Consensus recommendations on managing the selected comorbidities including cardiovascular disease, osteoporosis, and interstitial lung disease in rheumatoid arthritis

BACKGROUND

Rheumatoid arthritis (RA)-related comorbidities, including cardiovascular disease (CVD), osteoporosis (OP), and interstitial lung disease (ILD), are sub-optimally managed. RA-related comorbidities affect disease control and lead to impairment in quality of life. We aimed to develop consensus recommendations for managing RA-related comorbidities.

METHODS

The consensus statements were formulated based on emerging evidence during a face-to-face meeting of Taiwan rheumatology experts and modified through three-round Delphi exercises. The quality of evidence and strength of recommendation of each statement were graded after a literature review, followed by voting for agreement. Through a review of English-language literature, we focused on the existing evidence of management of RA-related comorbidities.

RESULTS

Based on experts' consensus, eleven recommendations were developed. CVD risk should be assessed in patients at RA diagnosis, once every 5 years, and at changes in DMARDs therapy. Considering the detrimental effects of nonsteroidal anti-inflammatory drugs (NSAIDs) and corticosteroids on CVD risks, we recommend using the lowest possible dose of corticosteroids and prescribing NSAIDs cautiously. The OP/fragility fracture risk assessment includes dual-energy X-ray absorptiometry and fracture risk assessment (FRAX) in RA. The FRAX-based approach with intervention threshold is a useful strategy for managing OP. RA-ILD assessment includes risk factors, pulmonary function tests, HRCT imaging and a multidisciplinary decision approach to determine RA-ILD severity. A treat-to-target strategy would limit RA-related comorbidities.

CONCLUSIONS

These consensus statements emphasize that adequate control of disease activity and the risk factors are needed for managing RA-related comorbidities, and may provide useful recommendations for rheumatologists on managing RA-related comorbidities.

Lymph node revealing solution and traditional 10% buffered formaldehyde for detecting lymph nodes in colorectal carcinoma

BACKGROUND

Cancer stage has been the most important factor in evaluating the prognosis and treatment of colorectal carcinoma, and the presence of lymph node metastasis in the resected specimen plays a key role in serial staging. We evaluated a newly proposed "lymph node revealing solution" (LNRS) that proponents claim is inexpensive, easy, rapid, and innocuous, and that could help to establish the stage of disease more accurately than buffered formaldehyde (formalin). Our study compared traditional 10% formalin and LNRS as second search solutions to determine whether LNRS is a more useful and practical solution than formalin.

METHODS

Thirty randomly selected colorectal carcinomas from low anterior resection (LAR) were studied. The specimens were handled routinely on the first day. Then, the entire fat of odd-numbered cases was immersed in three times its volume of LNRS, and the entire fat of even-numbered cases was immersed in 10 times its volume of formalin overnight. The chi-squared test was used to evaluate the results.

RESULTS

Of 145 cassettes in the second search by LNRS, seven had no lymph nodes. Of 107 cassettes in the second search by formalin, 18 had no lymph nodes. Totally, 792 lymph nodes were found with an average number of 26.4 per case and 1.53/cm (per centimeter of specimen) in all 30 cases. By the LNRS method, 138 lymph nodes were found in the 15 odd-numbered cases, and by the formalin method, 89 lymph nodes were found in the 15 even-numbered cases. We were able to adjust the stage upward in two cases by LNRS-fixation method. There were no changes in staging in the formalin-fixation method cases.

CONCLUSIONS

LNRS showed no statistically significant difference from formalin in the numbers of total lymph nodes, positive lymph nodes, or minute (less than 1 mm) lymph nodes found. Nonetheless, we do believe that LNRS is a potential replacement solution for formalin due to its fast fixation, ease of searching, high identification rate and time-saving procedure.

Fine-needle aspiration cytology of retroperitoneal extramedullary hematopoiesis: a case report

We report a 69 year-old man with left renal hilar tumor, which was incidentally detected and clinically suspected to be malignant. Interpretations of fine-needle aspiration (FNA) and frozen section of this tumor were not conclusive, and originally malignancy could not be ruled out. Later, correlation with the patient's history and bone marrow biopsy with cytological and histological pictures resulted in the diagnosis of a tumor of extramedullary hematopoiesis (EMH). This case shows that FNA cytology may be a useful method for diagnosing EMH. However, we also demonstrate the potential pitfall of misdiagnosing atypical megakaryocytes as malignant cells on FNA smears, or even in frozen sections, when clinical history and clinical data are not available. EMH should be considered in the differential diagnosis of patients with bone marrow disorders and mass lesions in extramedullary sites.

Endoscopic sinus surgery and postoperative intravenous aminoglycosides in the treatment of atrophic rhinitis

A total of 29 atrophic rhinitis patients were treated by endoscopic sinus surgery between 1990 and 1995. After the surgery, a 7 to 10-day course of systematic aminoglycoside was administered. Two cases were excluded, due to later occurrence of nasal lymphoma in one patient and incompleteness of postoperative antibiotic therapy in the other. Among those included, atrophic rhinitis occurred in the absence of prior surgery in 24 patients, and the condition was secondary to a previous intranasal surgery in the other three patients. After a 1 to 6-year follow-up (mean: 63.4 months), seven patients were successfully managed without any characteristic symptom or sign of atrophic rhinitis. Another 18 patients felt improved. Only two patients did not have any improvement. The rate of improvement was 92.6%. Overall, one patient suffered from a left retrobulbar hematoma after operation. Exposed orbital fat was observed in the other patient. The orbital complication rate was therefore 7.4%. No other major complication occurred in this series. The bacteriologic, radiological, antroscopic, and pathologic findings are also included here. It is concluded that endoscopic sinus surgery in combination with adequate postoperative antibiotic therapy can significantly treat atrophic rhinitis.

Primary ethmoid sinus craniopharyngioma: a case report

A seven-year-old boy complained of intermittent epistaxis for several months. Computerized tomography (CT) scans showed increased soft tissue density over the left ethmoid sinus. Endoscopic sinus surgery was used to remove the mass completely. The pathological report was craniopharyngioma. No other focus of lesion was found, and he continues to do well.

Primary coexistent adenocarcinoma and choriocarcinoma of the stomach. A case report and review of the literature

We report a case of primary gastric choriocarcinoma with liver metastasis. The mixed histologic patterns included adenocarcinoma, undifferentiated carcinoma, and choriocarcinoma. Immunohistologic staining for the beta-subunit of human chorionic gonadotrophin (beta-HCG) showed positive results in the choriocarcinoma, adenocarcinoma, and normal mucosal gland. However, positive HCG cells were present at different intensities in the choriocarcinoma, adenocarcinoma, and normal mucosal gland. The level of HCG was significantly increased in serum. This unusual tumor probably resulted from dedifferentiation of a primary adenocarcinoma or developed directly from the mucosal glands.