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Background/Aims We report the features of chronic chilblain-like digital lesions newly presenting since the start of the covid-19 pandemic. Comparison with primary perniosis and acrocyanosis, reveals a unique phenotype which appears to be a long-covid phenomenon. Methods The case records of 26 patients with new onset persistent chilblain-like lesions presenting to the Rheumatology service of St George's University Hospital, London between Autumn 2020 and Spring 2022 were reviewed. Demographic and clinical features, serology, imaging, treatment response and outcome up to Summer 2022 were collated retrospectively. Results Chilblain-like lesions first occurred between September and March;2019/ 2020 6 cases, 2020/2021 18 cases and 2021/2022 2 cases. Mean age 35.4 (17-60) years, 88% female, 85% white, all non-smokers. Median body mass index (BMI) 20.2, range 17.0 - 33.2. BMI underweight (<18.5) in 27%. All cases reported new red-purple-blue colour changes of the fingers, some with pain, swelling and pruritis, affecting both hands in 12, one hand in 6, and both hands and feet in 8 cases. There was a past history of cold sensitivity or primary Raynaud's in 54%. Covid was confirmed in 3 cases, 2 - 8 months prior to onset of chilblain-like symptoms. Possible covid, unconfirmed, was suspected in 5 cases, 1 - 11 months earlier. Affected digits appeared diffusely erythro-cyanotic in 81%, with blotchy discrete maculo-papular erythematous lesions in 42%, some with both features. Involvement was asymmetric in 54%, thumbs spared in 69%. Complement was low in 50% (8/16), ANA positive in 26% (6/23). MRI of hands showed phalangeal bone marrow oedema in keeping with osteitis in 4 of 7 cases. More severe signs and symptoms were associated with low BMI, low C3/4 and a past history of cold sensitivity or Raynauds. Cold avoidance strategies were sufficient for 58%. Pain prompted a trial of NSAIDs, aspirin, nitrates, calcium channel blockers, hydroxychloroquine, oral or topical corticosteroid or topical tacrolimus in 42%. In general, these were minimally effective or not tolerated. 4 severe cases received sildenafil or tadalafil, effective in 2. In 27% complete remission occurred during the first summer season after symptoms commenced, median duration 6 (range 2 - 10) months. In the remaining 19 cases, chilblain-like symptoms returned or worsened in the subsequent second winter period, with 6 of 19 entering remission the following summer. For the remaining 13 persistent cases the total duration of symptoms spans more than a year, and in four cases more than 2 years. Conclusion This series illustrates a distinct chronic chilblain-like condition. Features similar to primary perniosis include female predominance, middle age, pruritic painful blotchy lesions, asymmetry and low BMI. Features in keeping with acrocyanosis include chronicity, extensive diffuse erythro-cyanotic discoloration, relative improvement in warm weather and lack of association with smoking.
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Objective: To study the contribution of teledentistry, via the WhatsApp application of the "Dentists of Senegal", on the management of oral and maxillofacial pathology. Material(s) and Method(s): This was a descriptive cross-sectional study. The study took place over a period of 3 months, from 1 October to December 30, 2020. This study was conducted on the WhatsApp group platform of the Senegalese Dentists. A total of 150 communications were included. Result(s): Public sector dentists sent more communications, 88% of the communications. By specialty, general practitioners had sent more communications, 82.7% of communications. For the oral surgery receiver site, 71% of communications were received. 65% of referring dentists had given a diagnosis. Patients with tumours and cysts represented more than half of the sample (53.3%) followed by trauma patients (18.6%). The most common infections were cellulitis (46.66%) and osteitis (33.33%). Oral and maxillofacial surgeons managed 69.33% of the pathology. Conclusion(s): WhatsApp is a fundamental contribution to the remote diagnosis and management of oral and maxillofacial pathologies, especially during the current covid-19 pandemic.Copyright © 2021
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Background: Current pharmacological treatments remain inadequate for a signifcant proportion of patients with rheumatoid arthritis (RA), and thus alternative treatment approaches are needed. Prior results from the frst 12 weeks of a proof-of-concept (POC) study showed that ATHENS, a non-invasive high-frequency vagus nerve therapy, was well-tolerated with meaningful reductions in RA disease severity as measured by the American College of Rheumatology response criteria (ACR) and the Disease Activity Score using 28 joints (DAS28)[1]. Objectives: The current analysis assessed long-term changes (52 weeks total follow-up) in disease activity as measured by ACR, DAS28, and the following MRI-assessed changes: synovitis, osteitis, bone erosion, and cartilage loss. Methods: Following the completion of the 12-week POC study, patients achieving a reduction in DAS28-CRP of ≥1.2 were given the option to enroll in the 9-month open-label extension (OLE) study. During the extension phase, patients were to use the wearable device for 15 minutes per day. Adjustment of conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) or biologic disease-modifying antirheumatic drugs (bDMARDs) were allowed during the OLE. Changes from baseline were assessed at 12 weeks (end of initial POC) and 52 weeks (end of the OLE). Structural damage and disease progression were evaluated by standardized MRI of the wrist and hand, with and without intravenous gadolinium-based contrast. MRIs were evaluated by two independent, central readers, blinded to clinical information and visit-order of the images, and were scored for synovitis, osteitis and bone erosion using the OMERACT-RAM-RIS method. Cartilage loss was also determined using the 9-point cartilage loss scale (CARLOS). Results: Twenty-seven of 30 patients completed the initial 12-week study, of whom 19 consented and entered the OLE. Of those 19 patients, 4 (21%) discontinued due to lack of efficacy, while the remaining 15 completed the 9-month extension. Due to the COVID-19 pandemic, 7 patients were unable to complete a 52-week MRI scan;MRI evaluations at baseline, 12 weeks, and 52 weeks were available for 8 patients. DAS28-CRP mean (standard deviation [SD]) change from baseline was-1.78 (1.01) at 12 weeks (n=19;p<0.0001) and-2.30 (1.22) at 52 weeks (n=15;p<0.0001). ACR20, ACR50, and ACR70 response rates were 68%, 42%, and 21% at 52 weeks (n=19;discontinued participants were deemed non-responders). MRI analysis of synovitis, osteitis, bone erosion, and cartilage loss showed no evidence of disease progression through 52 weeks compared with baseline (Table 1). During the 9-month extension study, two new adverse events were reported (cornea transplant and right hand dysesthesia) in 2 (11%) patients;neither was treatment-related and both resolved without intervention. No serious adverse events were reported. Conclusion: In patients with an initial treatment response to the Nēsos ATHENS therapy in the 12-week POC study, reductions in DAS28-CRP were sustained through 52 weeks. Although results should be interpreted cautiously given the small sample size and lack of control arm, MRI evaluation of synovitis, osteitis, bone erosion, and cartilage loss suggested no disease progression.
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Introduction: Studies have linked lower vitamin D levels with cardiovascular disease (CVD) and mortality in general population and chronic kidney disease (CKD). The preliminary evidence of vitamin D supplementation is encouraging but there is a huge void with respect to good quality long term data supporting the use of this promising intervention for translation into better outcomes for CVD in CKD. This study is exploring the effect of cholecalciferol supplementation on cardiovascular disease, markers of inflammation and bone metabolism in CKD. We present the baseline characteristics of feasibility phase of the trial. Methods: The study is a multicentric, prospective, randomized, placebo controlled, double blind trial in two parallel groups and feasibility phase is being done at Postgraduate Institute of Medical Education and Research, Chandigarh, India. The trial is registered at Clinical Trials Registry of India (CTRI/2019/05/019211). After a run-in period of 2 weeks, the enrolled subjects are randomized in 1:1 to receive either 60,000 IU/2 weeks of cholecalciferol or matching placebo. The subjects will be then followed up every three month till 3 years. The primary outcome of the study is a composite of major adverse cardiac events (MACE). Secondary outcome measures include all-cause mortality, need of RRT, change in hsCRP, IL-6, iPTH, FGF-23, bone specific alkaline phosphatase, and CTX-1. Results: A total of 720 subjects have been screened till date. Out of 119 enrolled, 86 subjects have been randomized over 24 months period. 76% subjects have completed annual follow up at 12 months, 66% subjects - 15thmonths follow up, 40%- 18 months follow up, 26% subjects - 21 months follow up, 6% subjects – 24 months follow up. Baseline characteristics and serum biomarkers levels has been analysed in 80 subjects. Mean age of the subjects were 51.3 ± 12.2 years and 58.8 % were males. Serum haemoglobin levels were 11.6 ±1.7 g/dl. Mean eGFR was 26.3 (17.4, 35.1) ml/min/1.73m2. Outcome events were;MACE: 1 (due to CVD), death other than due to MACE: 1 (due to COVID 19), subjects with composite of all-cause death and non-fatal MACE: 2, subject with need of RRT:1 and subjects with composite of 50% decline in GFR or need of RRT: 3. 2 serious adverse events unrelated to study drug were reported during the course of study. Table: Baseline levels of various serum biomarkers [Formula presented] Conclusions: Despite COVID 19 related restrictions being in place for most of the last 18 months, the study has been able to screen and enrol participants. The follow ups have been ensured either through physical or remote (mobile/telephonic) means. Once in the multi-centric phase, the study will be able to test a relatively inexpensive intervention in the form of vitamin D supplementation for CVD in CKD. No conflict of interest
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TYPE: Case Report TOPIC: Chest Infections INTRODUCTION: Blastomycosis is endemic to the midwest, south-central and southeast regions of North America. It should thus be suspected in the differential of patients presenting with atypical symptoms, as extrapulmonary manifestations can be seen. We present a case of disseminated blastomycosis to the spine prior to development of significant pulmonary symptoms. CASE PRESENTATION: 38 year old male presents to a tertiary center in Southern Indiana with back pain of 8 months, fever and dyspnea. Magnetic resonance imaging was significant for L1 osteitis and chest x-ray showed diffuse interstitial markings. Lab work showed leukocytosis with erythrocyte sedimentation rate of 91, and C-reactive protein of 45. He was initiated on broad spectrum antibiotics without any improvement. Due to worsening respiratory failure requiring supplemental oxygen, infectious disease and pulmonology specialists ruled out Legionella, Aspergillosis, COVID-19, HIV, Histoplasmosis, Mycoplasma, Hantavirus and Tuberculosis. Blood cultures and respiratory panel were negative. Urinary blastomycosis antigen was positive. Patient completed 14 days of amphotericin B and was discharged on itraconazole for at least 1 year. DISCUSSION: Blastomycosis can have a broad spectrum of manifestations with pulmonary infection in more than 79% of patients. Extrapulmonary dissemination is less common though can occur in approximately 25-40% of symptomatic patients. Osseous blastomycosis is the second most common dissemination site following the skin and is seen in approximately 5-25% of patients. CONCLUSIONS: We recommend early consideration of blastomycosis in patients with atypical infectious symptoms who reside in Blastomyces endemic regions. Early diagnosis is key in initiating appropriate treatment and preventing severe complications of disseminated disease. DISCLOSURE: Nothing to declare. KEYWORD: blastomycosis