Transulnar angiography and intervention: The next frontier in vascular access?

• This study demonstrates that in a single center, single operator experience, ulnar artery catheterization is feasible, though even compared to radial access, a significant learning curve remains.
• Although ulnar access is a reasonable alternative approach to catheterization, the true benefits of ulnar access, compared to radial are unclear.
• Further large randomized multicenter, multi‐operator trials are needed to assess the true feasibility and benefit of ulnar artery catheterization.

     

Successful use of infliximab in the treatment of Reiter’s syndrome: a case report and discussion

Reiter’s syndrome is one of the reactive forms of seronegative spondyloarthropathies. Various therapies used in the management of Reiter’s syndrome are nonsteroidal antiinflammatory drugs (NSAIDs), antibiotics, and disease-modifying antirheumatic drugs (DMARDs) such as sulfasalazine (SSZ) or methotrexate (MTX). There is only one case report of successful treatment of Reiter’s syndrome with tumor necrosis factor-α (TNF-α) blockers in human immunodeficiency virus (HIV) patient (Gaylis N, 2003, J Rheumatol 30(2):407–411 Feb). We hereby report a case of Reiter’s syndrome treated successfully with infliximab, an anti-TNF-α chimeric monoclonal antibody. A 28-year-old white male presented with painful swelling of right elbow and ankle joints, urethritis. and lesions involving skin of soles of feet and penis. Detailed work-up of sexually transmitted diseases (STDs), HIV, and systemic etiology were negative. Despite aggressive treatment with antibiotics, NSAIDS, prednisone, and MTX for 3 months, he had persistent synovitis and worsening of skin lesions. He was then treated with infliximab 200 mg intravenously at weeks 0, 2, 6, and 14 weeks which resulted in complete resolution of arthritis and skin lesions within 6 weeks of infliximab therapy.     

Diffuse alveolar hemorrhage secondary to sarcoidosis

Clinical Rheumatology - Diffuse alveolar hemorrhage (DAH) is a pulmonary condition that can be caused by autoimmune disorders such as lupus, small vessel vasculitis, and antiphospholipid syndrome....     

Thousands of missing variants in the UK Biobank are recoverable by genome realignment

The UK Biobank is an unprecedented resource for human disease research. In March 2019, 49,997 exomes were made publicly available to investigators. Here we note that thousands of variant calls are unexpectedly absent from this dataset, with 641 genes showing zero variation. We show that the reason for this was an erroneous read alignment to the GRCh38 reference. The missing variants can be recovered by modifying read alignment parameters to correctly handle the expanded set of contigs available in the human genome reference. Given the size and complexity of such population scale datasets, we propose a simple heuristic that can uncover systematic errors using summary data accessible to most investigators.     

Cocaine use and its rheumatic manifestations: a case report and discussion

Cocaine use can be associated with a wide spectrum of rheumatic manifestations. It poses a diagnostic challenge as the patients usually withhold the information of cocaine use, and no serological tests are available to establish this diagnosis. We report a patient with vasculopathic syndrome secondary to cocaine use. Despite initial denial of drug abuse, skin biopsy suggested the diagnosis, which was subsequently confirmed by urine drug testing. Differentiating cocaine-associated pseudovasculitis from true vasculitis is necessary, as conventional treatment is usually ineffective without complete abstinence from cocaine use and may be associated with significant morbidity as well as mortality.     

Are proton pump inhibitors safe during pregnancy and lactation? Evidence to date

Symptoms of gastro-oesophageal reflux disease (GORD or GERD) are estimated to occur in 30-50% of pregnancies, with the incidence approaching 80% in some populations. As with many other conditions in pregnancy, medical therapy with pharmaceutical agents is a concern, as the potential teratogenicity of medications is not well known. Although prevalence numbers are high, many patients have mild and infrequent symptoms, which often respond to lifestyle and dietary modifications. The exact mechanism and pathogenesis of GERD associated with pregnancy is likely multifactorial. Treatment strategies for patients not responding to conservative therapies include a step-up approach initially starting with antacids and alginates, and progressing to histamine H(2) receptor antagonists followed by proton pump inhibitor (PPI) therapy if indicated by symptoms. Although PPI therapy is the most effective treatment available for GERD, the data related to the safety for use during pregnancy and postpartum breastfeeding are mostly obtained from cohort analysis. Given the significant adverse impact of GERD on quality of life and functionality, the use of this class of medications should not be overly restricted based solely on the pregnancy. Based on the studies presented, exposure to PPI therapy during pregnancy seems to predispose the fetus to minimal risk and, overall, these medications should be discussed with the primary physician if symptomatically necessary in the pregnant patient. This evidence-based review will address the management and safety of PPI therapy during pregnancy and lactation, and briefly review the pathogenesis, clinical presentation and diagnosis of GERD in this population.     

Methylene blue toxicity following infusion to localize parathyroid adenoma

The parathyroid glands are small, inconspicuous, and variable in number, colour and position. Their identification is vital for excision of hyper-functioning glands and for preservation of normally functioning ones in patients undergoing thyroidectomy. Intravenous infusion of methylene blue at a dose of 7.5 mg/kg is commonly used to aid visualization of the parathyroid glands intra-operatively. Methylene blue is generally considered benign, and there are only two cases published in the literature reporting toxicity following intravenous infusion--such toxicity is a diagnosis of exclusion. We report a case of methylene blue toxicity resulting in expressive aphasia, confusion and disinhibition following infusion for parathyroid adenoma localization. The patient made a complete recovery over 48 hours. Methaemoglobinaemia was excluded as a cause. We suggest that the mechanism of toxicity was a direct effect of methylene blue, although an adverse interaction with serotonin re-uptake inhibitors could not be excluded. In keeping with the UK National Poisons Information Service recommendations, we have altered our practice and now use methylene blue at a dose not exceeding 4 mg/kg. This has not affected our success rate for identification of parathyroid glands. We report this case to highlight the rare occurrence of methylene blue toxicity when used at a dose of 7.5 mg/kg.     

Double-Negative αβ T Cells Are Early Responders to AKI and Are Found in Human Kidney

Ischemia-reperfusion injury (IRI) is a major cause of AKI, and previous studies established important roles for conventional CD4⁺ T cells, natural killer T cells, and CD4⁺CD25⁺FoxP3⁺ Tregs in AKI pathogenesis. We recently identified CD4⁻CD8⁻ (double-negative; DN) T cells as an important subset of αβ T cell receptor–positive cells residing in mouse kidney. However, little is known about the pathophysiologic functions of kidney DN T cells. In this study, we phenotypically and functionally characterized murine kidney DN T cells in the steady state and in response to IRI. Unlike CD4⁺ and CD8⁺ T cells, DN T cells in the steady state expressed high levels of CD69, CD28, and CD40L; differentially expressed IL-27 and IL-10 anti-inflammatory cytokines; spontaneously proliferated at a very high rate; and suppressed in vitro proliferation of activated CD4⁺ T cells. Within the first 3–24 hours after IRI, kidney DN T cells expanded significantly and upregulated expression of IL-10. In adoptive transfer experiments, DN T cells significantly protected recipients from AKI by an IL-10–dependent mechanism. DN T cells also made up a large fraction of the T cell compartment in human kidneys. Our results indicate that DN T cells are an important subset of the resident αβ⁺ T cell population in the mammalian kidney and are early responders to AKI that have anti-inflammatory properties.