Nutritional status in patients with rheumatoid arthritis.

A nutritional assessment of 50 patients with rheumatoid arthritis (RA) showed evidence of malnutrition in 13 (26%), while all 50 control subjects had normal nutritional status. Of the anthropometric measurements the body-mass index and triceps skinfold thickness values in men and women were significantly reduced in RA patients compared with controls. Upper arm muscle circumference was significantly less in male but not female rheumatoid patients. In addition all six biochemical determinants of nutrition assayed-serum albumin, transferrin, retinol-binding protein, thyroxine-binding prealbumin, zinc, and folic acid-were significantly lower in the RA group of patients. Malnourished patients had more active disease than the remaining RA patients, with significantly higher ESR, C-reactive protein, and alpha 1 antichymotrypsin measurements. Significant inverse correlations were found between some biochemical measurements of nutrition and indices of disease activity. Our results suggest that in RA the severity of disease adversely affects the nutritional status.     

Transcatheter Versus Surgical Aortic Valve Replacement in Young,Low-Risk Patients With Severe Aortic Stenosis

Transcatheter aortic valve replacement (TAVR) is approved for all patient risk profiles and is an option for all patients irrespective of age. However, patients enrolled in the low- and intermediate-risk trials were in their 70s, and those in the high-risk trials were in their 80s. TAVR has never been systematically tested in young (<65 years), low-risk patients. Unanswered questions remain, including the safety and effectiveness of TAVR in patients with bicuspid aortic valves; future coronary access; durability of transcatheter heart valves; technical considerations for surgical transcatheter heart valve explantation; management of concomitant conditions such as aortopathy, mitral valve disease, and coronary artery disease; and the safety and feasibility of future TAVR-in-TAVR. The authors predict that balancing these questions with patients’ clear preference for less invasive treatment will become common. In this paper, the authors consider each of these questions and discuss risks and benefits of theoretical treatment strategies in the lifetime management of young patients with severe aortic stenosis.     

Treatments for pulmonary sarcoidosis

Corticosteroids (oral or inhaled) are commonly used to treat pulmonary sarcoidosis; however, there is no consensus about when to start treatment, what dose of steroids to give and for how long. Immunosuppressive and cytotoxic agents (used in immunosuppressive doses) are used in addition to oral corticosteroids to treat multisystem and chronic sarcoidosis, or as steroid-sparing agents. We summarize the findings from two Cochrane systematic reviews that have examined the efficacy of corticosteroids and immunosuppressive and cytotoxic drugs in the treatment of pulmonary sarcoidosis. Studies of corticosteroids differed in outcome measures, dose of drug given and length of treatment. For many outcome measures, data could not be pooled for meta-analysis. Oral corticosteroids improved chest X-ray appearance over 3-24 months, with improvement in global score in one study. Little evidence was found of improvement in lung function or of any long-term disease-modifying effect. Follow-up data could not be analysed. Inhaled corticosteroids improved symptoms in one small study but not lung function or chest X-ray. Side-effects of steroids were not well reported. In the immunosuppressive and cytotoxics review, no data could be combined for meta-analysis. Data on lung function, chest X-ray and dyspnoea were largely inconclusive. Methotrexate had a steroid-sparing effect in one small study. Significant adverse events were associated with cyclosporine A, chloroquine and pentoxifylline. Evidence from randomized-controlled trials (RCTs) supporting the use of immunosuppressive and cytotoxic agents is limited.     

Comparison of disability and quality of life in rheumatoid and psoriatic arthritis

OBJECTIVE: There is controversy about the severity of peripheral psoriatic arthritis (PsA) compared to rheumatoid arthritis (RA). Early reports found PsA to be a milder disorder, excepting the mutilans form. Recent reports suggest that PsA can be as severe as RA. We compared severity, disability, and quality of life in patients with PsA and RA matched primarily for disease duration. METHODS: Data relating to the extent and severity of disease were recorded in a hospital clinic setting. Recent radiographs of hands and feet were read blinded to diagnosis, and information on function and quality of life was collected with the Health Assessment Questionnaire (HAQ) and EuroQol-5D, respectively. RESULTS: Forty-seven patients were matched for disease duration (median PsA 5 yrs, RA 7 yrs). The male/female ratio was 24/23 for PsA, 16/31 for RA, and median ages were 45 and 51 years, respectively. Patients with RA had significantly more joint involvement of metacarpophalangeal joints and wrists, whereas distal interphalangeal joints, spine, sternoclavicular joints, and sacroiliac joints were significantly more involved in PsA. No difference was found regarding Ritchie Articular Index, inflammatory markers, HAQ score, or EuroQol-5D. Patients with RA had significantly more damage on radiographs of hands and feet: median (range) Larsen score hands PsA 8 (0-91), RA 38 (0-125); feet PsA 4 (0-34), RA 11(0-56). Patients with RA were taking significantly more disease modifying drugs. CONCLUSION: Peripheral joint damage is significantly greater in RA than in PsA after equivalent disease duration, but function and quality of life scores are the same for both groups. The additional burden of skin disease in PsA may account for this.     

Supported discharge service versus inpatient care evaluation (SITE): a randomised controlled trial comparing effectiveness of an intensive community care service versus inpatient treatment as usual for adolescents with severe psychiatric disorders: self-harm,functional impairment,and educational and clinical outcomes

Clinical guidelines recommend intensive community care service treatment (ICCS) to reduce adolescent psychiatric inpatient care. We have previously reported that the addition of ICCS led to a substantial decrease in hospital use and improved school re-integration. The aim of this study is to undertake a randomised controlled trial (RCT) comparing an inpatient admission followed by an early discharge supported by ICCS with usual inpatient admission (treatment as usual; TAU). In this paper, we report the impact of ICCS on self-harm and other clinical and educational outcomes. 106 patients aged 12–18 admitted for psychiatric inpatient care were randomised (1:1) to either ICCS or TAU. Six months after randomisation, we compared the two treatment arms on the number and severity of self-harm episodes, the functional impairment, severity of psychiatric symptoms, clinical improvement, reading and mathematical ability, weight, height and the use of psychological therapy and medication. At six-month follow-up, there were no differences between the two groups on most measures. Patients receiving ICCS were significantly less likely to report multiple episodes (five or more) of self-harm (OR = 0.18, 95% CI: 0.05–0.64). Patients admitted to private inpatient units spent on average 118.4 (95% CI: 28.2–208.6) fewer days in hospitals if they were in the ICCS group compared to TAU. The addition of ICCS to TAU may lower the risk of multiple self-harm and may reduce the duration of inpatient stay, especially in those patients admitted for private care. Early discharge with ICCS appears to be a viable alternative to standard inpatient treatment.

     

Decision-making processes of a nurse working in mental health,regarding disclosure of confidential personal health information of a patient assessed as posing a risk

BackgroundNurses working in mental health routinely face difficult decisions regarding confidentiality and disclosure of patient information. There is public interest in protecting patient confidentiality, and there is a competing public interest in disclosing relevant confidential information to protect the patient or others from harm. However, inappropriate disclosures may constitute a breach of confidentiality. Despite the gravity of this situation, there is a paucity of literature to guide nurses’ decision-making processes regarding confidentiality and disclosure.AimTo examine decision-making processes of a nurse working in mental health, regarding disclosure of personal health information of a patient assessed as posing a risk.MethodsQualitative interpretivist approach using thematic analysis of data derived from an instrumental case study of NK v Northern Sydney Central Coast Area Health Service 2010, a Civil and Administrative Tribunal matter in New South Wales, Australia.FindingsThree important legal concerns relevant to nurses’ decision-making processes are illuminated. Firstly, for risk assessment there was an emphasis on a static notion of dangerousness. Secondly, rules of confidentiality and disclosure were not adequately observed. Thirdly, confidential information was disclosed without valid justification.DiscussionInappropriate decision-making processes that may lead to a breach of patient confidentiality were evident in the findings. Gaps in understanding nurses’ decision-making processes pertaining to confidentiality and disclosure of patient information that may be addressed by future research were also revealed.ConclusionFuture research that addresses gaps in understanding nurses’ decision-making processes identified by this instrumental case study would provide greater guidance for nurses when making decisions regarding confidentiality and disclosure related to risk.     

An infiltrating rheumatoid nodule?

The case is presented of a patient with mild rheumatoid arthritis who developed an enlarged painful tissue mass in the left lower leg. Although the history, clinical, and imaging appearances suggested that it was a soft tissue sarcoma, a biopsy specimen showed histological features consistent with either a rheumatoid nodule or subcutaneous granuloma annulare.