Postoperative complications in rheumatic disease patients undergoing arthroscopy on immunosuppression

BACKGROUND

There are currently no guidelines on peri-arthroscopic management of immunosuppressive (IS) treatment in rheumatic disease patients.

PURPOSE

The purpose of this study is to characterize the rheumatic disease patient population undergoing arthroscopy, compare the incidence of postoperative complications among patients who either remained on IS perioperatively, held IS perioperatively or were not on IS at baseline, and compare the incidence of postoperative complications by rheumatic disease type, medication type, and procedure.

METHODS

We conducted a retrospective review of all arthroscopic sports medicine surgeries in patients with a rheumatic disease diagnosis at our institution over an 11-year period. Patients on IS at baseline were grouped into those who remained on IS perioperatively or held all IS before the date of their surgery. These two groups were compared to patients who were not on IS at baseline. Incidence of postoperative complications was calculated for the three cohorts and by medication class, rheumatic disease type, and procedure risk. Analysis of variance (ANOVA), chi-squared, and Fisher's exact tests were used to determine the statistical significance of between-group differences in postoperative complication incidence.

RESULTS

We identified 1,316 rheumatic disease patients undergoing arthroscopy, with 214 of them taking IS medications at baseline. In total, 8.4% (n = 110) remained on IS perioperatively, 7.9% (n = 104) held IS perioperatively, and 83.7% (n = 1102) were not on IS at baseline. In all cohorts, seven patients experienced postoperative complications; six of whom experienced infections. Two (1.82%) occurred in patients remaining on IS perioperatively, zero infections occured in patients who held all IS, and four (0.36%) occured in patients who were not on any IS at baseline. There was no statistically significant difference in postoperative infections or complication rates among the three cohorts or further subgroups.

CONCLUSION

The risk of postoperative complications including infectious, major, and minor complications in patients on IS at the time of arthroscopy is low and acceptable.

Associations Between Patient-Reported Outcome Measures of Physical and Psychological Functioning and Willingness to Share Social Media Data for Research Among Adolescents With a Chronic Rheumatic Disease: Cross-Sectional Survey

Background

Social media data may augment understanding of the disease and treatment experiences and quality of life of youth with chronic medical conditions. Little is known about the willingness to share social media data for health research among youth with chronic medical conditions and the differences in health status between sharing and nonsharing youth with chronic medical conditions.

Objective

We aimed to evaluate the associations between patient-reported measures of disease symptoms and functioning and the willingness to share social media data.

Methods

Between February 2018 and August 2019, during routine clinic visits, survey data about social media use and the willingness to share social media data (dependent variable) were collected from adolescents in a national rheumatic disease registry. Survey data were analyzed with patient-reported measures of disease symptoms and functioning and a clinical measure of disease activity, which were collected through a parent study. We used descriptive statistics and multivariate logistic regression to compare patient-reported outcomes between youth with chronic medical conditions who opted to share social media data and those who did not opt to share such data.

Results

Among 112 youths, (age: mean 16.1, SD 1.6 y; female: n=72, 64.3%), 83 (74.1%) agreed to share social media data. Female participants were more likely to share (P=.04). In all, 49 (43.8%) and 28 (25%) participants viewed and posted about rheumatic disease, respectively. Compared to nonsharers, sharers reported lower mobility (T-score: mean 49.0, SD 9.4 vs mean 53.9, SD 8.9; P=.02) and more pain interference (T-score: mean 45.7, SD 8.8 vs mean 40.4, SD 8.0; P=.005), fatigue (T-score: mean 49.1, SD 11.0 vs mean 39.7, SD 9.7; P<.001), depression (T-score: mean 48.1, SD 8.9 vs mean 42.2, SD 8.4; P=.003), and anxiety (T-score: mean 45.2, SD 9.3 vs mean 38.5, SD 7.0; P<.001). In regression analyses adjusted for age, sex, study site, and Physician Global Assessment score, each 1-unit increase in symptoms was associated with greater odds of willingness to share social media data, for measures of pain interference (Adjusted Odds Ratio [AOR] 1.07, 95% CI 1.001-1.14), fatigue (AOR 1.08, 95% CI 1.03-1.13), depression (AOR 1.07, 95% CI 1.01-1.13), and anxiety (AOR 1.10, 95% CI 1.03-1.18).

Conclusions

High percentages of youth with rheumatic diseases used and were willing to share their social media data for research. Sharers reported worse symptoms and functioning compared to those of nonsharers. Social media may offer a potent information source and engagement pathway for youth with rheumatic diseases, but differences between sharing and nonsharing youth merit consideration when designing studies and evaluating social media-derived findings.

Flares in autoimmune rheumatic diseases in the post-COVID-19 vaccination period-a cross-sequential study based on COVAD surveys

OBJECTIVE

Flares of autoimmune rheumatic diseases (AIRDs) following COVID-19 vaccination are a particular concern in vaccine-hesitant individuals. Therefore, we investigated the incidence, predictors and patterns of flares following vaccination in individuals living with AIRDs, using global COVID-19 Vaccination in Autoimmune Diseases (COVAD) surveys.

METHODS

The COVAD surveys were used to extract data on flare demographics, comorbidities, COVID-19 history, and vaccination details for patients with AIRDs. Flares following vaccination were identified as patient-reported (a), increased immunosuppression (b), clinical exacerbations (c) and worsening of PROMIS scores (d). We studied flare characteristics and used regression models to differentiate flares among various AIRDs.

RESULTS

Of 15 165 total responses, the incidence of flares in 3453 patients with AIRDs was 11.3%, 14.8%, 9.5% and 26.7% by definitions a-d, respectively. There was moderate agreement between patient-reported and immunosuppression-defined flares (K = 0.403, P = 0.022). Arthritis (61.6%) and fatigue (58.8%) were the most commonly reported symptoms. Self-reported flares were associated with higher comorbidities (P = 0.013), mental health disorders (MHDs) (P < 0.001) and autoimmune disease multimorbidity (AIDm) (P < 0.001).In regression analysis, the presence of AIDm [odds ratio (OR) = 1.4; 95% CI: 1.1, 1.7; P = 0.003), or a MHD (OR = 1.7; 95% CI: 1.1, 2.6; P = 0.007), or being a Moderna vaccine recipient (OR = 1.5; 95% CI: 1.09, 2.2; P = 0.014) were predictors of flares. Use of MMF (OR = 0.5; 95% CI: 0.3, 0.8; P = 0.009) and glucocorticoids (OR = 0.6; 95% CI: 0.5, 0.8; P = 0.003) were protective.A higher frequency of patients with AIRDs reported overall active disease post-vaccination compared with before vaccination (OR = 1.3; 95% CI: 1.1, 1.5; P < 0.001).

CONCLUSION

Flares occur in nearly 1 in 10 individuals with AIRDs after COVID vaccination; people with comorbidities (especially AIDm), MHDs and those receiving the Moderna vaccine are particularly vulnerable. Future avenues include exploring flare profiles and optimizing vaccine strategies for this group.

Cardiac magnetic resonance assessment of cardiac involvement in autoimmune diseases

Cardiac magnetic resonance (CMR) is emerging as the modality of choice to assess early cardiovascular involvement in patients with autoimmune rheumatic diseases (ARDs) that often has a silent presentation and may lead to changes in management. Besides being reproducible and accurate for functional and volumetric assessment, the strength of CMR is its unique ability to perform myocardial tissue characterization that allows the identification of inflammation, edema, and fibrosis. Several CMR biomarkers may provide prognostic information on the severity and progression of cardiovascular involvement in patients with ARDs. In addition, CMR may add value in assessing treatment response and identification of cardiotoxicity related to therapy with immunomodulators that are commonly used to treat these conditions. In this review, we aim to discuss the following objectives: •Illustrate imaging findings of multi-parametric CMR approach in the diagnosis of cardiovascular involvement in various ARDs;•Review the CMR signatures for risk stratification, prognostication, and guiding treatment strategies in ARDs;•Describe the utility of routine and advanced CMR sequences in identifying cardiotoxicity related to immunomodulators and disease-modifying agents in ARDs;•Discuss the limitations of CMR, recent advances, current research gaps, and potential future developments in the field.

Gastrointestinal endoscopic findings of autoimmune and autoinflammatory diseases in pediatric rheumatology patients

OBJECTIVE

Rheumatic diseases in children are chronic and multisystemic diseases. In this study, it was aimed to evaluate gastrointestinal endoscopic findings in children diagnosed as autoimmune or autoinflammatory rheumatic diseases consulted with pediatric gastroenterology for gastrointestinal complaints.

METHODS

The patients followed up by the Pediatric Rheumatology Department and consulted to the Pediatric Gastroenterology Department due to gastrointestinal complaints were included in the study. File records of the patients were analyzed retrospectively.

RESULTS

A total of 28 patients were included in the study. Twelve of the patients had autoimmune disease (Juvenile idiopathic arthritis [JIA], systemic lupus erythematosus, Sjögren's syndrome, and scleroderma) and the other 16 had autoinflammatory disease (familial Mediterrnean fever, hyper Immunoglobulin D syndrome, undifferantiated systemic autoinflammatory disease, and systemic JIA). Four of the patients with familial Mediterrnean fever also diagnosed as JIA. The mean age of the patients was 11.7±3.5 years. The main gastrointestinal complaints of patients with both autoimmune and autoinflammatory diseases were abdominal pain and diarrhea. Inflammatory bowel disease was found in 33% of those with autoimmune disease and 56% of those with autoinflammatory disease in patients underwent endoscopic evaluation. M694V mutation was present in 62% of the patients with autoinflammatory disease presented with gastrointestinal complaints.

CONCLUSION

Both autoimmune and autoinflammatory rheumatic diseases can cause gastrointestinal complaints and should be referred to a pediatric gastroenterologist for early diagnosis.

Physical activity assessment with wearable devices in rheumatic diseases: a systematic review and meta-analysis

OBJECTIVES

In the management of rheumatic musculoskeletal disorders (RMDs), regular physical activity (PA) is an important recognized non-pharmacological intervention. This systematic review and meta-analysis aims to evaluate how the use of wearable devices (WDs) impacts physical activity in patients with noninflammatory and inflammatory rheumatic diseases.

METHODS

A comprehensive search of articles was performed in PubMed, Embase, CINAHL and Scopus. A random-effect meta-analysis was carried out on the number of steps and moderate-vigorous physical activity (MVPA). Univariable meta-regression models were computed to assess the possibility that the study characteristics may act as modifiers on the final meta-analysis estimate.

RESULTS

In the analysis, 51 articles were included, with a total of 7488 participants. Twenty-two studies considered MVPA outcome alone, 16 studies considered the number of steps alone, and 13 studies reported information on both outcomes. The recommended PA threshold was reached for MVPA (36.35, 95% CI 29.39, 43.31) but not for daily steps (-1092.60, -1640.42 to -544.77). Studies on patients with fibromyalgia report a higher number (6290, 5198.65-7381.62) of daily steps compared with other RMDs. Patients affected by chronic inflammatory arthropathies seemed to fare better in terms of daily steps than the other categories. Patients of younger age reported a higher overall level of PA than elderly individuals for both the number of steps and MVPA.

CONCLUSION

Physical activity can be lower than the recommended threshold in patients with RMDs when objectively measured using WD. WDs could be a useful and affordable instrument for daily monitoring physical activity in RMDs and may support an increase in activity levels.

PROSPERO TRIAL REGISTRATION

CRD42021227681, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=227681.

Immunogenicity and safety of vaccination in children with paediatric rheumatic diseases: a scoping review

Children with paediatric rheumatic diseases (PRDs) are at increased risk of vaccine-preventable disease. Safe and effective vaccination is central to preventive care in PRD patients; however, uncertainty surrounding immunogenicity and safety has contributed to suboptimal vaccination. The aim of this study was to evaluate treatment effect on immunogenicity to vaccination in PRD patients and assess vaccine safety, specifically adverse events following immunisation (AEFI) and disease flare. Scoping review. In this scoping review, a systematic search of PubMed, CINAHL and Embase databases was conducted from 2014 to 23 August 2022 to identify observational studies evaluating the immunogenicity and safety of commonly used vaccinations in PRD patients. The primary outcome was immunogenicity (defined as seroprotection and protective antibody concentrations), with secondary outcomes describing AEFI and disease flare also extracted. Due to extensive heterogeneity related to diagnostic and vaccination variability, narrative synthesis was used to describe the findings of each study. Study quality was assessed via the Mixed Methods Appraisal Tool. The review was prospectively registered with PROSPERO (CRD42022307212). The search yielded 19 studies evaluating immunogenicity to vaccination and incidence of AEFI and disease flares in this population, which were of acceptable quality. Corticosteroids did not have deleterious effects on vaccine response. Treatment with conventional disease-modifying antirheumatic drugs (DMARDs) and biologic DMARDs generally had no effect immunogenicity in PRD patients. While patients exhibited adequate seroprotection, protective antibody levels were lower in patients on some immunosuppressant agents. Varicella infections were recorded post vaccination in several patients with low protective antibody levels undergoing treatment with DMARDs and corticosteroids. Most vaccines appear safe and effective in PRD patients, despite immunosuppressant treatment. Booster vaccinations should be considered with some studies highlighting inadequate seroprotection following primary course of vaccinations with acceleration of antibody decline over time. There was limited evidence to support avoiding live vaccines in PRD patients.

An update on the considerations for patients with rheumatic disease being treated with rituximab during the COVID-19 pandemic and the potential drug treatment strategies

INTRODUCTION

Over the last two decades, rituximab has become an increasingly popular drug in the treatment of a wide range of rheumatic diseases. However, with the advent of the COVID-19 pandemic, clinicians face challenges in weighing risk against benefit in its use.

AREAS COVERED

A review of existing data was performed to examine the relationship between rituximab use, morbidity and mortality from COVID-19, and vaccine efficacy in patients with rheumatic diseases, aiming to guide clinicians in continued use of the medication and consider the direction of future research. A literature review was performed through a search of the PubMed database, using the terms ((SARS-CoV-2) OR (COVID-19)) AND (rituximab) AND (rheumatic), which generated an initial 55 results, with relevant articles then selected for inclusion.

EXPERT OPINION

In order to safeguard patients with an ongoing need for rituximab therapy, vaccination remains the primary concern. A target of performing booster doses 6 months after last rituximab dose is a reasonable estimate, which may be made more precise by use of B cell counts, although primary immunization should not be delayed. In those patients who remain seronegative, the use of newer antivirals and broadly neutralizing antibody infusions may help provide further safeguards.

Satisfaction and Adherence to Biological Treatment in Patients with Rheumatic Diseases

BACKGROUND

Autoimmune inflammatory rheumatic diseases have long been treated by conventional disease-modifying anti-rheumatic drugs. Biological therapy is a new era in the treatment of rheumatic diseases, but satisfaction and adherence to it is still not well tested.

AIM

To assess the satisfaction and adherence to biological treatment among patients with autoimmune inflammatory rheumatic diseases.

METHODS

A cross sectional study was conducted among 56 patients suffering from inflammatory rheumatic diseases using Morisky 8 questionnaire and Treatment Satisfaction Questionnaire for Medication (TSQM) over a period of one month.

RESULTS

About 76.8% of the patients had medium adherence and the underlying cause of missing doses was the unavailability of the drugs. The mean satisfaction with biological treatment was 62.7±6.9. Patients who did not receive formal education had significantly higher satisfaction with the biological treatment than others 64.94±5.01 at a P value 0.04 (<0.05).

CONCLUSION

Patients with inflammatory rheumatic diseases in our study showed medium adherence and satisfaction. Authorities in the medical field are providing great help to these patients in need of biological therapy, but ensuring the availability of all doses of the biological treatment regimen is still necessary. Patient, family and nurse education programs are also necessary to maximize adherence and satisfaction.

Kinetics of quantitative hepatitis B surface antigen in patients with rheumatic disease and chronic hepatitis B receiving biologic agents

The effect of biologic treatment on quantitative Hepatitis B surface Antigen (qHBsAg) levels and HBsAg clearance in rheumatic patients with chronic HBV infection has not been well studied. We prospectively followed rheumatic patients with HBeAg-negative chronic HBV infection (n = 28) treated with biologics and oral antivirals, categorized into patients with chronic hepatitis B (CHB, group A n = 13) and chronic HBV infection (group B n = 15) and matched them to appropriate non-rheumatic controls. qHBsAg kinetics were serially measured and compared between groups. No HBV reactivation (HBVr) was recorded during the 108.25 patient-year follow-up. Among patients with CHB, the annual rapid qHBsAg decline (i.e. decline >0.5 log₁₀  IU/mL/year) as well as HBsAg clearance did not differ between rheumatic patients [n = 4 (32.7%), n = 1 (7.7%)] and controls [n = 6 (28.4%), p = .726 and n = 2 (7.7%), p = .818, respectively]. In contrast, there was a slower annual qHBsAg decline in rheumatic patients with chronic HBV compared to non-rheumatic controls (-0.04 vs -0.13 log₁₀  IU/mL at year 1, p = .019) with no cases of rapid qHBsAg decline or HBsAg clearance in rheumatic patients (0%) compared to a cumulative incidence of 24% and a rate of 20%, respectively in controls. In biologic-treated rheumatic patients with HBeAg-negative HBV receiving antiviral prophylaxis, there was slower qHBsAg decline, lower cumulative rates of rapid qHBsAg decline and HBsAg clearance compared to non-rheumatic controls.

Neonatal Rupture of the Tricuspid Valve and Maternal Lupus: Is There a Correlation?

Valve dysfunction is not widely recognized as a feature in newborns born to mothers with positive anti-Ro/SSA antibodies, and only scarce reports have suggested an association between rupture of the atrioventricular valve tensor apparatus and these maternal antibodies. We report the follow-up from fetal life to the time of postnatal surgery of a patient with severe tricuspid regurgitation due to a flail of the anterior tricuspid valve leaflet who was born to an anti-Ro/SSA antibodies positive mother.

Awareness of rheumatic fever and rheumatic heart disease among the population in taif, Saudi Arabia 2020

Objective

Studies assessing knowledge about rheumatic fever (RF) and rheumatic heart disease (RHD) are scarce in KSA. The aim of this study was to assess the awareness about ARF and RHD among the population at Taif city, Saudi Arabia.

Methods

A cross-sectional study was done on 716 of residents of Taif city. A pre-designed questionnaire that collected data about the participants' demographic characters, their history of sore throat and medication used, participants' knowledge about cause and complications of sore throat, its relation to RHD, treatment, primary and secondary prevention of RHD.

Results

77% of the participants had a history of sore throat, of them 58.4% took antibiotics as a self-medication. A significant higher prevalence of previous history of sore throat was present among 42-50-year-old females, graduated, and those with an income above 10000 SR. Participants with an age of 18-24 years and graduated, had significantly higher percent of those who knew about: cause and complications of sore throat, sore throat is associated with heart diseases, and if treating sore throat can prevent heart disease. Females had a significantly higher percent of those who knew about: complications of sore throat, being extremely aware of that primary prevention of sore throat by using antibiotics such as penicillin and being extremely aware of secondary prevention of recurrence RF and decrease progression of RHD.

Conclusion

Raising awareness about ARF and RHD through health education programs is needed.

Mental health in patients with rheumatic diseases related to COVID-19 pandemic: Experience in a tertiary care center in Latin America

OBJECTIVE

To determine the factors associated with anxiety, depression, and concern within the COVID-19 pandemic in a population with autoimmune diseases.

METHODS

A telephonic survey was conducted during the early stages of the pandemic in a tertiary care center, which included patients with systemic autoimmune diseases. Mental health variables were assessed with Patient Health Questionnaire 2, General Anxiety Disorder 7 scores, and pandemic-related concern questions. Sociodemographic aspects were also evaluated.

RESULTS

Of the total 334 participants, 291 (87.1%) were women, with a median age of 46 years; systemic lupus erythematosus (SLE) was the most frequent diagnosis (144, 43.2%); 44 patients (13.2%) showed depression and 32 (9.6%) anxiety. The variables associated with depression were all the pandemic concern items, body mass index, anxiety, and a higher COVID-19 symptom score. Anxiety was associated with depression, all pandemic concern items, and a higher COVID-19 symptom score. Women presented higher scores in all concern items. The SLE group presented higher scores in concern questions and difficulty finding medication.

CONCLUSION

During the COVID-19 outbreak, rheumatic patients are vulnerable to psychiatric conditions, which makes it imperative for physicians who treat these patients to pay careful attention in order to detect them promptly and to settle coping strategies.

The Pattern of Valvular Heart Diseases in India During Pregnancy and Its Outcomes

INTRODUCTION

The incidence of rheumatic heart disease is very high in India. The data on the pattern of valvular heart diseases during pregnancy and its outcomes is very scarce. Again, the data in the Indian scenario, the differences in outcomes between different grades of valvular heart diseases and its impact on pregnancy outcomes is very less. We planned to study the different patterns of valvular heart diseases during pregnancy and their outcomes with respect to cardiac complication and perinatal outcomes.

MATERIALS AND METHODS

It was a hospital-based prospective observational study. We recruited 71 patients after taking written informed consent. All patients were with term gestation and valvular heart diseases. We did 2D echocardiography to analyze the valve lesion and assess the valve lesion with its maternal and perinatal outcomes.

RESULTS

The mean age of participants in the study was 27 + 5.2 years. A total of 54 patients (76.1%) were less than 30 years and 17 (23.9%) were more than 30 years of age. Six patients (8.5%) presented with New York Heart Association (NYHA) class I, 39 patients (54.9%) presented with NYHA class II, 25 patients (35.2%) presented with NYHA class III and one patient (1.4%) presented with NYHA class IV. The most common etiology of valvular heart diseases was found to be rheumatic in 62 patients (87.3%). The most common valve involved was the mitral valve (69%). New-onset atrial fibrillation (AF) was reported in 26.8% patients and pulmonary edema developed in 15.5% patients. Live birth was observed in 66 patients (93%) compared to stillbirth reported in five patients (7%).

CONCLUSION

No significant difference in maternal and perinatal outcomes between moderate and severe grades of different valvular heart diseases.

What Lies Ahead for Young Hearts in the 21st Century - Is It Double Trouble of Acute Rheumatic Fever and Kawasaki Disease in Developing Countries?

Rheumatic heart disease (RHD), the principal long-term sequel of acute rheumatic fever (ARF), has been a major contributor to cardiac-related mortality in general population, especially in developing countries. With improvement in health and sanitation facilities across the globe, there has been almost a 50% reduction in mortality rate due to RHD over the last 25 years. However, recent estimates suggest that RHD still results in more than 300,000 deaths annually. In India alone, more than 100,000 deaths occur due to RHD every year (Watkins DA et al., N Engl J Med, 2017). Children and adolescents (aged below 15 years) constitute at least one-fourth of the total population in India. Besides, ARF is, for the most part, a pediatric disorder. The pediatric population, therefore, requires special consideration in developing countries to reduce the burden of RHD. In the developed world, Kawasaki disease (KD) has emerged as the most important cause of acquired heart disease in children. Mirroring global trends over the past two decades, India also has witnessed a surge in the number of cases of KD. Similarly, many regions across the globe classified as “high-risk” for ARF have witnessed an increasing trend in the incidence of KD. This translates to a double challenge faced by pediatric health care providers in improving cardiac outcomes of children affected with ARF or KD. We highlight this predicament by reviewing the incidence trends of ARF and KD over the last 50 years in ARF “high-risk” regions.

Prevalence, therapy and tumour response in patients with rheumatic immune-related adverse events following immune checkpoint inhibitor therapy: a single-centre analysis

Background:

Immune checkpoint inhibitors (ICIs) improved cancer therapy by inducing a higher immune system activity. This effect can cause rheumatic immune-related adverse events (rh-irAEs), which have not yet been extensively studied.

Methods:

We analysed 437 patients between 2014 and 2019, treated with ipilimumab (anti-CTLA-4) and/or nivolumab (anti-PD-1) or pembrolizumab (anti-PD-1) at the Clinic for Internal Medicine III, Oncology, Haematology and Rheumatology at the University Hospital Bonn, Germany.

Results:

Of the 437 patients 60% were males. Patients were mainly treated for melanoma, lung cancer, head and neck tumour and urothelial carcinoma. At least one immune-related adverse event (irAE) was observed in 163 patients (37.3%), including rh-irAE. Most common side effects were rash, colitis and hepatitis. We identified 19 patients (4.3%) with a minimum of one rh-irAE due to ICI therapy; three of those had a pre-existing rheumatic disease. Arthralgia developed most frequently in eight patients (42.1%). Other rh-irAEs were: arthritis (n = 7; distinguished in rheumatoid arthritis, psoriatic arthritis, juvenile idiopathic arthritis and undifferentiated arthritis), myalgia (n = 2) and myositis (n = 3). Most rh-irAEs were classified as moderately severe (Common Terminology Criteria of Adverse Events grade 2: 68.4%). Median time between starting ICI therapy and the occurrence of rh-irAE was 109 days (interquartile range 40–420 days). Fifteen patients (78.9%) were treated with glucocorticosteroids. In four cases additional therapy with methotrexate or tocilizumab was required. Even though patients benefited from ICI treatment, therapy had to be discontinued in six of the participants due to rh-irAE. Interestingly, patients with rh-irAE had a significantly higher tumour response compared with patients without rh-irAE (94.4% versus 43.5%; p < 0.0001).

Conclusion:

Rh-irAEs occur under ICI therapy, especially in patients with higher tumour response. However, they are not the most frequent irAE after ICI exposure: 9.3% of all irAEs were rheumatic (20 rh-irAE cases in 19 patients of a total of 215 irAE cases in 163 patients).

Children at the Heart of Global Cardiac Surgery: An Advocacy Stakeholder Analysis

One in a hundred babies, or 1.3 million per year around the world, are born with congenital heart defects (CHD), of which over 70% will require medical or surgical treatment within their first year of life. In low- and middle-income countries, the majority does not receive the treatment they need or receive suboptimal care. Despite a higher pediatric cardiac surgical disease burden, low-income countries only have 0.07 pediatric cardiac surgeons per million pediatric population, compared to 9.51 per million in high-income countries. Here, we perform a stakeholder analysis of existing advocacy bodies within the field of pediatric global cardiac surgery and identify gaps and opportunities in advocating for cardiac care for children with CHD. We propose a framework to optimize civil society messaging in order to more effectively advocate domestically and internationally to hold national and international policy makers accountable for existing gaps and disparities in CHD care around the world.

Pharmacological Interventions for Pulmonary Involvement in Rheumatic Diseases

Among the diverse forms of lung involvement, interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH) are two important conditions in patients with rheumatic diseases that are associated with significant morbidity and mortality. The management of ILD and PAH is challenging because the current treatment often provides only limited patient survival benefits. Such challenges derive from their common pathogenic mechanisms, where not only the inflammatory processes of immune cells but also the fibrotic and proliferative processes of nonimmune cells play critical roles in disease progression, making immunosuppressive therapy less effective. Recently, updated treatment strategies adopting targeted agents have been introduced with promising results in clinical trials for ILD ad PAH. This review discusses the epidemiologic features of ILD and PAH among patients with rheumatic diseases (rheumatoid arthritis, myositis, and systemic sclerosis) and the state-of-the-art treatment options, focusing on targeted agents including biologics, antifibrotic agents, and vasodilatory drugs.

Impact of Interferon-Based Therapy on Hepatitis C-Associated Rheumatic Diseases: A Nationwide Population-Based Cohort Study

Whether hepatitis C virus (HCV) infection-associated risk of rheumatic diseases is reversed by anti-HCV therapy remain elusive. A nationwide population-based cohort study of the Taiwan National Health Insurance Research Database was conducted. Of 19,298,735 subjects, 3 cohorts (1:4:4, propensity score-matched), including HCV-treated (6919 HCV-infected subjects with interferon and ribavirin therapy ≥ 6 months), HCV-untreated (n = 27,676) and HCV-uninfected (n = 27,676) cohorts, were enrolled and followed (2003–2015). The HCV-uninfected cohort had the lowest cumulative incidence of rheumatic diseases (95% confidence interval (CI): 8.416–10.734%), while HCV-treated (12.417–17.704%) and HCV-untreated (13.585–16.479%) cohorts showed no difference in the cumulative incidences. Multivariate analyses showed that HCV infection (95% CI hazard ratio (HR): 1.54–1.765), female sex (1.57–1.789), age ≥ 49 years (1.091–1.257), Charlson comorbidity index ≥ 1 (1.075–1.245), liver cirrhosis (0.655–0.916), chronic obstruction pulmonary disease (1.130–1.360), end-stage renal disease (0.553–0.98), diabetes mellitus (0.834–0.991) and dyslipidemia (1.102–1.304) were associated with incident rheumatic diseases. Among the 3 cohorts, the untreated cohort had the highest cumulative incidence of overall mortality, while the treated and un-infected cohorts had indifferent mortalities. Conclusions: HCV infection, baseline demographics and comorbidities were associated with rheumatic diseases. Although HCV-associated risk of rheumatic diseases might not be reversed by interferon-based therapy, which reduced the overall mortality in HCV-infected patients.

Rheumatic immune-related adverse events associated with immune checkpoint inhibitors compared with placebo in oncologic patients: a systemic review and meta-analysis

OBJECTIVE

We aim to characterize the incidence and relative risk of rheumatic and systemic immune-related adverse effects (irAEs) among immune checkpoint inhibitor (ICI) therapy compared with those after placebo treatment.

METHODS

Randomized clinical trial studies with placebo control with the following keywords were searched from Embase, PubMed, Cochrane databases: immune checkpoint inhibitors, neoplasms, randomized controlled trials, and adverse effects.

RESULTS

Among the 5444 published and 316 registration records, nine placebo-controlled randomized clinical trials met our selection criteria, and included data from 5560 patients. Compared with placebo use, using ICIs increases the risk of overall-rheumatic irAEs. The incidence and relative risk of all-grade rheumatic irAEs were 18.40% [95% confidence interval (CI) 12.16-25.59%, p < 0.01] and 2.30 (95% CI 1.32-4.02), respectively, while musculoskeletal irAEs were 11.30% (95% CI 9.76-12.85%) and 1.01 (95% CI 0.84-1.22). The incidence and relative risk of severe rheumatic irAEs were 5.72% (95% CI 3.92-7.82%), and 8.29 (95% CI 3.75-18.35), respectively. Arthralgia was the most common rheumatic irAE (incidence 11.00%, 95% CI 9.55-12.64%; relative risk 0.99, 95% CI 0.82-1.19), although usually not severe. Colitis (incidence 3.23%, 95% CI 1.27-7.98%; relative risk 6.53, 95% CI 2.66-16.04) and pneumonitis (incidence 3.11%, 95% CI 1.56-6.21; relative risk 4.04, 95% CI 1.65-9.89) were commonly observed and tended to be severe. Hepatitis, hypophysitis, thyroiditis, and myositis were rare and less recorded, yet can be severe and life threatening. Other extremely rare severe rheumatic irAEs included sarcoidosis (n = 11), autoimmune arthritis (n = 8), autoimmune uveitis (n = 3), autoimmune pericarditis, bursitis, osteochondrosis, psoriasis, polymyalgia rheumatica, systemic inflammatory response syndrome, and Sjögren syndrome (n = 1, each).

CONCLUSION

ICI therapy increased the incidence and relative risk of all-grade and severe rheumatic irAEs. Arthralgia was the most commonly observed non-severe irAE, while colitis and pneumonitis were commonly observed severe irAEs. Rare rheumatic irAEs like hepatitis, hypophysitis, thyroiditis, and myositis warrant special attention.

The Potential Contribution of Chronic Pain and Common Chronic Pain Conditions to Subsequent Cognitive Decline, New Onset Cognitive Impairment, and Incident Dementia: A Systematic Review and Conceptual Model for Future Research

BACKGROUND

Growing evidence suggests that chronic pain and certain chronic pain conditions may increase risk for cognitive decline and dementia.

OBJECTIVE

In this systematic review, we critically evaluate available evidence regarding the association of chronic pain and specific common chronic pain conditions to subsequent decline in cognitive function, new onset cognitive impairment (CI), and incident Alzheimer's disease and related dementias (ADRD); outline major gaps in the literature; and provide a preliminary conceptual model illustrating potential pathways linking pain to cognitive change.

METHODS

To identify qualifying studies, we searched seven scientific databases and scanned bibliographies of identified articles and relevant review papers. Sixteen studies met our inclusion criteria (2 matched case-control, 10 retrospective cohort, 2 prospective cohort), including 11 regarding the association of osteoarthritis (N = 4), fibromyalgia (N = 1), or headache/migraine (N = 6) to incident ADRD (N = 10) and/or its subtypes (N = 6), and 5 investigating the relation of chronic pain symptoms to subsequent cognitive decline (N = 2), CI (N = 1), and/or ADRD (N = 3).

RESULTS

Studies yielded consistent evidence for a positive association of osteoarthritis and migraines/headaches to incident ADRD; however, findings regarding dementia subtypes were mixed. Emerging evidence also suggests chronic pain symptoms may accelerate cognitive decline and increase risk for memory impairment and ADRD, although findings and measures varied considerably across studies.

CONCLUSION

While existing studies support a link between chronic pain and ADRD risk, conclusions are limited by substantial study heterogeneity, limited investigation of certain pain conditions, and methodological and other concerns characterizing most investigations to date. Additional rigorous, long-term prospective studies are needed to elucidate the effects of chronic pain and specific chronic pain conditions on cognitive decline and conversion to ADRD, and to clarify the influence of potential confounding and mediating factors.

Barefoot Running: Between Fashion and Real Way to Prevent Joint Osteo Lesions?

Background and objectives

Running has gone from a vital necessity for the man to a playful sport. Different rheumatic and orthopedic pathologies have appeared, in front of which the shoe industry has reacted by creating reinforced shoes that are supposed to overcome the induced lesions. Several years later, the trend toward reinforcement has gone toward minimalism, which is the absence of reinforcement, that is, a more natural race.

Method

We observed variations of kinetics and kinematics in young, unprofessional, healthy runners during a shoe race and a shoeless race, which is the form of maximum minimalism. We then correlated minimalism variations with the variables of the race and the joint angles.

Results

We observed significant difference (P < 0.01) in the cycle rate, the cycle length, the step rate, and the angle of attack between running with and without shoes. A small variation of the minimalism index is associated with an increase in knee angle (r²> 0.5). Conversely, a large variation in the minimalism index is related to a decrease in the knee angle (r²> 0.5). The minimalism index has no impact on the angulation of the ankle and hip (r²< 0.3).

Conclusion

Slow transition will bring gains in terms of decreasing the length of the stride, which limits the load on the shin. Greater flexibility can be achieved by decreasing the flexion angle of the knee, which decreases the demand for quadriceps muscles and the risk of knee injury with a greater risk of injury at the tibial level.

Zika Virus and Arthritis/Arthralgia: A Systematic Review and Meta-Analysis

Dengue, chikungunya and Zika viruses share similar disease features, rendering them difficult to distinguish clinically. Incapacitating arthralgia/arthritis is a specific manifestation associated with chikungunya virus infection. However, the profile of arthralgia/arthritis in Zika virus (ZIKV) cases has not been well characterized. Articles were extracted from PubMed and Scopus databases reporting original data from patients with arthralgia/arthritis, according to the Cochrane Collaboration. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, 137 articles reporting ZIKV-associated joint symptoms were reviewed. Arthralgia was more frequently reported (n = 124 from case studies, n = 1779 from population-based studies) than arthritis (n = 7 and n = 121, respectively). Arthralgia was resolved in <1 week in 54%, and within 1–2 weeks in 40% of cases. The meta-analysis of cases in population-based studies identified a pooled prevalence of 53.55% for arthralgia. The pooled prevalence of arthralgia/arthritis during outbreaks depended on the geographic location, with a higher joint symptom burden observed in the Americas compared to South East Asia (Brazil: 60.79%; Puerto Rico: 68.89% and South East Asia: 26.46%). We conclude that non-specific constitutional arthralgia is the most common joint manifestation during ZIKV infection, being present in nearly half of cases but resolving by two weeks in >90% of these. We found no evidence of chronic rheumatic manifestations following ZIKV infection.

Novel Muscle Imaging in Inflammatory Rheumatic Diseases-A Focus on Ultrasound Shear Wave Elastography and Quantitative MRI

In recent years, imaging has played an increasing role in the clinical management of patients with rheumatic diseases with respect to aiding diagnosis, guiding therapy and monitoring disease progression. These roles have been underpinned by research which has enhanced our understanding of disease pathogenesis and pathophysiology of rheumatology conditions, in addition to their key role in outcome measurement in clinical trials. However, compared to joints, imaging research of muscles is less established, despite the fact that muscle symptoms are very common and debilitating in many rheumatic diseases. Recently, it has been shown that even though patients with rheumatoid arthritis may achieve clinical remission, defined by asymptomatic joints, many remain affected by lingering constitutional systemic symptoms like fatigue, tiredness, weakness and myalgia, which may be attributed to changes in the muscles. Recent improvements in imaging technology, coupled with an increasing clinical interest, has started to ignite new interest in the area. This perspective discusses the rationale for using imaging, particularly ultrasound and MRI, for investigating muscle pathology involved in common inflammatory rheumatic diseases. The muscles associated with rheumatic diseases can be affected in many ways, including myositis-an inflammatory muscle condition, and myopathy secondary to medications, such as glucocorticoids. In addition to non-invasive visual assessment of muscles in these conditions, novel imaging techniques like shear wave elastography and quantitative MRI can provide further useful information regarding the physiological and biomechanical status of the muscle.

Rheumatic Manifestations in Patients Treated with Immune Checkpoint Inhibitors

Immune checkpoint inhibitors (ICIs) are monoclonal antibodies that activate the immune system, aiming at enhancing antitumor immunity. Their clinical efficacy is well-documented, but the side effects associated with their use are still under investigation. These drugs cause several immune-related adverse events (ir-AEs), some of which stand within the field of rheumatology. Herein, we present a literature review performed in an effort to evaluate all publicly available clinical data regarding rheumatic manifestations associated with ICIs. The most common musculoskeletal ir-AEs are inflammatory arthritis, polymyalgia rheumatica and myositis. Non-musculoskeletal rheumatic manifestations are less frequent, with the most prominent being sicca, vasculitides and sarcoidosis. Cases of systemic lupus erythematosus or scleroderma are extremely rare. The majority of musculoskeletal ir-AEs are of mild/moderate severity and can be managed with steroids with no need for ICI discontinuation. In severe cases, more intense immunosuppressive therapy and permanent ICI discontinuation may be employed. Oncologists should periodically screen patients receiving ICIs for new-onset inflammatory musculoskeletal complaints and seek a rheumatology consultation in cases of persisting symptoms.

Immune checkpoint inhibitor-induced musculoskeletal manifestations. A multicentre prospective study

Background

Immune checkpoint inhibitors (ICI) are anti-cancer drugs that act by enhancing anti-tumour immunity. Due to their mechanism of action, they have been associated with immune related adverse events (Ir-AE), including musculoskeletal manifestations.

Aim

To assess a) the prevalence, clinical and imaging (MRI) characteristics of ICI-induced musculoskeletal immune related adverse events (ir-AE) in a prospective manner, b) the potential association of musculoskeletal ir-AE with oncologic response and changes in the immune system at the level of soluble molecules (cytokines) as well as T/B cell subpopulations.

Methods

This a multicentre prospective study. We plan to recruit all patients who are going to start treatment with ICI from October 2019 until October 2020 in all collaborating Oncology Departments. This study is consisted of a clinical and a laboratory arm.

Results

The study is currently recruiting patients.

Conclusions

We anticipate that this study will provide useful data regarding the clinical characteristics of ICI-induced musculoskeletal manifestations as well as potential predictive biomarkers.

Curcumin in Autoimmune and Rheumatic Diseases

Over recent decades, many clinical trials on curcumin supplementation have been conducted on various autoimmune diseases including osteoarthritis, type 2 diabetes, and ulcerative colitis patients. This review attempts to summarize the highlights from these clinical trials. The efficacy of curcumin either alone or in conjunction with existing treatment was evaluated. Sixteen clinical trials have been conducted in osteoarthritis, 14 of which yielded significant improvements in multiple disease parameters. Eight trials have been conducted in type 2 diabetes, all yielding significant improvement in clinical or laboratory outcomes. Three trials were in ulcerative colitis, two of which yielded significant improvement in at least one clinical outcome. Additionally, two clinical trials on rheumatoid arthritis, one clinical trial on lupus nephritis, and two clinical trials on multiple sclerosis resulted in inconclusive results. Longer duration, larger cohort size, and multiple dosage arm trials are warranted to establish the long term benefits of curcumin supplementation. Multiple mechanisms of action of curcumin on these diseases have been researched, including the modulation of the eicosanoid pathway towards a more anti-inflammatory pathway, and the modulation of serum lipid levels towards a favorable profile. Overall, curcumin supplementation emerges as an effective therapeutic agent with minimal-to-no side effects, which can be added in conjunction to current standard of care.

Acquired heart disease in children is not necessarily rheumatic

Acquired heart diseases (AHD) cause significant morbidity and mortality in children. There are limited studies on their burden in children. We conducted a retrospective study of 85 consecutive children diagnosed with AHD using clinical evaluation and echocardiography at Medical College, Kanpur, India to determine the aetiology and outcome of AHD in children. We found rheumatic heart disease (RHD) in one-third, cardiomyopathies or myocarditis combined in a further third and the remaining third were other causes, including pericardial diseases and metabolic or genetic disorders. These latter diseases were frequently misdiagnosed, causing significant morbidity and mortality. Hence, in children of all age groups presenting with unexplained shock, dyspnoea, hepatomegaly and ascites, cardiac status should be carefully and critically evaluated so that non-rheumatic AHD may not be missed.

Emerging role of metabolomics in rheumatology

The pursuit for understanding disease pathogenesis, in this age of rapid laboratory diagnostics and fast-paced research, has led scientists worldwide to take recourse in hypothesis-free approaches for molecular diagnosis. Metabolomics is one such powerful tool that explores comprehensibly the metabolic alternations in human diseases. It involves study of small molecules of less than 1 kD in size by either LSMS or nuclear magnetic resonance. Unlike genomics, which tells us what may have happened, metabolomics reflects what did happen. The NMR technique has an advantage of analyzing metabolites without sample preparation, thereby diminishing artifacts, is less cumbersome and with the latest database on Metabolome; about 30 000 metabolites can be identified. The study of metabolomics for several rheumatic diseases, including rheumatoid arthritis, lupus, osteoarthritis and vasculitis, has revealed distinctive metabolic signatures. Thus, metabolomics is a technique that promises precision medicine with better biomarkers, robust predictors of drug response and of disease outcome, discovery of newer metabolites and pathways in disease pathogenesis, and finally, targeted drug development. This review intends to decipher its relevance in common rheumatic diseases.

Diffuse connective tissue disorders in HIV-infected patients

Background:

Human immunodeficiency virus (HIV) infection has been associated with various autoimmune disorders.

Aim:

To review the spectrum of diffuse connective tissue disorders (dCTD) in HIV-infected patients, in the context of highly active anti-retroviral therapy.

Methods:

Electronic search of the literature was performed using the terms HIV, AIDS, autoimmune, rheumatic/rheumatological, immune reconstitution inflammatory syndrome, Systemic Lupus Erythematosus, Diffuse Infiltrative Lymphocytosis Syndrome, Sjogren’s syndrome, vasculitis, Behçet’s disease, cryoglobulins, Henoch-Schönlein purpura, and antiphospholipid syndrome.

Results:

We reviewed the clinical manifestations, natural history and treatment of dCTDs, since the implementation of Highly Active Anti-Retroviral Therapy (HAART), and the emergence of new pathogenic mechanisms, such as the immune reconstitution inflammatory syndrome.

Conclusions:

Caution in differentiating clinical and laboratory findings of dCTDs from non-specific manifestations of acute and chronic HIV infection is warranted due to the common presentation. Patients with chronic infection and access to HAART have a normal life expectancy and dCTDs, although rare, must be correctly addressed. HAART alone or combined with immunosuppressive therapy result in favourable outcomes.

Fine versus coarse atrial fibrillation in rheumatic mitral stenosis: The impact of aging and the clinical significance

BACKGROUND

Atrial fibrillation (AF) as the most rhythm disturbance in patients with rheumatic mitral stenosis (MS), is classified in to coarse and fine subtypes according to the height of fibrillatory wave amplitude. The aim of this study is to identify the factors associated with the presence of fine versus coarse morphology in patients with rheumatic MS.

METHODS

In this cross-sectional study, patients with confirmed diagnosis of severe rheumatic MS admitted between March 2013 and March 2017 were screened. Patients were categorized to sinus rhythm (SR) and AF rhythm (coarse and fine subtypes) groups according to the admission electrocardiogram. The association between various clinical and echocardiographic factors and the development of fine versus coarse AF were examined.

RESULTS

Among 754 patients with the diagnosis of rheumatic MS, 288 (198 female) were found to have AF (38%). Among them 206 (71.5%), and 82 (28.5%) patients had fine and coarse morphology respectively. Patient in these two groups were quite similar in terms of echocardiographic parameters and comorbidities. However, patients with fine morphology AF were significantly older. (p-Value=.007).

CONCLUSION

Coarse morphology of AF is common in patients with rheumatic MS. While echocardiographic or most clinical parameters do not seem to associate with the occurrence of coarse or fine morphology, age seems to be the only independent factor correlated with the presence of fine subtype of AF in this population.

Prevalence of rheumatic musculoskeletal symptoms in rural and urban areas : a cross-sectional study in northern India

OBJECTIVES

To study the prevalence of rheumatic musculoskeletal symptoms in rural and urban areas of Lucknow.

METHOD

The survey was carried out in a cluster of rural (n = 5118) and urban (n = 5053) communities of Lucknow through a door-to-door survey. Demographic data were collected and subjects with musculoskeletal pain (MSK pain) were identified. A Hindi adapted version of the Community Oriented Program for the Control of Rheumatic Diseases questionnaire was used. Trained community volunteers completed the questionnaire.

RESULTS

Present and past MSK pain was the most common self-reported problem in urban areas (34.1%), while it was the third most common self-reported problem in rural areas (15.1%), after abdominal pain and cough. Females (214.9 and 419.5 per 1000) were more affected than males (118.8 and 265.2 per 1000) in rural and urban areas, respectively. Point prevalence of MSK pain (pain in last week) was higher in urban areas (28.2%) compared to rural areas (14.1%). In rural as well as urban areas, knee (rural: 49.3%, urban: 50.6%) and spine (rural: 56%, urban: 43.6%) were highly reported pain sites. Fatigue ([n] rural: 328, urban: 368) weakness ([n] rural: 310, urban: 324) and anorexia ([n] rural: 84, urban: 142) were most common systemic symptoms reported by urban as well as rural people. Urethritis/balanitis and ulcers in the mouth were the most common other symptoms reported by people in both the areas.

CONCLUSION

MSK pain is a predominant health problem of both rural and urban areas. Sex-adjusted prevalence is higher among females than males. Knee and back were highly prevalent pain sites in both rural and urban areas of Lucknow.

Anesthesia in pregnancy with heart disease

Management of pregnant women with heart disease remains challenging due to the advancement of innovations in cardiac surgery and correction of complex cardiac anomalies, and more recently, with the successful performance of heart transplants, cardiac diseases are not only likely to coexist with pregnancy, but will also increase in frequency over the years to come. In developing countries with a higher prevalence of rheumatic fever, cardiac disease may complicate as many as 5.9% of pregnancies with a high incidence of maternal death. Since many of these deaths occur during or immediately following parturition, heart disease is of special importance to the anesthesiologist. This importance arises from the fact that drugs used for preventing or relieving pain during labor and delivery exert a major influence - for better or for worse - on the prognosis of the mother and newborn. Properly administered anesthesia and analgesia can contribute to the reduction of maternal and neonatal mortality and morbidity.

Mitral Valve Surgery for Rheumatic Lesions in Young Patients

BACKGROUND

The appropriateness of rheumatic mitral valve repair remains controversial due to the risks of recurrent mitral dysfunction and need for reoperation. The aims of this study were to determine the overall short- and long-term outcomes of pediatric rheumatic mitral valve surgery in our center.

METHODS

Single-center, observational, retrospective study that analyzed the results of rheumatic mitral valve surgery in young patients, consecutively operated by the same team, between 1999 and 2014.

RESULTS

We included 116 patients (mean age = 12.6 ± 3.5 years), of which 66 (57%) were females. A total of 116 primary surgical interventions and 22 reoperations were performed. Primary valve repair was possible in 86 (74%) patients and valve replacement occurred in 30 (26%). Sixty percent of the patients were followed up beyond three months after surgery (median follow-up time = 9.2 months [minimum = 10 days; maximum = 15 years]). Long-term clinical outcomes were favorable, with most patients in New York Heart Association functional class I (89.6%) and in sinus rhythm (85%). Freedom from reoperation for primary valve repair at six months, five years, and ten years was 96.4% ± 0.25%, 72% ± 0.72%, and 44.7% ± 1.34%, respectively. Freedom from reoperation for primary valve replacement at six months, five years, and ten years was 100%, 91.7% ± 0.86%, and 91.7% ± 0.86%, respectively. Mitral stenosis as the primary lesion dictated early reintervention.

CONCLUSIONS

Despite the greater rate of reoperation, especially when the primary lesion was mitral stenosis, rheumatic mitral valve repair provides similar clinical outcomes as compared with replacement, with the advantage of avoiding anticoagulation.

Cardiac surgery in Africa: a thirty-five year experience on open heart surgery in Cote d'Ivoire

BACKGROUND

Few centers for open heart surgery (OHS) are in Sub-Saharan Africa. Lack of OHS results is also noted. By reporting our African experience on OHS, the aim of this study was to fill the gap.

METHODS

It is a retrospective study on 2,612 patients who were subject to an OHS between 1978 and 2013. Data were collected from demographical, clinical, investigative studies, surgical and outcomes parameters.

RESULTS

There were 1,475 cases of rheumatic heart diseases (RHD), 126 endomyocardial fibrosis (EMF), 741 congenital heart diseases (CHDs) and 270 various affections. Related to rheumatic valvular surgery we enumerated 1,175 monovalvular (mitral n=778, aortic n=336, tricuspid n=61); 280 bivalvular (mitral + aortic n=150, mitral + tricuspid n=130) and 20 trivalvular. For RHD, average age was 26±10.1 years (4-69 years) and 60% of our patients presented a functional class III or IV according to New York Heart Association (NYHA) classification. A total of 1,481 valvular replacements (bioprostheses n=489, mechanical prostheses n=992) and 445 valvular repair were carried out with a global and late mortality surgery respectively at 7% and 8%. One hundred and twenty-six [126] cases of EMF with right sided form 39, left sided form 40, and bilateral form 47 were colligated. Average age was 12±0.6 years (2-15 years). All patients with EMF underwent surgery; an endocardectomy in all patients combined with valvular reconstruction (n=36) or valvular replacement (n=90) was carried out with a hospital mortality at 16% (n=20). Concerning CHD, the most frequent were ventricular septal defect (VSD) (n=240), atrial septal defect (ASD) (n=200), partial atrio-ventricular sepal defect (n=30) and tetralogy of Fallot (T4F) (n=220), a total correction was performed for those CHD with an early mortality at 6.4% (n=44).

CONCLUSIONS

OHS in Cote d'Ivoire was successfully performed in most of our patients, the spectrum of acquired valvular heart diseases and CHDs in our country is similar to others in Sub-Saharan Africa.

Rheumatic Disease Autoantibodies in Autoimmune Liver Diseases

BACKGROUND

Autoimmune liver diseases (ALDs) are known to be associated with systemic autoimmune rheumatic diseases (SARDs) and their autoantibodies. We aimed to study the prevalence of SARDs and related autoantibodies, as well as their prognostic implications in a group of patients with ALDs.

METHODS

This was a cross-sectional study. Sixty patients with ALDs (38.3% with autoimmune hepatitis; 11.7% with primary biliary cirrhosis; 25% with primary sclerosing cholangitis and 25% with overlap syndrome) were studied for the presence of SARDs and their autoantibodies.

RESULTS

There was autoimmune rheumatic disease in 20% of the studied sample. Systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) were the commonest (11.6% and 5%, respectively). Antinuclear antibodies (ANAs) were present in 35% of the patients, followed by anti-Ro (20.0%); anti-nucleosome (18.3%); rheumatoid factor (10%) anti-CCP (8.3%); anti-RNP (8.3%); anti-ds-DNA (6.6%); anti-La (3.3%); anti-Sm (3.3%), anti-ribosomal P (3.3%). Anti-Ro (p = 0.0004), anti-La (p = 0.03), anti-RNP (p = 0.04) and anti-Sm (p = 0.03) were commonly found in patients with SARD, but not anti-DNA, anti-nucleosome and anti-ribosomal P. No differences were found in liver function tests regarding to the presence of autoantibodies.

CONCLUSIONS

There was a high prevalence of SARD and their autoantibodies in ALD patients. Anti-Ro, anti-La, anti-RNP and anti-Sm positivity points to an association with systemic autoimmune rheumatic diseases. The presence of autoantibodies was not related to liver function tests.

Radiofrequency Ablation of Left Atrial Reentrant Tachycardias in Rheumatic Mitral Valve Disease: A Case Series

BACKGROUND

Left atrial (LA) reentrant tachycardias are not uncommon in regions where rheumatic heart disease is prevalent. Some of these arrhythmias may be curable by radiofrequency ablation (RFA). However, there are limited data pertaining to this in existing literature.

CASE REPORT

Three patients who had rheumatic mitral valve disease with past history of surgical-/catheter-based intervention and having no significant residual disease had symptomatic atrial flutter despite optimal medical management. An electrophysiological study confirmed an LA focal/micro-reentrant mechanism in all. There was patchy scarring of the LA, and successful RFA of these arrhythmias could be achieved.

CONCLUSION

The focal nature of the scar in these patients may suggest that the rheumatic involvement of the atrium or the hemodynamic consequence of the vulvar lesion causes nonuniform insult to the atrial tissue and limited scar. At least in some patients with limited scarring, early RFA may help in the maintenance of sinus rhythm.

Mitral valve repair versus replacement

Degenerative, ischemic, rheumatic and infectious (endocarditis) processes are responsible for mitral valve disease in adults. Mitral valve repair has been widely regarded as the optimal surgical procedure to treat mitral valve dysfunction of all etiologies. The supporting evidence for repair over replacement is strongest in degenerative mitral regurgitation. The aim of the present review is to summarize the data in each category of mitral insufficiency and to provide recommendations based upon this data.

Repair options in rheumatic aortic valve disease in young patients: potential problems with pericardial cusp extension

This article outlines the arguments against cusp extension, which were put forward at the debate entitled "Repair options in rheumatic aortic disease in young patients" at the Symposium on Surgery for Rheumatic Heart Disease organized by The World Society for Pediatric and Congenital Heart Surgery at The Sixth World Congress of Paediatric Cardiology and Cardiac Surgery, February 17-22, 2013, Cape Town, South Africa. We propose that cusp extension should be avoided because (1) these patients are usually old enough to receive the same valve substitutes as adults, (2) lack of antibioprophylaxis compliance will likely result in early reintervention, (3) cusp extension mandates rerepair within four to five years and is more expensive in the long term, and (4) it is fraught with myocardial ischemic complications. Thus, a mechanical, bioprosthetic, or autograft valve replacement may be superior for patients unless they have unrestricted access to repetitive interventions. A single surgical technique does not suffice in the treatment of rheumatic aortic valve disease, and a diversified approach should be adopted dependent on both the patients' characteristics and the financial constraints.

Cardiac operations for North American children with rheumatic diseases: 1985-2005

Certain pediatric rheumatic diseases are known to affect the heart, sometimes requiring surgical intervention. The Pediatric Cardiac Care Consortium database was used to characterize cardiac surgical intervention among children with rheumatic diseases from 1985 to 2005. From this large database, the records for patients younger than 21 years who underwent cardiac surgery for any rheumatic disorder were extracted. The data collected included the type of procedure performed, the age at the time of the procedure, and the year the procedure was performed. The 261 pediatric patients identified underwent 361 cardiac surgical procedures for complications of rheumatic heart disease (RHD; 160 patients), neonatal lupus (NLE; 53 patients), Kawasaki disease (KD; 28 patients), systemic lupus erythematosus (SLE; 13 patients), and juvenile rheumatoid arthritis (JRA; 7 patients). Multiple procedures were performed for 23% of the patients. The most common procedures included pacemaker implantations among infants with NLE, coronary artery bypass grafts for KD primarily in 5- to 15-year-olds, and cardiac valve operations among adolescents with RHD, SLE, and JRA. Six perioperative deaths occurred. The proportion of annual pediatric cardiac surgical volume attributable to rheumatic diseases did not change during the period studied. Despite advances in their medical care, children with rheumatic diseases continue to sustain measurable morbidity and mortality due to the cardiovascular manifestations of their disease.