Psoriatic arthritis: recent advances in pathogenesis and treatment.

Psoriatic arthritis has been recognized as a distinct form of inflammatory arthritis on the basis of clinical and epidemiologic studies. Although the pathogenesis of psoriatic arthritis remains unclear, the role of genetic, immunologic, and environmental factors has been studied. Although there is evidence to support the contribution of these factors in psoriatic arthritis, none is conclusive. Some of the therapeutic modalities used in psoriatic arthritis are based on pathogenetic factors. Thus, anti-inflammatory medications form the mainstay of therapy. Disease-modifying drugs have been used, with the most recent approach being dietary modification in response to identifying arachidonic acid metabolites as possible contributors to the disease process.     

Short‐term outcome of neuropsychiatric events in systemic lupus erythematosus upon enrollment into an international inception cohort study

Objective

To determine the short‐term outcome of neuropsychiatric (NP) events upon enrollment into an international inception cohort of patients with systemic lupus erythematosus (SLE).

Methods

The study was performed by the Systemic Lupus International Collaborating Clinics. Patients were enrolled within 15 months of SLE diagnosis and NP events were characterized using the American College of Rheumatology case definitions. Decision rules were derived to identify NP events attributable to SLE. Physician outcome scores of NP events and patient‐derived mental component summary (MCS) and physical component summary (PCS) scores of the Short Form 36 were recorded.

Results

There were 890 patients (88.7% female) with a mean ± SD age of 33.8 ± 13.4 years and mean disease duration of 5.3 ± 4.2 months. Within the enrollment window, 271 (33.5%) of 890 patients had at least 1 NP event encompassing 15 NP syndromes. NP events attributed to SLE varied from 16.5% to 33.9% using alternate attribution models and occurred in 6.0–11.5% of patients. Outcome scores for NP events attributed to SLE were significantly better than for NP events due to non‐SLE causes. Higher global disease activity was associated with worse outcomes. MCS scores were lower in patients with NP events, regardless of attribution, and were also lower in patients with diffuse and central NP events. There was a significant association between physician outcome scores and patient MCS scores only for NP events attributed to SLE.

Conclusion

In SLE patients, the short‐term outcome of NP events is determined by both the characteristics and attribution of the events.     

Risk factors for coronary heart disease in women with systemic lupus erythematosus: the Toronto Risk Factor Study

OBJECTIVE: Because women with systemic lupus erythematosus (SLE) are 5-8 times more likely to develop coronary heart disease (CHD) than are women in the general population, we assessed the prevalence of classic risk factors for CHD in women with SLE. METHODS: Consecutive female patients with SLE who were without evidence of CHD and were attending a large lupus clinic in Toronto were studied. The control population was recruited from among age-matched subjects attending a family practice unit for an annual physical examination. The prevalence of classic CHD risk factors and the 10-year risk of a CHD-related event were determined using the Framingham risk assessment formula. Lipid subfractions, other metabolic risk factors, lifestyle variables, and demographic characteristics were also compared between the 2 groups. RESULTS: We studied 250 SLE patients and 250 controls whose mean +/- SD age was 44.8 +/- 12 years and 44.3 +/- 15 years, respectively. Hypertension and diabetes were significantly more common among the SLE patients. Although the SLE patients had a higher mean number of CHD risk factors per patient, the 10-year risk of a CHD-related event, using the Framingham multiple risk factor assessment, was the same in SLE patients and controls (3.2%). Compared with controls, SLE patients had higher levels of very low-density lipoprotein cholesterol and total triglycerides, and had higher levels of homocysteine despite having higher folate levels. Premature menopause, sedentary lifestyle, and an at-risk body habitus were also more prevalent in SLE patients. CONCLUSION: Women with SLE have a range of detectable coronary risk factors that are not fully reflected in the Framingham risk factor formula. These factors are likely to contribute to the loss of protection from CHD that has been observed in SLE.     

Effect of antimalarial agents on the fasting lipid profile in systemic lupus erythematosus

OBJECTIVE: To ascertain the relative effect of antimalarial (AM) agents on fasting lipid fractions in patients with systemic lupus erythematosus (SLE). METHODS: The study was cross sectional including all patients with SLE who were seen in our lupus clinic with fasting lipid profiles measured as part of evaluation from November 1995 to March 1999. RESULTS: A total of 123 patients with a mean age of 45.3 years and mean disease duration 13.4 years were studied; 73.2% were taking prednisone with a mean +/- SD dose of 10.9 +/- 9.2 mg/day, 48.0% were taking AM, and 30.8% were taking both. In the entire group, patients taking AM had a 12.5% lower total cholesterol (TC) (5.11 +/- 1.27 vs 5.84 +/- 1.23; p = 0.002), 22.1% lower very low density lipid-cholesterol (VLDL-C) (0.66 +/- 0.40 vs 0.85 +/- 0.39; p = 0.01), and 15.7% lower LDL-C (3.01 +/- 1.14 vs 3.58 +/- 1.10; p = 0.007). For patients taking prednisone, those taking concomitant AM (n = 38) had significantly lower TC (5.26 +/- 1.30 vs 5.99 +/- 1.29; p = 0.01), VLDL-C (0.65 +/- 0.39 vs 0.85 +/- 0.41; p = 0.02), and LDL-C (3.05 +/- 1.20 vs 3.69 +/- 1.09; p = 0.01) than those without AM (n = 48). For patients taking < or = 10 mg/day prednisone, TC (4.69 +/- 0.88 vs 5.74 +/- 1.20; p < 0.001), VLDL-C (0.61 +/- 0.37 vs 0.83 +/- 0.44; p = 0.05), and LDL-C (2.57 +/- 0.76 vs 3.49 +/- 1.04; p < 0.001) were still lower in patients with concomitant AM (n = 22) than those without AM (n = 36). CONCLUSION: TC, VLDL-C, and LDL-C levels were significantly lower in patients taking AM, including patients taking concomitant prednisone. Thus AM may have beneficial effects in SLE in addition to disease suppression.     

Caring for cognitively impaired older patients in the general hospital: A qualitative analysis of similarities and differences between a specialist Medical and Mental Health Unit and standard care wards

Background

Around half of people aged over 70 years admitted as an emergency to general hospital have dementia, delirium or both. Dissatisfaction is often expressed about the quality of hospital care. A Medical and Mental Health Unit was developed to provide best practice care to cognitively impaired older patients. The Unit was evaluated by randomised controlled trial compared to standard care wards. Part of this evaluation involved structured non-participant observations of a random sub-sample of participants and the recording of field notes.

Objectives

The aim of this paper is to compare and contrast the behaviours of staff and patients on the Medical and Mental Health Unit and standard care wards and to provide a narrative account that helps to explain the link between structure, process and reported outcomes.

Design

Field notes were analysed using the constant comparison method.

Setting

A large hospital within the East Midlands region of the United Kingdom.

Participants

Patient participants were aged over 65, and identified by Admissions Unit physicians as being ‘confused’. Most patients had delirium or dementia.

Results

Sixty observations (360 h) were made between March and December 2011. Cognitively impaired older patients had high physical and psychological needs, and were cared for in environments which were crowded, noisy and lacked privacy. Staff mostly prioritised physical over psychological needs. Person-centred care on the Medical and Mental Health Unit was mostly delivered during activity sessions or meal times by activities coordinators. Patients on this unit were able to walk around more freely than on other wards. Mental health needs were addressed more often on the Medical and Mental Health Unit than on standard care wards but most staff time was still taken up delivering physical care. More patients called out repetitively on the Unit and staff were not always able to meet the high needs of these patients.

Conclusion

Care provided on the Medical and Mental Health Unit was distinctly different from standard care wards. Improvements were worthwhile, but care remained challenging and consistent good practice was difficult to maintain. Disruptive vocalisation may have been provoked by concentrating cognitively impaired patients on one ward.     

Successive unfolding of two different collagen vascular diseases in the same patient

Genetic factors may be important in the development of autoimmune disease. We describe the development of fulminant systemic lupus erythematosus in a patient 5 years after recovery from polymyositis. The successive unfolding of different autoimmune diseases in the same individual is suggestive of sequential gene activation.     

Primary malignant lymphoma of the spleen in systemic lupus erythematosus

Malignant lymphoma has been infrequently reported in the course of systemic lupus erythematosus (SLE). We report a case of primary malignant lymphoma of the spleen, an unusual site of primary lymphoma, complicating the course of systemic lupus erythematosus (SLE). Our patient had been treated with low dose prednisone and hydroxychloroquine only, and her lupus was quiescent at the time of presentation with the lymphoma. Thus primary malignant lymphoma should be considered in the differential diagnosis of splenomegaly in SLE.