Author(s) Mahmoud; Zayat, Ahmed S; Yusof, Md Yuzaiful Md; Dutton, Katherine; Teh, Lee Suan; Yee, Chee-Seng; D'Cruz, David; Ng, Nora; Isenberg, David; Ciurtin, Coziana; Conaghan, Philip G; Emery, Paul; Edwards, Christopher J; Hensor, Elizabeth M A; Vital, Edward M
Source Rheumatology; Nov 2021; vol. 60 (no. 11); p. 5194-5204
Language English
Database CINAHL
AbstractObjectives To determine whether SLE patients with inflammatory joint symptoms and US synovitis/tenosyovitis achieve better clinical responses to glucocorticoids compared with patients with normal scans. Secondary objectives included identification of clinical features predicting US synovitis/tenosynovitis. Methods In a longitudinal multicentre study, SLE patients with physician-diagnosed inflammatory joint pain received intramuscular methylprednisolone 120 mg once. Clinical assessments, patient-reported outcomes and bilateral hand/wrist USs were collected at 0, 2 and 6 weeks. The primary outcome (determined via internal pilot) was the early morning stiffness visual analogue scale (EMS-VAS) at 2 weeks, adjusted for baseline, comparing patients with positive (greyscale ≥2 and/or power Doppler ≥1) and negative US. Post hoc analyses excluded FM. Results Of 133 patients, 78 had a positive US. Only 53 (68%) of these had one or more swollen joint. Of 66 patients with one or more swollen joint, 20% had a negative US. A positive US was associated with joint swelling, symmetrical small joint distribution and serology. The primary endpoint was not met: in the full analysis set (N  = 133) there was no difference in baseline-adjusted EMS-VAS at week 2 [−7.7 mm (95% CI −19.0, 3.5); P  = 0.178]. After excluding 32 patients with FM, response was significantly better in patients with a positive US at baseline [baseline-adjusted EMS-VAS at 2 weeks −12.1 mm (95% CI −22.2, −0.1); P  = 0.049]. This difference was greater when adjusted for treatment [−12.8 mm (95% CI −22, −3); P  = 0.007]. BILAG and SLEDAI responses were higher in US-positive patients. Conclusion In SLE patients without FM, those with a positive US had a better clinical response to therapy. Imaging-detected synovitis/tenosynovitis may be considered to decide on therapy and enrich clinical trials.

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Author(s) Wong ; Viyasar, Thevarajah; Layton, Benjamin; Lauder, Joshua
Source British Journal of Hospital Medicine (17508460); Nov 2022; vol. 82 (no. 11); p. 369-376
Language English
Publication Date Nov 2022
DOI 10.12968/hmed.2021.0322
ISSN 17508460
Database CINAHL
Nitrous oxide, also known as 'laughing gas', is one of the most widely used recreational drugs among teenagers in the UK. Copious inhalation of nitrous oxide may increase intra-alveolar pressure, resulting in barotrauma secondary to alveolar rupture. Pneumomediastinum and subcutaneous emphysema are common clinical findings in nitrous oxide-associated barotrauma. Prolonged nitrous oxide misuse may inactivate vitamin B12 through the alteration of its metabolism, causing demyelination of the central and peripheral nervous system. A spectrum of neurological manifestations has been reported, including peripheral neuropathy, myelopathy and subacute combined degeneration of the spinal cord. Medical therapies and psychosocial interventions aiming at nitrous oxide cessation are important treatment steps to achieve partial or complete recovery from the adverse effects associated with inhalation of nitrous oxide.

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Author(s) Hossain M.I.; Sen R.; Adiyodi J.; Hampson P.; Nowell C.; Khan S.; Sundararaman S.; Basu S.
Institution(s) (Hossain, Sen, Adiyodi) East Lancashire Hospitals NHS Trust, Burnley, United Kingdom
(Hampson, Nowell) The Binding Site, Birmingham, United Kingdom
(Khan) Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, United Kingdom
(Sundararaman) West Midlands University Hospitals Coventry and Warwickshire, Coventry, United Kingdom
(Basu) The Royal Wolverhampton NHS Trust, Wolverhampton, United Kingdom
Source Blood; Nov 2021; vol. 138 ; p. 3007
Language English
Database EMBASE
AbstractIntroduction Patients with Multiple Myeloma (MM) often have a significant delay between onset of symptoms and diagnosis of disease. As a result, a significant number of patients present via emergency routes with severe co-morbidities which affect survival rates. Timely diagnosis relies on the early recognition of symptoms and blood test results which may indicate disease. Methods We examined the medical records of 142 newly diagnosed MM patients (121 intact immunoglobulin and 21 light chains) across 2 UK Hospitals. Patients included had not previously been diagnosed with a plasma cell dyscrasia, including Monoclonal Gammopathy of Undetermined Significance (MGUS). Clinical symptoms and blood test results were examined from the time of initial presentation to the healthcare system with symptoms indicative of MM, to the point of diagnosis in order to highlight patterns of symptoms and blood tests results which may give an early indication of disease. Blood tests results recorded included globulin, calcium, creatinine, erythroid sedimentation rate and haemoglobin. Time to diagnosis from presentation with symptoms indicative of MM was also measured as well as the patient pathway from the point of presentation to the point of diagnosis. Results The median time to diagnosis from initial presentation was 77 days (range 0 - 12,986). Initial presentation was most commonly via primary care (58.1%). Urgent secondary care presentation was documented in 28.5% which included acute medical unit (15.6%), the emergency department (7.1%), and other secondary care specialities (5.7%) respectively. Multiple GP visits were common prior to haematology referral with a median of 3 visits (range 1 - 40). Initial presenting symptoms varied, but of those with data recorded (n=107) back/bone pain was the most common (58.2%) followed by anaemia (18.7%), fracture (7.5%), recurrent infection (7.5%) and renal impairment (3.7%) respectively. Interestingly, analysis of evaluable blood test results revealed a raised globulin was most often evident prior to diagnosis with 58% of patients recording an abnormal globulin a median of 140 days (range 3 - 4297) prior to diagnosis of disease. Conclusions Multiple GP visits prior to establishing a diagnosis of myeloma is very common. Inclusion of abnormal globulin to reflex electrophoresis request and serum free light chain assay may serve as a useful trigger for investigation when interpreted alongside presenting symptoms and other blood test results. Increased awareness of myeloma warning signs in primary care may reduce diagnostic delay and avoid presentation with severe co-morbidities in emergency settings. Disclosures: No relevant conflicts of interest to declare.Copyright © 2021 American Society of Hematology

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Author(s) Haque A. (adam.haque@manchester.ac.uk); Al-Khaffaf H.
Institution(s) (Haque, Al-Khaffaf) Cumbria and Lancashire Vascular and Endovascular Centre, East Lancashire Hospitals NHS Trust, Blackburn BB2 3HH, United Kingdom
Source Annals of Vascular Surgery; 2021
Language English
Database EMBASE
AbstractBackground: The association of dialysis fistulas and heart failure is believed to be due to high cardiac output. N-terminal pro-B-Type Natriuretic Peptide (pro-BNP) which is secreted by the cardiac ventricles in response to excessive stretching of the myocytes has been used as a marker of heart failure with 90% sensitivity. We report our early experience using pro-BNP levels to test the efficacy of the novel 'secondary extension technique' (SET) in improving myocardial function by reducing fistula flow. Method(s): Eleven patients with high fistula flows (>3000 mL/m, all brachio-cephalic) and raised pro-BNP underwent SET between 2011 and 2015. SET involves extending the anastomosis from brachial to either proximal radial or ulnar arteries. We measured pro-BNP levels, fistula flow and clinical improvements both pre and post operatively. Result(s): SET resulted in a median (IQR) flow rate decrease of 57.9 (11.9)% which correlated with a fall in pro-BNP of 69.6 (39)%. Seven of the 11 patients in the series pro-BNP level returned to a normal value at average follow-up of 3 months post SET. All patients had HOF-related symptom resolution post-procedure and remained asymptomatic at last follow-up Conclusion(s): Our pilot data suggests that SET is an effective way of reducing fistula flow. It also shows that BNP may be a reliable biomarker in assessing the impact of the technique on cardiac function. These results warrant further investigation in the form of a definitive, multicenter study.Copyright © 2021

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