This morning, Dr. Una Makris, from the UT Southwestern Division of Rheumatology, gave an excellent talk on the diagnosis and management of chronic low back pain in older adults, a problem that costs more annually than most chronic medical conditions. In her talk, she noted that a multi-modal approach, with physical therapy, cognitive behavioral therapy, pain control, and a host of other methods to deal with this problem. Significant research in the area suggests that we are over-treating and over-spending, without a considerable impact on the burden of this often debilitating condition. In fact, a recent article in the JAMA notes that among older adults with a new primary care visit for back pain, early imaging was not associated with better 1-year outcomes. For more information, check out the articles below:
STRAIGHT FROM THE HOUSESTAFF – the April 2015 UT Southwestern Internal Medicine Journal Watch! They have summarized important issues in clinical practice, from alcoholic hepatitis to which medications to use for stroke prevention in afib. Make sure to take the EKG challenge at the end! You will have to view this post on our website to access the PDF. There is a quick run down of the topics below:
- Extended report: Prediction of cardiovascular risk in rheumatoid arthritis: performance of original and adapted SCORE algorithms. Dr. Brian Skaug reviewing Arts, et al. Ann Rheum Dis. 2015 Feb 17. pii: annrheumdis-2014-206879. doi: 10.1136/annrheumdis-2014-206879
- Trial of Early, Goal-Directed Resuscitation for Septic Shock [The Protocolised Management in Sepsis (ProMISe) Trial]. Dr. James Galloway reviewing Mouncey PR et al. N Engl J Med. 2015;372(14):1301-11.
- A Randomized Trial of Icatibant in ACE-Inhibitor-Induced Angioedema. Dr. James Galloway reviewing Bas M, et al. N Engl J Med. 2015;372(5):418-25.
All of the work above comes from the IMJW Editorial Board: Jan Petrasek, Brian Skaug, Ben Galloway, Natalia Rocha, Doug Darden, and Jeanney Lew!
Lofgren syndrome! Below is a quick 101 cheat sheet on Lofgren syndrome, check it out!
- Lofgren syndrome is a form of acute sarcoidosis (not to be confused with Loffler’s syndrome)
- Initially described in 1953 by Sven Halvar Lofgren, a Swedish clinician
- More common in Scandinavian, Irish and African populations
- The syndrome is comprised of the combination of
- Erythema Nodosum
- Hilar adenopathy
- Migratory polyarthralgia
- In men, more common to have bilateral ankle arthritis instead of EN
- The combination of all features of Lofgren syndrome has a 95% specificity for sarcoidosis, allowing for clinical diagnosis without pathology
- However, consider the ddx for EN and hilar adenopathy: primary TB, sarcoid, coccidiodomycosis, histo, blasto, yersiniosis and chlamydia
- The syndrome is associated with a good prognosis
- Some patients have spontaneous remission and others require only NSAIDs to control their symptoms
- In one retrospective study of 80 patients, 67% were treated with NSAIDs and 41% with steroids and only 17% had a recurrence
A Review of Monoclonal Antibodies for Internists, by Dr. Brian Skaug
(Note: this post contains a powerpoint, which is best viewed on the website. Click the title above!)
- Excluding headaches, neurological complications of Behçet syndrome (neuro-Behçet syndrome) occur in less than 12% of cases, often a few years after the onset of the other systemic features.
Clinical Manifestations and Diagnosis
- In parenchymal disease, meningoencephalitis occurs, with a mixed inflammatory cell infiltrate leading to necrosis and apoptotic neuronal loss. Inflammatory infiltration, rather than fibrinoid necrosis, is seen around small vessels.
- The brainstem and mid-brain are the most commonly affected areas, but spinal cord lesions and cerebral involvement may also occur and, occasionally, neuro-Behçet syndrome presents as a pseudotumour cerebri.
- Brainstem involvement usually presents subacutely, with headache, cranial neuropathies or cerebellar or corticospinal tract dysfunction.
- Sensorineural hearing loss can occur, resulting in sudden deafness, balance disturbances and dizziness.
- The characteristic MRI lesion in parenchymal neuro-Behçet syndrome is a unilateral upper brainstem lesion extending into the thalamus and basal ganglia.
- Analysis of cerebrospinal fluid shows a neutrophilic (in early disease) or lymphocytic (in late disease) pleocytosis, but usually no oligoclonal bands.
- Neurovascular disease accounts for approximately 20% of cases of neuro-Behçet syndrome and symptoms include dural sinus thrombosis, intracranial aneurysm and extracranial aneurysm and/or dissection.
- The clinical findings are usually limited to those of intracranial hypertension (that is, headache, vomiting, altered levels of consciousness and papilloedema).
- Intracranial hypertension may be present without MRI abnormalities and should be managed in the same way as idiopathic benign intracranial hypertension.
- Aneurysms of the cerebral, vertebral and carotid arteries can also occur.
- Headaches are often under-treated. An effort should be made to classify the type of headache and, in the case of migraine, agents such as pizotifen and βblockers should be offered.
- Parenchymal disease:
- Initial Management: treated with high-dose steroids in the first instance, along with initiation of a DMARD, usually azathioprine.
- Methotrexate, mycophenolate, cyclophosphamide, tacrolimus and IFN-α are probably effective, although evidence is lacking.
- Cyclosporin is potentially neurotoxic and should not be used for patients with a history of CNS disease.
- The alternative therapeutic option for severe and aggressive disease is the early use of a biologic agent (i.e. anti-TNF therapy, like infliximab)
- Neurovascular disease:
- Cerebral vascular thrombosis and aneurysms also require aggressive immunosuppression.
- Anti-coagulation for venous thrombosis needs to be assessed on a case-by-case basis.
Ambrose, N. L. & Haskard, D. O. Nat. Rev. Rheumatol. 9, 79–89 (2013); published online 25 September 2012; doi:10.1038/nrrheum.2012.156
Pathergy phenomenon is when a small red bump or pustule occurs 1 to 2 days after a forearm is pricked with a sterile needle. This test is often associated with Behcet’s disease having a low sensitivity but high specificity for the disease, as a positive test supports a diagnosis of Behcet’s and is not definite. This past week’s NEJM had a case of a patient with newly diagnosed Behcet’s disease and a positive pathergy test. Click on the links below to read the article from NEJM and learn more from the Hopkins Vasculitis Center.
(image courtesy of The Johns Hopkins Vasculitis Center)
The Johns Hopkins Vasculitis Center – Behcet’s Disease
A 25-Year Old Man with Oral Ulcers, Rash, and Odynophagia
Fenofibrate and losartan have uric acid–lowering effects and may be agents of choice in patients with primary indications for either drug who have coexisting hyperuricemia.
STRAIGHT FROM THE HOUSESTAFF – the February 2015 Internal Medicine Journal Watch! They have summarized important issues in clinical practice, from Metformin in CKD to pre-exposure prophylaxis for HIV. There is even an EKG challenge at the end, if you are up for it! You will have to view this post on our website to access the PDF. There is a quick run down of the topics below:
- American Diabetes Association’s Standards of Medical Care in Diabetes – 2015.
- Dr. Jeremy Warshauer reviewing Grant RW, et al. Diabetes Care 2015 Jan;38 Supplement 1
- Metformin in Patients With Type 2 Diabetes and Kidney Disease: A Systematic Review
- Dr. Nicolas Barros reviewing Inzucchi, SE, et al. JAMA 2014; 312(24):2668-2675
- Preliminary analysis of the Very Early Diagnosis of Systemic Sclerosis (VEDOSS) EUSTAR multicentre study: evidence for puffy fingers as a pivotal sign for suspicion of systemic sclerosis
- Dr. Brian Skaug reviewing Minier T, et al. Ann Rheum Dis 2014;73: 2087–2093
- Using drugs to discriminate – adverse selection in the insurance marketplace
- Dr. Ashish Gupta reviewing Jacobs DB and Sommers BD. N Engl J Med. 2015 Jan 29;372(5):399-402
General Internal Medicine
- Disorders of Plasma Sodium — Causes, Consequences, and Correction
- Dr. Nicolas Barros reviewing Sterns, R, et al. NEJM 2015; 372:55-65
- Acid–Base Problems in Diabetic Ketoacidosis
- Dr. Nicolas Barros reviewing Kamel K, et al. NEJM 2015 ; 372:546-554
- A Clinical Practice Guideline From the AABB
- Dr. Nicolas Barros reviewing Kaufman RN, et al. Ann Intern Med. 2015 Feb 3;162(3):205-13
- Association of Albumin-Creatinine Ratio and Cystatin C With Change in Ankle-Brachial Index: The Multi-Ethnic Study of Atherosclerosis (MESA)
- Dr. Ben Jenny reviewing Garimella P, et al. Am J Kidney Dis. 2015;65(1):33-40
- Tenofovir-Based Preexposure Prophylaxis for HIV Infection Among African Women
- Dr. Brad Cutrell and Dr. Nicolas Barros reviewing Marrazzo J, et al. 2015; 372:509-518
- Infectious Diseases Diagnosis and Treatment of C. difficile in Adults: Systematic Review
- Dr. Brad Cutrell and Dr. Nicolas Barros reviewing Bagdasarian N, et al. JAMA 2015; 313(4):398-408
- An interferon-free antiviral regimen for HCV after liver transplantation
- Dr. Jan Petrasek reviewing Kwo et al., NEJM. 2014; Dec 18;371(25):2375-82
- Decreasing Mortality Among Patients Hospitalized with Cirrhosis in the United States From 2002 through 2010
- Dr. Jan Petrasek reviewing Schmidt et al., Gastroenterology. 2015 Jan 23.
- Twelve or 30 Months of Dual Antiplatelet Therapy after Drug-Eluting Stents (DAPT trial)
- Dr. Ben Jenny reviewing Mauri L, et al. N Engl J Med. 2014 Dec 4;371(23):2155-66.
- Dr. Ben Jenny
All of the work above comes from the IMJW Editorial Board (with Dr. Brad Cuttrell): Jan Petrasek, Purav Mody, Nicolas Barros, Ragisha Gopalakrishnan, Jeremy Warshauer, Shetal Patel, Ben Jenny (not Jennings), Vishwanatha Lanka, Brian Skaug, Ashish Gupta, and Roma Mehta!