Non-surgical management of hip and knee osteoarthritis; comparison of ACR/AF and OARSI 2019 and VA/DoD 2020 guidelines.

Background and objectives: Osteoarthritis (OA) is the most common form of arthritis and is associated with significant morbidity and mortality. There are several available recently updated guidelines for the management of hip and knee OA. Herein, we describe the similarities and differences among the 2019 American College of Rheumatology/Arthritis Foundation (ACR/AF), the 2019 Osteoarthritis Research Society International (OARSI), and the 2020 Veterans Affairs and Department of Defense (VA/DoD) treatment guidelines. Results: In all the three guidelines, patient education, weight loss encouragement for overweight patients, exercise, and self-efficacy and self-management programs were considered core treatments for hip and knee OA. Topical NSAIDs are strongly recommended for knee OA, oral NSAIDs and intraarticular steroid injections are also recommended among all three guidelines. The ACR/AF and VA/DoD recommend the use of paracetamol and topical capsaicin in contrast to the OARSI guidelines. Intra-articular hyaluronic acid is not recommended by the ACR/AF in contrast to the OARSI and VA/DoD. Another difference is the use of tramadol in patients with persistent knee or hip OA pain, which is recommended by ACR/AF as opposed to VA/DoD and OARSI who recommend against the use of opioid analgesics without exceptions. Conclusion: All three guidelines are mostly consistent in their recommendations.

Musculoskeletal System and Connective Tissue Related Hospital Admission in England and Wales Between 1999 and 2019: An Ecologic Study.

Background There is a lack of data describing inpatient hospitalization trends for musculoskeletal and connective tissue diseases in the United Kingdom. Aim We aim to provide a comprehensive analysis of the trends of musculoskeletal and connective tissue disease related hospitalizations between 1999 and 2019 in England and Wales. Method We conducted an ecologic study. The data were obtained from the Hospital Episode Statistics database in England and the Patient Episode Database in Wales between 1999 and 2019. We used ICD-10 (International Classification of Diseases, 10th Revision) codes M00-M99 to identify hospital admissions. Results The total annual hospital admission rate increased from 1,303.63 (95% CI: 1,300.55-1,306.71) in 1999 to 2,479.09 (95% CI: 2,475.14-2,483.04) in 2019 per 100,000 persons (p<0.01). The ICD-10 categories other joint disorders, osteoarthritis, and other dorsopathies accounted for 19.6%, 19.6%, and 18.6% of hospitalizations, respectively. Advanced age groups experienced a larger increase in hospitalization rates (128.6% in the age group of 75 years and above vs. 45.9% in the age group below 15 years). Females contributed to 57.7% of hospitalizations and experienced a larger increase in hospitalization rate compared to males (103.8% vs. 73.8%). Conclusion Between 1999 and 2009, the hospitalization rate for musculoskeletal and connective tissue diseases has steadily increased in England and Wales. However, the rate has plateaued or declined in many of musculoskeletal and connective tissue diseases between 2010 and 2019. Due to the chronicity of these diseases, their significant morbidity, and significant long-term disability, national interventions are needed to mitigate the effects of the increased cost of treatment.

Bilateral Retinal Vasculitis as the First Presentation of Systemic Lupus Erythematosus.

BACKGROUND Systemic lupus erythematosus (SLE) can involve any part of the eye. Keratoconjunctivitis sicca (dry eye) is the most common ocular manifestation, followed by scleritis, episcleritis, and retinitis. Retinal disease affects around 10% of patients with SLE. Mild retinopathy may be asymptomatic. However, severe cases can cause visual loss requiring urgent ophthalmic evaluation. CASE REPORT We present a case of bilateral retinal vasculitis as the presenting manifestation of SLE. A 14-year-old girl with a history of schizophrenia presented to the emergency department (ED) with generalized weakness. Four days before her presentation, she developed itching in her eyes and frontal headaches. In the ED, she reported blurry vision in her left eye only and diffuse arthralgia. The ophthalmic evaluation showed bilateral reduced visual acuity, worse in the left eye. Both eyes had diffuse hemorrhages, white retinal lesions, and blurred optic disc margins. She was diagnosed with panuveitis and retinal vasculitis. The patient was then found to have SLE, diagnosed by the presence of arthralgias, panuveitis, severe bilateral retinal vasculitis, positive ANA and anti-dsDNA, and normocytic anemia. The patient received intravenous methylprednisolone with subsequent oral prednisone upon discharge, hydroxychloroquine, and azathioprine. One year after her presentation, she had significant visual improvement and no other system involvement. CONCLUSIONS Retinal vasculitis, as the presenting symptom of SLE, has been overlooked in large studies. However, the number of case reports documenting this as a presenting symptom, often with minimal or no organ involvement, suggests that upon diagnosis, patients might benefit from a skilled ophthalmic evaluation.

Recurrent Syncope Due to Concurrent Cardiac Sarcoidosis and Large-Vessel Vasculitis.

BACKGROUND Cardiac sarcoidosis and large-vessel vasculitis are both rare diseases with a variety of presenting symptoms. Both can result in high morbidity and mortality if not diagnosed early. While they are each relatively uncommon on their own, there have been a few reports suggesting they may be more related than previously thought. This case report suggests that the 2 diseases can become symptomatic concurrently, complicating diagnosis. CASE REPORT A 68-year-old male patient was diagnosed concurrently with cardiac sarcoidosis and vasculitis after several episodes of syncope thought to be due to arrhythmia. The patient was treated with high-dose corticosteroids, and repeat imaging showed decreased inflammatory changes in the cardiac tissue and large blood vessels. CONCLUSIONS Prior case reports have described vasculitis and sarcoidosis in the same patient; however, these patients usually had a long history of known sarcoidosis involving several organ systems. This case suggests that physicians should be alert to more limited forms of the disease in a patient with cardiac myopathy of unknown origin with new arrythmia. More research is also needed to determine how granulomatous disease and vasculitis are related to each other.

Hospitalization and Post-hospitalization Outcomes Among Teaching Internal Medicine, Employed Hospitalist, and Locum Tenens Hospitalist Services in a Tertiary Center: a Prospective Cohort Study.

BACKGROUND: There are no prospective studies comparing hospitalization and post-hospitalization outcomes between teaching internal medicine services and non-teaching hospitalists, and no prospective studies comparing these outcomes between locum and employed hospitalists. OBJECTIVE: To compare the length of stay, hospital costs readmission rate, and mortality rate in patients treated by teaching internal medicine services vs. hospitalists and among patients treated by locum vs. employed hospitalists. DESIGN: Prospective cohort study. Propensity score was used to obtain weighted estimates. SETTING: Referral center. PATIENTS: All patients 18 years and older admitted to internal medicine services. INTERVENTION: Treatment by teaching internal medicine services vs. hospitalists. Treatment by locum hospitalists vs. employed hospitalists. MAIN MEASURES: Primary outcome was adjusted length of stay and secondary outcomes included hospital cost, inpatient mortality, 30-day all-cause readmission, and 30-day mortality. KEY RESULTS: A total of 1273 patients were admitted in the study period. The mean patient age was 61 ± 19 years, and the sample was 52% females. Teaching internal medicine physicians admitted 526 patients and non-teaching hospitalists admitted 747 patients. Being seen exclusively by teaching internal medicine physicians comports with a shorter adjusted hospital stay by 0.6 days (95% CI - 1.07 to - 0.22, P = .003) compared to non-teaching hospitalists. Adjusted length of stay was 1 day shorter in patients seen exclusively by locums compared to patients seen exclusively by employed services (95% CI - 1.6 to - 0.43, P < .001) with an adjusted average hospital cost saving of 1339 dollars (95% CI - 2037 to - 642, P < .001). There was no statistically significant difference in other outcomes. CONCLUSIONS: Teaching internal medicine services care was associated with a shorter stay but not with increased costs, readmission, or mortality compared to non-teaching services. In contrary to the "expected," patients treated by locums had shorter stays and decreased hospital costs but no increase in readmissions or mortality.

Lorecivivint, an intra-articular potential disease-modifying osteoarthritis drug.

Introduction: Osteoarthritis (OA) is the most common form of arthritis. Knee OA is associated with joint pain, activity limitation, physical disability, reduced health-related quality of life, and increased mortality. To date, all pharmacologic treatments for OA are directed toward pain management. Lorecivivint (LOR) is an investigational agent that has potential as a disease-modifying osteoarthritis drug (DMOAD). It modulates the Wnt signaling pathway by inhibiting CDC-like kinase 2 and dual-specificity tyrosine phosphorylation-regulated kinase 1 A which are molecular regulators in Wnt signaling, chondrogenesis, and inflammation. Areas covered: This paper discusses the current pharmacologic guidelines for the treatment of knee OA and illuminates the potential of a new agent, Lorecivivint, as a disease-modifying osteoarthritis drug (DMOAD). Efficacy and safety and the challenges for this novel agent come under the spotlight. Expert opinion: LOR may be a potential DMOAD for the treatment of patients with knee OA. While the Phase 2A trial did not meet its primary endpoint, preplanned analyses did identify a target population for further evaluation of its potential as a DMOAD. Phase 3 trials are ongoing, but this intra-articular drug is currently considered safe and well tolerated, with no significant reported systemic side effects.

Successful treatment of antisynthetase syndrome presenting as rhabdomyolysis with rituximab.

Rhabdomyolysis is a syndrome of muscle necrosis with subsequent release of intracellular content into the blood. There are various causes for rhabdomyolysis that include trauma, medications and rarely autoimmune conditions such as autoimmune myositis. Antisynthetase syndrome is an autoimmune condition characterized by positive antisynthetase antibody, myopathy, lung disease and arthritis. To our knowledge, rhabdomyolysis in antisynthetase syndrome has not been reported in the literature. In this report, we present a patient who presented with features of rhabdomyolysis and was diagnosed with antisynthetase syndrome. This patient was treated with systemic steroids with partial improvement, followed by rituximab, which led to significant improvement in his condition. In addition, we summarize all cases reported in the literature of inflammatory myopathy-associated rhabdomyolysis.

Tendonitis and Tendon Rupture After Treatment With Rituximab: A Case Series.

CLINICAL DATA: Rituximab is a mouse/human chimeric anti-CD20 IgG1 monoclonal antibody used to treat cancer and autoimmune conditions. Side effects of rituximab include fever, rash, cytopenia and hypotension, back pain, arthralgia, and myalgia. Here, we report on 3 patients who developed moderate to severe tendonitis after the second infusion of rituximab. THERAPEUTIC CHALLENGE: We report 3 patients who developed tendonitis after the second infusion of rituximab. These patients were undergoing treatment for connective tissue diseases. All 3 patients received 2 rituximab infusions, 2 weeks apart. The 3 cases developed clinical tendonitis that was confirmed by magnetic resonance imaging in 2 cases. INTERPRETATION: This is the first case series reporting new onset tendonitis in patients with connective tissue diseases after rituximab therapy. All 3 cases developed tendonitis 1 week after receiving the second dose of rituximab. Clinical features of tendonitis resolved 3-4 months in all cases. The underlying pathogenic mechanism by which rituximab causes tendonitis is not clear, but tendonitis and tendon rupture have been reported after using other medications such as quinolones. The tendon damage was progressive leading to tendon rupture in 1 patient, highlighting the importance of early recognition. It is plausible that there is a cause-effect relation between tendonitis and administration of rituximab in our 3 cases, since none of these cases had previous history of tendonitis; however, more data are needed to confirm this observation.

Type-B lactic acidosis associated with progressive multiple myeloma.

We report a 64-year-old lady with stage II, Immunoglobulin-G lambda multiple myeloma (MM) (standard risk), who presented with type-B lactic acidosis (LA), and multi-organ dysfunction associating myeloma progression, and ending in imminent death. In the context of literature review of all previously reported similar cases, this report highlights and discusses the association of type-B LA and MM (especially progressive disease), and also emphasizes the poor outcome. Early recognition of this condition with intensive supportive care, and treatment of multiple myeloma may improve outcomes. 

Spontaneous subdural hematoma in a patient with Philadelphia chromosome-positive acute lymphoblastic leukemia with normal platelet count after dasatinib treatment.

Dasatinib, which is an inhibitor of BCR-ABL and SRC family tyrosine kinases, is used for the treatment of patients with Philadelphia chromosome (Ph) positive leukemia, especially for those who develop resistance or who are intolerant to imatinib. The most common adverse effects attributed to its use are: myelosuppression, nausea, diarrhea, and peripheral edema. Hemorrhage, which could be gastrointestinal, genitourinary or central nervous system, is a less frequent adverse effect. In this case, we report a patient affected by precursor B-cell acute lymphoblastic leukemia (ALL) positive for the Ph chromosome translocation treated with the tyrosine kinase inhibitor (TKI) dasatinib. During the treatment with dasatinib the patient developed subdural hematoma (SDH). She did not have any head trauma, thrombocytopenia, coagulopathy or meningeal involvement, making dasatinib-induced platelet dysfunction the most likely cause of SDH.