The Spectrum of Pericardial Involvement in Giant Cell Arteritis and Polymyalgia Rheumatica: A Systematic Review of Literature.

BACKGROUND: Giant cell arteritis (GCA) is a systemic vasculitis that commonly co-occurs with polymyalgia rheumatica (PMR) in elderly patients. Pericardial disease is an unusual manifestation of these inflammatory conditions, which has been reported only in case reports and small observational studies. However, no extensive research has been performed to study the demographics and clinical history of GCA or PMR patients with concomitant pericardial features. As a result, the medical evidence to help guide the physicians when evaluating such individuals is limited. OBJECTIVE: To perform a systematic review of the medical literature in order to summarize the epidemiological and clinicopathological aspects of this unique association. METHODS: We conducted an extensive search of PubMed, Cochrane Library, Ovid, Google Scholar, and gray literature to identify all the cases of GCA and PMR with pericardial involvement. The demographics, clinical features, and outcomes of the final cohort were reviewed and analyzed. RESULTS: The analysis comprised 52 clinical cases (51 identified from 46 articles and 1 from the residents' clinic). These included 44 patients with GCA and 8 with PMR. The mean age at presentation was 69.5 years, with only 46% of patients older than 70 years. The most common abnormality was pericardial effusion (85%), and in 37%, the pericardial event was the initial disease manifestation. Although a significant proportion of the patients were symptomatic (69%), the classic cranial symptoms were present in only 40%. Overall, the outcome was good even in the presence of large-vessel disease, which is usually a poor prognostic factor in classic GCA. On group analysis, patients with PMR were more likely to develop cardiac tamponade (37.5%; odds ratio, 25.8; confidence interval, 2.2-297.5; p = 0.01), whereas those with GCA were more likely to have large-vessel vasculitis (43%; odds ratio, 5.18; confidence interval, 0.58-252.1; p = 0.04). CONCLUSIONS: This study illustrates that patients with pericardial involvement represent a clinical phenotype of GCA (and possibly PMR), which is quite different from the cranial or large-vessel forms. These patients have a better prognosis likely due to younger age and presence of more overt symptoms resulting in early diagnosis.

'Utilization of telemetry monitoring for non-cardiac conditions in non-critical patients: what are the trends and perceptions amongst medical residents?'

BACKGROUND & OBJECTIVE: Current evidence shows that telemetry monitoring is commonly overutilized for 'non-cardiac' diseases such as COPD exacerbation, pneumonia, pulmonary embolism and sepsis. This issue has not been addressed clearly in the recent American Heart Association (AHA) guidelines and no standard recommendations on the use of telemetry in non-cardiac conditions exist; therefore, clinicians continue to make such decisions based on personal preferences.As medical residency is an important phase during which young physicians develop clinical skills and habits for their future practice, the aim of this study was to understand the prevalent trends related to inappropriate telemetry use amongst the medical residents at a community hospital and the associated factors which influence the use of telemetry monitoring in non-cardiac patients. METHODS: All the residents undergoing internal medicine training at a community hospital were surveyed with the help of a questionnaire regarding the utility of telemetry in non-critical patients admitted with non-cardiac conditions. RESULTS: Survey was completed by 37 residents. Analysis of the responses showed that despite the frequent use of telemetry in non-cardiac conditions, majority of the medical residents are unaware of the correct indications. Seventy-three percent choose 'continuous' telemetry when placing the order while only 16% (often or always) discontinue telemetry after 24 hours of uneventful use. Although 84% residents admitted that telemetry is overutilized, still 49% felt that it leads to better patient care while 70% considered it superior to frequent vitals monitoring for early detection of hemodynamic instability. Possible causes of inappropriate use included 'Lack of knowledge about the related literature' and 'Following trends set by the peers'. CONCLUSION: Majority of the medical residents overutilize telemetry in non-cardiac conditions due to lack of knowledge, perceived sense of security and inappropriate trends set by their colleagues. In order to abolish these tendencies, we propose the provision of adequate educational resources to the clinical staff at every level along with other system-based strategies.

'Preclinical' rheumatoid arthritis in patients with celiac disease: A cross-sectional study.

Objective: Preclinical or latent RA is characterized by the presence of autoantibodies in the absence of clinical symptoms. The objective of this study was to identify the prevalence of preclinical RA in patients with Celiac disease in order to determine whether or not such individuals should be screened for RA based on the high-risk. Method: A cross-sectional study was carried out on patients with celiac disease in a tertiary care center in Rawalpindi, Pakistan. After initial assessment, RA-autoantibody levels (Rheumatoid factor and anti-CCP) were checked. Descriptive analysis was performed on the data gathered. Results: Sixteen patients with known celiac disease were identified to have positive rheumatoid factor and/or anti-CCP levels with an overall prevalence rate of 35%. This trend was significant for celiac patients having history of inflammatory arthritis and active celiac disease. No statistical significance was seen in baseline characteristics for categories of patients with positive rheumatoid factor versus with positive anti-CCP antibodies. Conclusion: Patients with CD can be considered as a high-risk group based on the high prevalence rate of rheumatoid factor/anti-CCP positivity observed in this study and should be considered for further RA screening/preventive studies. Abbreviations: RA = Rheumatoid arthritis; CD = Celiac disease; anti-CCP = anti-citrullinated cyclic peptide) antibodies; RF = Rheumatoid factor; GFD = Gluten-free diet.

Interpretation of hemoglobin A1C in primary care setting.

Diagnostic tests for diabetes have evolved with the emphasis shifting from blood glucose levels and/or oral glucose tolerance test to measurement of hemoglobin A1c (HbA1c) levels. With the advent of modern and standardized methods assaying the percentage of glycosylated hemoglobin, clinicians are relying more and more on HbA1c for the management of diabetic patients. A brief review of literature shows, although HbA1c is an important tool in the diagnosis and management of diabetes, it is still far from being perfect. Clinicians need to be more aware about these limitations and take extra steps to avoid medical errors.

Cancer-associated myositis: an elusive entity.

Inflammatory myopathies are characterized by the skeletal muscle inflammation leading to symptoms of myopathy along with varying involvement of other organs such as lung, skin and joints. The strong association between inflammatory myopathies and malignancy has been well recognized. Recently, â€Ëœcancer-associated myositis (CAM)’, has been proposed to be a paraneoplastic syndrome due to the anti-tumor immunity secondary to similar tumor and regenerating muscle antigens. As the prognosis of myositis depends on the prognosis and treatment of the underlying malignancy, physicians must determine the degree of testing necessary to detect cancer both at myositis onset and thereafter. However, there are no clear guidelines regarding the best approach. Emerging medical evidence shows that identification of certain risk factors and serology patterns can be utilized to predict cancer risk in patients with myositis.

Beating the urine drug test - a case report on niacin toxicity.

Niacin is a form of vitamin B3 which is used for the medical treatment of hyperlipidemia and niacin deficiency. However, within the last few years, it is being advertised on the Internet as a quick way to detoxify the human body in an attempt to evade urine drug tests. This claim is without any medical or scientific evidence and as a result, many cases have been reported where young adults have ended up with niacin toxicity. In this case report, we discuss a rare presentation of niacin toxicity and the effects Internet has had on the healthcare being practised by both the physicians and the patients themselves.