How to taper glucocorticoids in inflammatory rheumatic diseases? A narrative review of novel evidence in rheumatoid arthritis,systemic lupus erythematosus,and giant cell arteritis

Glucocorticoids (GCs) remain regularly used drugs in patients with chronic inflammatory rheumatic diseases. As long-term intake at high dosages is associated with harm, it is generally advised that GCs be tapered and stopped. However, most recommendations concerning tapering have been eminence- or consensus-based. In this narrative review, we present novel data from recent studies (SEMIRA, CORTICOLUP, and GiACTA) shedding light from different angles on the effects of tapering GCs in patients with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and giant cell arteritis (GCA). In RA and SLE, our main findings comprise that (a) the majority of RA and SLE patients can successfully taper their GC, but that (b) tapering increases the risk of flare. In GCA, tocilizumab was shown to be a potent GC-sparing agent. Finally, we also present exemplary tapering schemes for RA, SLE, and GCA, although different tapering regimens have not yet been sufficiently compared in randomized trials.     

Renal interventions after abdominal aortic aneurysm repair using an aortic endograft with suprarenal fixation

BACKGROUND: Our aim was to determine whether suprarenal fixation in endografts compromises renal artery (RA) flow and whether subsequent RA intervention is precluded by the stent struts. METHODS: Prospectively acquired data from 104 patients with endovascular aneurysm repair (EVAR) of an abdominal aortic aneurysm using the Zenith endograft (Cook, Inc., Bloomington, IN) were analyzed. The Zenith device uses a 26-mm, uncovered, barbed Z stent for suprarenal function. RESULTS: No RA stenosis, occlusion, or infarction resulted from the suprarenal stent. In 3 of 104 (2.9%) patients, RA compromise (2 stenoses, 1 occlusion) was caused by impingement of graft material on the lowermost RA. The 2 RA stenoses were stented successfully at 1 and 7 months post-EVAR. Six of 104 (5.8%) patients developed late stenoses unrelated to the endograft: all were stented successfully from 19 to 36 months after EVAR. One patient with severe RA stenosis had balloon angioplasty pre-EVAR and then was stented electively 6 weeks post-EVAR. CONCLUSIONS: Our data show that the suprarenal fixation of the Zenith aortic endograft does not cause RA stenosis, occlusion, or infarction, nor does it preclude post-EVAR renal artery intervention.     

Early results of complete off-pump coronary revascularization using left internal thoracic artery with composite radial artery

Objective: Off-pump coronary artery bypass (OPCAB) using the left internal thoracic artery (LITA) with a composite radial artery (RA) was employed for arterial revascularization in order to minimize neurological complication. Methods: Sixty-one patients underwent OPCAB using the LITA with a composite RA. Angiography was performed in all patients at two weeks postoperatively. Results: The mean number of distal anastomoses was 3.2±0.4 A Y-composite graft was used in 55 patients, and K-composite graft was used in the other 6 patients. There was no hospital death, no neurological complication nor deep sternal infection Furthermore, there was no episode of perioperative myocardial infarction nor hypoperfusion syndrome. Patients have been angina-free during a mean follow-up period of 1 year. The graft patency of the LITA to the left anterior descending artery (LAD) was 100% (61/61 anastomoses). The RA became occluded in 4 patients, and the patency rate was 95.6% (130/136 anastomoses). String or coronary-coronary bypass resulting from flow competition was observed in the LITA of 6 patients and in the RA of 13 patients. The string of the LITA occurred in the segment distal from the anastomosis with the composite RA. The string or coronary-coronary bypass was observed more often in cases in which the recipient coronary artery had less than 75% stenosis. Conclusion: OPCAB using only the LITA with a composite RA can be successfully and safely performed in patients with multivessel disease. Late postoperative follow-up of the flow competition is necessary to delineate the significance of flow competion.     

Initial experience in endoscopic radial artery harvesting

We report the initial experience of endoscopic radial artery (RA) harvesting (ERA) using Vasoview System. The expected advantages of ERA are superior cosmetic results and fewer wound complications to the conventional open technique. ERA was performed in 33 patients from September 2004 to September 2005. Preoperatively, Allen's test with Doppler imaging was performed in all patients. ERA was successfully performed within 50 minutes except in the first 3 patients (the mean time for harvest: 37 minutes). Direct injury of the RA occurred in 1 patient, but the RA could be used as a graft for coronary artery bypass grafting (CABG) by repairing with end-to-end anastomosis. Only 1 RA graft occluded as determined by the early postoperative angiography. Local dissection of the RA was observed in 2 patients, but no flow disturbance was observed. Delayed wound healing occurred in 1 aged patient. No significant nerve complications were encountered. ERA is easy to adopt and has greater cosmetic advantages.     

Modification of the Senning procedure in the double-switch operation: The triangular double-door technique

We developed a modified Senning procedure in the double-switch operation for the patients with congenitally corrected transposition of the great arteries (ccTGA). In our technique, the right atrial (RA) free wall is not used as a baffle for draining systemic venous blood to the left atrium. Instead, a patch material is used for the baffling. A wide communication between the pulmonary venous chamber and RA is created by making the triangular double door with the RA-free wall, and the window is closed with in situ pericardial flap. We have successfully adopted this technique in our recent two consecutive ccTGA patients.     

Allocation procedure has no impact on patient and graft outcome after liver transplantation

The aim of our study was to compare the postoperative outcome after liver transplantation (LT) in patients who received a donor liver via standard or rescue allocation (RA). Special emphasize was laid on the effect extended donor criteria might have on the outcome. One hundred and ten LTs have been performed at the University Hospital Aachen, Germany. A total of 49 patients were included in the standard allocation (SA) group and 53 patients in the RA group. The outcome of LT in both groups was evaluated by the length of stay on the intensive care unit (ICU), duration of hospitalization, 1‐year patient survival, 1‐year graft survival, incidence of primary nonfunction and major complications. Patients in group RA had a significant shorter ICU and overall hospital stay. The 1‐year graft survival was 87.8% in group SA and 88.7% in group RA. The 1‐year patient survival was 87.9% in group SA and 96.2% in group RA. The number of re‐LT was 2% in group SA and 7.5% in group RA. Organs that were rejected for transplantation several times can successfully be transplanted through the RA procedure, thereby enlarging the donor pool without negative effects on the quality of LT.     

Early prosthetic valve failure in a patient with rheumatoid arthritis

Abstract   Heart lesions in patients with rheumatoid arthritis (RA) are well documented in literature; however, in the majority of cases these are incidental findings at postmortem. Most patients do not require cardiac surgical intervention unless they develop complications such as significant valvular regurgitation. Patients with RA often require orthopedic operations and therefore a bioprosthetic valve replacement is normally advocated to avoid problems related to anticoagulation. We report a case of a 64-year-old woman with seropositive RA who had undergone bioprosthetic aortic valve replacement three years previously. She re-presented with early prosthetic valve failure due to accelerated degeneration and calcification. This was treated successfully with redo replacement with a mechanical prosthesis. Here, we discuss our experience and debate the various valve choices available that should be considered in patients with rheumatoid disease.     

Renal artery repair: consequence of operative failures.

OBJECTIVE: This report examines the blood pressure and renal function response in 20 consecutive patients after secondary renal revascularization following failed operative repair. SUMMARY BACKGROUND DATA: Most reports describing operative failure of renal artery (RA) repair emphasize the technical aspects of redo RA reconstruction and the immediate blood-pressure response to secondary operation. This report examines the eventual renal function and estimated survival after secondary intervention. METHODS: Primary methods of RA reconstruction, primary blood pressure and renal function responses, and causes of failed RA repair were defined for 20 patients requiring reoperation for recurrent hypertension or renal insufficiency. These parameters were compared with secondary procedures and eventual blood pressure and renal function response. The eventual outcome for these 20 patients was compared with 514 patients managed by primary renal revascularization during the same period. RESULTS: Failure of primary RA repair correlated with complex fibromuscular dysplasia requiring branch ex vivo reconstruction (p = 0.020). RA thrombosis frequently required nephrectomy (83%), whereas RA stenosis was successfully reconstructed (91 %; p = 0.001). Primary and secondary blood-pressure responses were equivalent (94% vs. 95% cured or improved); however, primary and eventual renal function responses differed significantly (p = 0.015), with seven patients dialysis-dependent on follow-up. Eventual dialysis dependence was associated with preoperative azotemia (p = 0.022), bilateral failure of primary RA repair (p = 0.007), and an increased risk of follow-up death (p = 0.002). Considering all 534 patients, failed RA repair demonstrated a significant and independent association with eventual dialysis dependence and decreased dialysis-free survival. CONCLUSIONS: Contemporary rates of reoperation after surgical RA repair are low. In properly selected patients, beneficial blood-pressure response is reliably observed after both primary and secondary operative procedures. However, secondary procedures are associated with a significant and independent risk of eventual dialysis dependence.     

Arthroscopic rotator cuff debridement in patients with rheumatoid arthritis

There is little information available concerning the results of rotator cuff debridement in patients with rheumatoid arthritis (RA). We performed a review of 16 shoulders with underlying RA that underwent arthroscopic rotator cuff tear debridement; there were 10 full-thickness tears and 6 partial-thickness tears. Of the 10 patients with full-thickness rotator cuff tears, 8 had unsatisfactory results, whereas none of the patients with partial-thickness tears had unsatisfactory results. Pain was improved in 5 of 6 shoulders with partial-thickness cuff tears, whereas only 5 of 10 with full-thickness tears had an improvement with regard to pain. Motion did not improve in either group. Patients with RA who require operative intervention for pain relief because of rotator cuff tearing can be treated successfully with debridement alone. However, pain relief was less predictable with large or massive tears when compared with partial-thickness tears, and functional gains were not achieved in either group.     

Pneumonia por Legionella após uso de Infliximabe em paciente com Artrite Reumatoide

The antagonists of tumour necrosis factor (anti‐TNF) have been successfully used in several chronic inflammatory diseases such as Rheumatoid Arthritis (RA), but some studies have observed the development of infections by intracellular pathogens in patients using anti‐TNF. We report a case of a female patient with previous diagnosis of RA for 16 years that used several disease‐modifying anti‐rheumatic drugs (DMARDs) that resulted in treatment failure, and then was treated with infliximab. After fifteen days of the second dose, the patient developed ventilatory‐dependent chest pain, dry cough and dyspnea. She was hospitalized, and the diagnosis of pneumonia by Legionella pneumophila was confirmed by the presence of Legionella antigen in an urine test. TNF is an inflammatory cytokine that also acts inhibiting the bacterial growth of intracellular pathogens, and its inhibition seems to increase susceptibility to these infections in some patients.     

An update on thermal imaging in rheumatoid arthritis

This review aims to summarise the recent literature concerning the usage of thermal imaging in the study of rheumatoid arthritis (RA). Most RA studies have applied thermal imaging as a static process alone although thermal imaging has been conducted with an additional dynamic/functional component. Algorithms to automate the analysis of thermal imaging in RA have also been described. Several RA thermal imaging studies have demonstrated differences in thermographic findings between RA patients and healthy controls and/or compared thermographic parameters with other clinical/functional/imaging parameters; while fewer studies have assessed the role of thermal imaging in discriminating disease severity in RA. Thermal imaging is a relatively low cost, non-invasive imaging technique offering an objective measurement of joint surface temperature in RA joint inflammation assessment. Although there has been an increasing literature build up on the use of thermography in RA, more validation work is still necessary to delineate the potential role(s) of its use among patients with RA. This timely review focusses on the recent literature concerning thermal imaging, and provides clinicians with an update on its recent development in RA.     

Risk of Total Knee and Hip Arthroplasty in Patients With Rheumatoid Arthritis: A 12-Year Retrospective Cohort Study of 65,898 Patients

BackgroundRheumatoid arthritis (RA) is an inflammatory disease that causes the destruction of soft tissues and cartilage around joints. Owing to the widespread use of potent disease-modifying antirheumatic drugs, the need for total knee and hip arthroplasties (TKA and THA) has been reduced in patients with RA. However, the current association between RA and either THA or TKA has not been demonstrated in large-scale epidemiological studies.MethodsWe conducted a large-scale retrospective cohort study of patients diagnosed with RA during a 12-year period (2000-2012) in Taiwan. We recruited 32,949 patients with RA and 32,949 individually propensity score-matched non-RA controls.ResultsAfter adjusting for confounding factors, we found that the risk of THA or TKA was 4.02 times higher in patients with RA than in those without RA (95% confidence interval [CI], 3.77-4.52). The risk of THA or TKA was highest in patients with RA younger than 40 years (adjusted hazard ratio, 43.18; 95% CI, 16.01-116.47). Compared with non-RA patients, patients with RA were 4.82 times more likely to undergo THA (95% CI, 3.84-6.04), 3.85 times more likely to undergo TKA (95% CI, 3.48-4.25), and 19.06 times more likely to undergo both THA and TKA (95% CI, 8.90-40.80).ConclusionThese findings document a 4.02-fold greater long-term risk of undergoing THA or TKA in RA patients relative to non-RA patients in Taiwan.     

Pathophysiological links between rheumatoid arthritis and the Epstein-Barr virus: an update

Numerous associations have been documented between the Epstein-Barr virus (EBV) and rheumatoid arthritis (RA). Thus, anti-EBV antibody titers are higher in RA patients than in healthy controls. Lymphocytes from RA patients show impaired responses to EBV. Several EBV antigens share similarities with self antigens; more specifically, the glycine/alanine repeats in EBNA-1 resemble synovial proteins and the EBV gp110 glycoprotein contains a copy of the shared epitope. Cell-mediated responses to EBV replicative cycle proteins and to gp110 have been documented in joint fluid from RA patients. In situ hybridization and PCR techniques have identified EBV antigens and genetic material within the rheumatoid synovium, albeit with variable yields. The EBV burden in peripheral blood mononuclear cells is higher in RA patients than in controls. EBNA-1 can undergo citrullination, and the EBV can induce antibodies to citrullinated peptides. RA patients are at increased risk for lymphoma, including EBV-associated lymphoma. Despite these multiple and complex links between EBV and RA, proof of a causal association is lacking. EBV infection may contribute indirectly to the pathophysiology of RA by impairing immune control of EBV replication, causing increased exposure to EBV antigens and, thereby, chronic inflammation. The effect of biotherapies for RA on EBV-host relations needs to be investigated.     

Non-Hodgkin's lymphoma as an unexpected diagnosis in a shoulder arthroplasty

Shoulder arthroplasty (SA) is commonly performed in patients with rheumatoid arthritis (RA) who have been treated with long-term immunosuppressive medication. RA is associated with an increased risk of neoplasms of the immune system. A case of non-Hodgkin's lymphoma as an unexpected diagnosis after the routine pathologic examination of the soft tissues after SA was detected in a 54-year-old woman with long-standing RA and prolonged immunosuppressive therapy. Although this case does not support the cost-effectiveness of routine specimen evaluation during SA, we suggest that histological analysis of the surgical tissues is appropriate and should be performed in all patients who have been treated with prolonged immunosuppressive medication, especially RA patients as well as patients who have suspicious surgical findings.     

Effect of rheumatoid arthritis on physical performance of patients

To determine the changes occurRing in physical performance of patients with RA, 188 patients have been observed over a ten-year period. The observation included two groups: the test group comprising 93 patients with RA who have never been treated by any disease-modifying antirheumatic drugs (DMARDs) and the control group comprising 95 patients with RA who have regularly taken DMARDs under the rheumatologist's supervision. The average age of the test group was considerably higher, there were more retired persons with a prolonged course of illness, their physical performance being more intensely affected than that of the control group. Further analysis during the observation period showed significant decrease of physical performance in both groups regardless of their being treated or not by the DMARDs which, in our opinion, only modify the illness. To conclude, irrespective of the application of the DMARDs, RA is undoubtedly an illness with considerable socio-economic significance since it leads to great physical disability (invalidity) of all RA patients.     

Acquired permanent dislocation of the patella in a patient with rheumatoid genu valgum

A case of acquired permanent dislocation of the patella associated with severe genu valgum in a patient with rheumatoid arthritis (RA) is herein reported. The pain and genu valgum progressed because of poor RA control. The patient had no history of major trauma of the knee before or after the onset of RA. The most reasonable hypothesis to explain this patient''s pathology is that occult patellar dislocation developed after a minor trauma and progressed to permanent dislocation; poor RA control then worsened both the patellar dislocation and genu valgum. Total knee arthroplasty (TKA) with patella reduction was successfully performed with release of the lateral retinaculum and extension of the extensor mechanism by partial snipping of the rectus femoris tendon. Two years after the operation, the patient exhibited improvement in her Knee Society Knee and Function Scores from preoperative scores of 18 and 20 to postoperative scores of 94 and 80, respectively. Acquired permanent dislocation of the patella associated with severe genu valgum in patients with RA is rare. Excellent results were obtained with TKA, and the proximal realignment method was a useful procedure for patella reduction.     

The Pitfalls in Surgical Management of Lumbar Canal Stenosis Associated with Rheumatoid Arthritis

There have been few clinical studies in the area of cervical spine that focused on surgery for treating degenerative lumbar disease in patients with rheumatoid arthritis (RA). High rates of wound complications and instrumentation failure have been reported more for RA than for non-RA patients, although clinical outcomes are similar between the two groups. Lumbar canal stenosis in RA is caused not only by degeneration but also by RA-related spondylitis, which includes facet arthritis and inflammation around the vertebral endplate. The pitfalls in surgical management of lumbar canal stenosis in RA patients are highlighted in this study. The study reviewed 12 patients with RA,who were surgically treated for lumbar canal stenosis. Two out of five patients with pulmonary fibrosis died of worsened pulmonary condition, even though there were no perioperative pulmonary complications. Two patients with pedicle screw fixation showed no instrumentation failure, but two patients with spinous process fixation needed re-operation or vertebral fracture. Surgical treatment for lumbar canal stenosis in RA patients needs to be individually adjusted. Preoperative assessments and treatments of pulmonary fibrosis and osteopenia are essential. Surgery for lumbar canal stenosis with RA should be deferred for patients with advanced pulmonary fibrosis because of its potential life-threatening risk. Fusion surgery is indicated only in patients with kyphosis or severe symptoms caused by intervertebral instability. Pedicle screw fixation with hydroxyapatite granules or sublaminar tape is recommended. Closer follow-up after surgery is necessary because of possible delayed wound infection, instrumentation failure, pathological fracture, and respiratory deterioration.     

Combined renal artery stenosis and aortic aneurysm: Treatment options

The purpose of this study was to analyze outcomes of two different treatment strategies in patients treated for renal artery (RA) stenosis and a coincidental abdominal aortic aneurysm (AAA). A total of 50 patients were encountered who required treatment for concomitant RA stenosis and an AAA from 1980 to 1994. Simultaneous operative aortic and RA reconstruction was done in 32 patients, whereas 18 patients were treated with preoperative percutaneous transluminal renal artery angioplasty (PTRA). The two groups were well matched with respect to age, AAA size, incidence of hypertension, preoperative creatinine level, and creatinine clearance (allp values >0.07). Aortorenal bypass (18 RAs), reimplantation (18 RAs), or endarterectomy (2 RAs) was performed to correct a mean RA stenosis of 88%, whereas 23 RAs (91% mean stenosis) were treated with preoperative PTRA. PTRA failed in four patients with RA stenosis, and they were successfully treated with surgery (3 bypasses and 1 reimplantation). Statistical analysis did not demonstrate a significant difference between these four failed PTRA-patients, the 14 successful PTRA patients, and the 32 RA reconstruction patients in terms of operating time (p=0.15), operative blood loss (p=0.20), intensive care unit days (p=0.71), or total hospital days (p=0.94). Among the 40 patients available for follow-up, hypertension was cured in seven, improved in 10, unchanged in 15, and worse in eight with no difference demonstrated between the groups (p=0.73). These data suggest that preoperative PTRA has no specific advantage over surgical RA reconstruction in patients with concomitant RA stenosis and AAA. Failed PTRA did not preclude or complicate subsequent operative RA revascularization.Presented at the Fourteenth Annual Meeting of the Southern California Vascular Surgical Society, September 15–17, 1995, La Jolla, Calif.     

Cardiovascular safety of biologic therapies for the treatment of RA

Cardiovascular disease represents a major source of extra-articular comorbidity in patients with rheumatoid arthritis (RA). A combination of traditional cardiovascular risk factors and RA-related factors accounts for the excess risk in RA. Among RA-related factors, chronic systemic inflammation has been implicated in the pathogenesis and progression of atherosclerosis. A growing body of evidence--mainly derived from observational databases and registries--suggests that specific RA therapies, including methotrexate and anti-TNF biologic agents, can reduce the risk of future cardiovascular events in patients with RA. The cardiovascular profile of other biologic therapies for the treatment of RA has not been adequately studied, including of investigational drugs that improve systemic inflammation but alter traditional cardiovascular risk factors. In the absence of large clinical trials adequately powered to detect differences in cardiovascular events between biologic drugs in RA, deriving firm conclusions on cardiovascular safety is challenging. Nevertheless, observational research using large registries has emerged as a promising approach to study the cardiovascular risk of emerging RA biologic therapies.     

Harvesting of the radial artery: subfasciotomy or full skeletonization: a comparative study

BACKGROUND: Long fasciotomy of the posterior aspect of the radial artery (RA) for the purpose of sympathectomy is one of the surgical techniques for the preparation of this graft. We compared the early results of this technique with those of the RA graft harvested as a pedicle in the conventional fashion. METHODS: The study patients have been selected from the patients who underwent coronary artery bypass grafting (CABG) using the RA graft harvested either with a long posterior fasciotomy (group 1) or as a whole with a pedicle in the classical manner (group 2). Only the patients with a flow study have been included. The flow index was described as the bleeding amount of the RA in a minute per body surface area (mL/m2 min). The flow index has been performed before and after fasciotomy in group 1, and after full skeletonization in group 2. The clinical and demographic parameters and flow indices were measured and compared between the groups, and in group 1, before and after fasciotomy. RESULTS: From 218 patients with CABG using the RA between January 1998 and August 2005, a total of 57 patients were recruited into the study. Group 1 consisted of 25 patients. Thirty-two patients constituted group 2. Subfascial dissection of the RA increased the blood flow index from 48 +/- 20 mL/m2 min to 51 +/- 19 mL/m2 min (p < 0.001). The comparison of the clinical, perioperative characteristics of the patients was not different between the groups. CONCLUSIONS: The necessity of total skeletonization of the RA should not be the only option when the aim is to reduce the spasm. While subfascial dissection (sympathectomy) of the pediculed RA alone provides a satisfactory increase in the blood flow index, it also reduces the manipulation time as well as the risk of injury to the graft.