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Chen-Xu M, Kassam C, Cameron E, Ryba S, Yiu V. Impact of electronic AKI alert/care bundle on AKI inpatient outcomes: a retrospective single-center cohort study. Ren Fail 2024; 46:2313177. [PMID: 38345055 PMCID: PMC10863540 DOI: 10.1080/0886022x.2024.2313177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 01/27/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Outcomes among acute kidney injury (AKI) patients are poor in United Kingdom (UK) hospitals, and electronic alerts and care bundles may improve them. We implemented such a system at West Suffolk Hospital (WSH) called the 'AKI order set'. We aimed to assess its impact on all-cause mortality, length of stay (LOS) and renal function among AKI patients, and its utilization. METHODS Retrospective, single-center cohort study of patients ≥ 18 years old with AKI at WSH, a 430-bed general hospital serving a rural UK population of approximately 280,000. 7243 unique AKI events representing 5728 patients with full data were identified automatically from our electronic health record (EHR) between 02 September 2018 and 1 July 2021 (median age 78 years, 51% male). All-cause mortality, LOS and improvement in AKI stage, demographic and comorbidity data, medications and AKI order set use were automatically collected from the EHR. RESULTS The AKI order set was used in 9.8% of AKI events and was associated with 28% lower odds of all-cause mortality (multivariable odds ratio [OR] 0.72, 95% confidence interval [CI] 0.57-0.91). Median LOS was longer when the AKI order set was utilized than when not (11.8 versus 8.8 days, p < .001), but was independently associated with improvement in the AKI stage (28.9% versus 8.7%, p < .001; univariable OR 4.25, 95% CI 3.53-5.10, multivariable OR 4.27, 95% CI 3.54-5.14). CONCLUSIONS AKI order set use led to improvements in all-cause mortality and renal function, but longer LOS, among AKI patients at WSH.
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Affiliation(s)
- Michael Chen-Xu
- West Suffolk Hospital NHS Foundation Trust, Suffolk, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Christopher Kassam
- West Suffolk Hospital NHS Foundation Trust, Suffolk, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Emma Cameron
- West Suffolk Hospital NHS Foundation Trust, Suffolk, UK
| | - Szymon Ryba
- West Suffolk Hospital NHS Foundation Trust, Suffolk, UK
| | - Vivian Yiu
- West Suffolk Hospital NHS Foundation Trust, Suffolk, UK
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Odler B, Tieu J, Artinger K, Chen-Xu M, Arnaud L, Kitching RA, Terrier B, Thiel J, Cid MC, Rosenkranz AR, Kronbichler A, Jayne DRW. The plethora of immunomodulatory drugs: opportunities for immune-mediated kidney diseases. Nephrol Dial Transplant 2023; 38:ii19-ii28. [PMID: 37816674 DOI: 10.1093/ndt/gfad186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Indexed: 10/12/2023] Open
Abstract
In recent decades, insights into the molecular pathways involved in disease have revolutionized the treatment of autoimmune diseases. A plethora of targeted therapies have been identified and are at varying stages of clinical development in renal autoimmunity. Some of these agents, such as rituximab or avacopan, have been approved for the treatment of immune-mediated kidney disease, but kidney disease lags behind more common autoimmune disorders in new drug development. Evidence is accumulating as to the importance of adaptive immunity, including abnormalities in T-cell activation and signaling, and aberrant B-cell function. Furthermore, innate immunity, particularly the complement and myeloid systems, as well as pathologic responses in tissue repair and fibrosis, play a key role in disease. Collectively, these mechanistic studies in innate and adaptive immunity have provided new insights into mechanisms of glomerular injury in immune-mediated kidney diseases. In addition, inflammatory pathways common to several autoimmune conditions exist, suggesting that the repurposing of some existing drugs for the treatment of immune-mediated kidney diseases is a logical strategy. This new understanding challenges the clinical investigator to translate new knowledge into novel therapies leading to better disease outcomes. This review highlights promising immunomodulatory therapies tested for immune-mediated kidney diseases as a primary indication, details current clinical trials and discusses pathways that could be targeted in the future.
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Affiliation(s)
- Balazs Odler
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Johanna Tieu
- Faculty of Health and Medical Sciences, University of Adelaide; Adelaide, Australia
- Rheumatology Unit, The Queen Elizabeth Hospital, Adelaide, Australia
- Rheumatology Unit, Lyell McEwin Hospital, Adelaide, Australia
| | - Katharina Artinger
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Michael Chen-Xu
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Laurent Arnaud
- National Reference Center for Rare Auto-immune and Systemic Diseases Est Sud-Est (RESO), Strasbourg, France
| | - Richard A Kitching
- Centre for Inflammatory Diseases, Monash University Department of Medicine, Monash Medical Centre, Clayton, Victoria, Australia
- Departments of Nephrology and Paediatric Nephrology, Monash Medical Centre, Clayton, Victoria, Australia
| | - Benjamin Terrier
- Department of Internal Medicine, National Reference Center for Autoimmune Diseases, Hôpital Cochin, Assistance Publique Hôpitaux de Paris (AP-HP), Université de Paris, Paris, France
| | - Jens Thiel
- Division of Rheumatology and Immunology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Maria C Cid
- Department of Autoimmune Diseases, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain
| | - Alexander R Rosenkranz
- Division of Nephrology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Andreas Kronbichler
- Department of Medicine, University of Cambridge, Cambridge, UK
- Department of Internal Medicine IV, Nephrology and Hypertension, Medical University Innsbruck, Innsbruck, Austria
| | - David R W Jayne
- Department of Medicine, University of Cambridge, Cambridge, UK
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Humphrey TJL, Dosanjh D, Hiemstra TF, Richter A, Chen-Xu M, Qian W, Jha V, Gatley K, Adhikari R, Dowling F, Smith RM. PROphylaxis for paTiEnts at risk of COVID-19 infecTion (PROTECT-V). Trials 2023; 24:185. [PMID: 36915199 PMCID: PMC10009350 DOI: 10.1186/s13063-023-07128-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 01/30/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND Despite the introduction of vaccination, there remains a need for pre-exposure prophylactic agents against SARS-CoV-2. Several patient groups are more vulnerable to SARS-CoV-2 infection by virtue of underlying health conditions, treatments received or suboptimal responses to vaccination. METHODS PROTECT-V is a platform trial testing pre-exposure prophylactic interventions against SARS-CoV-2 infection in vulnerable patient populations (organ transplant recipients; individuals with oncological/haematological diagnoses, immune deficiency or autoimmune diseases requiring immunosuppression or on dialysis). Multiple agents can be evaluated across multiple vulnerable populations sharing placebo groups, with the option of adding additional treatments at later time points as these become available. The primary endpoint is symptomatic SARS-CoV-2 infection, and each agent will be independently evaluated in real time when the required number of events occurs. Presently, three agents are approved in the platform: intranasal niclosamide, nasal and inhaled ciclesonide and intravenous sotrovimab. DISCUSSION Despite the introduction of vaccination, there remains a need for pre-exposure prophylactic agents against SARS-CoV-2. Several patient groups are more vulnerable to COVID-19 disease by virtue of underlying health conditions, treatments received or suboptimal responses to vaccination. TRIAL REGISTRATION ClinicalTrials.gov NCT04870333. EudraCT 2020-004144-28.
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Affiliation(s)
- Toby J L Humphrey
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- University of Cambridge, Cambridge, UK
| | - Davinder Dosanjh
- Birmingham and West Midlands Lung Research Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Alex Richter
- Birmingham and West Midlands Lung Research Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Michael Chen-Xu
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- University of Cambridge, Cambridge, UK
| | - Wendi Qian
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Vivekanand Jha
- George Institute for Global Health, New Delhi, India
- School of Public Health, Imperial College, London, UK
- Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, India
| | - Katrina Gatley
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Rakshya Adhikari
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Francis Dowling
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Rona M Smith
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
- University of Cambridge, Cambridge, UK.
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Wong J, Leach L, Chen-Xu M, Truman L. Rare case of sudden onset sensorineural hearing loss in a patient diagnosed with sarcoidosis. BMJ Case Rep 2022; 15:15/7/e248969. [DOI: 10.1136/bcr-2022-248969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We report the case of a woman in her 30s who was referred to the ear, nose and throat department with sudden onset left-sided sensorineural hearing loss (SNHL), left anterior uveitis and erythematous lower limb lesions with bilateral pitting oedema. Based on her symptoms, an underlying inflammatory systemic disease was suspected. Autoantibodies were negative but an X-ray and high-resolution CT scan of the chest were suggestive of sarcoidosis, which was confirmed on endoscopic bronchial biopsy. Following treatment with a course of oral steroids, the patient’s hearing has improved but she still suffers from episodes of uveitis. While immune-mediated inner ear disorders are a recognised cause of SNHL, sarcoidosis is a very rare cause. This case demonstrates the importance of screening for systemic autoimmune aetiology in SNHL and highlights the importance of an effective multidisciplinary team in the diagnosis and management of these patients.
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Chen-Xu M, Coath FL, Ducker G, Fordham S, Mukhtyar CB. Maxillary artery involvement in giant cell arteritis demonstrated by ultrasonography. J R Coll Physicians Edinb 2021; 51:366-368. [PMID: 34882135 DOI: 10.4997/jrcpe.2021.410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
We describe two cases of giant cell arteritis where involvement of the superficial temporal artery and maxillary artery were demonstrated using colour doppler ultrasonography. Maxillary artery involvement is responsible for the symptoms of jaw claudication and toothache, and even headaches might be due to the involvement of the middle meningeal artery which is a branch of the maxillary artery. The maxillary artery has been difficult to visualise until now. There are international consensus definitions of ultrasonographic abnormalities seen in the superficial temporal artery affected by giant cell arteritis. We have used those definitions to demonstrate hypoechoic changes in the maxillary artery affected by giant cell arteritis. The maxillary artery can be visualised in the infratemporal fossa from an echo window between the condylar and coronoid processes of the mandible. This is the first proof of concept evidence that maxillary arteries can be visualised using bedside ultrasonography in giant cell arteritis.
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Affiliation(s)
- Michael Chen-Xu
- Rheumatology Department, Norfolk and Norwich University Hospital, Norwich, UK
| | - Fiona L Coath
- Rheumatology Department, Norfolk and Norwich University Hospital, Norwich, UK
| | - Georgina Ducker
- Rheumatology Department, Norfolk and Norwich University Hospital, Norwich, UK
| | - Sarah Fordham
- Rheumatology Department, Norfolk and Norwich University Hospital, Norwich, UK
| | - Chetan B Mukhtyar
- Rheumatology Department, Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UY, UK,
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Chen-Xu M, Hyseni D, Achilleos K. P022 Audit of musculoskeletal ultrasound to optimise DMARD therapy among patients in a district general hospital. Rheumatology (Oxford) 2021. [DOI: 10.1093/rheumatology/keab247.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background/Aims
Musculoskeletal ultrasound (MSUS) has utility in optimising the use of conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and biologic DMARDs (bDMARDs) in patients with inflammatory arthritis. However, it is unclear whether this is useful among patients with concomitant chronic pain and/or fibromyalgia, who often have elevated disease activity scores. We aimed to evaluate the impact of MSUS on inflammatory arthritis patients with concomitant chronic pain and/or fibromyalgia who met criteria for treatment escalation in a district general rheumatology service.
Methods
We conducted a retrospective audit of inflammatory arthritis patients with concomitant chronic pain and/or fibromyalgia who were eligible for DMARD escalation and underwent a MSUS since 2017. Scanning was performed by either a trained rheumatologist or musculoskeletal ultrasonographer. Synovitis was assessed following OMERACT guidelines.
Results
43 patients with inflammatory arthritis and concomitant chronic pain and/or fibromyalgia who underwent MSUS were identified. The mean age was 57.0 years (SD 15.6), and 34 patients (79%) were female. Rheumatoid arthritis was the most frequent diagnosis with 32 patients (74%), with psoriatic arthritis in 5 (12%), undifferentiated inflammatory arthritis in 4 (9%) and axial spondylarthritis (axSpA) in 2 (5%). 20 patients (47%) had a concurrent diagnosis of fibromyalgia. The median tender joint count among non-axSpA patients was 10 (IQR 4-15) and 2 (IQR 0-4) for swollen joints. MSUS was requested for consideration of a bDMARD switch in 21 patients (49%), a new bDMARD in 15 (35%), and starting an adjunctive csDMARD among 7 (16%). 34 patients (79%) were already established on csDMARDs, with 15 patients (35%) being on one or more, and methotrexate being the most prescribed csDMARD in 26 (76%). 14 patients (33%) were already established on bDMARDs, 9 (21%) had been on them previously and 20 (47%) were bDMARD naïve. Among those on bDMARDs, anti-TNFs agents were the most prescribed (71%). Active synovitis was identified in 17 patients (40%). Greyscale synovitis, tenosynovitis and enthesitis were seen in 30 (70%), 10 (23%) and 2 patients (5%), respectively. Erosions were identified in 12 patients (28%), with 2 (17%) having new erosions. 27 patients (63%) had either a csDMARD started (n = 7, 33%), or a bDMARD started (n = 11, 31%) or switched (n = 9, 25%) after MSUS. Those with fibromyalgia were less likely to start or switch DMARDs (8/20 patients, 40%) than those without (19/23 patients, 82.6%), Pchi-squared = 0.004. Furthermore, active synovitis on MSUS was associated with DMARD escalation (14/17 patients [82.4%] with synovitis versus 13/26 patients [50%] without; Pchi-squared = 0.03).
Conclusion
MSUS avoided unnecessary DMARD escalation in a significant proportion of patients with inflammatory arthritis and features of concomitant chronic pain and/or fibromyalgia (n = 26, 37%), potentially resulting in reduced patient exposure to harmful DMARD side effects, and cost savings for the service.
Disclosure
M. Chen-Xu: None. D. Hyseni: None. K. Achilleos: None.
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Affiliation(s)
- Michael Chen-Xu
- West Suffolk NHS Foundation Trust, Rheumatology, Bury St Edmunds, UNITED KINGDOM
| | - Dovenik Hyseni
- West Suffolk NHS Foundation Trust, Rheumatology, Bury St Edmunds, UNITED KINGDOM
| | - Katerina Achilleos
- West Suffolk NHS Foundation Trust, Rheumatology, Bury St Edmunds, UNITED KINGDOM
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Chen-Xu M, Achilleos K. Periorbital purpura of AL amyloidosis. Rheumatology (Oxford) 2021; 60:1165. [PMID: 32944781 DOI: 10.1093/rheumatology/keaa545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Michael Chen-Xu
- Department of Rheumatology, West Suffolk NHS Foundation Trust, UK
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Chen-Xu M, Sykes M. EP35 Cryoglobulinaemic vasculitis: an uncommon complication of Sjögren’s syndrome. Rheumatol Adv Pract 2020. [PMCID: PMC7607341 DOI: 10.1093/rap/rkaa052.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Case report - Introduction We present the case of a 70-year-old female with a background of anti-Ro positive Sjögren’s syndrome with difficult sicca symptoms who presented with worsening Raynaud’s, bilateral lower limb petechiae/purpura, fatigue, and progressive peripheral neuropathy. Blood tests revealed positive cryoglobulins with hypocomplementemia, and nerve conduction studies objectively confirmed the peripheral neuropathy. The patient was diagnosed with cryoglobulinaemic vasculitis and treated with pulsed intravenous cyclophosphamide and oral prednisolone, which resolved her rash and halted the progression of her symptoms. Cryoglobulinaemic vasculitis is a rare complication of Sjögren’s syndrome occurring in only 3–4% of patients with the disease. Case report - Case description A 70-year-old female with known Sjögren’s syndrome presented with a two-month history of an intermittent red, pin-prick rash affecting her lower legs, worsening fatigue and Raynaud’s, and a progression of longstanding symptoms of pins and needles from her ankles up to her knees, shortly after an acute Epstein-Barr virus infection. Her Sjögren’s syndrome was diagnosed after she presented with difficult sicca symptoms, fatigue and Raynaud’s phenomenon, and strongly positive ANA and anti-Ro antibodies (>240 u/mL). Past medical history was notable for microscopic colitis. On examination, she had bilateral pitting oedema with a purpuric rash affecting both legs. She had reduced sensation to both knees, but with normal power and downgoing plantars. Her joints examined normally. There were no ischaemic changes in her peripheries. Blood tests showed a positive cryoglobulin consisting of a monoclonal IgM paraprotein with polyclonal lambda light chains. She had a normal kappa: lambda ratio and Bence-Jones proteins. Inflammatory markers were raised (CRP 34mg/L, ESR 93mm/hour), with hypocomplementemia (C4 0.05g/L, normal C3). Otherwise, her full blood count, electrolytes, renal and liver function tests, chest X-ray, urine dipstick, hepatitis serology, ANCA profile, B12, folate and ferritin were unremarkable. Nerve conduction studies showed a length-dependent, moderately severe sensory motor axonal peripheral neuropathy, which Neurology agreed was due to a vasculitic process. The patient was diagnosed with a cryoglobulinaemic vasculitis with peripheral nerve involvement secondary to her Sjögren’s syndrome. This was initially treated with prednisolone 40mg daily, intravenous pulsed cyclophosphamide, which resolved her rash and halted the progression of her peripheral neuropathy. Pregabalin was prescribed for pain relief. After completing six cycles of cyclophosphamide, the patient was commenced on azathioprine. This was then replaced with mycophenolate due to leukopenia. She was gradually weaned off steroids, and her vasculitis to date remains biochemically and clinically stable. Case report - Discussion The presence of the combination of a petechial/purpuric rash on her lower limbs, worsening fatigue and Raynaud’s, and symptoms consistent with a progressive peripheral neuropathy raised the suspicion of a vasculitic process in this patient, which warranted urgent investigation. She had a type II mixed cryoglobulinemia which is the most common type of cryoglobulinemia found in Sjögren’s syndrome, evidenced by the presence of a monoclonal IgM paraprotein with polyclonal lambda light chains. Cryoglobulinaemic vasculitis is a systemic vasculitis characterised by the deposition of immune complexes into small vessels, commonly affecting the peripheral nerves, skin, and joints. Clinically, this can manifest with arthralgias/arthritis; constitutional symptoms, such as fatigue and fever; neurologically, with peripheral neuropathies, cranial nerve and central nervous system involvement; and with vascular symptoms, such as petechiae/purpura, skin ulcers, hyperviscosity syndrome, and Raynaud’s. Laboratory features consistent with a diagnosis of cryoglobulinaemic vasculitis aside from the sine qua non of positive cryoglobulins include hypocomplementemia (especially complement C4), positive rheumatoid factor, and a positive serum monoclonal component. We suspect that her cryoglobulinaemic vasculitis was most likely due to Sjögren’s syndrome, although it could have been triggered by the preceding Epstein-Barr virus infection, as this can be associated with cryoglobulinemia also. The decision to treat aggressively with pulsed intravenous cyclophosphamide and prednisolone was made given the severity of the patient’s symptoms, especially her progressive peripheral neuropathy. Given the paucity of data in the literature on the management of cryoglobulinaemic vasculitis secondary to rheumatological conditions, cyclophosphamide and prednisolone were chosen as these are proven in the other small vessel vasculitides, such as ANCA-associated vasculitis. This case is of interest as cryoglobulins are found in approximately 7–16% of patients with Sjögren’s syndrome, with cryoglobulinaemic vasculitis seen in only 3–4% of patients with the disease. Case report - Key learning points Cryoglobulins are uncommon in Sjögren’s syndrome, occurring in 7–16% of those with the disease. Symptomatic cryoglobulinaemic vasculitis among those with Sjögren’s syndrome is rare, seen in only 3–4% of cases. The presence of cryoglobulins in Sjögren’s syndrome is of clinical significance, as it is associated with higher global systemic disease activity and extra glandular involvement. Compared to non-cryoglobulinaemic patients with Sjögren’s syndrome, those with cryoglobulinemia are more likely to have lymphadenopathy, constitutional symptoms, peripheral nervous system and pulmonary involvement, and glandular, articular, and cutaneous features of the disease. The type of cryoglobulinemia found in Sjögren’s syndrome is the mixed type, which are either formed from a monoclonal immunoglobulin (usually IgM) and a polyclonal immunoglobulin (type II), or two polyclonal immunoglobulins (type III). Other conditions associated with mixed cryoglobulinemia include rheumatoid arthritis and systemic lupus erythematosus (SLE), although the most common cause of these is chronic hepatitis C (80–90% of cases). Other causes of mixed cryoglobulinemia include other viral infections, including Epstein-Barr virus and hepatitis B, and certain bacterial and parasitic infections. Most of the literature on the management of cryoglobulinaemic vasculitis is in the context of patients with this due to chronic hepatitis C and revolves around treating this with the appropriate antiviral therapy. Consequently, the current treatment options for moderate-to-severe cryoglobulinaemic vasculitis secondary to rheumatological conditions are the same as those for the other small vessel vasculitides, using a combination of cyclophosphamide and glucocorticoids to induce remission, and azathioprine as maintenance therapy. In severe cases, plasma exchange and rituximab can also be considered as agents to induce remission in cryoglobulinaemic vasculitis.
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Affiliation(s)
- Michael Chen-Xu
- West Suffolk NHS Foundation Trust, Bury St Edmunds, United Kingdom
| | - Mark Sykes
- West Suffolk NHS Foundation Trust, Bury St Edmunds, United Kingdom
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Chen-Xu M, Yokose C, Rai SK, Pillinger MH, Choi HK. Contemporary Prevalence of Gout and Hyperuricemia in the United States and Decadal Trends: The National Health and Nutrition Examination Survey, 2007-2016. Arthritis Rheumatol 2019; 71:991-999. [PMID: 30618180 DOI: 10.1002/art.40807] [Citation(s) in RCA: 421] [Impact Index Per Article: 84.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Accepted: 12/04/2018] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To estimate the current prevalence rates and decadal trends of gout and hyperuricemia in the US, as well as the prevalence of urate-lowering therapy (ULT) among gout patients, using 2007-2016 data from a nationally representative survey of American men and women (the National Health and Nutrition Examination Survey [NHANES]). METHODS Using data from 5,467 participants in the NHANES 2015-2016, we estimated the most recent prevalence rates of gout and hyperuricemia. When the NHANES was conducted, all participants were asked about their history of gout (as diagnosed by a health professional) and medication use. Hyperuricemia was defined as having a serum urate level of >7.0 mg/dl in men and >5.7 mg/dl in women. We examined decadal trends in these estimates using data from the NHANES 2007-2016 and investigated ULT usage trends using the NHANES 2007-14 (the most recent data available to date). RESULTS In 2015-2016, the prevalence of gout was 3.9% among adults in the US (9.2 million people), with 5.2% [5.9 million] in men and 2.7% [3.3 million] in women. Mean serum urate levels were 6.0 mg/dl in men and 4.8 mg/dl in women, and hyperuricemia prevalence rates were 20.2% and 20.0%, respectively. The prevalence rates of gout and hyperuricemia remained stable between 2007 and 2016 (P for trend > 0.05). The prevalence of ULT use among patients with gout was 33% in 2007-2014 and remained stable over time (P for trend > 0.05). CONCLUSION In this nationally representative survey sample of adults in the US, the prevalence rates of gout and hyperuricemia remained substantial, albeit unchanged, between 2007 and 2016. Despite these rates, only one-third of gout patients were receiving ULT.
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Affiliation(s)
| | - Chio Yokose
- Massachusetts General Hospital and Harvard University, Boston, Massachusetts
| | - Sharan K Rai
- Massachusetts General Hospital and Harvard University, Boston, Massachusetts
| | | | - Hyon K Choi
- Massachusetts General Hospital and Harvard University, Boston, Massachusetts
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Johnston L, Holley A, Chen-Xu M, Al-Sinan A, Larsen P, Harding S. PM156 Does Low on Treatment Platelet Reactivity Identify Acs Patients At Increased Risk of Bleeding? Glob Heart 2014. [DOI: 10.1016/j.gheart.2014.03.1547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Bass M, Chen-Xu M, Sasse A, La Flamme A, Larsen P, Harding S. Stimulation of platelet toll-like receptors results in marked platelet activation that is partially inhibited by prasugrel but not aspirin. Heart Lung Circ 2014. [DOI: 10.1016/j.hlc.2014.04.136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Chen-Xu M, Johnston L, Holley A, Sasse A, Larsen P, Harding S. Comparison of the Multiplate and VerifyNow Assays for Monitoring Residual Platelet Reactivity after Clopidogrel. Heart Lung Circ 2012. [DOI: 10.1016/j.hlc.2012.03.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Johnston L, Holley A, Chen-Xu M, Larsen P, Harding S. Significant Disagreement Between the VerifyNow and Multiplate Assays in the Classification of High Platelet Reactivity on Clopidogrel. Heart Lung Circ 2012. [DOI: 10.1016/j.hlc.2012.05.434] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Chen-Xu M, Topless R, McKinney C, Merriman ME, Phipps-Green A, Dalbeth N, Gow PJ, Harrison AA, Highton J, Jones PB, Nissen M, Smith MD, van Rij A, Jones GT, Rodriguez-Rodriguez L, Fernandez-Gutierrez B, Teruel M, Balsa A, Pascual-Salcedo D, Ortiz AM, Gonzalez-Gay MA, Steer S, Maehlen M, Lie B, Wordsworth BP, Stamp LK, Martin J, Merriman TR. Replication of association of the interleukin 23 receptor rs1343151 variant with rheumatoid arthritis in Caucasian sample sets. Ann Rheum Dis 2011; 71:155-7. [PMID: 21926184 DOI: 10.1136/annrheumdis-2011-200591] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Hollis-Moffatt JE, Chen-Xu M, Topless R, Dalbeth N, Gow PJ, Harrison AA, Highton J, Jones PBB, Nissen M, Smith MD, van Rij A, Jones GT, Stamp LK, Merriman TR. Only one independent genetic association with rheumatoid arthritis within the KIAA1109-TENR-IL2-IL21 locus in Caucasian sample sets: confirmation of association of rs6822844 with rheumatoid arthritis at a genome-wide level of significance. Arthritis Res Ther 2010; 12:R116. [PMID: 20553587 PMCID: PMC2911910 DOI: 10.1186/ar3053] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Revised: 05/25/2010] [Accepted: 06/16/2010] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION The single nucleotide polymorphism (SNP) rs6822844 within the KIAA1109-TENR-IL2-IL21 gene cluster has been associated with rheumatoid arthritis (RA). Other variants within this cluster, including rs17388568 that is not in linkage disequilibrium (LD) with rs6822844, and rs907715 that is in moderate LD with rs6822844 and rs17388568, have been associated with a number of autoimmune phenotypes, including type 1 diabetes (T1D). Here we aimed to: one, confirm at a genome-wide level of significance association of rs6822844 with RA and, two, evaluate whether or not there were effects independent of rs6822844 on RA at the KIAA1109-TENR-IL2-IL21 locus. METHODS A total of 842 Australasian RA patients and 1,115 controls of European Caucasian ancestry were genotyped for rs6822844, rs17388568 and rs907715. Meta-analysis of these data with published and publicly-available data was conducted using STATA. RESULTS No statistically significant evidence for association was observed in the Australasian sample set for rs6822844 (odds ratio (OR)=0.95 (0.80 to 1.12), P=0.54), or rs17388568 (OR=1.03 (0.90 to 1.19), P=0.65) or rs907715 (OR=0.98 (0.86 to 1.12), P=0.69). When combined in a meta-analysis using data from a total of 9,772 cases and 10,909 controls there was a genome-wide level of significance supporting association of rs6822844 with RA (OR=0.86 (0.82 to 0.91), P=8.8x10(-8), P=2.1x10(-8) including North American Rheumatoid Arthritis Consortium data). Meta-analysis of rs17388568, using a total of 6,585 cases and 7,528 controls, revealed no significant association with RA (OR=1.03, (0.98 to 1.09); P=0.22) and meta-analysis of rs907715 using a total of 2,689 cases and 4,045 controls revealed a trend towards association (OR=0.93 (0.87 to 1.00), P=0.07). However, this trend was not independent of the association at rs6822844. CONCLUSIONS The KIAA1109-TENR-IL2-IL21 gene cluster, that encodes an interleukin (IL-21) that plays an important role in Th17 cell biology, is the 20th locus for which there is a genome-wide (P<or=5x10(-8)) level of support for association with RA. As for most other autoimmune diseases, with the notable exception of T1D, rs6822844 is the dominant association in the locus. The KIAA1109-TENR-IL2-IL21 locus also confers susceptibility to other autoimmune phenotypes with a heterogeneous pattern of association.
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Affiliation(s)
- Jade E Hollis-Moffatt
- Department of Biochemistry, 710 Cumberland Street, University of Otago, Dunedin 9054, New Zealand
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