Serum S100A8/A9 and MMP-9 levels are elevated in systemic lupus erythematosus patients with cognitive impairment.

Objective: Cognitive impairment (CI) is one of the most common manifestations of Neuropsychiatric Systemic Lupus Erythematosus (NPSLE). Despite its frequency, we have a limited understanding of the underlying immune mechanisms, resulting in a lack of pathways to target. This study aims to bridge this gap by investigating differences in serum analyte levels in SLE patients based on their cognitive performance, independently from the attribution to SLE, and exploring the potential for various serum analytes to differentiate between SLE patients with and without CI. Methods: Two hundred ninety individuals aged 18-65 years who met the 2019-EULAR/ACR classification criteria for SLE were included. Cognitive function was measured utilizing the adapted ACR-Neuropsychological Battery (ACR-NB). CI was defined as a z-score of ≤-1.5 in two or more domains. The serum levels of nine analytes were measured using ELISA. The data were randomly partitioned into a training (70%) and a test (30%) sets. Differences in the analyte levels between patients with and without CI were determined; and their ability to discriminate CI from non-CI was evaluated. Results: Of 290 patients, 40% (n=116) had CI. Serum levels of S100A8/A9 and MMP-9, were significantly higher in patients with CI (p=0.006 and p=0.036, respectively). For most domains of the ACR-NB, patients with CI had higher S100A8/A9 serum levels than those without. Similarly, S100A8/A9 had a negative relationship with multiple CI tests and the highest AUC (0.74, 95%CI: 0.66-0.88) to differentiate between patients with and without CI. Conclusion: In this large cohort of well-characterized SLE patients, serum S100A8/A9 and MMP-9 were elevated in patients with CI. S100A8/A9 had the greatest discriminatory ability in differentiating between patients with and without CI.

Testicular adrenal rest tumours in an adult patient with congenital adrenal hyperplasia.

Testicular adrenal rest tumours (TART) are found in patients with congenital adrenal hyperplasia (CAH) with the severity of testicular infiltration linearly related to the degree of enzymatic defect and subsequent compliance with treatment. We report a highly unusual case of TART in an adult patient with CAH caused by 21-hydroxylase deficiency who had not engaged with health services over a 3-year period. Typical imaging features of TART include bilateral well-defined lesions adjacent to the rete testes. However, in this rare case, the follow-up imaging found that the entirety of the testicular parenchyma had been replaced with TART and the patient had gone on to develop an adrenal nodule. As these testicular tumours are commonly misdiagnosed as primary germ tumours and tend respond well to treatment with circadian or reverse glucocorticoids, it is essential for the radiologist to be aware of both the common and more unusual imaging features appearances of TART in patients with CAH in order to facilitate early diagnosis and thus timely initiation of treatment.

Cerebellar developmental venous anomaly with associated cavernoma causing a hemorrhage - a rare occurrence.

Developmental venous anomalies (DVAs) are variations in the transmedullary veins required for drainage of the brain. Normally, when occurring in isolation, DVAs are not clinically significant and are therefore usually a benign diagnosis. Thus, they are most often an incidental finding unless associated with an adjacent pathology. However, intracranial haemorrhage induced by a DVA alone can rarely occur and has been scarcely reported. In this case report we discuss a 58-year-old woman who presented with signs and symptoms of a cerebellar syndrome. Following a non-contrast CT, a CT angiogram and MRI contrast scan of the brain, she was found to have a cerebellar DVA and an intracranial haemorrhage. Subsequent imaging 3 months later with CT and MRI redemonstrated additional evidence of a cavernoma. The patient was managed conservatively.

Pulmonary sarcoidosis masquerading as metastatic cervical cancer: a pitfall in CT scans and positron emission tomography (PET).

Sarcoidosis has been associated with co-existing malignancies in several organs, including the breast and thyroid gland as well as lymphomas. However, the occurrence of sarcoidosis with cervical cancer is rare with only nine previous cases reported in the published literature. We present a case of pulmonary sarcoidosis imitating mediastinal lymph node metastases on the staging CT scan and positron emission tomography imaging. The presence of thoracic lymphadenopathy without any pelvic lymphadenopathy prompted histological confirmation of sarcoidosis on endobronchial ultrasound guided biopsy. Misdiagnosing pulmonary sarcoidosis as metastases would have precluded the patient from receiving the curative treatment and likely resulted in suboptimal outcomes.

Association between depression and anxiety with skin and musculoskeletal clinical phenotypes in systemic lupus erythematosus.

OBJECTIVES: To study the clinical phenotypes, determined based on cumulative disease activity manifestations, and sociodemographic factors associated with depression and anxiety in SLE. METHODS: Patients attending a single centre were assessed for depression and anxiety. SLE clinical phenotypes were based on the organ systems of cumulative 10-year SLE Disease Activity Index 2000 (SLEDAI-2K), prior to visit. Multivariable logistic regression analyses for depression, anxiety, and coexisting anxiety and depression were performed to study associated SLE clinical phenotypes and other factors. RESULTS: Among 341 patients, the prevalence of anxiety and depression was 34% and 27%, respectively, while 21% had coexisting anxiety and depression. Patients with skin involvement had significantly higher likelihood of anxiety compared with patients with no skin involvement [adjusted odds ratio (aOR) = 1.8; 95% CI: 1.1, 3.0]. Patients with skin involvement also had higher likelihood of having coexisting anxiety and depression (aOR = 2.0, 95% CI: 1.2, 3.9). Patients with musculoskeletal (MSK) (aOR = 1.9; 95% CI: 1.1, 3.5) and skin system (aOR = 1.8; 95% CI: 1.04, 3.2) involvement had higher likelihood of depression compared with patients without skin or musculoskeletal involvement. Employment status and fibromyalgia at the time of the visit, and inception status were significantly associated with anxiety, depression, and coexisting anxiety and depression, respectively. CONCLUSION: SLE clinical phenotypes, specifically skin or MSK systems, along with fibromyalgia, employment and shorter disease duration were associated with anxiety or depression. Routine patient screening, especially among patients with shorter disease duration, for these associations may facilitate the diagnosis of these mental health disorders, and allow for more timely diagnosis.

Prevalence and metric of depression and anxiety in systemic lupus erythematosus: A systematic review and meta-analysis.

OBJECTIVES: To systematically review and synthesize literature on 1) the overall prevalence of depression and anxiety in SLE patients in identified studies, and 2) the pooled prevalence per metrics of depression and anxiety in adult SLE patients. METHODS: This review used (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) PRISMA guidelines and in-depth searches in four databases (1954-2016; Ovid-based Medline, Embase, PsycINFO and CINAHL) to identify articles on the prevalence of depression and/or anxiety in adult SLE patients. Included studies were critically appraised and analyzed. The prevalence of depression and anxiety was studied for all included studies, and whenever possible, pooled prevalence (PP) was determined for more commonly used metrics. Statistical and publication bias was assessed using funnel plots. RESULT: A total of 3103 references were identified, 226 were selected for detailed review and 72 were included in the final analysis. OVERALL PREVALENCE: The depression PP, obtained from 69 studies representing 23,386 SLE patients, was 35.0% (95% CI: 29.9%-40.3%). The anxiety PP, obtained from 38 studies representing 4439 SLE patients, was 25.8% (95% CI: 19.2%-32.9%). PREVALENCE PER METRICS USED: The more commonly used instruments included the Centre for Epidemiological Studies - Depression (CES-D), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Hospital Anxiety and Depression Scales (HADS-A/D), and Hamilton Rating Scales for Depression/Anxiety (HAM-D/A)]. The CES-D was utilized in 13 studies including 1856 SLE patients; depression PP was 41.5% (95% CI: 35.1%-48.1%). The BDI was utilized in 14 studies including 1355 SLE patients and the BAI in 3 studies including 489 patients; depression PP was 39.9% (95% CI: 31.1%-49.1) and anxiety PP was 38.4% (95% CI: 34.2%-42.8%). The HADS-D was utilized in 14 studies including 1238 SLE patients and the HADS-A in 12 studies including 1099 patients respectively; its depression PP was 24.4% (95% CI: 19.1%-30.1%) and anxiety PP was 38.3% (95% CI: 29.1%-47.9%). The HAM-D was utilized in 4 studies including 267 SLE patients and the HAM-A in 4 studies including 213 patients respectively; its depression PP was 40.0% (95% CI: 23.0%-59.0%) and anxiety PP was 39.0% (95% CI: 32.0%-45.0%). CONCLUSION: There was high variability in the prevalence of depression and anxiety, ranging from 8.7%-78.6% and 1.1%-71.4%, respectively. This could be attributed to the lack of consistency in the metrics used and its definition for depression and anxiety in SLE. Studies that used a specific metric, such as the CES-D, BDI or HAM-D, yielded similar depression prevalence. The HADS-D had the lowest prevalence. All metrics of anxiety yielded similar anxiety prevalence.

Optical Loupes: A Useful Tool for the Oncall Otorhinolaryngologist-Our Experience.

We aimed to evaluate the efficacy and utility of loupes for ENT on-calls. We conducted a 2 month prospective clinical study using loupes during on-calls. We examined patients twice, with and without loupes and compared visibility and diagnostic ease. We used the loupes in a total of 71 patients for a variety of ENT emergencies. We found that visibility and diagnostic ease was improved in all cases. During procedures we found that improved visibility led to better instrument placement and more satisfactory outcomes. Loupes have been previously used intra-operatively with good results. The obstacles to wider usage are reportedly the expense and learning curve required. We have acquired some cheap loupes and have found evidence that earlier usage eases the transition. We have found that they are a useful addition to the on-call ENT armoury as they facilitate superior visibility and improved instrument placement.

Assessment of the psychometric properties of patient-reported outcomes of depression and anxiety in systemic lupus erythematosus.

OBJECTIVES: This study aimed to: 1) determine the prevalence of depression and anxiety in SLE patients using the Center for Epidemiological Studies-Depression Scale [CES-D], Hospital Anxiety and Depression Scale [HADS], and Beck Anxiety Inventory [BAI] questionnaires; 2) study the criterion validity, interpretability, and test-retest reliability of CES-D, HADS and BAI; and 3) evaluate their diagnostic accuracy when compared to the assessment of an independent psychiatric assessment using the Mini-International Neuropsychiatric Interview (MINI). METHODS: 159 consecutive SLE participants were screened for depression and anxiety using the CES-D, HADS, and BAI, and underwent the MINI. Sensitivity and specificity were evaluated against the MINI. Test-retest reliability was studied. Receiver operator characteristic (ROC) curves were utilized to determine the cut-off scores for CES-D, HADS and BAI. RESULTS: The prevalence of depression ranged from 29% (HADS-D) to 52% (CES-D) and the prevalence of anxiety ranged from 45% (BAI) to 50% (HADS-A). ROC showed similar performance for CES-D and HADS-D. The diagnostic accuracy of HADS-A outperformed BAI. Furthermore, these self-reported questionnaires demonstrated good to excellent test-retest reliability. Analyses exhibited optimal cut-offs for CES-D (26), BAI (19), HADS-A (6), and HADS-D (8) that optimized their sensitivity and specificity as screening metrics for depression and anxiety in SLE patients. CONCLUSIONS: Anxiety and depression are highly prevalent in patients with SLE. Patient-reported outcome questionnaires such as the CES-D, HADS, and BAI may be useful tools to screen for depression and anxiety in SLE. Our results suggest that SLE-specific cut-offs may improve diagnostic accuracy of current screening metrics in patients with lupus.

What is the prevalence of cognitive impairment in lupus and which instruments are used to measure it? A systematic review and meta-analysis.

OBJECTIVES: To systematically review the literature on the prevalence of Cognitive Dysfunction (CD) in SLE patients in studies that used a specified neuropsychological instrument. METHODS: This review was prepared with a protocol following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis-Protocols statement. Literature search in Ovid Medline, Embase, and Psyc INFO for articles on CD in adult SLE patients was conducted. Included studies were critically appraised (Newcastle-Ottawa Evaluation Scale) and the Pooled Prevalence (PP) of CD was studied for all instruments. The association between demographics and CD, the risk of CD in SLE compared to healthy subjects and patients with RA, and the course of CD over time were studied narratively whenever sufficient information was available. RESULT: Of 8054 references, 670 were selected for detailed review and 78 were included in the final analysis. Comprehensive Battery (CB) was utilized in 35 studies in 2463 SLE patients and PP was 38% (95%; CI: 33-43%). The CD prevalence was higher in NPSLE [PP 39% (95% CI: 24-55%]. Automated Neuropsychological Assessment Metric (ANAM) was utilized in 7 studies in 438 patients (PP of CD 26% (95% CI: 12-42%). Other less frequently utilized tools were the Modified Mini-Mental State Exam (MMSE), Montreal Cognitive Assessment (MoCA), Controlled Oral Word Association Test (COWAT) and The Hopkins Verbal Learning Test-Revised (HVLT-R) and subjective tools and others. The relative risk for CD in SLE was greater when compared to RA and to healthy individuals; RR being 1.80 and 2.80, respectively. Information on demographics and its association with CD was very heterogeneous among studies. CONCLUSION: Patients with lupus have a high prevalence of CD. The delay in diagnosis of CD is complex; although caregivers and patients express concerns about cognitive function, testing for CD often imposes administrative and cost burdens. There is an unmet need to identify the best screening, diagnostic metrics of CD. The assessment of cognitive function over time, and the association of demographics with CD, will require further research.

Hot tonsillectomy for paediatric obstructive sleep apnoea.

Obstructive sleep apnoea is a common presentation in paediatric ear, nose and tongue (ENT) outpatients. The use of sleep studies is controversial however once a diagnosis has been made, frequently treatment is surgery. Should these patients be operated on as urgent cases? A 5-year-old boy was admitted under the paediatric team with difficultly breathing and desaturations to 77%. The patient had previously been seen by ENT as an outpatient with an 8-month history of obstructive sleep apnoea and was listed for an adenotonsillectomy with the standard waiting time. During this admission he had an emergency adenotonsillectomy. The patient improved immediately with no large desaturations in recovery and normal observations throughout his stay. It is never ideal to do a paediatric emergency operation and we have reviewed the evidence base to answer the question: Should these patients be treated urgently when seen in outpatients?