Stress and resilience in rheumatic diseases: a review and glimpse into the future

Stress resilience factors, and interventions to ease stress and enhance resilience, are gaining increasing attention for the treatment of rheumatic conditions. This Review presents a digest of empirical work on the factors that determine the risk of adapting poorly to a rheumatic condition, and on the resilience factors that counteract such risks. We consider the types of stress-management and resilience treatments that are most effective in promoting the physical and psychological functioning of patients at risk of long-term adjustment problems. Prospective research shows that cognitive-behavioral and social risk and resilience factors predict the long-term physical and psychological functioning of patients with rheumatic conditions. Furthermore, validated screening instruments are becoming increasingly useful in clinical practice to identify and select patients at risk. Stress-management and resilience interventions offer promising ways to improve the long-term functioning of patients. These treatment methods might be especially useful when they are tailored to the specific risk and resilience factors of patients, and when they incorporate innovative approaches to the delivery of services, including internet applications such as eHealth, to increase efficiency and availability of treatments, and to optimize patient empowerment in rheumatic conditions.     

An elevated level of TSH might be predictive of differentiated thyroid cancer

Suppression therapy of thyreostimulin (TSH) using thyroid hormones improves survival of subjects operated for differentiated thyroid cancer. The TSH level might be different depending on the type of nodule. The objective of this study was to compare retrospectively the TSH level between two groups of subjects who underwent total thyroidectomy for a nodule, matched on sex, ethnicity, age and biological method of TSH measurement, one whose final histology was benign and one malignant. There was no significant difference between the two groups in terms of age, sex, family history of thyroid disease or thyroid autoimmunity. The subjects, whose final histology was malignant, had a mean TSH level significantly higher than subjects with benign disease (1.55 mU/l versus 0.96 mU/l, P = 0.003). Cancer risk was greater when the TSH was in the upper tertile of normal range. There was no correlation between the risk of thyroid cancer and age, sex, family history of thyroid disease, or menopausal status. The relative risk of having thyroid carcinoma was higher when the margins of nodules were blurred or in the presence of microcalcifications. These data confirm a trend toward baseline values of TSH higher in subjects with a thyroid-differentiated cancer. However, we could not define a preoperative threshold that would reliably determine the malignant or benign nature of the nodule.     

Effects of lidocaine infiltration on cost of rhinoplasty made under general anesthesia

This study aimed to compare the effects of combined and noncombined lidocaine with adrenaline infiltration in general anesthesia (GA) procedures, in which the standard anesthesia depth is monitored by Bispectral Index monitoring, on minimum alveolar concentration (MAC) levels and the costs. Following approval by the local ethics committee, an American Society of Anesthesiologists physical status I–II group of 40 adult patients for whom elective rhinoplasties under GA were planned was divided into 2 double-blind randomized groups. In group 1, GA and lidocaine + adrenaline were administered, whereas in group 2, only GA and adrenaline were administered. All the patients who had been taken to the operation room underwent electrocardiography and measurements of the peripheral oxygen saturation, end-tidal carbon dioxide, heart rate, mean blood pressure, and Bispectral Index monitoring. Using the operation time and the MAC% values, the total consumed inhalation agent amounts were calculated, and the cost difference was determined. The mean blood pressure values were lower in group 1 (P < 0.05). In group 1, the MAC% was 20.83% lower than that of group 2; the consumed desflurane amount was 20.29%, and the cost was 20.29% lower than that of group 2 (P < 0.05). In rhinoplasties under GA, the lidocaine + adrenaline combination infiltration not only decreased inhaled anesthetic requirement and cost but also supported the hemodynamic stability. In addition, surgical satisfaction increased in the lidocaine + adrenaline group because of small number of agitated patients during the recovery period.     

Bacterial endotoxin activity in human serum is associated with dyslipidemia, insulin resistance, obesity, and chronic inflammation

OBJECTIVE

To investigate whether bacterial lipopolysaccharide (LPS) activity in human serum is associated with the components of the metabolic syndrome (MetS) in type 1 diabetic patients with various degrees of kidney disease and patients with IgA glomerulonephritis (IgAGN).

RESEARCH DESIGN AND METHODS

Serum LPS activity was determined with the Limulus Amoebocyte Lysate chromogenic end point assay in type 1 diabetic patients with a normal albumin excretion rate (n = 587), microalbuminuria (n = 144), macroalbuminuria (n = 173); patients with IgAGN (n = 98); and in nondiabetic control subjects (n = 345). The relationships of the LPS/HDL ratio and MetS-associated variables were evaluated with Pearson correlation.

RESULTS

The MetS was more prevalent in type 1 diabetic patients (48%) than in patients with IgAGN (15%). Diabetic patients with macroalbuminuria had a significantly higher serum LPS/HDL ratio than patients with IgAGN. In the normoalbuminuric type 1 diabetic group, patients in the highest LPS/HDL quartile were diagnosed as having the MetS three times more frequently than patients in the lowest quartile (69 vs. 22%; P < 0.001). High LPS activity was associated with higher serum triglyceride concentration, earlier onset of diabetes, increased diastolic blood pressure, and elevated urinary excretion of monocyte chemoattractant protein-1.

CONCLUSIONS

High serum LPS activity is strongly associated with the components of the MetS. Diabetic patients with kidney disease seem to be more susceptible to metabolic endotoxemia than patients with IgAGN. Bacterial endotoxins may thus play an important role in the development of the metabolic and vascular abnormalities commonly seen in obesity and diabetes-related diseases.In patients with type 1 diabetes, long duration of the disease and poor glycemic control increase the risk for micro- and macrovascular complications. A significant proportion of type 1 diabetic patients who develop these complications exhibit clinical features commonly seen in subjects with the metabolic syndrome (MetS), including dyslipidemia, insulin resistance, obesity, hypertension, and chronic inflammation (1,2). Vascular diseases are also common in patients with IgA glomerulonephritis (IgAGN), and those with a progressive form of the disease run a significantly elevated risk of developing different cardiovascular sequela (3). Whether the MetS is independently associated with the progression of IgAGN is currently unclear, but at least several related factors, including hyperuricemia, hypertriglyceridemia, weight, insulin resistance, and inflammation, seem to associate with the development of kidney dysfunction in IgAGN (4,5).Many of these clinical subphenotypes likely emerge from the complex interactions between a genetic background, lifestyle, and environmental factors. Recent studies have highlighted the role of the innate immune system in the developmental process of these metabolic abnormalities (6). Our living environment is inhabited with commensal and pathogenic bacteria, which have both beneficial and detrimental effects on human health. If the immune defense functions properly, these microorganisms rarely cause any serious infections in healthy individuals. The situation is different in immunocompromised patients—local infections, use of antibiotics, and even diet may lead to the colonization of opportunistic bacteria in various sites of the body. In diabetic patients, long duration of the disease and poor glycemic control increase the risk for urinary tract, pulmonary, oral, and skin infections (6,7).Lipopolysaccharides (LPS) are unique glycolipids in the cell wall of gram-negative bacteria. LPS molecules, also known as bacterial endotoxins, may trigger acute and chronic inflammation, leading to immune cell activation and cytokine release. HDL cholesterol is one of the most important factors involved in the elimination of LPS molecules from circulation. In healthy subjects, LPS is mainly bound to HDL, whereas in patients with sepsis, LPS is redistributed toward LDL and VLDL lipoproteins (8). High LPS activity combined with low HDL levels increases the risk for cardiovascular disease (9).LPS infusion in mammals leads to the appearance of factors known to be associated with the MetS: elevated levels of proinflammatory markers, dyslipidemia, fasting hyperglycemia, insulin resistance, and obesity (10–12). In some research applications, bacterial endotoxins have been used to induce acute kidney injury in animals. Monocyte chemoattractant protein-1 (MCP1) is a potential marker for progressive renal disease because its expression and excretion are also regulated by bacterial endotoxins (13,14).We have recently shown that high serum levels of LPS activity are associated with the development and progression of kidney disease in Finnish type 1 diabetic patients. Most of the patients with high serum LPS activity exhibited features of dyslipidemia and insulin resistance (15). These metabolic abnormalities are frequently observed in diabetic patients with micro- or macrovascular complications (2). To our knowledge, no previous studies have explored the potential links between bacterial endotoxins and the MetS in subjects with impaired kidney function. Therefore, we wanted to investigate whether serum LPS activity is associated with metabolic risk factors in three distinct study populations: type 1 diabetic patients with various degrees of kidney disease, patients with IgAGN, and nondiabetic subjects.     

Hormone replacement therapy and mortality in 52- to 70-year-old women: the Kuopio Osteoporosis Risk Factor and Prevention Study

OBJECTIVES: To analyze prospectively the association between hormone replacement therapy (HRT) and mortality in women before old age. DESIGN AND METHODS: A group of 11,667 women (91% of the age cohort of the area) aged 52-62 years from the population-based Kuopio Osteoporosis Risk Factor and Prevention Study were followed for 7 years in 1994-2001. Information about HRT use and health events was obtained from two repeated questionnaires in 1989 and 1994. Information about deaths and causes of death from the follow-up period was obtained from the Statistics Finland. Cox's proportional-hazards models were used to calculate risk of death related to the use of HRT. RESULTS: At the start of follow-up, 2203 women had used HRT > 5 years, 3945 women < or = 5 years and 5519 women had never used it. During the follow-up, 361 deaths occurred. Compared with non-users of HRT, the adjusted hazard ratio (HR) of death from any cause was 1.05 (95% confidence interval (CI) 0.80-1.36) in women who used HRT < or = 5 years and 1.06 (95% CI 0.78-1.46) in women who used HRT > 5 years. The adjusted HR for coronary heart disease (CHD) mortality in women who used HRT < or = 5 years was 0.79 (95% CI 0.36-1.73), and in women who used HRT > 5 years, 2.16 (95% CI 0.93-4.98). For breast cancer mortality the adjusted HR for < or = 5 years of HRT use was 0.96 (95% CI 0.32-2.82) and 2.62 (95% CI 0.98-7.00) for > 5 years of HRT use. CONCLUSIONS: History of HRT use does not affect overall or CHD mortality in women. More than 5 years of HRT use may increase the risk of breast cancer mortality.     

Celiac disease prevalence in children and adolescents with type 1 diabetes from Serbia

Background: The association between celiac disease (CD) and type 1 diabetes mellitus (T1DM) is well known. Up to now, CD prevalence in children and adolescents with T1DM in Serbia has not been reported. The aim of the present study was to determine CD prevalence and its clinical manifestations in patients with T1DM. Methods: One hundred and twenty‐one patients (70 girls, 51 boys; mean age, 10.8 years) with T1DM (mean duration of diabetes, 3.4 years) and 125 control group participants (75 girls, 50 boys; mean age, 10.4 years) were tested for CD on tissue transglutaminase antibodies (tTG). In seven serologically positive T1DM patients endoscopic small bowel biopsies were taken and examined on histopathology. In all patients with CD and T1DM age, duration of T1DM, height for age, body mass index, glycosylated hemoglobin and clinical symptoms were noted. Results: Nine patients with T1DM were positive on IgA tTG antibodies. In seven of them small bowel biopsy was performed, and all were proven to have CD on histopathology. The prevalence of biopsy‐proven CD in children and adolescents with T1DM was significantly higher in the study group compared to controls (5.79%. vs 0.8%, P < 0.05). Conclusion: The significantly higher prevalence of CD in children with type 1 diabetes, in accordance with the large volume of data published in the literature, underlines the need for yearly screening of CD in patients with diabetes in order to promptly start a gluten‐free diet when appropriate.     

Magazine alcohol advertising compliance with the Australian Alcoholic Beverages Advertising Code

The purpose of this study was to assess the frequency and content of alcoholic beverage advertisements and sales promotions in magazines popular with adolescents and young people in Australia, and assess the extent to which the ads complied with Australia's self-regulatory Alcoholic Beverages Advertising Code (ABAC). Alcohol advertisements and promotions were identified in a sample of 93 magazines popular with young people. The identified items were coded against 28 measures constructed to assess the content of the items against the five sections of the ABAC. Two thirds of the magazines contained at least one alcohol advertisement or promotion with a total of 142 unique items identified: 80 were brand advertisements and 62 were other types of promotional items (i.e. sales promotions, event sponsorships, cross promotions with other marketers and advertorials). It was found that 52% of items appeared to contravene at least one section of the ABAC. The two major apparent breaches related to section B - the items having a strong appeal to adolescents (34%) and to section C - promoting positive social, sexual and psychological expectancies of consumption (28%). It was also found that promotional items appeared to breach the ABAC as often as did advertisements. It is concluded that the self-regulating system appears not to be working for the alcoholic beverages industry in Australia and that increased government surveillance and regulation should be considered, giving particular emphasis to the inclusion of promotional items other than brand advertising. [Donovan K, Donovan R, Howat P, Weller N. Magazine alcohol advertising compliance with the Australian Alcoholic Beverages Advertising Code. Drug Alcohol Rev 2007;26:73 - 81]     

Effects of dexmedetomidine on the duration of anaesthesia and wakefulness in bupivacaine epidural block

BACKGROUND: The purpose of this study was to examine the effects of intravenous dexmedetomidine on the duration of bupivacaine-induced epidural anaesthesia and level of wakefulness and the respective side-effects. METHODS: Sixty ASA I-II patients were included in the study. Consecutive patients were allocated to groups according to the last digit (odd/even) of their admission numbers. All patients had epidural anaesthesia with bupivacaine 0.5% performed by the same experienced anaesthesiologist. In the first group, the patients were administered intravenous dexmedetomidine infusion just after the epidural block and continued during the operation, while those in the second group were administered physiologic saline infusion at the same amount and duration. RESULTS: The recovery time of sensory block was significantly longer in the first group. The bispectral index values were lower in the first group than in the second. Also, heart rate was significantly lower in Group I than in Group II. Regarding side-effects, shivering was significantly less frequent in the first group, whereas there was a significant increase in the requirement of atropine in the first group as dexmedetomidine caused bradycardia. CONCLUSION: Intravenous administration of dexmedetomidine prolonged the duration of epidural anaesthesia, provided sedation and had few side-effects.