of patients (INR < 2.0 or > 3.0). No significant differences in INR control were observed with respect to patient age (< 65, 65-75, and > 75 years), although to achieve adequate control of anticoagulation, the frequency of testing increased significantly with age. Annual risks of bleeding complications, thromboembolism, and stroke were 0.76%, 0.35%, and 0.84%, respectively. No significant differences in these events were observed between the three age groups studied. Patients who had thromboembolic events and haemorrhagic complications were significantly more likely to have been under-anticoagulated (INR < 2.0) and over-anticoagulated (INR > 3.0), respectively, at the time of their clinical event. CONCLUSIONS: Computerised long term oral anticoagulation for NRAF in a community setting of elderly and diverse patients is safe and effective. Anticoagulation control, bleeding events, thromboembolic episodes, and stroke rates are directly comparable with those reported in major clinical trials. The authors therefore support the strategy of rate control with long term oral anticoagulation for NRAF in general clinical practice.

Troponin I, laboratory issues, and clinical outcomes in a district general hospital: crossover study with "traditional" markers of myocardial infarction in a total of 1990 patients.

AIMS: Review of the clinical outcomes and practical issues of replacing traditional cardiac enzymes with troponin I (cTnI) in a district general hospital. METHODS: Crossover study of three sequential three month stages during which serial cardiac enzymes were replaced with a single cTnI measurement available at three set times within 24 hours for the duration of the second three month stage. The study was carried out in a 630 bed district general hospital with 1990 admissions of suspected cardiac ischaemia over the study period as a whole. Account was taken of seasonal factors. RESULTS: The introduction of troponin was associated with 8.5% more patients with non-ischaemic heart disease (IHD) being discharged on the day after admission, saving approximately 107 bed days each year. Approximately 50% more patients were diagnosed with myocardial infarction during the cTnI stage. There was no increase in readmission within one month or early death with cTnI. Approximately 3% false positive and 1.5% false negative cTnI results were recorded. All false positive cTnI results were coding errors or attributable to known assay interference effects. All false negatives were potentially explained by sample timing factors. The lack of standardisation in troponin assay services impacts clinically. CONCLUSION: Younger patients without IHD were discharged earlier during the cTnI stage in apparent safety. Blood sample timing needs to be verified when cTnI is used as an adjunct to early discharge. There were no unexplained false positives or negatives. Standardisation related issues arose.

Pancreatic injury: an audit and a practical approach.

Pancreatic injuries are uncommon, difficult to diagnose and there is no uniform standard for treatment. The purpose of this study was to audit the management of pancreatic injuries in our practice. Equally important is to attempt to find out a simple management plan particularly in the era of increasing conservative treatment of injured patients. There were 22 cases of pancreatic injury. The average Glasgow coma scale of 10.9 and injury severity score of 29.1. When computed tomography is used it has a sensitivity of 33.3% which became 100% if repeated or other injuries were identified. There was one case in grade I which was treated non-operatively. There were 15 patients in grade II and they were treated by drainage. Distal pancreatectomy and splenectomy was the treatment of 3 patients with grade III injury. One patient had pancreatico-jejunostomy for grade IV injury and subsequently developed pancreatic fistula. Pancreaticoduodenectomy was the treatment of choice for two patients with grade V and both subsequently died. The over all mortality of this series was 22.7% and intra-abdominal abscesses noted in 9.1%. This series indicated that there is a need to adopt 'bail out' procedures particularly in grade IV and V pancreatic injury. A simplified management plan is suggested.

Postinfarction left ventricular remodeling: a pathophysiological and therapeutic review.

Over the last 50 years, studies investigating the pathogenesis of left ventricular dysfunction have resulted in many potential therapeutic targets being identified and novel classes of drugs designed to treat this condition. Despite this, the long-term prognosis of patients with clinical heart failure remains poor with mortality rates equivalent to many terminal malignancies. This article reviews our present understanding of the pathophysiology of post-infarction left ventricular dysfunction and provides a rationale for current drug usage, drugs undergoing clinical trials and compounds still under pre-clinical development. In addition, the complexities involved in deciphering intra-cellular signalling pathways mediating ventricular hypertrophy which may form the basis of future treatments are also discussed.

The open artery hypothesis: potential mechanisms of action.

The postinfarction period is one of intense dynamic activity because the cardiovascular system undergoes a number of adaptive responses attempting to maintain cardiac output. These homeostatic responses contribute to the processes involved in postinfarction ventricular remodeling and involve acute, chronic, systemic, and local reactions. Almost immediately, neurohormones are activated that alter hemodynamic load, and, later, stimulate myocyte hypertrophy, while locally, inflammatory processes clear necrotic debris, reorganize the extracellular matrix, and orchestrate scar formation. Where the initial cardiac insult is sufficiently large (eg, necrosis of more than 40% of left ventricular mass), remodeling responses are exaggerated and may become maladaptive, contributing to the poor long-term prognosis associated with myocardial infarction. Although several studies have shown clear benefits after neurohormonal modulation and/or manipulation of ventricular loading forces in the postinfarction setting, relatively few studies have investigated the potential merits of a patent infarct-related artery during postinfarction ventricular remodeling. In particular, the salutary effects of late revascularization of previously occluded vessels remains controversial. Thus, though this issue remains speculative, our present practice must be governed by circumstantial evidence and hypothetical arguments. This article discusses the potential mechanisms whereby late reperfusion of an infarcted myocardial region may benefit long-term prognosis.

The effects of time delay and temperature on capillary blood gas measurements.

Monitoring of blood gas measurements is an important part of the assessment of patients with chronic lung disease. Increasingly, this is being done in the patients' homes by specialist nurses. This makes it important to know the effect of time delay and storage temperature on the reliability of capillary blood gas analysis results. In this study, the effect of a delay of 1 and 2 h and of storage at both room temperature and in ice, on blood stored in glass capillary tubes was investigated. Samples, initially taken from the earlobes, were transferred to glass capillary tubes and used to provide duplicate initial samples for immediate analysis, and then single samples at 1 and 2 h stored at room temperature or in ice. The duplicate baseline measurements showed good reproducibility. There was a small, but statistically significant, increase in PCO2 when samples were stored in capillaries at room temperature, or in ice, both at 1 and 2 h. Small changes in PO2 were not statistically significant, either in ice or at room temperature. None of the changes was considered to be sufficient to be of clinical significance, thus supporting the use of capillary blood sampling even when there might be a delay of 1-2 h and transport is at room temperature, as might be the case when taking domiciliary samples.