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1.
J Clin Rheumatol ; 26(1): 24-32, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30273264

RESUMO

BACKGROUND/OBJECTIVE: Immunostimulatory drugs including immune checkpoint inhibitors and levamisole can induce inflammatory disease including vasculitis, rashes, tissue necrosis, and arthritis. METHODS: This prospective cohort study determined the 5-year outcomes of cocaine-levamisole-induced inflammatory disease as to outcomes and survival. Thirty-one consecutive cocaine-levamisole autoimmune patients and 45 primary vasculitis patients were characterized as to clinical differentiating features, antineutrophil cytoplasmic antibody (ANCA) status, treatment, the presence of acute and chronic arthritis, and 5-year outcome. RESULTS: Seventy-one percent (22/31) of cocaine-levamisole vasculopathy cases were ANCA positive (86% p-ANCA and 14% c-ANCA), whereas 53% (23/45) of the primary vasculitis were ANCA positive (p = 0.04). The ANCA-positive cocaine-levamisole cohort at onset were characterized by younger age (45 ± 12 vs 53 ± 14 years, p = 0.04), superficial skin necrosis (82% vs 54%, p = 0.036), depressed complement C3 (27% vs 4%, p = 0.33), antiphospholipid antibodies (50% vs 4%, p < 0.001), neutropenia (18% vs 0%, p = 0.044), and elevated antimyeloperoxidase (MPO) antibody levels (100% vs 67%, p < 0.001). Chronic cocaine-levamisole disease was characterized by severe cicatrical deformities of the face and extremities (45.5% vs 8.3%, p = 0.005). Arthralgias (71% vs 82%, p = 0.19) and acute arthritis (33% vs 32%, p = 0.25) were similar between the 2 groups. However, a substantial proportion cocaine-levamisole-induced autoimmune patients (18% vs 0%, p = 0.045) developed a chronic deforming inflammatory arthritis that was rheumatoid factor, anti-cyclic-citrillinated antibody antibody, and HLA-B27 negative, but p-ANCA-and MPO antibody positive. CONCLUSIONS: Patients exposed to cocaine-levamisole may develop serious chronic sequelae including cicatrical cutaneous and facial deformities and an atypical seronegative, p-ANCA and MPO antibody-positive, HLA-B27-negative chronic deforming inflammatory arthritis.


Assuntos
Vasculite Associada a Anticorpo Anticitoplasma de Neutrófilos/imunologia , Anticorpos Anticitoplasma de Neutrófilos/imunologia , Artrite/induzido quimicamente , Cocaína/efeitos adversos , Levamisol/efeitos adversos , Adulto , Fatores Etários , Idoso , Vasculite Associada a Anticorpo Anticitoplasma de Neutrófilos/epidemiologia , Artralgia/induzido quimicamente , Artralgia/epidemiologia , Artralgia/fisiopatologia , Artrite/imunologia , Doença Crônica , Estudos de Coortes , Feminino , Deformidades Adquiridas da Mão/diagnóstico , Deformidades Adquiridas da Mão/epidemiologia , Hospitais Universitários , Humanos , Masculino , Pessoa de Meia-Idade , New Mexico , Prevalência , Prognóstico , Estudos Prospectivos , Medição de Risco , Índice de Gravidade de Doença , Fatores Sexuais
2.
Rheumatol Int ; 39(9): 1643-1650, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31134290

RESUMO

Rickettsia rickettsii, a tick borne disease, is the pathogen responsible for inducing Rocky Mountain Spotted Fever (RMSF), an illness that can progress to fulminant multiorgan failure and death. We present a case where R. rickettsii, acquired on a camping trip, precipitated a flare of peripheral arthritis and episcleritis in an HLA-B27 positive patient. Although Yersinia, Salmonella, Mycobacteria, Chlamydia, Shigella, Campylobacter, and Brucella have been previously associated with HLA-B27 spondyloarthritis, this unusual case demonstrates that obligate intracellular rickettsial organisms, and specifically, R. rickettsii, can also induce flares of HLA-B27 spondyloarthritis. Rickettsial infections in general can rapidly become fatal in both healthy and immunosuppressed patients, and thus, prompt diagnosis and therapy are required.


Assuntos
Certolizumab Pegol/administração & dosagem , Antígeno HLA-B27/imunologia , Hospedeiro Imunocomprometido , Rickettsia rickettsii/imunologia , Espondilartrite/tratamento farmacológico , Rickettsiose do Grupo da Febre Maculosa/microbiologia , Inibidores do Fator de Necrose Tumoral/administração & dosagem , Antibacterianos/administração & dosagem , Progressão da Doença , Doxiciclina/administração & dosagem , Feminino , Antígeno HLA-B27/genética , Humanos , Pessoa de Meia-Idade , Rickettsia rickettsii/efeitos dos fármacos , Espondilartrite/diagnóstico , Espondilartrite/genética , Espondilartrite/imunologia , Rickettsiose do Grupo da Febre Maculosa/diagnóstico , Rickettsiose do Grupo da Febre Maculosa/tratamento farmacológico , Rickettsiose do Grupo da Febre Maculosa/imunologia , Resultado do Tratamento
3.
Rheumatol Int ; 38(3): 393-401, 2018 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29353388

RESUMO

We hypothesized that ultrasound (US) guidance improves outcomes of corticosteroid injection of trochanteric bursitis. 40 patients with greater trochanteric pain syndrome defined by pain to palpation over the trochanteric bursa were randomized to injection with 5 ml of 1% lidocaine and 80 mg of methylprednisolone using (1) conventional anatomic landmark palpation guidance or (2) US guidance. Procedural pain (Visual Analogue Pain Scale), pain at outcome (2 weeks and 6 months), therapeutic duration, time-to-next intervention, and costs were determined. There were no complications in either group. Ultrasonography demonstrated that at least a 2-in (50.8 mm) needle was required to consistently reach the trochanteric bursa. Pain scores were similar at 2 weeks: US: 1.3 ± 1.9 cm; landmark: 2.2 ± 2.5 cm, 95% CI of difference: - 0.7 < 0.9 < 2.5, p = 0.14. At 6 months, US was superior: US: 3.9 ± 2.0 cm; landmark: 5.5 ± 2.6 cm, 95% CI of difference: 0.8 < 1.6 < 2.4, p = 0.036. However, therapeutic duration (US 4.7 ± 1.4 months; landmark 4.1 ± 2.9 months, 95% CI of difference - 2.2 < - 0.6 < 1.0, p = 0.48), and time-to-next intervention (US 8.7 ± 2.9 months; landmark 8.3 ± 3.8 months, 95% CI of difference - 2.8 < - 0.4 < 2.0, p = 0.62) were similar. Costs/patient/year was 43% greater with US (US $297 ± 99, landmark $207 ± 95; p = 0.017). US-guided and anatomic landmark injection of the trochanteric bursa have similar 2-week and 6-month outcomes; however, US guidance is considerably more expensive and less cost-effective. Anatomic landmark-guided injection remains the method of choice, but should be routinely performed using a sufficiently long needle [at least a 2 in (50.8 mm)]. US guidance should be reserved for extreme obesity or injection failure.


Assuntos
Anestésicos Locais/administração & dosagem , Anestésicos Locais/economia , Bolsa Sinovial/efeitos dos fármacos , Bursite/tratamento farmacológico , Bursite/economia , Custos de Medicamentos , Glucocorticoides/administração & dosagem , Glucocorticoides/economia , Lidocaína/administração & dosagem , Lidocaína/economia , Metilprednisolona/administração & dosagem , Metilprednisolona/economia , Ultrassonografia de Intervenção/economia , Adulto , Idoso , Pontos de Referência Anatômicos , Anestésicos Locais/efeitos adversos , Bolsa Sinovial/diagnóstico por imagem , Bolsa Sinovial/fisiopatologia , Bursite/diagnóstico por imagem , Bursite/fisiopatologia , Análise Custo-Benefício , Desenho de Equipamento , Feminino , Fêmur , Glucocorticoides/efeitos adversos , Humanos , Injeções Intralesionais , Lidocaína/efeitos adversos , Masculino , Metilprednisolona/efeitos adversos , Pessoa de Meia-Idade , Agulhas/economia , Medição da Dor , Palpação/economia , Dados Preliminares , Fatores de Tempo , Resultado do Tratamento , Ultrassonografia de Intervenção/efeitos adversos , Estados Unidos
4.
J Clin Rheumatol ; 24(6): 295-301, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-29424762

RESUMO

BACKGROUND/OBJECTIVE: The objective of this study was to determine whether the extended or flexed knee positioning was superior for arthrocentesis and whether the flexed knee positioning could be improved by mechanical compression. METHODS: Fifty-five clinically effusive knees underwent arthrocentesis in a quality improvement intervention: 20 consecutive knees in the extended knee position using the superolateral approach, followed by 35 consecutive knees in the flexed knee position with and without an external compression brace placed on the suprapatellar bursa. Arthrocentesis success and fluid yield in milliliters were measured. RESULTS: Fluid yield for the extended knee was greater (191% greater) than the flexed knee (extended knee, 16.9 ± 15.7 mL; flexed knee, 5.8 ± 6.3 mL; P < 0.007). Successful diagnostic arthrocentesis (≥2 mL) was 95% (19/20) in the extended knee and 77% (27/35) in the flexed knee (P = 0.08). After mechanical compression was applied to the suprapatellar bursa and patellofemoral joint of the flexed knee, fluid yields were essentially identical (extended knee, 16.9 ± 15.7 mL; flexed knee, 16.7 ± 11.3 mL; P = 0.73), as were successful diagnostic arthrocentesis (≥2 mL) (extended knee 95% vs. flexed knee 100%, P = 0.12). CONCLUSIONS: The extended knee superolateral approach is superior to the flexed knee for conventional arthrocentesis; however, the extended knee positioning and flexed knee positioning have identical arthrocentesis success when mechanical compression is applied to the superior knee. This new flexed knee technique for arthrocentesis is a useful alternative for patients who are in wheelchairs, have flexion contractures, cannot be supine, or cannot otherwise extend their knee.


Assuntos
Artrocentese , Articulação do Joelho/cirurgia , Osteoartrite do Joelho , Dor Processual , Posicionamento do Paciente/métodos , Idoso , Artrocentese/efeitos adversos , Artrocentese/métodos , Feminino , Humanos , Articulação do Joelho/fisiopatologia , Masculino , Pessoa de Meia-Idade , Osteoartrite do Joelho/diagnóstico , Osteoartrite do Joelho/fisiopatologia , Osteoartrite do Joelho/cirurgia , Avaliação de Resultados em Cuidados de Saúde , Dor Processual/diagnóstico , Dor Processual/prevenção & controle , Melhoria de Qualidade
5.
Rheumatol Int ; 32(2): 513-8, 2012 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-21253739

RESUMO

Although intraarticular injections are important to the management of rheumatoid arthritis, there are few studies regarding the cost-effectiveness of alternative injection techniques. This randomized controlled study addressed the cost-effectiveness of two different low-cost, anatomic landmark palpation-directed intraarticular injection techniques. Ninety-six symptomatic rheumatoid knees were randomized to two different low-cost, palpation-guided intraarticular injection techniques utilizing (1) a conventional syringe or (2) a mechanical syringe, the RPD (the reciprocating procedure device). Three milliliters of 1% lidocaine were used to anesthetize the synovial membrane, followed by arthrocentesis and hydrodissection, and injection of 80 mg of triamcinolone acetonide utilizing the one-needle two-syringe technique. Baseline pain, procedural pain, aspirated fluid volume, pain at outcome (2 weeks and 6 months), responders, reinjection rates, cost/patient/year, and cost/responder/year were determined. Pain was measured with the 10 cm Visual Analogue Pain Scale (VAS). Both techniques significantly reduced pain scores at outcome from baseline (P < 0.001). The mechanical syringe technique resulted in a greater volume of aspirated fluid (P < 0.01), a 38% reduction in procedural pain (P < 0.001), a 24% reduction in pain scores at outcome (P < 0.03), an increase in the responder rate (P < 0.025), 33% increase in the time to next injection (P < 0.001), 23% ($35 US) reduction in cost/patient/year for a patient treated in a physician office (P < 0.001), 24% reduction ($26 US) in cost/patient/year for a hospital outpatient (P < 0.001), and 51% ($151 US) reduction in cost/responder/year (P < 0.001). The outcomes and cost-effectiveness of intraarticular injection of the rheumatoid knee can be improved significantly with low-cost alternations in technique.


Assuntos
Artralgia/tratamento farmacológico , Artrite Reumatoide/tratamento farmacológico , Adulto , Idoso , Anti-Inflamatórios/administração & dosagem , Anti-Inflamatórios/economia , Artralgia/economia , Artralgia/etiologia , Artrite Reumatoide/complicações , Artrite Reumatoide/economia , Análise Custo-Benefício/economia , Análise Custo-Benefício/tendências , Feminino , Humanos , Injeções Intra-Articulares/economia , Injeções Intra-Articulares/métodos , Injeções Intra-Articulares/tendências , Masculino , Pessoa de Meia-Idade , Triancinolona/administração & dosagem , Triancinolona/economia
6.
Hepatology ; 52(3): 1124-33, 2010 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-20607688

RESUMO

The Extension for Community Healthcare Outcomes (ECHO) Model was developed by the University of New Mexico Health Sciences Center as a platform to deliver complex specialty medical care to underserved populations through an innovative educational model of team-based interdisciplinary development. Using state-of-the-art telehealth technology, best practice protocols, and case-based learning, ECHO trains and supports primary care providers to develop knowledge and self-efficacy on a variety of diseases. As a result, they can deliver best practice care for complex health conditions in communities where specialty care is unavailable. ECHO was first developed for the management of hepatitis C virus (HCV), optimal management of which requires consultation with multidisciplinary experts in medical specialties, mental health, and substance abuse. Few practitioners, particularly in rural and underserved areas, have the knowledge to manage its emerging treatment options, side effects, drug toxicities, and treatment-induced depression. In addition, data were obtained from observation of ECHO weekly clinics and database of ECHO clinic participation and patient presentations by clinical provider. Evaluation of the ECHO program incorporates an annual survey integrated into the ECHO annual meeting and routine surveys of community providers about workplace learning, personal and professional experiences, systems and environmental factors associated with professional practice, self-efficacy, facilitators, and barriers to ECHO. The initial survey data show a significant improvement in provider knowledge, self-efficacy, and professional satisfaction through participation in ECHO HCV clinics. Clinicians reported a moderate to major benefit from participation. We conclude that ECHO expands access to best practice care for underserved populations, builds communities of practice to enhance professional development and satisfaction of primary care clinicians, and expands sustainable capacity for care by building local centers of excellence.


Assuntos
Serviços de Saúde Comunitária/tendências , Acessibilidade aos Serviços de Saúde/tendências , Hepatite C/tratamento farmacológico , Avaliação de Resultados em Cuidados de Saúde , Coleta de Dados , Hepatite C/psicologia , Humanos , New Mexico , Participação do Paciente , Médicos de Família , Prisões , População Rural
7.
Arthritis Rheum ; 62(7): 2055-63, 2010 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-20309864

RESUMO

OBJECTIVE: To determine the histopathologic basis of altered brain neurometabolites in neuropsychiatric systemic lupus erythematosus (NPSLE). METHODS: Brain neurometabolite concentrations in a 20-voxel area of the brain were determined premortem by magnetic resonance spectroscopy (MRS) in 7 individuals with NPSLE. Absolute concentrations of neurometabolite for N-acetylaspartate (NAA), choline, creatine, and lactate were measured. After the death of the patients, histopathologic changes were determined at autopsy of the brain and were matched voxel-by-voxel with the neurometabolites. RESULTS: The mean +/- SD absolute concentrations of NAA (9.15 +/- 1.78 mM in patients versus 12.2 +/- 0.8 mM in controls; P < 0.01) and creatine (6.43 +/- 0.16 mM in patients versus 6.90 +/- 0.60 mM in controls; P < 0.003) were significantly reduced and the concentration of choline (2.51 +/- 0.42 mM in patients versus 1.92 +/- 0.32 mM in controls; P < 0.04) was significantly elevated in NPSLE patients as compared with controls. Widespread heterogeneous changes in the histologic features of the brain were present, including microinfarcts, microhemorrhages, bland angiopathy, thrombotic angiopathy with platelet and fibrin thrombi, neuronal necrosis in various states of resolution, reduced numbers of axons and neurons, vacuole and space formation among the fibers, reduced numbers of oligodendrocytes, reactive microglia and astrocytes, lipid-laden macrophages, and cyst formation. Neurometabolite abnormalities were closely associated with underlying histopathologic changes in the brain: 1) elevated choline levels were independently associated with gliosis, vasculopathy, and edema (r = 0.75, P < 0.004 in the multivariate model); 2) reduced creatine levels with reduced neuronal-axonal density and gliosis (r = 0.72, P < 0.002 in the multivariate model); 3) reduced NAA levels with reduced neuronal-axonal density (r = 0.66, P < 0.001 in the multivariate model); and 4) the presence of lactate with necrosis, microhemorrhages, and edema (r = 0.996, P < 0.0001 in the multivariate model). CONCLUSION: Altered neurometabolites in NPSLE patients, as determined by MRS, are a grave prognostic sign, indicating serious underlying histologic brain injury.


Assuntos
Biomarcadores/metabolismo , Encéfalo/patologia , Vasculite Associada ao Lúpus do Sistema Nervoso Central/patologia , Adulto , Ácido Aspártico/análogos & derivados , Ácido Aspártico/metabolismo , Encéfalo/metabolismo , Colina/metabolismo , Creatina/metabolismo , Evolução Fatal , Feminino , Nível de Saúde , Humanos , Ácido Láctico/metabolismo , Vasculite Associada ao Lúpus do Sistema Nervoso Central/metabolismo , Vasculite Associada ao Lúpus do Sistema Nervoso Central/fisiopatologia , Espectroscopia de Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Prognóstico , Índice de Gravidade de Doença , Adulto Jovem
8.
J Clin Rheumatol ; 17(4): 173-8, 2011 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-21617556

RESUMO

PURPOSE: Injections into the palmar hand for trigger finger, palmar flexor tenosynovitis, and Dupuytren contracture can be very painful. This randomized, controlled study evaluated nerve block anesthesia at the wrist for prevention of procedural pain associated with painful injection of the palmar hand. METHODS: Forty-seven corticosteroid injections for trigger fingers in 19 individuals were randomized to (1) anesthesia consisting of median and ulnar nerve block with 1% lidocaine anesthesia followed by standard injection or (2) standard injection alone using the 1-needle 2-syringe technique consisting of transthecal dilation of the synovial sheath with 0.5 mL 1% lidocaine with a mechanical syringe, the reciprocating procedure device, followed by injection with 20 mg triamcinolone acetonide. Baseline pain, needle insertion/sheath dilation pain, corticosteroid injection pain, resolution of trigger finger, and pain at outcome (2 weeks) were determined. RESULTS: Standard injection for trigger finger was associated with significant pain in 100% of subjects. Nerve blocks at the wrist provided effective anesthesia, resulting in a 56% reduction in injection pain compared with direct injection (P < 0.01). There was 100% resolution of trigger finger in both treatment groups. Pain at the 2-week outcome, reduction in pain from baseline, responders, and nonresponders were not statistically different (P > 0.3 for all). Eighty-eight percent of subjects preferred nerve block anesthesia to direct injection (P < 0.0001). CONCLUSIONS: Nerve block anesthesia at the wrist before palmar injection is preferred by patients and is highly effective in preventing pain associated with injection of the palmar hand for trigger finger and other painful hand procedures.


Assuntos
Corticosteroides/administração & dosagem , Anestésicos Locais/uso terapêutico , Mãos , Injeções/efeitos adversos , Bloqueio Nervoso/métodos , Dor/prevenção & controle , Articulação do Punho/inervação , Corticosteroides/uso terapêutico , Adulto , Anestésicos Locais/administração & dosagem , Contratura de Dupuytren/tratamento farmacológico , Feminino , Humanos , Injeções Intra-Articulares , Lidocaína/administração & dosagem , Lidocaína/uso terapêutico , Pessoa de Meia-Idade , Bloqueio Nervoso/efeitos adversos , Dor/etiologia , Tenossinovite/tratamento farmacológico , Resultado do Tratamento , Triancinolona/administração & dosagem , Triancinolona/uso terapêutico , Dedo em Gatilho/tratamento farmacológico
9.
J Clin Rheumatol ; 17(8): 409-15, 2011 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-22089991

RESUMO

OBJECTIVE: The present randomized controlled study investigated whether sonographic needle guidance affected the outcomes of intra-articular injection for osteoarthritis of the knee. METHODS: Ninety-four noneffusive knees with osteoarthritis were randomized to injection by conventional palpation-guided anatomic landmark injection or sonographic image-guided injection enhanced with a 1-handed mechanical (the reciprocating procedure device) syringe. After intra-articular placement and synovial space dilation were confirmed by sonography, a syringe exchange was performed, and 80 mg of triamcinolone acetonide was injected with the second syringe through the indwelling intra-articular needle. Baseline pain, procedural pain, pain at outcome (2 weeks and 6 months), responders, therapeutic duration, reinjection rates, total cost, and cost per responder were determined. RESULTS: Relative to conventional palpation-guided anatomic landmark methods, sonographic guidance for injection of the knee resulted in 48% reduction in procedural pain (P < 0.001), a 42% reduction in pain scores at outcome (P < 0.03), 107% increase in the responder rate (P < 0.001), 52% reduction in the nonresponder rate (P < 0.001), a 36% increase in therapeutic duration (P = 0.01), a 13% reduction ($17) in cost per patient per year, and a 58% ($224) reduction in cost per responder per year for a hospital outpatient (P < 0.001). CONCLUSIONS: Sonographic needle guidance reduced procedural pain and improved the clinical outcomes and cost-effectiveness of intra-articular injections of the osteoarthritic knee.


Assuntos
Injeções Intra-Articulares/economia , Osteoartrite do Joelho/tratamento farmacológico , Triancinolona Acetonida/administração & dosagem , Ultrassonografia de Intervenção/economia , Idoso , Análise Custo-Benefício , Feminino , Humanos , Injeções Intra-Articulares/efeitos adversos , Masculino , Pessoa de Meia-Idade , Dor/prevenção & controle , Medição da Dor , Resultado do Tratamento
10.
Arthritis Care Res (Hoboken) ; 72(6): 850-858, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-30927517

RESUMO

OBJECTIVE: To demonstrate the effectiveness of the Extension for Community Healthcare Outcomes (Project ECHO) in educating primary care clinicians (PCCs) to provide best practice rheumatic care to patients in under-resourced communities in New Mexico. METHODS: Attendee data for weekly teleECHO sessions, lectures, grand rounds, and mini-residency trainings were evaluated from June 2006 to June 2014. Participant feedback was evaluated from January 2009 to December 2014, when the program was approved for continuing medical education (CME) credits. Retrospective review of diagnoses associated with case presentations was conducted from June 2006 to June 2014 to evaluate the types of cases presented. A focus group was conducted with a convenience sample of 8 New Mexico PCCs who participated in ECHO Rheumatology (ECHO Rheum) for 1 year or longer. RESULTS: Over the course of 9 years, ECHO Rheum educated 2,230 clinicians, consisting primarily of physicians (53%) and nurse practitioners (22%). A total of 1,958 CME credits were awarded to those who participated. There were 1,173 cases presented; 85% of the cases reflected the 3 most common diagnoses: rheumatoid arthritis (n = 715), fibromyalgia (n = 241), and systemic lupus erythematosus (n = 54). In addition, ECHO Rheum conducted 15 two-day mini-residencies involving 30 PCCs; 21 of these clinicians subsequently completed the American College of Rheumatology online certification. CONCLUSION: Results from this study demonstrate that participation in ECHO Rheum provides clinicians in under-resourced areas access to best-practice knowledge and training in rheumatology.


Assuntos
Serviços de Saúde Comunitária , Área Carente de Assistência Médica , Reumatologia , Grupos Focais , Pesquisa Qualitativa
11.
Arch Gynecol Obstet ; 279(3): 285-92, 2009 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-18568356

RESUMO

INTRODUCTION: National and international regulatory agencies and professional societies mandate systematic improvements in both the safety of patients and heath care workers (HCW), including the integration of safety technologies into the procedures of obstetrics and gynecology (Ob-Gyn). MATERIALS AND METHODS: Using national resources for patient safety and literature review, these safety technologies were identified: (1) a safety needle to reduce needle sticks to HCW, and (2) the reciprocating procedure device (RPD) to reduce injuries to patients. These technologies were introduced in a trial fashion into routine breast cyst aspiration, and physician responses were determined. RESULTS: The safety needle presented a number of difficulties associated with the safety sheath, but could be used efficiently for breast cyst aspiration. The RPD safety device functioned well for breast aspiration procedures and was well accepted by physicians. CONCLUSIONS: New safety technologies can be successfully evaluated and introduced into the clinic to improve patient and HCW safety during outpatient breast procedures. Since these technologies have been demonstrated to decrease injuries to patients and HCW by 60-70%, serious efforts should be undertaken to systematically integrate safety technologies into the routine practice, including aspiration of breast cysts.


Assuntos
Biópsia por Agulha/métodos , Biópsia por Agulha/normas , Cisto Mamário/cirurgia , Acidentes de Trabalho/prevenção & controle , Biópsia por Agulha/instrumentação , Feminino , Pessoal de Saúde , Humanos , Ferimentos Penetrantes Produzidos por Agulha/prevenção & controle , Segurança/normas
12.
J Clin Rheumatol ; 15(2): 56-60, 2009 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-19265345

RESUMO

PURPOSE: We hypothesized that the size of syringe influenced needle control in physician-performed procedures. MATERIALS AND METHODS: Operators were tested for their ability to control a 1-, 3-, 5-, 10-, and 20-mL syringe and equivalent sizes of the new safety device, the reciprocating procedure device (RPD), using the quantitative needle-based displacement method. Three hundred twenty clinical syringe procedures were then randomized to either a 3- or 10-mL conventional syringe or to a 3- or 10-mL RPD. Patient pain was measured with the Visual Analog Pain Scale (VAPS). RESULTS: Increasing syringe size was associated with the undesirable characteristic of unintended forward penetration (loss of control of the needle in the forward direction) (r(2) = 0.97, slope = 2.14, 95% CI: 1.54-2.76, P < 0.002), and unintended retraction (loss of control of the needle in the reverse direction) (r(2) = 0.97, slope 2.15, 95% CI: 1.54-2.76, P < 0.002). In addition, 2-handed operation of a syringe resulted in greater control than 1-handed operation of a syringe (P < 0.001). When 1-handed operation was required, the RPD control syringe reduced unintended penetration by 52.3% (P >or= 0.001), unintended retraction by 56.8% (P >or= 0.001), and patient pain by 54.7% (P >or= 0.001) at each device size. CONCLUSIONS: For greater safety and control when operating the conventional syringe, smaller syringe sizes and 2 hands instead of 1 hand should be used whenever possible. If 1-handed operation of a syringe is necessary, a safety technology like the RPD control syringe should be used.


Assuntos
Competência Clínica , Injeções Intra-Articulares/instrumentação , Dor/etiologia , Seringas/efeitos adversos , Desenho de Equipamento/efeitos adversos , Humanos , Medição da Dor
13.
J Clin Aesthet Dermatol ; 12(11): 23-26, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32038753

RESUMO

Painful, palpable purpura usually indicate underlying vasculitis. We report a case of systemic vasculitis treated with immunosuppression that developed painful, vasculitis-like purpuric lesions that progressed rapidly to fulminant Kaposi sarcoma (KS). These purpuric, tumorous lesions resolved completely following the suspension of immunosuppression; however, without immunosuppression, the underlying autoimmunity recurred. This case highlights the potential for early KS to present as a vasculitis mimic or pseudovasculitis that clinicians should keep in mind when purpuric, vasculitis-like lesions develop in an immunosuppressed patient with vasculitis. It is important to recognize these pseudovasculitis lesions as KS rather than recurrent vasculitis so that immunosuppression can be withdrawn.

14.
Semin Arthritis Rheum ; 49(2): 296-302, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-30952423

RESUMO

OBJECTIVE: The goal of this study was to determine the characteristics of Behçet's disease (BD) in the American Southwest. MATERIAL AND METHODS: This was a cross-sectional study of BD patients clinically encountered during a 2-year period. All subjects fulfilled the International Study Group criteria (ISG) or International Criteria for Behcet's Disease (ICBD). Age, gender, clinical characteristics, substance use, and HLA-B51 status were determined. RESULTS: 63 patients (female: male ratio: 4.7:1) fulfilled ISG criteria and 76 the ICBD criteria (estimated prevalence of 8.9-10.6 per 100,000). 84.1% (53/63) were initially diagnosed with non-BD primary diagnoses including inflammatory arthritis (15.9%), fibromyalgia (7.9%), vasculitis (7.9%), or systemic lupus erythematosus (7.9%). Common BD manifestations were oral aphthous ulcers (100%), acneiform lesions (69.8%), genital aphthous ulcers (61.9%), papulopustular lesions (52.4%), pseudofolliculitis (42.9%), inflammatory arthritis (41.3%), anterior uveitis (23.8%), posterior uveitis (15.9%), pathergy (15.9%), deep vein thrombosis (14.3%), non-ocular vasculitis (11.1%), erythema nodosum (7.9%), arterial thrombosis (6.3%), and retinal vasculitis (1.6%). BD ethnic proportions were 49.2% Hispanic American (HA), 31.7% European-American (EA), 14.3% Native American (NA), and 1.7% Silk Road. HLA-B51 was present more in NA (89.0%, p = 0.02) and HA (74.2%, p = 0.02) compared to EA (42.1%). Therapy of BD was conventional, except for the frequent use of hydroxychloroquine. CONCLUSIONS: BD is common in the American Southwest with a prevalence of 8.9-10.6 cases per 100,000. BD patients are commonly initially diagnosed with alternative primary conditions. Hydroxychloroquine may be an effective alternative therapy for BD. This is one of the first reports of BD in HA and NA populations.


Assuntos
Síndrome de Behçet/epidemiologia , Inibidores Enzimáticos/uso terapêutico , Hidroxicloroquina/uso terapêutico , Adulto , Síndrome de Behçet/diagnóstico , Síndrome de Behçet/tratamento farmacológico , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Sudoeste dos Estados Unidos/epidemiologia
15.
Clin Rheumatol ; 38(8): 2255-2263, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30953230

RESUMO

INTRODUCTION/OBJECTIVES: We hypothesized that mechanical compression of the knee in rheumatoid arthritis (RA) would mobilize occult extractable fluid and improve arthrocentesis success. METHODS: Sixty-seven consecutive knees with RA and 186 knees with OA and were included. Conventional arthrocentesis was performed and success and volume (milliliters) determined; the needle was left intraarticularly, and mechanical compression was applied with an elastomeric knee brace. Arthrocentesis was then resumed until fluid return ceased. Fluid was characterized as to volume and cell counts. RESULTS: In the RA, knee mechanical compression decreased failed diagnostic arthrocentesis from 56.7% (38/67) to 26.9% (18/67) (- 47.4%, p = 0.003) and increased absolute arthrocentesis yield from 4.7 ± 10.3 ml to 9.8 ± 9.8 ml (108% increase, 95% CI - 8.5 < - 5.1 < - 1.7 p = 0.0038). Total extractable fluid yield was 96% greater in RA (9.8 ± 9.8 ml) than OA (5.0 ± 9.4 ml, p = 0.0008), and occult extractable fluid was 77% greater in RA than OA (RA 5.3 ± 8.7 ml, OA 3.0 ± 5.5 ml, p = 0.046). Large effusions versus small effusions in RA demonstrated increased neutrophils in synovial fluid (p = 0.04) but no difference in radiologic arthritis grade (p = 0.87). In contrast, large effusions versus small effusions in OA demonstrated no difference in neutrophils in synovial fluid (p = 0.87) but significant different radiologic arthritis grade (p = 0.04). CONCLUSION: Mechanical compression improves the success of diagnostic and therapeutic knee arthrocentesis in both RA and OA. Large effusions in RA are associated with increased neutrophil counts but not arthritis grade; in contrast, large effusions in OA are associated with more severe arthritis grades but not increased neutrophil counts. Key points• Mechanical compression of the painful knee improves arthrocentesis success and fluid yield in both rheumatoid arthritis and osteoarthritis.• The painful rheumatoid knee contains approximately 100% more fluid than the osteoarthritic knee.• Large effusions in the osteoarthritic knee are characterized by higher grades of mechanical destruction but not increased neutrophil counts.• In contrast, large effusions in the rheumatoid knee are characterized by higher synovial fluid neutrophil counts but not the grade of mechanical destruction, indicating different mechanisms of effusion formation in rheumatoid arthritis versus osteoarthritis.


Assuntos
Artrite Reumatoide/terapia , Braquetes , Inflamação/terapia , Osteoartrite do Joelho/terapia , Líquido Sinovial , Idoso , Artrocentese , Feminino , Humanos , Joelho , Masculino , Pessoa de Meia-Idade , Estresse Mecânico
16.
J Emerg Med ; 35(2): 119-25, 2008 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-18281176

RESUMO

The purpose of this study was to determine whether the new reciprocating procedure device (RPD) is superior to the conventional syringe for the administration of local anesthesia. There were 209 local lidocaine anesthesia procedures randomized between the RDP and the conventional syringe. Outcome measures included administration time, anesthesia pain, procedure pain, and operator satisfaction. The RPD significantly reduced anesthesia administration time by 49% (RPD: 0.68 +/- 0.59 min, Syringe: 1.32 +/- 1.01 min, p < 0.001, 95% confidence interval [CI] for % reduction: 36%-60%), reduced anesthesia pain by 27% (RPD visual analog pain scale score: 4.05 +/- 2.64; Syringe: 5.55 +/- 3.00; p < 0.001, 95% CI 14%-38%), reduced significant procedure pain by 74% (p < 0.001, 95% CI 60%-87%), and improved physician satisfaction by 63% (p < 0.001, 95% CI 53%-74%). The RPD markedly reduces the pain associated with lidocaine anesthesia administration, reduces administration time, and maintains the effectiveness of local anesthesia. The RPD is superior to and significantly more effective than the conventional syringe for the administration of local lidocaine anesthesia.


Assuntos
Anestesia Local/instrumentação , Anestésicos Locais/administração & dosagem , Lidocaína/administração & dosagem , Adulto , Idoso , Feminino , Humanos , Injeções Intra-Articulares , Masculino , Pessoa de Meia-Idade , Medição da Dor
17.
Clin Rheumatol ; 37(8): 2251-2259, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28913649

RESUMO

We hypothesized that constant compression of the knee would mobilize residual synovial fluid and promote successful arthrocentesis. Two hundred and ten knees with grade II-III osteoarthritis were included in this paired design study: (1) conventional arthrocentesis was performed with manual compression and success and volume (milliliters) determined; and (2) the intra-articular needle was left in place, and a circumferential elastomeric brace was tightened on the knee to provide constant compression. Arthrocentesis was attempted again and additional fluid volume was determined. Diagnostic procedural cost-effectiveness was determined using 2017 US Medicare costs. No serious adverse events were noted in 210 subjects. In the 158 noneffusive (dry) knees, sufficient synovial fluid for diagnostic purposes (≥ 2 ml) was obtained in 5.0% (8/158) without compression and 22.8% (36/158) with compression (p = 0.0001, z for 95% CI = 1.96), and the absolute volume of arthrocentesis fluid obtained without compression was 0.28 ± 0.79 versus 1.10 ± 1.81 ml with compression (293% increase, p = 0.0001). In the 52 effusive knees, diagnostic synovial fluid (≥ 2 ml) was obtained in 75% (39/52) without compression and 100% (52/52) with compression (p = 0.0001, z for 95% CI = 1.96), and the absolute volume of arthrocentesis without compression was 14.7 ± 13.8 versus 25.3 ± 15.5 ml with compression (72.1% increase, p = 0.0002). Diagnostic procedural cost-effectiveness was $655/sample without compression and $387/sample with compression. The new technique of constant compression via circumferential mechanical compression mobilizes residual synovial fluid beyond manual compression improving the success, cost-effectiveness, and yield of diagnostic and therapeutic arthrocentesis in both the effusive and noneffusive knee.


Assuntos
Artrocentese/métodos , Braquetes , Bandagens Compressivas , Osteoartrite do Joelho/diagnóstico , Osteoartrite do Joelho/terapia , Líquido Sinovial , Artrocentese/economia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Dor Processual/diagnóstico
18.
Womens Health (Lond) ; 12(1): 79-81, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-26696393

RESUMO

Extension for Community Healthcare Outcomes creates knowledge networks that enable a transition from centralized specialty care at academic institutions to empowerment of primary care providers to provide more highly skilled care closer to home.


Assuntos
Medicina Interna/tendências , Osteoporose/terapia , Assistência Centrada no Paciente/tendências , Melhoria de Qualidade/tendências , Centros Médicos Acadêmicos/tendências , Conservadores da Densidade Óssea/uso terapêutico , Serviços de Saúde Comunitária/tendências , Feminino , Humanos , Avaliação de Resultados em Cuidados de Saúde
19.
Environ Toxicol Pharmacol ; 20(3): 395-403, 2005 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-21783618

RESUMO

Natural killer (NK) cells are a subset of lymphocytes that are capable of killing tumor and virally-infected cells. Dibutyltin (DBT) is a catalyst in the production of PVC plastics and a breakdown product of tributyltin (TBT). DBT is a significant environmental contaminant. This study investigates the mechanism by which DBT exposure decreases the immune function of human NK cells. NK cells destroy their target cells by releasing cytotoxic proteins, perforin, and granzyme B. We examined the effect of DBT exposures on the levels of cytotoxic proteins and their mRNAs. Exposure of NK cells to DBT for 1h caused significant decreases in the mRNAs for granzyme B and perforin but not in protein levels. A 24h exposure to DBT decreased mRNAs as well as protein levels for both granzyme B and perforin. Exposure to DBT for 1h followed by either a 24 or 48h period in DBT-free media, decreased levels of granzyme B and perforin. The results indicate that decreases in granzyme B and perforin levels in NK cells are consequences of DBT exposure. Additionally, DBT causes rapid decreases in mRNAs for perforin and granzyme B, suggesting decreases in transcription and/or increases in mRNA degradation.

20.
Am J Kidney Dis ; 42(6): 1212-20, 2003 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-14655193

RESUMO

BACKGROUND: Hemodialysis (HD) is associated with protein catabolism and augmented apoptosis. Although the effect of metabolic acidosis and inflammatory cytokines on activation of the ubiquitin-proteasome pathway and branched-chain keto acid dehydrogenase (BCKAD) is well known, the effect of HD on these pathways remains unexplored. METHODS: Twelve patients with end-stage renal disease were studied before and during HD. Eight controls also were studied. Plasma levels of complement components and cytokines, interleukin-1 (IL-1), IL-6, and tumor necrosis factor-alpha (TNF-alpha) were measured. Messenger RNA (mRNA) levels of caspase-3, a mediator of apoptosis; ubiquitin, a marker of proteolysis; and BCKAD-E2, an enzyme regulating branched-chain amino acid oxidation, were estimated in skeletal muscle biopsy specimens by means of reverse-transcriptase polymerase chain reaction. Annexin-V expression was quantified by DNA array. Before the study, participants were placed on a 1.2-g/kg/d protein diet, and metabolic acidosis was corrected. RESULTS: During HD, plasma IL-6 levels increased from 7.54 +/- 2.24 to 27.86 +/- 4.94 pg/dL (P < 0.001). Complement component, IL-1, and TNF-alpha levels did not change significantly during HD. mRNA levels of caspase-3 (0.50 +/- 0.01 versus 0.81 +/- 0.04), annexin-V (0.94 +/- 0.06 versus 1.48 +/- 0.05; P < 0.001), ubiquitin (1.10 +/- 0.03 versus 1.44 +/- 0.03), and BCKAD-E2 (0.47 +/- 0.01 versus 0.81 +/- 0.04) increased in muscle during HD compared with pre-HD values (P < 0.001). mRNA levels of ubiquitin (0.62 +/- 0.03) and BCKAD-E2 (0.58 +/- 0.02) were greater in controls than pre-HD values (P < 0.05). There were significant positive correlations between plasma IL-6 levels and expression of caspase-3, ubiquitin, and BCKAD-E2 genes. CONCLUSION: HD causes activation of cytokines, which may mediate the increase in gene expression of caspase-3, ubiquitin, and BCKAD-E2 in skeletal muscles.


Assuntos
Apoptose , Inflamação/sangue , Falência Renal Crônica/sangue , Proteínas/metabolismo , Diálise Renal , 3-Metil-2-Oxobutanoato Desidrogenase (Lipoamida)/biossíntese , 3-Metil-2-Oxobutanoato Desidrogenase (Lipoamida)/genética , Acidose/etiologia , Acidose/metabolismo , Adulto , Biópsia , Caspase 3 , Caspases/biossíntese , Caspases/genética , Terapia Combinada , Proteínas do Sistema Complemento/análise , Citocinas/sangue , Dieta com Restrição de Proteínas , Feminino , Regulação da Expressão Gênica , Humanos , Inflamação/complicações , Falência Renal Crônica/complicações , Falência Renal Crônica/dietoterapia , Falência Renal Crônica/terapia , Masculino , Pessoa de Meia-Idade , Músculo Esquelético/metabolismo , Músculo Esquelético/patologia , RNA Mensageiro/análise , Diálise Renal/efeitos adversos , Ubiquitina/biossíntese , Ubiquitina/genética
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