The 2022 EULAR/ACR Points to Consider at the Early Stages of Diagnosis and Management of Suspected Haemophagocytic Lymphohistiocytosis/Macrophage Activation Syndrome (HLH/MAS)

OBJECTIVE

Haemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS) are life-threatening systemic hyperinflammatory syndromes that can develop in most inflammatory contexts. They can progress rapidly, and early identification and management are critical for preventing organ failure and mortality. This effort aimed to develop evidence-based and consensus-based points to consider to assist clinicians in optimising decision-making in the early stages of diagnosis, treatment and monitoring of HLH/MAS.

METHODS

A multinational, multidisciplinary task force of physician experts, including adult and paediatric rheumatologists, haematologist/oncologists, immunologists, infectious disease specialists, intensivists, allied healthcare professionals and patients/parents, formulated relevant research questions and conducted a systematic literature review (SLR). Delphi methodology, informed by SLR results and questionnaires of experts, was used to generate statements aimed at assisting early decision-making and optimising the initial care of patients with HLH/MAS.

RESULTS

The task force developed 6 overarching statements and 24 specific points to consider relevant to early recognition of HLH/MAS, diagnostic approaches, initial management and monitoring of HLH/MAS. Major themes included the simultaneous need for prompt syndrome recognition, systematic evaluation of underlying contributors, early intervention targeting both hyperinflammation and likely contributors, careful monitoring for progression/complications and expert multidisciplinary assistance.

CONCLUSION

These 2022 EULAR/American College of Rheumatology points to consider provide up-to-date guidance, based on the best available published data and expert opinion. They are meant to help guide the initial evaluation, management and monitoring of patients with HLH/MAS in order to halt disease progression and prevent life-threatening immunopathology.

The 2022 EULAR/ACR points to consider at the early stages of diagnosis and management of suspected haemophagocytic lymphohistiocytosis/macrophage activation syndrome (HLH/MAS)

OBJECTIVE

Haemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS) are life-threatening systemic hyperinflammatory syndromes that can develop in most inflammatory contexts. They can progress rapidly, and early identification and management are critical for preventing organ failure and mortality. This effort aimed to develop evidence-based and consensus-based points to consider to assist clinicians in optimising decision-making in the early stages of diagnosis, treatment and monitoring of HLH/MAS.

METHODS

A multinational, multidisciplinary task force of physician experts, including adult and paediatric rheumatologists, haematologist/oncologists, immunologists, infectious disease specialists, intensivists, allied healthcare professionals and patients/parents, formulated relevant research questions and conducted a systematic literature review (SLR). Delphi methodology, informed by SLR results and questionnaires of experts, was used to generate statements aimed at assisting early decision-making and optimising the initial care of patients with HLH/MAS.

RESULTS

The task force developed 6 overarching statements and 24 specific points to consider relevant to early recognition of HLH/MAS, diagnostic approaches, initial management and monitoring of HLH/MAS. Major themes included the simultaneous need for prompt syndrome recognition, systematic evaluation of underlying contributors, early intervention targeting both hyperinflammation and likely contributors, careful monitoring for progression/complications and expert multidisciplinary assistance.

CONCLUSION

These 2022 EULAR/American College of Rheumatology points to consider provide up-to-date guidance, based on the best available published data and expert opinion. They are meant to help guide the initial evaluation, management and monitoring of patients with HLH/MAS in order to halt disease progression and prevent life-threatening immunopathology.

High levels of dietary arachidonic acid triglyceride exhibit no subchronic toxicity in rats

Arachidonic acid (AA), an n-6 long-chain polyunsaturated fatty acid (LC-PUFA), serves an important role in the body as a structural fatty acid of many tissues including neurological tissues. It is also a precursor of the n-6 class of eicosanoids and is the most abundant n-6 LC-PUFA found in human breast milk. We have optimized the production of a microfungal source of a triglyceride oil (ARASCO) which is enriched in AA to about 40% by weight. To establish the safety of this oil as a food, we evaluated the effect of ARASCO in Sprague-Dawley rats (20/sex/group) gavaged at dose levels of 1.0 and 2.5 g/kg/d for a period of 90 d, paying special attention to any potential neurotoxicity of the oil. Two groups of control animals received either untreated standard laboratory diet (untreated control) or the same diet and vehicle oil at the same dose volume administered to the treated animals (vehicle control). Physical observations, ophthalmoscopic examinations, body weight, food consumption, clinical chemistry, hematology parameters, neurobehavioral assessments, and macroscopic as well as microscopic postmortem evaluations were performed. Tissue fatty acid analyses indicated that the AA levels in the brain, heart, and liver of the high-dose ARASCO-fed animals increased by 8, 59, and 76%, respectively, indicating that the AA in the oil was readily incorporated into tissue lipids. In spite of this high elevation in tissue AA levels, no developmental, histopathological, or neuropathological differences were seen in the animals administered ARASCO compared with the vehicle control animals. Being highly enriched in AA, ARASCO offers the means to study the effect of this fatty acid in experimental settings and in human metabolic studies.

Preclinical evaluation of single-cell oils that are highly enriched with arachidonic acid and docosahexaenoic acid

Arachidonic acid (ARA) and docosahexaenoic acid (DHA) are important in human brain and retina development, and there is growing evidence showing the importance of these fatty acids in infant nutrition. Triglyceride oils, highly enriched in ARA (ARASCO) and DHA (DHASCO), were evaluated using very high dose acute (20 g/kg) and 4-wk subchronic gavage feedings in weanling Sprague-Dawley rats. The combination of these oils, Formulaid, was also tested in the 4-wk subchronic study, ARASCO, DHASCO and Formulaid were found to have a no-observable-adverse-effect level of more than 2.5 g/ kg/day, 1.25 g/kg/day and 3.75 g/kg/day, respectively. This represents a 50-fold safety margin over the intended use of Formulaid in infant formula. Survival, clinical signs, body weight gain, food consumption, haematology, clinical chemistry and histopathological evaluations failed to show any significant differences in animals administered ARASCO, DHASCO or Formulaid compared with that in control animals administered equal amounts of high oleic sunflower oil. The bioavailability of ARASCO, DHASCO and Formulaid was verified by increases in DHA and ARA levels in heart and liver tissues in these animals. Because these oils are enriched in only a single bioactive fatty acid, and they have been shown to be safe, they may offer a new source of these fatty acids in speciality foods such as infant formula.

Ignored trichomonal infestation diagnosed by Papanicolaou smear

OBJECTIVE

To compare the occurrence of Trichomonas vaginalis as demonstrated by culture and by Papanicolaou (PAP) smears in a sexually transmitted disease (STD) clinic.

SETTING

The largest out-patient venereological clinic in Denmark.

SUBJECT AND METHODS

As the prevalence of trichomonal infestation has decreased considerable in recent years direct microscopy of vaginal wet mounts is no longer performed routinely. Instead the screening diagnostic procedure is based on culture. We have retrospectively collected data on culture-negative women with Trichomonas vaginalis organisms present in cervical smears, taken on a routine basis to exclude atypical cells, and compared with the clinical findings.

RESULTS

Since 1992 a total of 17 women were found to harbour Trichomonas vaginalis in cervical smear. A vaginal discharge was described in 10 women, six of whom had concomittant unspecific vaginitis. However, four women had unexplained vaginal discharge that could have been related to infestation with Trichomonas vaginalis. In addition one asymptomatic woman had a male partner with persistent urethritis.

CONCLUSION

The prevalence of trichomoniasis is underestimated in women attending the clinic if the diagnosis is based on culture alone. PAP smears may be helpful in demonstrating characteristic trichomonal organisms. In general we do not recommend the PAP smear be used to diagnose STDs. However the finding of trichomanal organisms in smears should prompt a repeated culture and direct microscopy of vaginal wet mount.

Trauma center verification

Sanctioned trauma center designation began in the late 1970's to improve hospital capabilities to care for injured patients. Guided by criteria established by the American College of Surgeons Committee on Trauma and led by surgeons dedicated to improving trauma care, many states focused early on the quality of care issue only to later struggle with the political consequences that followed the designation process. Institutional commitment to trauma care was often stated but seldom measured. Unlike the designation process with its strong emphasis on capabilities assessment, the verification process focused on performance documentation. Confirmation was sought in response time of key personnel, completeness of registry database, and trauma death audits. Trauma Committee minutes were reviewed and prehospital personnel interviewed to confirm institutional involvement in paramedic education and overall EMS system design. Other areas of documentation included trauma education at all levels, research, nursing audits, and outreach programs. We conclude that trauma center designation and verification are both essential and complementary. Effective trauma system performance requires trauma center designation plus a verification process to confirm institutional commitment of these resources for optimal care of the injured patient.