Corticosteroid-induced neuropsychiatric disorders: review and contrast with neuropsychiatric lupus.

The aim of this review is to analyze the available literature regarding the neuropsychiatric (NP) disturbances associated with corticosteroid (CS) therapy; to determine the nature, severity, and frequency of these NP symptoms; and to identify the various risk factors involved in the development of CS-induced NP disturbances. We searched the available literature since the advent of corticosteroid therapy (1950) utilizing the PubMed database ( www.pubmed.gov). Primary articles were identified, and they and their pertinent references were reviewed. Due to potential confusion between NP manifestations of CS therapy and central nervous system (CNS) involvement of systemic lupus erythematosus (SLE), a condition often treated with CS, a brief review of NP manifestations of SLE was also performed. The presentation of CS-induced neuropsychiatric disorders (CIPD) can be quite varied with depression, hypomania, and overt psychosis being the most common manifestations. CIPD can also include bipolar affective changes, delirium, panic attacks, agoraphobia, obsessive-compulsive disorder, anxiety, insomnia, restlessness, fatigue, catatonia, reversible dementia-like cognitive changes, impaired memory, and concentration. No factors have been identified that allow for the accurate prediction of development of CIPD. A dose-dependent relationship (increased risk when the daily prednisone-equivalent dose is ≥40 mg) has been observed in most cases of CIPD, although there have been case reports with lower doses, alternate-day therapy, and even inhaled CS. Women are more commonly affected with most symptoms occurring in the first 6 weeks of starting treatment. SLE has been the only specific illness that has been linked to a greater risk of CIPD and the NP manifestations of SLE may mimic those of CIPD, with most occurring in the first year of diagnosis. Antiribosomal P, antineuronal, or antiphospholipid antibodies are frequently seen in patients with SLE developing CIPD. Imaging and EEG abnormalities, the coexistence of non-CNS manifestations of SLE, and the presence of serious disturbances in memory and concentration are more suggestive of NP-SLE than CIPD. Although NP symptoms associated with the use of CS generally resolve with discontinuation of the medication, prophylaxis with lithium, and treatment with antidepressants, anticonvulsants and electroconvulsive therapy for severe mania and depression have been reported with successful outcomes. A greater understanding of the underlying mechanism of CIPD, risk factors involved, treatment options, and the distinguishing features from NP-SLE will ultimately lead to more directed therapy for such patients.

Perspectives about complementary and alternative medicine in rheumatology.

Complementary and alternative medical (CAM) treatments are considered nonmainstream therapies. The popularity and widespread usage of CAM reflects the inadequacies of the current understanding and management of rheumatic and musculoskeletal (and other) diseases despite significant progress. Better science in the future will relegate certain CAM therapies to the margins of medicine or to history and perhaps see the adoption of others into mainstream medicine. Despite the recent increased interest in CAM, particularly for rheumatic diseases, few clinically important contributions have emerged thus far.

Fish oil in rheumatic diseases.

In current practice, dietary interventions and over-the-counter dietary supplements, including fish oil, vitamins, and others, comprise a significant proportion of alternate therapy use. The aim of this article is to clarify the appropriate place for the use of fish oil in rheumatologic practice amid the complexities of modern management.

Spondyloarthropathy after ampullary carcinoma resection: "post-Whipple" disease.

The development of bowel-bypass syndrome complicating the Whipple procedure for biliary tract carcinoma is described here for the first time. A 56-year-old HLA-B27 + man, treated with excision of adenocarcinoma of the ampulla of Vater, developed an undifferentiated spondyloarthropathy, initially unresponsive to nonsteroidal anti-inflammatory drugs and doxycycline, but eventually controlled with sulfasalazine and tapered corticosteroids. This condition represents another example of a rheumatic syndrome occurring after disruption of gastrointestinal tract continuity and likely development of small bowel bacterial overgrowth.

Back pain made simple: an approach based on principles and evidence.

In cases of low back pain, the goal is to detect serious problems and to prevent the pain from becoming chronic by promptly detecting risk factors. The authors lay out a simple, evidence-based approach to low back pain.