How is it best to treat early rheumatoid arthritis patients?

During the past decade, many important changes have occurred in the treatment of rheumatoid arthritis, perhaps the most important of which has been the realization that early diagnosis and early treatment are critical. This has challenged our health-care systems to make sure that patients with early arthritis have access to the appropriate physicians. Additionally, the last decade has also seen many new treatment options become available for patients with rheumatoid arthritis. These new options have included the use of old drugs more effectively; the use of combinations of two or more disease-modifying anti-rheumatic drugs; new evidence to support the use of steroids; the resurrection of tetracyclines; the introduction of leflunomide; and, finally, the tumour necrosis factor inhibitors etanercept and infliximab. The availability of all these new options is clearly excellent news for patients with RA and their physicians. It is hoped that we will, in the next few years, better understand how most effectively to utilize these treatment options for the optimal care of our patients.     

Coronary perforation: What color is your parachute?

• Coronary perforation is a rare but devastating complication of PCI, requiring rescue devices such as covered stents.
• This paper documents the successful use of a pericardial covered stent in 9/9 patients for coronary perforation.
• Pericardial covered stents have theoretical advantages over PTFE covered stents, but clinical studies proving this are not feasible.

     

Postprandial hyperglycaemia: to treat or not to treat?

Accumulating evidence suggests that the postprandial or the post-75 g glucose load rise in plasma glucose are a contributing factor to the development of atherosclerosis. Many epidemiological studies have shown that post-load hyperglycaemia is a strong and independent risk factor for cardiovascular disease. The few interventional studies available also support a role for postprandial or post-load hyperglycaemia on cardiovascular disease or mortality or on validated surrogates of atherosclerosis. The mechanism through which acute hyperglycaemia could exert its deleterious effects on the vessel wall is very likely multifactorial, but the overproduction of free radicals is probably involved. There is growing evidence that treating postprandial hyperglycaemia should probably be part of the strategies for the prevention and management of cardiovascular diseases in pre-diabetes as well as in diabetes.     

Prandial hyperglycemia: Is it important to track and treat?

Prandial hyperglycemia comprises 16 to 18 hours in type 2 diabetes. Depending on quality of diabetes control, 30% to 70% of the variance of hemoglobin A1c is determined by postprandial glucose excursions. A large amount of evidence now shows that postprandial/postchallenge glucose value is an independent cardiovascular risk factor, especially for coronary heart disease. Excessive postprandial hyperglycemia initiates a cascade of proatherogenic disturbances, which leads to endothelial dysfunction and plaque instability. Measurement of 2-hour postprandial glucose after big meals should be performed once or twice a week in subjects with type 2 diabetes. Measurement of 2-hour glucose after a 75-g oral glucose tolerance test is the only way to detect subjects with impaired glucose tolerance and isolated postchallenge hyperglycemia in the diagnosis for diabetes. α-Glucosidase inhibitors, glinides, and shortacting analogue insulin allow a well-tailored control of type 2 diabetes with excessive postprandial hyperglycemia. Prospective trials have demonstrated that strict control of postprandial hyperglycemia reduces the incidence of cardiovascular events.     

Psoriatic arthritis: How to diagnosis it early?

Psoriatic arthritis (PsA) is an inflammatory arthritis that usually develops after the onset of cutaneous psoriasis. There is evidence that early diagnosis will lead to better long-term outcomes. Identifying inflammatory arthritis in subjects with psoriasis is the key to early diagnosis of PsA. Screening strategies using questionnaires or biomarkers targeted at subjects with psoriasis may result in early identification of PsA. This article reviews the importance of early diagnosis of PsA and the strategies available for screening psoriasis patients for PsA.     

Primary HIV infection: to treat or not to treat?

PURPOSE OF REVIEW: The aim of this article is to review new data on the use of antiretroviral therapy in primary HIV infection. RECENT FINDINGS: The concept of 'hit HIV hard and early' supporting the use of antiretroviral therapy to treat the early stages of HIV infection has been revisited. Recent demonstration of massive, rapid and largely irreversible HIV-mediated destruction of memory CD4+ T cells predominantly occurring in the gut suggests that primary HIV infection may be the only time that intervention could confer lasting immunological benefit. There are no data, however, from randomized controlled trials supporting the use of antiretroviral therapy in primary HIV infection, although a number of observational studies have demonstrated limited, transient improvements in measured immunological outcomes. The first randomized controlled trials powered to address whether antiretroviral therapy of a limited duration in primary HIV infection can influence long-term CD4 decline (SPARTAC) is now fully recruited but will report in 2-3 years. In addition, given that individuals with primary HIV infection contribute disproportionately towards onward HIV transmission, there may be an additional public health impetus for earlier diagnosis and intervention in primary HIV infection. SUMMARY: In the absence of randomized controlled trials data demonstrating clinical benefit of antiretroviral therapy intervention in primary HIV infection, clinical guidelines remain unclear. Intervention seems a logical strategy to counter the high viraemia, enhanced onward transmissibility, and immunological destruction which occurs during primary HIV infection. The nature, duration and timing of that intervention after HIV acquisition remains unknown.     

Double hit lymphoma: How do we define it and how do we treat it?

Double/triple hit lymphoma is recognised as a distinct entity within the heterogeneous group of high grade B-cell lymphomas, accounting for between 5 and 10% of cases of diffuse large B-cell lymphoma. Under the WHO 2016 it is now known as high-grade B-cell lymphoma with rearrangements of MYC and BCL2 and/or BCL6. When treated with standard chemotherapy it has a poor outcome. There is currently no standard of care for the management of this condition.Diagnosing double hit lymphoma requires identification of translocations of MYC and BCL2 and/or BCL6. This review will discuss the role of stratification to screen cases based on immunohistochemical profiling as a viable option. Treatment options in the frontline and relapsed setting will be reviewed based on the current literature. Recognition of the risk of CNS involvement and how best to manage this will be discussed. Future considerations and current research will be described.     

Neonatal colon perforation due to anorectal malformations: Can it be avoided?

Anorectal malformations (ARM) are common anomalies in neonates. Diagnostic and therapeutic delays in the management of ARM may lead to colonic perforation, and even death. Physical examination of the perineum is often sufficient to diagnose ARM in neonates. Notwithstanding, delayed diagnosis of ARM has become increasingly familiar to surgeons, as evidenced by the number of recent publications on this topic in the literature. In this commentary, we discuss spontaneous colonic perforation due to delayed diagnosis of ARM in neonates, and highlight the importance of early diagnosis in assuring good outcomes with surgical management. At this point, a thorough examination of the perineum during the initial newborn assessment is mandatory, particularly in those patients presenting with abdominal signs or symptoms.     

Vertebral fragility fractures – How to treat them?

Approximately 20% of men and women aged 50 years or older will present with a vertebral fragility fracture - a prevalence that steadily increases with age. The condition may be associated with severe pain and disability, significant reductions in overall quality of life, mobility, social participation, sleep quality and increased fear for the future. There is, however, no current consensus on what constitutes the best management of symptomatic vertebral fractures. Moreover, evidence supporting common treatment approaches is scarce and often of poor quality. The lack of adequate management of VFF and associated osteoporosis and the burden of this condition to patient and society are estimated to increase substantially in coming years as recurrent, disabling episodes are set to occur. This chapter will address these issues, including a discussion on existing care pathways for vertebral fragility fractures, and an overview of the evidence supporting recommendations of the main international clinical practice guidelines.