Treatment consensus for management of polymyositis and dermatomyositis among rheumatologists,neurologists and dermatologists

Although rheumatologists, neurologists and dermatologists see patients with polymyositis (PM) and dermatomyositis (DM), their management appears to vary depending on the physician’s specialty. The aim of the present study was to establish the treatment consensus among specialists of the three fields to standardize the patient care. We formed a research team supported by a grant from the Ministry of Health, Labor and Welfare, Japan. Clinical questions (CQ) on the management of PM and DM were raised. A published work search on CQ was performed primarily using PubMed. Using the nominal group technique, qualified studies and results in the published work were evaluated and discussed to reach consensus recommendations. They were sent out to the Japan College of Rheumatology, Japanese Society of Neurology and Japanese Dermatological Association for their approval. We reached a consensus in 23 CQ and made recommendations and a decision tree for management was proposed. They were officially approved by the three scientific societies. In conclusion, a multidisciplinary treatment consensus for the management of PM and DM was established for the first time.     

Weather effects in rheumatoid arthritis: from controversy to consensus. A review

OBJECTIVE: To review and evaluate the evidence for the widespread view that signs and symptoms of rheumatoid arthritis (RA) are influenced, or even caused, by the weather. METHODS: A literature search from 1985 to April 2003 was performed using the PubMed database of the US National Library of Medicine. Additional relevant articles were identified from the bibliographies, and from our own archives. Methods and findings of the studies were critically reviewed. RESULTS: Only temperature and humidity appear to have clear influences on the symptoms of RA, although the reported findings do not agree. In many cases, the apparent controversies can be explained by the intimate relationship between temperature and humidity, and by taking local circumstances into account. The differences in the methods applied in studies on effects of weather on RA strongly hampered our evaluation. CONCLUSION: RA variables are positively correlated with the humidity of the microclimate at the patient's skin. High outdoor relative humidity is unfavorable, but has less influence when there are few barriers for water vapor, like clothes, and when air conditioning is used. High temperature is unfavorable since it increases absolute humidity, but beneficial as well, since it reduces the presence of barriers, and stimulates the use of air conditioning. The classic opinion, "Cold and wet is bad, warm and dry is good for RA patients," seems to be true only as far as humidity is concerned.     

Practices for managing a flare of long-standing rheumatoid arthritis: survey among French rheumatologists

OBJECTIVE: To describe the practices of rheumatologists in France for managing a flare in a patient being treated for long-standing rheumatoid arthritis (RA) and to estimate the corresponding costs. METHODS: A survey questionnaire was sent to the 2485 practicing rheumatologists in France; 917 completed questionnaires were returned (37% response rate). The questionnaire collected information on the respondents and on their recommendations for managing a fictional patient with a 10-year history of RA in flare, with a recent episode of neck pain, despite prednisone and methotrexate therapy. Investigational and treatment (first month) costs were estimated from the perspective of society in 2001 Euros. RESULTS: Over 80% of the respondents recommended measuring laboratory inflammation parameters, complete blood cell counts, liver enzymes, serum creatinine, and radiographs (hands, anteroposterior cervical spine view, wrists, knees); 50-70% recommended additional cervical spine incidences, elbow and chest radiographs, and bone absorptiometry. Adding anti-TNF therapy (24%) or another DMARD (10%), increasing the methotrexate dosage (24%), and substituting leflunomide for methotrexate were the main recommended treatments. Most respondents suggested continuing the glucocorticoid in the same dosage (61%) or a higher dosage (36%). Analgesics and non-steroidal anti-inflammatory drugs were recommended by 65% and 41% of respondents and rehabilitation therapy by 83%. The median cost was 500 Euro (mean 1105 Euro; range 80-4089 Euro). CONCLUSION: We found a high level of agreement among French rheumatologists regarding the evaluation of established RA. Marked variations in recommended treatments were observed and translated into major cost differences.     

Surgical management and pathological assessment of pancreatoduodenectomy with venous resection: an international survey among surgeons and pathologists

BackgroundThe aim of this survey was to gain insights in the current surgical management and pathological assessment of pancreatoduodenectomy with portal–superior mesenteric vein resection (VR).MethodsA systematic literature search was performed to identify international expert surgeons (N = 150) and pathologists (N = 40) who published relevant studies between 2009 and 2019. These experts and Dutch surgeons (N = 17) and pathologists (N = 20) were approached to complete an online survey.ResultsOverall, 76 (46%) surgeons and 37 (62%) pathologists completed the survey. Most surgeons (71%) estimated that preoperative imaging corresponded correctly with intraoperative findings of venous involvement in 50–75% of patients. An increased complication risk following VR was expected by 55% of surgeons, mainly after Type 4 (segmental resection-venous conduit anastomosis). Most surgeons (61%) preferred Type 3 (segmental resection-primary anastomosis). Most surgeons (75%) always perform the VR themselves. Standard postoperative imaging for patency control was performed by 54% of surgeons and 39% adjusted thromboprophylaxis following VR. Most pathologists (76%) always assessed tumor infiltration in the resected vein and only 54% of pathologists always assess the resection margins of the vein itself. Variation in assessment of tumor infiltration depth was observed.ConclusionThis international survey showed variation in the surgical management and pathological assessment of pancreatoduodenectomy with venous involvement. This highlights the lack of evidence and emphasizes the need for research on imaging modalities to improve patient selection for VR, surgical techniques, postoperative management and standardization of the pathological assessment.     

HIV therapy in 2003: consensus and controversy

HIV therapy has well-established and substantial clinical benefits. Awareness of these benefits has brought many infected persons into care. Many more infected persons would be treated were it not for the frequent side effects associated with antiretroviral drugs. All antiretroviral agents can cause both short-term and long-term toxicities. This is a particularly vexing problem as current data does not allow accurate predictions of treatment toxicities and, in many cases, side effects are only partially reversible. Moreover, therapy is frequently associated with the selection of drug-resistant viral isolates and incomplete viral suppression. This is commonly caused by inadequate medication adherence and leads to increasingly severe virologic failure. The present review will address both the striking advantages of HIV therapy as well as the ongoing challenges in its application.     

Surgical management of the hand in scleroderma.

Disabling deformity of the hand is a hallmark feature of the person afflicted with scleroderma. However, existing literature provides little guidance to operative treatment for the wide spectrum of hand derangement. Although arthrodesis is generally recommended for severe flexion contractures of the interphalangeal joints, other surgical procedures such as arthroplasty, excision of painful calcinosis, and digital sympathectomy have been employed sparingly, undoubtedly due to potentially hazardous soft tissue conditions. Based on experience with 70 scleroderma patients requiring 272 hand operations, this article provides further insight as to the role of surgical treatment for the scleroderma hand. The favorable results in this relatively large series of cases support the efficacy of precisely timed and skillfully executed surgery in the alleviation of pain, prevention of tissue loss, preservation of function, and improvement in aesthetics. For the ischemic tissues of the scleroderma hand the prerequisite for uncomplicated surgery is a tension-free wound, often requiring judicious skeletal shortening and healing by secondary intention.     

Definition of colorectal anastomotic leakage: A consensus survey among Dutch and Chinese colorectal surgeons

AIM To determine the level of consensus on the definition of colorectal anastomotic leakage(CAL) among Dutch and Chinese colorectal surgeons.METHODS Dutch and Chinese colorectal surgeons were asked to partake in an online questionnaire. Consensus in the online questionnaire was defined as 80% agreement between respondents on various statements regarding a general definition of CAL,and regarding clinical and radiological diagnosis of the complication.RESULTS Fifty-nine Dutch and 202 Chinese dedicated colorectal surgeons participated in the online survey. Consensus was found on only one of the proposed elements of a general definition of CAL in both countries: ‘extravasation of contrast medium after rectal enema on a CT scan'. Another two were found relevant according to Dutch surgeons: ‘necrosis of the anastomosis found during reoperation',and ‘a radiological collection treated with percutaneous drainage'. No consensus was found for all other proposed elements that may be included in a general definition.CONCLUSION There is no universally accepted definition of CAL in the Netherlands and China. Diagnosis of CAL based on clinical manifestations remains a point of discussion in both countries. Dutch surgeons are more likely to report ‘subclinical' leaks as CAL,which partly explains the higher reported Dutch CAL rates.     

Survey of practices regarding management of early rheumatoid arthritis by rheumatologists in France

OBJECTIVE: To describe the practices of rheumatologists in France regarding the initial management of early rheumatoid arthritis (RA) and to estimate the associated costs. METHODS: A questionnaire on the diagnosis and treatment of early RA was sent to the 2485 practicing rheumatologists in France. The results of the 917 completed questionnaires (37% response rate) were analyzed, and initial investigation and treatment costs, including the first month of treatment, were calculated from a socio-economic perspective. RESULTS: For the RA diagnosis, more than 80% of the respondents recommended the erythrocyte sedimentation rate, C-reactive protein, complete blood count, rheumatoid factor, antinuclear antibody and wrist radiographs. In 40% and 60% of the cases, antikeratin antibody, liver enzymes, serum creatine, serum protein electrophoresis and radiographs (chest, foot and knee) were advocated. Initial drugs administered were non-steroidal antiinflammatory agents (88%), analgesics (76%), disease modifying anti-rheutmatic drugs (74% with methotrexate in 46% of cases, followed by hydroxychloroquine [13%], sulfasalazine [8%], leflunomide [7%], intramuscular gold therapy [6%]), and glucocorticoids (21%). Rehabilitation was recommended by 51% of the respondents. The median cost for this initial management was 273 euros (mean 301 euros, range 49-1,336 euros). CONCLUSION: Marked variations occur among French rheumatologists in the initial management of early RA. These data may be helpful in identifying obstacles to physician compliance with recommendations regarding everyday clinical practice and to set up more a specific evaluative study.     

Variation among rheumatologists in the use of prednisone and second-line agents for the treatment of rheumatoid arthritis

Objective. To test for and estimate variation among rheumatologists in their prescribing of prednisone and second-line agents for the treatment of rheumatoid arthritis (RA), after taking into account the characteristics of their patients. Methods. Multiple logistic regression incorporating random effects for rheumatologists, with adjustment for patient characteristics. Results. Values for the likelihood-ratio statistic provided strong evidence of such variation. Random-effect variance estimates showed that the variation is of great magnitude. Conclusion. Even after patient characteristics have been taken into account, the data show that the rheumatologist may strongly influence the use of prednisone and second-line agents by a patient.     

SFE-AFCE-SFMN 2022 consensus on the management of thyroid nodules: Surgical treatment

The SFE-AFCE-SFMN 2022 consensus deals with the management of thyroid nodules, a condition that is a frequent reason for consultation in endocrinology. In more than 90% of cases, patients are euthyroid, with benign non-progressive nodules that do not warrant specific treatment. The clinician's objective is to detect malignant thyroid nodules at risk of recurrence and death, toxic nodules responsible for hyperthyroidism or compressive nodules warranting treatment. The diagnosis and treatment of thyroid nodules requires close collaboration between endocrinologists, nuclear medicine physicians and surgeons, but also involves other specialists. Therefore, this consensus statement was established jointly by 3 societies: the French Society of Endocrinology (SFE), French-speaking Association of Endocrine Surgery (AFCE) and French Society of Nuclear Medicine (SFMN); the various working groups included experts from other specialties (pathologists, radiologists, pediatricians, biologists, etc.). This section deals with the surgical management of thyroid nodules.     

Current situation,consensus and controversy of perioperative nutrition management in pancreatic surgery: A narrative review

Pancreatic surgery contains several major procedures of pancreatectomy. Surgical trauma, severe complications and preoperative nutritional disorders will affect...     

Definition and subcategorization of idiopathic short stature: between consensus and controversy

Although various expert and consensus meetings have been held, there remains uncertainty about the definition of idiopathic short stature (ISS) and its subgroups. In this short review, the hypothetical pathophysiology, diagnosis and subcategorization of ISS are discussed. ISS in childhood may be the result of a combination of variants of three groups of genes: (1) single genes (or combinations of a few single genes) of which mutations, deletions or duplications are associated with a relatively large negative effect on height; (2) genes of which relatively frequently occurring polymorphisms are associated with a small negative effect on height; and (3) genes associated with delayed maturation of the epiphyseal plate. Differentiation between ISS and short children born small for gestational age and those with dysmorphic syndromes, systemic diseases or growth hormone deficiency and resistance can be difficult. Subcategorization based on distance to target height and onset of puberty is arbitrary, but useful.