The clinical & metabolic correlates of fatigue in inflammatory arthritis & clinically suspect arthralgia

The earliest stages of inflammatory arthritis are associated with systemic inflammation and a complex set of symptoms including fatigue. Fatigue is common and burdensome. The mechanisms underlying fatigue are not well understood and, as a result, it is not always easy to manage. Systemic inflammation and metabolic perturbations may play a role in the development of fatigue. A correlation between systemic inflammation and metabolic perturbation has previously been observed in early inflammatory arthritis. While low-density lipoprotein lipids were some of the chief metabolites which contributed to the metabolic signature associated with systemic inflammation, technical limitations in those studies limited their ability to define more broadly other metabolic pathways involved. Given the likely importance of changes in metabolism to the development of fatigue, I set out to further analyse metabolic disturbance in an early arthritis cohort, assessing both sera, filtered to remove interfering high molecular weight species, and urine to provide a broader and clearer picture of the metabolic status of the patients. I have assessed the relationships between metabolic profiles and [1] systemic inflammation and [2] fatigue to shed further light on the drivers of fatigue in early inflammatory arthritis

How I do it: transapical cannulation for acute type-A aortic dissection

Aortic dissection is the most frequently diagnosed lethal disease of the aorta. Half of all patients with acute type-A aortic dissection die within 48 hours of presentation. There is still debate as to the optimal site of arterial cannulation for establishing cardiopulmonary bypass in patients with type-A aortic dissection

Facial expression of affect in children with Cornelia de Lange Syndrome

Background: Individuals with Cornelia de Lange syndrome (CdLS) have been reported to show comparatively high levels of flat and negative affect but there have been no empirical evaluations. In this study, we use an objective measure of facial expression to compare affect in CdLS with that seen in Cri du Chat syndrome (CDC) and a group of individuals with a mixed aetiology of intellectual disabilities (ID). Method: Observations of three groups of 14 children with CdLS, CDC and mixed aetiology of ID were undertaken when a one-to-one interaction was ongoing. Results: There was no significant difference between the groups in the duration of positive, negative or flat affect. However, the CdLS group displayed a significantly lower ratio of positive to negative affect than children in the other groups. Discussion: This difference partially confirms anecdotal observations and could be due to the expression of pain caused by health problems associated with CdLS or neurological expression of the CdLS gene in facial muscles related to expression of positive affect. However, further research is needed to directly test these possible associations. </p

Introducing ECMO/ECLS in sub-Saharan Africa – prospects and perspectives

Background: The introduction of modern medical technologies reduced mortality in adults and increased survival in infants less than five years old. Cardiac and respiratory failure can be managed through mechanical circulatory support devices such as ECMO/ECLS (Extracorporeal Membrane Oxygenation/ Extracorporeal Life Support).Main Findings: We evaluate the importance and potential impact of using ECMO/ECLS in improving health care in sub-Saharan Africa. The intention of this recommendation is to introduce this concept as a feasible rescue method for clinicians in the region. The potential use of ECMO/ECLS will be discussed with focus on infrastructure for the retrieval services from the referring hospitals to designated ECMO centres.Conclusion: ECLS resources and time that should be committed to training of staff and on-going education should not be underestimated. ECLS should only be commenced, maintained and weaned in the hands of trained, experienced and knowledgeable medical personnel cognisant that the results will be benchmarked by ELSO (Extracorporeal Life Support Organization) and available for consumption in the public domain. Partnership models are key to the ECLS success with well-defined roles and responsibilities for each party. The possible way for ECMO/ECLS in Africa should be combining with a two-pronged education programme: Improving critical care services in themselves, and once they get to an acceptable level in this department then is to manage ECLS patients for a few hours. To upgrade critical care services, this is vital for Africa, and only then to introduce ECMO/ECLS

Management of glaucoma as a neurodegenerative disease.

Glaucoma is a neurodegenerative disease with an estimated prevalence of 60 million people, and the most common cause of irreversible blindness worldwide. The mainstay of treatment has been aimed at lowering intraocular pressure, currently the only modifiable risk factor. Unfortunately, despite adequate pressure control, many patients go on to suffer irreversible visual loss. We first briefly examine currently established intraocular pressure lowering-treatments, with a discussion of their roles in neuroprotection as demonstrated by both animal and clinical studies. The review then examines currently available intraocular pressure independent agents that have shown promise for possessing neuroprotective effects in the management of glaucoma. Finally, we explore potential future treatments such as immune-modulation, stem cell therapy and neural regeneration as they may provide further protection against the neurodegenerative processes involved in glaucomatous optic neuropathy

Predictors of quality of life, functional status, depression and fatigue in early arthritis:Comparison between clinically suspect arthralgia, unclassified arthritis and rheumatoid arthritis

Background: Rheumatoid arthritis (RA) is often preceded by symptomatic phases during which classification criteria are not fulfilled. The health burden of these “at-risk” stages is not well described. This study assessed health-related quality of life (HRQoL), function, fatigue and depression in newly presenting patients with clinically suspect arthralgia (CSA), unclassified arthritis (UA) or RA.Methods: Cross-sectional analysis of baseline Patient-Reported Outcome Measures (PROMs) was conducted in patients from the Birmingham Early Arthritis Cohort. HRQoL, function, depression and fatigue at presentation were assessed using EQ-5D, HAQ-DI, PHQ-9 and FACIT-F. PROMs were compared across CSA, UA and RA and with population averages from the HSE with descriptive statistics. Multivariate linear regression assessed associations between PROMs and clinical and sociodemographic variables.Results: Of 838 patients included in the analysis, 484 had RA, 200 had CSA and 154 had UA. Patients with RA reported worse outcomes for all PROMs than those with CSA or UA. However, “mean EQ-5D utilities were 0.65 (95%CI: 0.61 to 0.69) in CSA, 0.61 (0.56 to 0.66) in UA and 0.47 (0.44 to 0.50) in RA, which was lower than in general and older (≥ 65 years) background populations.” In patients with CSA or UA, HRQoL was comparable to chronic conditions such as heart failure, severe COPD or mild angina. Higher BMI and older age (≥ 60 years) predicted worse depression (PHQ-9: -2.47 (-3.85 to -1.09), P &lt; 0.001) and fatigue (FACIT-F: 5.05 (2.37 to 7.73), P &lt; 0.001). Women were more likely to report worse function (HAQ-DI: 0.13 (0.03 to 0.21), P = 0.01) and fatigue (FACIT-F: -3.64 (-5.59 to -1.70), P &lt; 0.001), and residents of more deprived areas experienced decreased function (HAQ-DI: 0.23 (0.10 to 0.36), P = 0.001), greater depression (PHQ-9: 1.89 (0.59 to 3.18), P = 0.004) and fatigue (FACIT-F: -2.60 (-5.11 to 0.09), P = 0.04). After adjustments for confounding factors, diagnostic category was not associated with PROMs, but disease activity and polypharmacy were associated with poorer performance across all PROMs.Conclusions: Patient-reported outcomes were associated with disease activity and sociodemographic characteristics. Patients presenting with RA reported a higher health burden than those with CSA or UA, however HRQoL in the pre-RA groups was significantly lower than population averages.</div