Evaluation of Vaso-occlusive Crisis Management With Patient-Controlled Analgesia in Children With Sickle Cell Disease Requiring Hospitalization

OBJECTIVE

The aim of this study was to review the use of patient-controlled analgesia (PCA) in sickle cell disease (SCD) for pediatric patients with vaso-occlusive crisis (VOC) in our institution and to compare the effect of early vs late PCA start on pain relief and LOS.

METHODS

This retrospective study included all pediatric patients treated with PCA for a severe VOC from 2010 to 2016. "Early-PCA" was defined as start of PCA within 48 hours of arrival. Time to reach adequate analgesia was defined as the time to reach 2 consecutive pain scores less than 5/10 at 4-hour interval.

RESULTS

During the study period, 46 patients presented 87 episodes of VOC treated with PCA. Sixty-three patients with VOC were treated with Early-PCA and 24 with Late-PCA. Both groups were comparable except for median pain score at admission; the Early-PCA group had higher scores: 9.0/10 vs 7.0/10. Time to reach adequate analgesia could be evaluated only in a subset of patients (n = 32) but was shorter in the Early-PCA group with a median difference of 41.0 hours (95% CI -82.0 to -6.0). Early-PCA was associated with a median reduction in LOS of 3.4 days (95% CI -4.9 to -1.9). There was no difference between the 2 groups in terms of side effects and occurrence of acute chest syndrome during hospitalization.

CONCLUSIONS

In this study, a reduced time to reach adequate analgesia and LOS was noted in the Early-PCA group for severe VOC. A prospective study is required to confirm these results.

Statin-induced anti-HMGCR myopathy: successful therapeutic strategies for corticosteroid-free remission in 55 patients

Objective

To describe successful therapeutic strategies in statin-induced anti-HMGCR myopathy.

Methods

Retrospective data from a cohort of 55 patients with statin-induced anti-HMGCR myopathy, sequentially stratified by the presence of proximal weakness, early remission, and corticosteroid and IVIG use at treatment induction, were analyzed for optimal successful induction and maintenance of remission strategies.

Results

A total of 14 patients achieved remission with a corticosteroid-free induction strategy (25%). In 41 patients treated with corticosteroids, only 4 patients (10%) failed an initial triple steroid/IVIG/steroid-sparing immunosuppressant (SSI) induction strategy. Delay in treatment initiation was independently associated with lower odds of successful maintenance with immunosuppressant monotherapy (OR 0.92, 95% CI 0.85 to 0.97, P = 0.015). While 22 patients (40%) presented with normal strength, only 9 had normal strength at initiation of treatment.

Conclusion

While corticosteroid-free treatment of anti-HMGCR myopathy is now a safe option in selected cases, initial triple steroid/IVIG/SSI was very efficacious in induction. Delays in treatment initiation and, as a corollary, delays in achieving remission decrease the odds of achieving successful maintenance with an SSI alone. Avoiding such delays, most notably in patients with normal strength, may reset the natural history of anti-HMGCR myopathy from a refractory entity to a treatable disease.

Modeling the variability of insulin sensitivity for people with Type 1 Diabetes based on clinical data from an artificial pancreas study

Type 1 Diabetes is an autoimmune disease that eliminates endogenous insulin production. Without the crucial hormone insulin, which is necessary to equilibrate the blood glucose level, the patient must inject insulin subcutaneously. Treatment must be personalized (timing and size of insulin delivery) to achieve glycaemic equilibrium and avoid long-term comorbidities. Patients are educated on Functional Insulin Therapy (FIT) in order to independently adjust insulin delivery several times a day (at least prior to each meal and physical activity). Among personalized parameters, the Correction Factor is used to occasionally correct hyperglycemia via the injection of an insulin dose (bolus) and its value determines the bolus size. Although well-known in common diabetes practice for chronically poorly controlled patients, the phenomenon of "hyperglycemia induces insulin resistance" on a short term basis in patients with rather well controlled diabetes is presented here. Using a new database of evidence, we show that the insulin sensitivity factor, depends on the current level of glycaemia. This opens the door to refining dosing rules for patients and insulin delivery devices in artificial pancreas systems.

Evaluation of Vaso-Occlusive Crisis Management with Patient Controlled Analgesia in Children with Sickle Cell Disease Requiring Admission

BACKGROUND

Vaso-occlusive crisis (VOC) is one of the most distressing occurrences in patients with sickle cell disease (SCD). Patient controlled analgesia (PCA) is recommended by NIH and expert opinions favor its early use.

OBJECTIVES

We aim to review the use of PCA in patients with VOC and to evaluate if its early use is associated with faster pain control and reduced length of stay (LOS).

DESIGN/METHODS

This retrospective single center study included all paediatric patients admitted and treated with PCA for a severe VOC from 2010 to 2016. “Early” use was defined as start of PCA within 48 hours of arrival in the emergency department (ED) and “late” use after 48 hours. Time to reach adequate analgesia was defined as OUCHER, verbal scale or Faces Pain Scale < 5/10 obtained twice consecutively in a 4-hours interval. Time to reach adequate analgesia and LOS were compared between early-PCA and late-PCA groups.

RESULTS

A total of 46 patients presented 87 episodes of VOC treated with PCA during the study. Sixty-one episodes (70%) were treated with early-PCA and 26 (30%) with late-PCA. Both groups were comparable in terms of age (13.2 vs 12.8 years old), gender (55.8% female vs 57.7%), hemoglobin phenotype (80.3% HbSS vs 76.9%), but median pain score at admission was higher in early-PCA than in late-PCA (9/10 vs 7/10, median difference 1 (95% CI 0, 2). Early-PCA was associated with a median reduction in LOS of 3.15 days (95% CI 1.65, 4.82) (median early-PCA LOS 6.4 vs late-PCA 10.0 days). Time to reach analgesia could be evaluated only in a subset of patients (20 in early-PCA and 12 in late-PCA group). Although time to reach adequate analgesia tended to be shorter in the early-PCA group, it was not statistically different: median102.9 hours vs 123.5 hours, difference of 30.4 (95% CI -4.0,72.5). Side effects were observed during 29 (33.3%) PCA treatments (19/61 (31.2%) episodes in early-PCA, 10/26 (38.5%) in late-PCA group) among which 16 (18.6%) were significant adverse events. These were observed in 15 patients who required interventions: 2 desaturations requiring oxygen without intubation, 8 neurologic abnormalities (hallucinations, visual abnormalities, no stroke), 6 urinary retentions.

CONCLUSION

Early use of PCA for severe VOC was associated with a reduced length of hospital stay despite that these patients had higher pain score on admission. Prospective studies are needed to support these positive outcomes.

Oral Analgesics Utilization for Children With Musculoskeletal Injury (OUCH Trial): An RCT

BACKGROUND

Musculoskeletal injuries (MSK-Is) are a common and painful condition among children that remains poorly treated in the emergency department (ED). We aimed to test the efficacy of a combination of an anti-inflammatory drug with an opioid for pain management of MSK-I in children presenting to the ED.

METHODS

In this randomized, double-blinded, placebo-controlled trial, we enrolled children between 6 and 17 years presenting to the ED with an MSK-I and a pain score >29 mm on the visual analog scale (VAS). Participants were randomly assigned to oral morphine (0.2 mg/kg) + ibuprofen (10 mg/kg) (morphine + ibuprofen) or morphine (0.2 mg/kg) + placebo of ibuprofen or ibuprofen (10 mg/kg) + placebo of morphine. Primary outcome was children with VAS pain score <30 mm at 60 minutes postmedication administration.

RESULTS

A total of 501 participants were enrolled and 456 were included in primary analyses (morphine + ibuprofen = 177; morphine = 188; ibuprofen = 91). Only 29.9% (morphine + ibuprofen), 29.3% (morphine), and 33.0% (ibuprofen) of participants achieved the primary outcome (P = .81). Mean VAS pain reduction at 60 minutes were -18.7 (95% confidence interval [CI]: -21.9 to -16.6) (morphine + ibuprofen), -17.0 (95% CI: -20.0 to -13.9) (morphine), -18.6 (95% CI: -22.9 to -14.2) (ibuprofen) (P = .69). Children in the morphine + ibuprofen group (P < .001) and in the morphine group (P < .001) experienced more side effects than those in the ibuprofen group. No serious adverse event was reported.

CONCLUSIONS

Combination of morphine with ibuprofen did not provide adequate pain relief for children with MSK-I in the ED. None of the study medication provided an optimal pain management because most of children did not reach a mild pain score (NCT02064894).

Validation of the scale on Satisfaction of Adolescents with Postoperative pain management - idiopathic Scoliosis (SAP-S)

Background

Spinal fusion is a common orthopedic surgery in children and adolescents and is associated with high pain levels postoperatively. If the pain is not well managed, negative outcomes may ensue. To our knowledge, there is no measure in English that assesses patient’s satisfaction with postoperative pain management following idiopathic scoliosis surgery. The aim of the present study was to assess the psychometric properties of the satisfaction subscale of the English version of the Satisfaction of Adolescents with Postoperative pain management – idiopathic Scoliosis (SAP-S) scale.

Methods

Eighty-two participants aged 10–18 years, who had undergone spinal fusion surgery, fully completed the SAP-S scale at 10–14 days postdischarge. Construct validity was assessed through a principal component analysis using varimax rotation.

Results

Principal component analysis indicated a three-factor structure of the 13-item satisfaction subscale of the SAP-S scale. Factors referred to satisfaction regarding current medication received (Factor 1), actions taken by nurses and doctors to manage pain (Factor 2) and information received after surgery (Factor 3). Cronbach’s alpha was 0.91, showing very good internal consistency. Data on satisfaction and clinical outcomes were also reported.

Conclusion

The SAP-S is a valid and reliable measure of satisfaction with postoperative pain management that can be used in both research and clinical settings to improve pain management practices. Although it was developed and validated with adolescents who had undergone spinal fusion surgery, it can be used, with further validation, to assess adolescents’ satisfaction with pain management in other postoperative contexts.

Développement et validation de la version canadienne-française de l’échelle de Satisfaction des Adolescents de la gestion de la Douleur postopératoire – Scoliose idiopathique (SAD-S)

Background: Spinal fusion for scoliosis generates moderate to severe pain intensity. There are currently no instruments available to measure adolescents’ satisfaction regarding post-spinal fusion pain management.

Aims: To develop and validate a scale on satisfaction of adolescents regarding pain management following spinal fusion for scoliosis.

Methods: A methodological design was used to develop and validate the French-Canadian scale “Satisfaction des Adolescents de la gestion de la Douleur postopératoire – Scoliose idiopathique (SAD-S)”. A modified Delphi method, with seven healthcare professionals and 10 adolescents, was used to establish content validity of the SAD-S. A pre-test of the scale was conducted with 10 adolescents post-spinal fusion. The final version of the scale was validated through a pilot study with 98 adolescents following their surgery.

Results: The SAD-S scale includes a total of 13 items. Principal component analysis yielded a two-factor structure (2 subscales): 1) Pain management education and 2) Education regarding medication. These two factors explained 47,8% of the total variance for satisfaction. A Cronbach’s alpha of 0,84 was obtained for internal consistency.

Conclusion: Validation of the SAD-S scale showed that it has good psychometric properties with this population. Further validation is required with a larger sample to pursue its validation.

Improvement in insulin resistance is greater when infliximab is added to methotrexate during intensive treatment of early rheumatoid arthritis-results from the IDEA study

OBJECTIVES

To determine the change in established biomarkers of cardiovascular (CV) risk, namely, total cholesterol/high-density lipoprotein cholesterol ratio (TC/HDL-C), N-terminal pro-brain natriuretic peptide (NT-proBNP) and insulin resistance (IR) in patients with early RA treated with two different treat-to-target strategies.

METHODS

Fasting glucose, lipids, insulin and NT-proBNP were measured at baseline, weeks 26 and 78 in 79 DMARD-naïve RA patients, free of CV disease, as part of a double-blind randomized controlled trial of MTX with either infliximab (IFX) or methylprednisolone as induction therapy. Homeostasis model assessment-estimated IR (HOMA-IR) (glucose*insulin/405) was used to measure IR. Multiple imputation was employed, and linear regression analyses were adjusted for baseline values.

RESULTS

Changes in DAS44-CRP did not differ between the treatment arms at weeks 26 and 78. Mean TC/HDL-C, HOMA-IR and NT-proBNP improved in both groups at weeks 26 and 78, although change in NT-proBNP was not statistically significant at week 78. Changes in TC/HDL-C and NT-proBNP were similar between treatment arms, but HOMA-IR values in the IFX + MTX arm were 42% lower than those treated with MTX + methylprednisolone at week 78 (P = 0.003); the difference remained significant after adjustment for baseline BMI, ACPA positivity, smoking status and intramuscular glucocorticoid use (P = 0.007).

CONCLUSION

When implementing a treat-to-target approach, treatment of early RA was associated with improvement in TC/HDL-C, HOMA-IR and NT-proBNP, and a greater long-term improvement in HOMA-IR was seen in those treated with IFX.

TRIAL REGISTRATION

EU Clinical Trials Register, http://www.clinicaltrialsregister.eu, Eudract-2005-005013-37; ISRTCNregisrty, http://www.isrctn.com, ISRCTN48638981.

A Randomized Controlled Trial on Oral Analgesic Utilization for Children Presenting With A Musculoskeletal Trauma in the Emergency Department

BACKGROUND: A single-agent approach to children’s moderate to severe pain is often inadequate. To date, no studies have evaluated the combined use of oral morphine and ibuprofen for optimal pain management of children presenting to an emergency department (ED) for muscu-loskeletal (MSK) trauma.

OBJECTIVES: To assess the efficacy of a combination of oral morphine and ibuprofen for pain management in children with MSK trauma in the ED.

DESIGN/METHODS: A double-blind, placebo-controlled, multi-centered, three-arm, randomized clinical trial of 500 patients was conducted at three pediatric tertiary care EDs. Patients were randomized (in a 2:1:1 ratio) to receive (orally): (a) morphine (0.2mg/kg) + ibuprofen (10mg/kg) (Group MOR + IBU) or (b) morphine (0.2 mg/kg) + placebo (Group MOR) or (c) ibuprofen (10mg/kg) + placebo (Group IBU). Patients 6 to 17 years of age, who presented to the ED with a MSK trauma, and a score &gt;30 mm on the 100mm visual analogue scale were eligible to participate. Primary outcome was pain intensity score under 30 mm (mild pain) at 60-minutes (T-60) after treatment administration.

RESULTS: A total of 456 patients were included in analyses: 177 (MOR + IBU), 188 (MOR), 91 (IBU). Mean age was 11.9±2.7 years, with a majority of boys (55.3%) and Soft tissue injuries (62%). There were no differences in baseline characteristics in the three groups. Baseline mean pain score was 60.9±16.2 mm. Only 30% (MOR + IBU), 29% (MOR) and 30% (IBU) of patients reached a pain score under 30 mm at T-60 (p=0.83). Mean pain scores at T-60 were 42.3±23.2 mm (MOR + IBU), 43.8 + 23.1 mm (MOR) and 42.3±23.3 mm (IBU) (p=0.83). No severe adverse events were observed in any of the groups, at any of the study measurement points.

CONCLUSION: Combination of morphine with ibuprofen did not provide any additional pain relief for children with MSK injuries, in the ED. None of the study medication provided optimal pain management, as the majority of children did not reach the WHO definition of mild pain. Alternative analgesic combinations should be investigated to optimize pain relief of children who present to the ED with MSK injuries.

Prevalence, mortality and healthcare utilization of cluster B personality disorders in Quebec: A province cohort study, 2001–2012

Background

Cluster B personality disorder (PD) is a highly prevalent mental health condition in general population (1 to 6% depending on the subtype and study). Patients affected are known to be heavier users of both mental and medical healthcare than other clinical conditions such as depression. Few studies have highlighted their elevated mortality rate compared to general population.

Methods

The estimates were produced using data from the integrated monitoring system for chronic disease of Quebec. It provides annual and life prevalence, mortality rate, years of and healthcare utilization profile Quebec inhabitants.

Results

A total of 7,995,963 people were included in the study. The life prevalence of cluster B PD is 2.6%. The mean years of lost life is 13 for men and 9 for women when they are compared to general population. The 3 most important causes of death are: suicide (20.4%), cardiovascular diseases (19.1%) and cancers (18.6%). The standardized mortality ratio (SMR) for each medical condition is superior in cluster B personality disorders than general population. The most important SMR is for suicide (male: 10.2 and female: 21). In the year 2011–2012, 78% had consulted a general practitioner, 62% a psychiatrist, 41% were admitted in an emergency department and 21% were hospitalized.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Fast-track recovery after day case surgery

BACKGROUND

Fast-track recovery processes are implemented for pediatric day case surgery. We conducted a prospective study to evaluate postoperative comfort and parental satisfaction of children included in this process to improve quality of care.

METHODS

We included all children scheduled for superficial procedures or dental treatment outside the operating room. A questionnaire was explained to parents before hospital discharge to evaluate the first night at home. Postoperative comfort evaluation included postoperative pain score (FLACC scale), incidence of postoperative nausea and vomiting, and postoperative behavior disorders. Incidence of posthospital behavior disturbance was evaluated measuring postoperative agitation at home, and disinterest with toys and games. Parental satisfaction was evaluated with a four-point Likert scale (1 = not satisfied at all, 2 = not satisfied, 3 = satisfied, 4 = very satisfied).

RESULTS

One hundred and forty-three questionnaires were returned to hospital. Despite reduced length of stay in short-stay unit after anesthesia (28 ± 34 min), we did not report serious complications, and global parental satisfaction was good about the care process. Pain scores (FLACC >3) were higher in the group scheduled for dental procedures, but were very low for the other superficial surgery. With an odd ratio of 5.8 (95% confidence interval 2-17; P = 0.001), postoperative behavior modification (agitation or disinterest with toys or games) was the strongest variable that can predict parental dissatisfaction.

CONCLUSION

Optimal pain management, better parental information about risks of postoperative behavior disturbances, and program integrating parent and child preparation should improve quality of care and global satisfaction in the fast-track recovery process.

Predicting the development of clinical arthritis in anti-CCP positive individuals with non-specific musculoskeletal symptoms: a prospective observational cohort study

OBJECTIVES

To monitor progression to inflammatory arthritis (IA) in individuals with non-specific musculoskeletal (MSK) symptoms and positive anticyclic citrullinated peptide (anti-CCP) antibodies. To develop a pragmatic model to predict development of IA in this patient group.

METHODS

In this prospective observational cohort, patients with new non-specific MSK symptoms and positive anti-CCP were recruited from regional primary care and secondary care referrals. Clinical, imaging and serological parameters were assessed at baseline. Cox regression analysis was performed to identify predictors of progression to IA and develop a risk score to stratify patients at presentation.

FINDINGS

100 consecutive patients (73 women, mean age 51 years) were followed up for median 19.8 months (range 0.1-69.0); 50 developed IA after a median 7.9 months (range 0.1-52.4), 34 within 12 months. The majority (43/50) fulfilled the 2010 American College of Rheumatology/European League Against Rheumatism criteria for rheumatoid arthritis. A model for progression to IA was devised using four variables: tenderness of hand or foot joints, early morning stiffness ≥30 min, high-positive autoantibodies, and positive ultrasonographic power Doppler signal. None of the five individuals at low risk (score 0) progressed to IA, compared with 31% of 29 at moderate risk (1-2) and 62% of 66 at high risk (≥3). Adding shared epitope increased the number at low risk (score 0-1; 0/11 progressed).

CONCLUSIONS

In patients presenting with non-specific MSK symptoms and anti-CCP, the risk of progression to IA could be quantified using data available in clinical practice. The proposed risk score may be used to stratify patients for early therapeutic intervention.

TRIAL REGISTRATION NUMBER

NCT02012764 at ClinicalTrials.gov.

Four-hour acetaminophen concentration estimation after ingested dose based on pharmacokinetic models

INTRODUCTION

The United Kingdom has recently changed the indications for N-acetylcysteine treatment for acetaminophen intoxication. Any ingestion over 75 mg/kg is now referred to the hospital. A model based on pharmacokinetic parameters was developed to predict 4-h acetaminophen concentration for this and other ingested doses.

METHODOLOGY

EMBASE and Medline were searched to obtain values for volume of distribution, absorption, and elimination constants and bioavailability for acetaminophen. Four-hour concentrations were calculated for ingestion doses currently recommended for hospital referral in different countries. Calculated plasma concentrations at 4 h for several doses were plotted against the Rumack-Matthew and the United Kingdom treatment lines.

RESULTS

Six articles were used for the calculations (4 adult and 2 pediatric). In order to achieve a 4-h acetaminophen concentration of 100 mg/L, doses (mg/kg ± 99.9CI) of 180.5 ± 43.2 for adults and 396.1 ± 115.5 for children were calculated.

DISCUSSION

A dose of 75 mg/kg would likely yield a 4-h acetaminophen concentrations well below 100 mg/L. Medical toxicologists and poison information specialists are left without evidence-based guidance for which patients or which ingestion history would now warrant referral to hospital for acetaminophen concentration measurement. Larger toxicokinetic studies in acetaminophen overdose are needed to define ingestion dose for referral to hospital.

A randomised controlled trial of etanercept and methotrexate to induce remission in early inflammatory arthritis: the EMPIRE trial

OBJECTIVE

To compare the efficacy of etanercept (ETN) and methotrexate (MTX) versus MTX monotherapy for remission induction in patients with early inflammatory arthritis.

METHODS

In a 78-week multicentre randomised placebo-controlled superiority trial, 110 DMARD-naïve patients with early clinical synovitis (≥1 tender and swollen joint, and within 3 months of diagnosis) and either rheumatoid factor, anticitrullinated protein antibodies or shared epitope positive were randomised 1:1 to receive MTX+ETN or MTX+placebo (PBO) for 52 weeks. Injections (ETN or PBO) were stopped in all patients at week 52. In those with no tender or swollen joints (NTSJ) for >26 weeks, injections were stopped early. If patients had NTSJ >12 weeks after stopping the injections, MTX was weaned. The primary endpoint was NTSJ at week 52.

RESULTS

No statistically significant difference was seen for the primary endpoint (NTSJ at week 52 (32.5% vs 28.1% [adjusted OR 1.32 (0.56 to 3.09), p=0.522]) in the MTX+ETN and MTX+PBO groups, respectively). The secondary endpoints did not differ between groups at week 52 or 78. Exploratory analyses showed a higher proportions of patients with DAS28-CRP<2.6 in the MTX+ETN group at week 2 (38.5% vs 9.2%, adjusted OR 8.87 (2.53 to 31.17), p=0.001) and week 12 (65.1% vs 43.8%, adjusted OR 2.49 (1.12 to 5.54), p=0.026).

CONCLUSIONS

In this group of patients with early inflammatory arthritis, almost a third had no tender, swollen joints after 1 year. MTX+ETN was not superior to MTX monotherapy in achieving this outcome. Clinical responses, however, including DAS28-CRP<2.6, were achieved earlier with MTX+ETN combination therapy.

TRIAL REGISTRATION NUMBER

The EMPIRE trial is registered on the following trial registries: Eudract-2005-005467-29; ISRCTN 55428162 (http://www.controlled-trials.com/ISRCTN55428162/EMPIRE). The full trial protocol can be obtained from the corresponding author.

A systematic literature review of strategies promoting early referral and reducing delays in the diagnosis and management of inflammatory arthritis

BACKGROUND

Despite the importance of timely management of patients with inflammatory arthritis (IA), delays exist in its diagnosis and treatment.

OBJECTIVE

To perform a systematic literature review to identify strategies addressing these delays to inform an American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) taskforce.

METHODS

The authors searched literature published between January 1985 and November 2010, and ACR and EULAR abstracts between 2007-2010. Additional information was obtained through a grey literature search, a survey conducted through ACR and EULAR, and a hand search of the literature.

RESULTS

(1) From symptom onset to primary care, community case-finding strategies, including the use of a questionnaire and autoantibody testing, have been designed to identify patients with early IA. Several websites provided information on IA but were of varying quality and insufficient to aid early referral. (2) At a primary care level, education programmes and patient self-administered questionnaires identified patients with potential IA for referral to rheumatology. Many guidelines emphasised the need for early referral with one providing specific referral criteria. (3) Once referred, early arthritis clinics provided a point of early access for rheumatology assessment. Triage systems, including triage clinics, helped prioritise clinic appointments for patients with IA. Use of referral forms standardised information required, further optimising the triage process. Wait times for patients with acute IA were also reduced with development of rapid access systems.

CONCLUSIONS

This review identified three main areas of delay to care for patients with IA and potential solutions for each. A co-ordinated effort will be required by the rheumatology and primary care community to address these effectively.

Remission induction comparing infliximab and high-dose intravenous steroid, followed by treat-to-target: a double-blind, randomised, controlled trial in new-onset, treatment-naive, rheumatoid arthritis (the IDEA study)

OBJECTIVES

In disease modifying antirheumatic drug (DMARD)-naive early rheumatoid arthritis (RA), to compare the efficacy of methotrexate (MTX) and infliximab (IFX) with MTX and intravenous corticosteroid for remission induction.

METHODS

In a 78-week multicentre randomised controlled trial, double-blinded to week 26, 112 treatment-naive RA patients (1987 American College of Rheumatology classification criteria) with disease activity score 44 (DAS44)>2.4 were randomised to MTX + IFX or MTX + single dose intravenous methylprednisolone 250 mg. A treat-to-target approach was used with treatment escalation if DAS44>2.4. In the IFX group, IFX was discontinued for sustained remission (DAS44<1.6 for 6 months). The primary outcome was change in modified total Sharp-van der Heijde score (mTSS) at week 50.

RESULTS

The mean changes in mTSS score at week 50 in the IFX and intravenous steroid groups were 1.20 units and 2.81 units, respectively (adjusted difference (95% CI) -1.45 (-3.35 to 0.45); p=0.132). Radiographic non-progression (mTSS<2.0) occurred in 81% vs 71% (OR 1.77 (0.56 to 5.61); p=0.328). DAS44 remission was achieved at week 50 in 49% and 36% (OR 2.13 (0.91 to 5.00); p=0.082), and at week 78 in 48% and 50% (OR 1.12 (0.47 to 2.68); p=0.792). Exploratory analyses suggested higher DAS28 remission at week 6 and less ultrasound synovitis at week 50 in the IFX group. Of the IFX group, 25% (14/55) achieved sustained remission and stopped IFX. No substantive differences in adverse events were seen.

CONCLUSIONS

In DMARD-naive early RA patients, initial therapy with MTX+high-dose intravenous steroid resulted in good disease control with little structural damage. MTX+IFX was not statistically superior to MTX+intravenous steroid when combined with a treat-to-target approach.

A randomized clinical trial of a nurse telephone follow-up on paediatric tonsillectomy pain management and complications

AIMS

To determine the effect of a nurse telephone follow-up on paediatric post-tonsillectomy pain intensity, complications, and use of other healthcare services.

BACKGROUND

After tonsillectomy, children experience moderate-to-severe pain for days. Parents tend to give insufficient analgesia, with resulting increases in pain and postoperative complications. In adults, nurse telephone follow-up for ambulatory surgeries reduces postoperative pain.

DESIGN

The study design was a randomized clinical trial.

METHODS

In this trial, children aged 4-12 years undergoing elective tonsillectomy in June-October 2010 were assigned to a nurse telephone follow-up with parents on postoperative days 1, 3, 5 and 10, or standard care with no follow-up but data collection. Outcomes included pain intensity, analgesics administered, complications, and healthcare use.

RESULTS

Of 45 participants, the intervention group (n = 24) received more analgesics on postoperative days 1 and 3, increased their fluid intake at days 1 and 3, but had more constipation at day 3 than the control group (n = 21). There was no significant difference regarding pain intensity or use of healthcare resources.

CONCLUSION

Nurse telephone follow-up was beneficial for some pain management and prevention of complications, although better analgesic treatments are needed. The intervention was simple, safe, and appreciated by parents.

A systematic literature review of strategies promoting early referral and reducing delays in the diagnosis and management of inflammatory arthritis

BACKGROUND

Despite the importance of timely management of patients with inflammatory arthritis (IA), delays exist in its diagnosis and treatment.

OBJECTIVE

To perform a systematic literature review to identify strategies addressing these delays to inform an American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) taskforce.

METHODS

The authors searched literature published between January 1985 and November 2010, and ACR and EULAR abstracts between 2007-2010. Additional information was obtained through a grey literature search, a survey conducted through ACR and EULAR, and a hand search of the literature.

RESULTS

(1) From symptom onset to primary care, community case-finding strategies, including the use of a questionnaire and autoantibody testing, have been designed to identify patients with early IA. Several websites provided information on IA but were of varying quality and insufficient to aid early referral. (2) At a primary care level, education programmes and patient self-administered questionnaires identified patients with potential IA for referral to rheumatology. Many guidelines emphasised the need for early referral with one providing specific referral criteria. (3) Once referred, early arthritis clinics provided a point of early access for rheumatology assessment. Triage systems, including triage clinics, helped prioritise clinic appointments for patients with IA. Use of referral forms standardised information required, further optimising the triage process. Wait times for patients with acute IA were also reduced with development of rapid access systems.

CONCLUSIONS

This review identified three main areas of delay to care for patients with IA and potential solutions for each. A co-ordinated effort will be required by the rheumatology and primary care community to address these effectively.

Diagnostic and prognostic value of history-taking and physical examination in undifferentiated peripheral inflammatory arthritis: a systematic review

OBJECTIVE

To review the diagnostic and prognostic value of history/physical examination among patients with undifferentiated peripheral inflammatory arthritis (UPIA).

METHODS

We conducted a systematic review evaluating the association between history/physical examination features and a diagnostic or prognostic outcome.

RESULTS

Nineteen publications were included. Advanced age, female sex, and morning stiffness were predictive of a diagnosis of rheumatoid arthritis (RA) from UPIA. A higher number of tender and swollen joints, small/large joint involvement in the upper/lower extremities, and symmetrical involvement were associated with progression to RA. Similar features were associated with persistent disease and erosions, while disability at baseline and extraarticular features were predictive of future disability.

CONCLUSION

History/physical examination features are heterogeneously reported. Several features predict progression from UPIA to RA or a poor prognosis. Continued measurements in the UPIA population are needed to determine if these features are valid and reliable predictors of outcomes, especially as new definitions for RA and disease states emerge.

Patients considered as having undifferentiated peripheral inflammatory arthritis: a systematic review

OBJECTIVE

To systematically review the differential diagnosis and minimal clinical investigation used prior to making a diagnosis of undifferentiated peripheral inflammatory arthritis (UPIA).

METHODS

A systematic literature search was performed for articles published between January 1950 and December 2008 in Medline and Embase, and for abstracts presented at the 2007 and 2008 meetings of the American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR). Studies including defined cohorts of patients with UPIA were retrieved according to predefined inclusion/exclusion criteria. Selected studies were systematically reviewed and relevant data extracted. Baseline characteristics were also recorded to obtain a clinical picture of patients classified as UPIA.

RESULTS

Seventy-four articles were included. Of those, 52 reported baseline characteristics. Tremendous variation existed among studies, reflecting the different inclusion/exclusion criteria used. Rheumatoid arthritis, spondyloarthropathies, osteoarthritis, crystal arthritis, connective tissue diseases, and infections were the most common diagnoses of exclusion for UPIA and made up the other subsets of patients in cohorts with mixed populations. The baseline investigation undertaken prior to diagnosis of UPIA was reported in 7 articles. History, physical examination, tender and swollen joint count, rheumatoid factor, HLA-B27, erythrocyte sedimentation rate, C-reactive protein, and radiographs of hands and feet were the only items mentioned in at least 50% of the reports.

CONCLUSION

Studies of UPIA are heterogeneous. Few studies reported on the minimal clinical investigation necessary to arrive at a diagnosis of UPIA. Differential diagnosis usually consisted of the most common rheumatologic conditions but could be vast.

Multinational evidence-based recommendations on how to investigate and follow-up undifferentiated peripheral inflammatory arthritis: integrating systematic literature research and expert opinion of a broad international panel of rheumatologists in the 3E Initiative

Objective

To develop evidence-based recommendations on how to investigate and follow-up undifferentiated peripheral inflammatory arthritis (UPIA).

Methods

697 rheumatologists from 17 countries participated in the 3E (Evidence, Expertise, Exchange) Initiative of 2008–9 consisting of three separate rounds of discussions and modified Delphi votes. In the first round 10 clinical questions were selected. A bibliographic team systematically searched Medline, Embase, the Cochrane Library and ACR/EULAR 2007–2008 meeting abstracts. Relevant articles were reviewed for quality assessment, data extraction and synthesis. In the second round each country elaborated a set of national recommendations. Finally, multinational recommendations were formulated and agreement among the participants and the potential impact on their clinical practice was assessed.

Results

A total of 39 756 references were identified, of which 250 were systematically reviewed. Ten multinational key recommendations about the investigation and follow-up of UPIA were formulated. One recommendation addressed differential diagnosis and investigations prior to establishing the operational diagnosis of UPIA, seven recommendations related to the diagnostic and prognostic value of clinical and laboratory assessments in established UPIA (history and physical examination, acute phase reactants, autoantibodies, radiographs, MRI and ultrasound, genetic markers and synovial biopsy), one recommendation highlighted predictors of persistence (chronicity) and the final recommendation addressed monitoring of clinical disease activity in UPIA.

Conclusions

Ten recommendations on how to investigate and follow-up UPIA in the clinical setting were developed. They are evidence-based and supported by a large panel of rheumatologists, thus enhancing their validity and practical use.

The role of biomarkers in the management of patients with rheumatoid arthritis

In recent years, patient outcomes have improved dramatically with the availability of effective treatments for the management of rheumatoid arthritis (RA). RA, however, is a heterogeneous disease with variable disease progression and treatment response. Whereas some patients respond to a single disease-modifying antirheumatic drug, others require more intensive treatment strategies. Assessing disease severity at diagnosis and monitoring disease activity on an individual level would be a more accurate way of tailoring therapy, ensuring optimal treatment for those at greatest risk of disease progression, long-term disability, and joint damage without unnecessary overtreatment. Assessment of disease activity and severity is currently based on a combination of clinical and laboratory parameters that aid treatment decisions. Use of biomarkers may provide a more accurate means of objectively assessing the disease. This article reviews the role of biomarkers in the management of RA.

Interstitial pneumonitis associated with infliximab therapy

Interstitial pneumonitis is a well documented, rare complication of methotrexate (MTX). We describe a patient with rheumatoid arthritis (RA) taking MTX for more than 3 years who then developed severe interstitial pneumonitis after a third infliximab infusion. Other similar cases are reviewed. Infliximab may potentiate pulmonary toxicity of MTX.

Etiology and outcome of acute liver failure: experience from a liver transplantation centre in Montreal

BACKGROUND

Acute liver failure is a rare condition in which massive liver injury is associated with the rapid development of hepatic encephalopathy. Although viral hepatitis and drug-induced liver injury are the most common causes, no specific etiology is found in a substantial proportion of cases reported from Europe and the United States.

AIM

To determine the etiology and outcome of patients with acute liver failure in the authors' institution.

PATIENTS AND METHODS

The charts of 81 consecutive patients admitted to Saint-Luc between 1991 and 1999 were reviewed.

RESULTS

The etiology was viral in 27 cases (33.2%), toxic or drug-induced in 22 (27.2%), of unknown origin in 22 (27.2%) and due to various causes in 10 (12.3%) (autoimmune, vascular, cancer). Of the 81 patients, 16% survived without liver transplantation, and 84% died or underwent liver transplantation. Survival without liver transplantation differed according to the mode of presentation: the survival rate was 27% in patients with hyperacute liver failure, 7% in those with acute liver failure and 0% in those with subacute liver failure. Among the 38 patients who underwent liver transplantation, survival one year after transplantation was 71%. In the 30 patients who died without liver transplantation, the main causes of death were cerebral edema and sepsis.

CONCLUSIONS

Acute liver failure is associated with a high mortality, and liver transplantation is the treatment of choice. In a significant proportion of cases, the etiology remains undetermined and is probably related to yet unidentified hepatotropic viruses.