Sex differences in clinical characteristics and their influence on clinical outcomes in an observational cohort of patients with rheumatoid arthritis

ObjectiveRheumatoid arthritis (RA) is more prevalent in women, but sex differences remain incompletely understood. This study aimed to elucidate sex differences in clinical characteristics and their potential impact on clinical outcomes in a large Korean cohort of patients with RA.MethodsIn total, 5376 RA patients from the KORean Observational study Network for Arthritis (KORONA) database were examined at baseline and for 3 consecutive years using the disease activity score 28 (DAS28), health assessment questionnaire (HAQ), and patient-reported outcomes (PROs). Within a subgroup with active disease (DAS28 ≥ 3.2) at baseline, sex impacts on clinical outcome during follow-up were analyzed using generalized estimating equation (GEE) models. The factors related to achieving clinical remission were analyzed using Cox-proportional hazard regression.ResultsAt baseline, women (n = 4574) were younger and had more erosive disease and longer disease duration than men (n = 802) with higher scores in DAS28, HAQ, and PROs. The prevalence of interstitial lung disease, cardiovascular disease, and diabetes in men was higher than that of women. In a RA subgroup with active disease at baseline, GEE analyses demonstrated that women RA significantly influenced the rate of change of DAS28 over time. In that group, men are associated with achieving DAS28 sustained remission and point remission.ConclusionsWomen with RA in Korea report higher levels of disease activity and PROs compared to men, whereas most comorbidities were more prevalent in men. The longitudinal change in disease activity and the rate of achieving clinical remission were found to be worse in women with RA.     

Adult congenital heart disease

Continued advances in the understanding and management of congenital heart disease (CHD) mean that over 90% of children born with CHD now survive to adulthood. This in turn results in greater numbers of adult patients presenting for medical and surgical care at non-specialist centres. A simple classification of adult congenital heart disease (ACHD) according to complexity can help clinicians to understand the implications of the specific cardiac anomaly encountered. Issues relating to the conduct of anaesthesia in ACHD patient include careful attention to euvolaemia, the preservation of sinus rhythm and cardiac output, and in complex patients, manipulating the balance between systemic and pulmonary blood flows. Additionally, effective antibiotic prophylaxis and the prevention of either excessive bleeding or thromboembolism are vitally important. It should not be forgotten that although many patients with simple or repaired cardiac lesions may be very well managed in a non-specialist unit, those with Eisenmenger’s syndrome or severe pulmonary hypertension have an extremely high risk of death in the perioperative period, and in all but life-threatening situations should always be managed within specialist centres.     

Esophageal adenocarcinoma after sleeve gastrectomy: actual or potential threat? Italian series and literature review

BackgroundSleeve gastrectomy (SG) leads to esophageal mucosal damage in an elevated percentage of cases, configuring a clinical condition of Barrett’s esophagus (BE) in a proportion as high as 15–18.8%. BE may rarely evolve into esophageal adenocarcinoma (EAC).ObjectivesTo raise awareness of BE as a precancerous lesion which may progress toward malignancy after this popular bariatric procedure.SettingBariatric referral centers, Italy.MethodsAll patients referred to our bariatric center who developed an EAC after SG between 2012 and 2019 were reviewed and consecutively included in this study. The available scientific literature regarding this complication is additionally reviewed.ResultsThe 3 male patients comprised in this case series underwent laparoscopic SG between 2012 and 2015 in different bariatric referral centers. Age and body mass index at baseline ranged from 21–54 years and 43.1–75.6 kg/m², respectively. All patients were lost to follow-up early after surgery (3.7 ± 1.4 months), and were diagnosed with EAC at a mean of 27.3 ± 7.6 months after SG. The 4 reported cases in the scientific literature developed an EAC at a mean of 32.5 ± 23 months from SG. Overall, a diagnosis of EAC was made approximately 30.3 ± 17.1 months postoperatively, which seems relatively and worryingly early after surgery.ConclusionAlthough the rate and probability of progression from BE to EAC is still not well defined, assuming that the rising popularity and execution of SG leads to a growth in the BE incidence, then the preoperative identification and stratification of cancer risk factors in this subset of patients is strongly encouraged. Clinical and endoscopic follow-ups are essential to allow for prevention and early diagnosis and for epidemiologic data collection purposes.     

A rare instance of Wilkie’s syndrome in a young male during the holy month of Ramadan

Introduction and importanceWilkie’s syndrome[SMA(Superior Mesenteric Artery) syndrome or Cast syndrome]) is a unique and rare presentation which may be included in the differential diagnosis especially when a Gastric outlet obstruction is being investigated and there is a history of an associated element of rapid weight loss. The purpose of presenting this case report is its uniqueness given a history of intermittent fasting rather than the usual eating disorders.Case presentationA crescendo worsening of symptoms of intractable vomiting, inability to eat, upper abdominal gas bloating and post meal abdominal pain since one week in a patient during a period of fasting for the first time had been observed.Clinical discussionAfter initial resuscitation, an ultrasound abdomen and an abdominal x ray revealed a distended stomach and a nasogastric tube was immediately introduced to avoid aspiration. A CT scan of the abdomen with contrast revealed the compressed duodenum in the aortomesenteric angle and the diagnosis of SMA syndrome was confirmed. An upper gastrointestinal endoscopy was also done to rule out other causes and it was found to be normal.ConclusionIn an acute presentation, the response to conservative management is remarkable and in the absence of any possible future reoccurrences the surgical options may be avoided. High index of suspicion, appropriate radiological diagnosis and stepwise treatment options may guide the troubled patient towards recovery in this rare presentation. A proper history taking is key in diagnosing such a condition and does not have to be limited to eating disorders, typically.     

Fournier’s gangrene as a rare complication in patient with uncontrolled type 2 diabetes treated with surgical debridement: A case report and literature review

IntroductionFournier’s gangrene is a potentially fatal emergency condition, supported by an infection of perineal and perianal region, characterized by necrotizing fasciitis with a rapid spread to fascial planes. FG, usually due to compromised host, may be sustained by many microbial pathogens.Case reportA 66-year-old man, with a history of uncontrolled type 2 diabetes, obesity with BMI 38, chronic kidney failure and chronic heart failure, was admitted to the Emergency Department with a large area of necrosis involving the perineal and perianal regions.DiscussionFournier’s gangrene is favoured by hypertension, obesity, chronic alcoholism, renal and heart failure. Generally, Fournier’s gangrene needs other procedures in addition to wound debridement such as colostomy, cystostomy, or orchiectomy.ConclusionWe report a case of FG found as complication in a patient with uncontrolled type 2 diabetes, treated with effective combination therapy with surgical debridement and antibiotics infusion.     

Lemierre’s syndrome or re-emerging disease: Case report and literature review

IntroductionLemierre's syndrome is a rare and potentially fatal entity characterized by the spread of an oropharyngeal infection, with secondary suppurative thrombophlebitis of the internal jugular vein and septic emboli.Presentation of caseWe discuss the case of a 52-year-old male who developed Lemierre’s syndrome following peritonsillar abscess. He presented with submandibular and submental swelling extending into the neck. His management included; incision and drainage of the abscesses; and prolonged anticoagulant therapy.ConclusionThe incidence of Lemierre's disease appears to be increasing, perhaps due to ignorance of the disease by many clinicians, and diagnosis is often delayed with potentially fatal consequences.     

Reduced port laparoscopic surgery using umbilical zigzag incision for Meckel’s diverticulitis

IntroductionReduced port laparoscopic surgery using an umbilical zigzag incision is comparable to conventional multiport laparoscopic surgery. This method is associated with improved cosmesis and decreased wound pain.Presentation of caseA 67-year-old man visited our hospital. He presented emergency room with a chief complaint of right lower abdominal pain by walking. The patient was diagnosed Meckel’s diverticulitis by computed tomography (CT). At first, antibiotics therapy and fasting were performed. Three months later, the patient underwent resection of Meckel’ diverticulum with zigzag transumbilical laparoscopic surgery. The patient’s postoperative course was good, and he rarely felt wound pain. The patient started oral intake three days after surgery, and was discharged 10 days after surgery.DiscussionZigzag transumbilical laparoscopic surgery is very useful for resection of the small intestine. This method is associated with improved cosmesis and decreased wound pain. In the case of Meckel’s diverticulitis, we suggest that interval resection of Meckel’s diverticulum was very useful as it was an operation that could be performed easily.ConclusionReduced port laparoscopic surgery using an umbilical zigzag incision is considered to be an excellent technique in terms of operability and aesthetic outcomes.