Acute Flare-ups Research Articles

Acute Flares of Knee Osteoarthritis (the ACT-FLARE Study): Protocol for a Web-Based Case-Crossover Study in Community-Dwelling Adults.

BackgroundThe cardinal feature of osteoarthritis (OA) is pain. Although heterogeneity in pain and function have been demonstrated in the long-term course of OA, the more proximate determinants of acute flare-ups remain less clear. How short-term intermittent or transient exposures trigger acute flare-ups has important implications for effective and sustainable self-management strategies.ObjectiveThe primary objective of this study is to identify potential triggers of acute flares in knee OA. Secondary objectives are to determine their course and consequences and describe high-risk participant profiles.MethodsWe carried out a Web-based case-crossover study. This study aims to recruit 620 community-dwelling adults aged ≥40 years, resident in England, and who have knee pain, with or without a recorded diagnosis of knee OA, and no preexisting diagnosis of inflammatory arthropathy. Participants will be recruited via 3 routes: (1) general practice registers, (2) offline community advertisement, and (3) online social media advertisement. By using questionnaires comparing periods before participants’ self-reported flare-up episodes (hazard periods) with periods during the study when their knee OA symptoms are stable (control periods), triggers preceding flare-ups will be identified and examined using conditional logistic regression. Time-to-resolution of flare-up will be examined by monitoring people’s daily pain, bothersomeness, and medication usage until the participant reports when their flare-up episode ends. Rates of flare-ups will be examined across different participant and flare characteristics using regression models to identify high-risk participant profiles. A study-specific Patient Advisory Group (PAG) is providing suggestion, input, and ongoing support for all stages of the research process.ResultsParticipant recruitment opened in July 2018 and is anticipated to continue for 6 months. The study results will be disseminated through a number of channels, including relevant national or international conferences and peer-reviewed publication in a medical journal, via advocacy or charity organizations, such as Versus Arthritis and across social media. Findings will be fed back to members of our PAG, study participants, and clinicians from participating primary care general practices. The PAG will also take an active role in the overall dissemination strategy.ConclusionsThis study will provide empirical evidence to help patients identify common knee OA flare triggers and provide health care professionals with questions to identify patients at most risk of frequent flare-ups.International Registered Report Identifier (IRRID)DERR1-10.2196/13428

‘Acute flare-ups’ in patients with, or at high risk of, knee osteoarthritis: a daily diary study with case-crossover analysis

To determine the natural history of flare-ups in knee osteoarthritis and their relation to physical exposures. Adults aged ≥45 years with a recent primary care consultation for knee OA/arthralgia completed a daily pen-and-paper diary for up to three months, including questions on average knee pain intensity, pain descriptors, other symptoms, activity interference, and selected physical exposures (prolonged kneeling, squatting, climbing stairs, ladders, and moving/lifting heavy objects). Informed by a systematic review, flare-ups were defined a priori. We calculated the rate of flare-ups in the sample, described their nature and duration, and estimated their association with physical exposures in the prior 48h. 67 participants completed at least one month of diaries, 37 (55%) were female, mean age 62 years (SD 10.6) with a mean body mass index of 24.6kg/m2 (SD 5.1). 30 participants experienced a total of 54 flare-ups (incidence density 1.12 (95%CI 0.80, 1.57) flare-ups/person-days). The median duration of flare-ups was eight days (range: 2-30). During a flare-up participants were more likely to report sharp, throbbing, stabbing, burning pain, swelling, limping, stiffness, being woken by pain, taking more analgesia, and stopping usual activities. Exposure to one or more physical exposure increased the risk of a flare-up in the subsequent 48h (odds ratio 2.19 (95%CI: 1.22, 4.05)). Our study with intensive longitudinal data collection suggests acute flare-ups may be experienced by a substantial number of patients. These episodes often last a week or longer, are disruptive, prompt changes in self-management, and may be triggered by high-loading physical activities.

Two-year delay in ulcerative colitis diagnosis is associated with anti-tumor necrosis factor alpha use.

BACKGROUNDUlcerative colitis (UC) is an uncommon inflammatory bowel disease (IBD). However, its incidence has recently increased in South Korea. Moreover, UC diagnoses are frequently delayed, and the relationship between diagnostic delay and UC prognosis has not been extensively studied in South Korean patients.AIMTo identify meaningful diagnostic delay affecting UC prognosis and to evaluate risk factors associated with diagnostic delay in South Korean patients.METHODSMedical records of 718 patients with UC who visited the outpatient clinic of six university hospitals in South Korea were reviewed; 167 cases were excluded because the first symptom date was unknown. We evaluated the relationship between the prognosis and a diagnostic delay of 3, 6, 12, 18, and 24 mo by comparing the prognostic factors [anti-tumor necrosis factor (TNF)-α use, admission history due to acute flare-ups, frequent admission due to flare-ups, surgery associated with UC, and the clinical remission state at the latest follow-up] at each diagnostic interval.RESULTSThe mean diagnostic interval was 223.3 ± 483.2 d (median, 69 d; 75th percentile, 195 d). Among the prognostic factors, anti-TNFα use was significantly increased after a diagnostic delay of 24 mo. Clinical risk factors predictive of a 24-mo diagnostic delay were age < 60 years at diagnosis [odd ratio (OR) = 14.778, 95% confidence interval (CI): 1.731-126.121], smoking history (OR = 2.688, 95%CI: 1.239-5.747, P = 0.012), and misdiagnosis of hemorrhoids (OR = 11.066, 95%CI: 3.596-34.053). Anti-TNFα use was associated with extensive UC at diagnosis (OR = 3.768, 95%CI: 1.860-7.632) and 24-mo diagnostic delay (OR = 2.599, 95%CI: 1.006-4.916).CONCLUSIONA diagnostic delay > 24 mo was associated with increased anti-TNFα use. Age < 60 years at diagnosis, smoking history, and misdiagnosis of hemorrhoids were risk factors for delayed diagnosis.

Dolor abdominal agudo en la enfermedad de Crohn. ¿Qué prueba de imagen urgente se debe hacer?

Crohn's disease is an autoimmune disease that predominantly affects the gastrointestinal tract. Crohn's disease is diagnosed at a young age and runs a chronic course with acute flare-ups. When patients with Crohn's disease present with flare-ups at the emergency department, they are usually managed in a way similar to patients with acute abdomen; there is no consensus about the most appropriate imaging work-up for patients with flare-ups of Crohn's disease. Thus, we decided to review the literature about the imaging tests indicated (whether related to their diagnostic performance or to lower exposure to ionizing radiation) for acute flare-ups in patients with Crohn's disease.

The role of Blastocystis hominis in the activation of ulcerative colitis.

Several studies have shown that a change in microbiota plays an important role in the pathogenesis of inflammatory bowel disease (IBD). Furthermore, with the emergence in recent studies of differences according to the subtype of IBD and whether the disease is active or in remission, there has started to be research into the relationship between IBD and several microorganisms. Blastocystis hominis is primary among these organisms. The aim of the present study was to determine the role of B. hominis in the acute flare-up of ulcerative colitis (UC). A total of 114 patients with UC were included in the study, with 52 in the active phase. The Mayo scoring system was used for the activity index. Patients determined with a flare-up agent other than B. hominis were excluded from the study. Fecal samples of the patients were examined by the polymerase chain reaction method for the presence of B. hominis. B. hominis positivity was determined in 37 (34%) patients with UC. Of the patients, 17 (32.6%) were in the acute flare-up phase, and 20 (32.2%) were in remission (p=0.961). In 11 (64.7%) of the B. hominis positive patients, the disease severity was determined as mild-moderate (p<0.001). The results of the present study showed that while there was no difference between the active and remission phases in respect of B. hominis presence, there was milder involvement in those determined with B. hominis.

Ligneous conjunctivitis due to plasminogen deficit: Diagnostic and therapeutic approach. With literature review

Ligneous conjunctivitis is a rare and poorly understood pathology. Infections and repeated microtraumas are often involved in acute disease flare-ups. This masquerade may lead to misdiagnosis and delayed treatment. We report two cases of ligneous conjunctivitis, describing various presentations of its natural history and focusing on the treatment of this rare disease.

Disease-Triggered Drug Release Effectively Prevents Acute Inflammatory Flare-Ups, Achieving Reduced Dosing.

For conditions with inflammatory flare-ups, fast drug-release from a depot is crucial to reduce cell infiltration and prevent long-term tissue destruction. While this concept has been explored for chronic diseases, preventing acute inflammatory flares has not been explored. To address this issue, a preventative inflammation-sensitive system is developed and applied to acute gout, a condition where millions of inflammatory cells are recruited rapidly, causing excruciating and debilitating pain. Rapid drug release is first demonstrated from a pH-responsive acetalated dextran particle loaded with dexamethasone (AcDex-DXM), reducing proinflammatory cytokines in vitro as efficiently as free drug. Then, using the air pouch model of gout, mice are pretreated 24 h before inducing inflammation. AcDex-DXM reduces overall cell infiltration with decreased neutrophils, increases monocytes, and diminishes cytokines and chemokines. In a more extended prophylaxis model, murine joints are pretreated eight days before initiating inflammation. After quantifying cell infiltration, only AcDex-DXM reduces the overall joint inflammation, where neither free drug nor a conventional drug-depot achieves adequate anti-inflammatory effects. Here, the superior efficacy of disease-triggered drug-delivery to prevent acute inflammation is demonstrated over free drug and slow-release depots. This approach and results promise exciting treatment opportunities for multiple inflammatory conditions suffering from acute flares.

The natural history of flare-ups: a daily diary study of patients with, or at high risk of, knee osteoarthritis

Purpose: To determine, in a sample of community dwelling adults, the natural history of flare-ups in knee osteoarthritis (OA). Methods: 330 adults aged 45 years and over with a recent primary care consultation for knee OA/arthralgia and no existing diagnosis of inflammatory disease were invited to complete a daily pen-and-paper diary for up to 3 months. Average knee pain intensity in the past 24 hours (0-10NRS) was rated daily, along with pain quality, other symptoms, and interference with usual activities. Informed by a systematic review of the literature, flare-ups were defined as an increase in pain intensity of a minimum of 2 points above participants’ rating of their usual pain intensity, sustained for a minimum of 2 consecutive days (i.e. excluding more transient episodes of pain). A flare-up was judged ‘resolved’ when pain intensity returned to usual levels for at least 5 consecutive days. We calculated the rate of flare-ups in the sample as an incidence density per 100 person-days at risk and used descriptive statistics and plots to summarise duration and nature of flare-ups. Results: 67 participants (mean age 62.2 (SD 10.6); 55% female) completed at least one month of diaries. 30 participants experienced a total of 54 flare-ups (incidence density 1.09 flare-ups per 100 person-days). On average, flare-ups showed reductions in pain within 2 days followed by a longer, gradual return to ‘usual’ pain intensity (Fig. 1). The pattern differed between individuals with the median time to resolution = 8 days (range: 2-30). During a flare-up participants were more likely to report several additional features compared to days when they were not in a flare: swelling (50% vs 35%), limping (64% vs 42%), stiffness (60% vs 26%), night pain (34% vs 10%). On a third of flare-up days, patients increased their pain medication. Despite this, on 15% of flare-up days, pain stopped usual activities. Conclusions: Our small study with intensive longitudinal data collection suggests acute flare-ups may be experienced by a substantial number of patients. These episodes often last a week or longer, interfere with sleep and daily activities, and lead to increased analgesic use.

Prognostic factors in chronic heart failure in Niger

The aim of our work was to investigate the prognostic factors in chronic heart failure at the cardiology center of the National Hospital of Niamey This is a prospective, cross-sectional study including patients with chronic heart failure or acute flare-ups with altered LVEF during the period of December 21, 2015 to May 21, 2016. We study the following parameters: anthropological, clinical, electrical, echogardiographic, biological, therapeutic and outlook. The primary outcome measure was survival after hospitalization. Eighty-four patients were retained. The mean age was 51.39 ± 18.38 years with extremes of 18 and 85 years. The sex ratio was 1.4 in favor of women. Hypertensive heart disease is the most frequent etiology (42.9%) followed by ischemic heart disease (13.1%). The mortality rate at the end of the study was 39.28%. Prognostic factors were found: advanced age (≥ 55 years) and male sex were predictive of death and rehospitalization. Acute onset, tachycardia, low systolic blood pressure, arrhythmia and crackling rattle influenced mortality. The ischemic etiology has a worse prognosis than other causes. At the ECG, left branch block and ventricular extrasystole had an effect on mortality while rehospitalizations were inflamed by left branch block and lengthening the duration of the QRS complex. Cavity dilatation and LVEF < 30% influenced mortality and rehospitalization. For biological parameters, mortality was influenced by hyponatremia, hyperkalaemia and anemia; rehospitalization with hyponatremia, hypokalaemia, anemia and hyperleukocytosis. The research of prognostic factors is paramount in the management of patients with chronic heart failure.

\u201cI just know\u201d: exploring self-knowledge in chronic obstructive pulmonary disease

The importance of lay knowledge in health care settings, particularly in relation to long-term conditions, has received increasing attention over the past few decades. However, there remains some way to go before patients’ experiential or self-knowledge forms part of current clinical decision making and care provision. Chronic obstructive pulmonary disease (COPD) is a chronic respiratory condition which affects people on a daily basis. People living with this condition develop experiential knowledge about their symptoms and are, arguably, best placed to assess these and treat any acute worsening of their condition accordingly. Here we explore how people with COPD articulate their knowledge and make sense of it within the context of their everyday lives. We re-analysed data from a qualitative interview-based study with 44 participants living with moderate to severe COPD using a grounded theory approach. We found that participants focused their attention on symptoms and sensations of the chest while developing an embodied self-awareness that allowed them to assess whether they were experiencing an acute worsening of their condition. Participants appeared confident in using this self-knowledge to distinguish such acute flare ups from the daily variability of their condition, described as good days and bad days. We suggest that people with COPD are very attuned to their bodies despite the vagueness and sometimes seemingly unrelated nature of their symptoms and signs. We argue that self-knowledge should be acknowledged as valid and meaningful by both patients and clinicians. This is particularly important because of the clinical uncertainty about the precise onset and presentation of acute exacerbations in COPD.

Artritis microcristalinas

IntroduccionThe microcrystalline arthritis are a group of diseases with the same origin, the deposit at joint and periarticular structures of crystals. GoutThis entity is caused by deposition of crystals of monosodium urate level articular and periarticular. ClinicClinically, they can manifest like mono, oligo or polyarthritis and change from acute flare-ups to chronic forms, so they can simulate other inflammatory joint diseases, assuming a challenge to clinicians. DiagnosticIdentification of crystals in synovial fluid is very important to achieve diagnosis. TreatmentInitial treatment in all cases is to cure the acute flare of inflammation, individualizing the treatment according to the patient's comorbidities. In gout, it is critical to normalize the serum uric acid levels for long time, to reduce the previous deposits. To this end, in addition to the classic lowering uric acid treatments, such as allopurinol, other treatments are being developed, in recent years. Calcium pyrophosphate deposition diseaseIt has some characteristics clinical and diagnostic similar to the gout. It is more prevalent in older age. No treatment has been effective to reabsorb crystals and to prevent acute flares.

SAT-149 - A revisit of anti-HBc IgM in the differentiation of acute HBV infection from chronic HBV infection with acute flare-up

SAT-149 - A revisit of anti-HBc IgM in the differentiation of acute HBV infection from chronic HBV infection with acute flare-up

Tattooing and psoriasis: demographics, motivations and attitudes, complications, and impact on body image in a series of 90 Finnish patients.

Koebner phenomenon (KP) affects up to a third of patients with psoriasis and can occur on tattoos. Little is known about the extent of tattooing and its consequences among psoriatic patients. A survey was conducted to determine the demographics, motivations and attitudes towards tattoos, and complications among tattooed patients with psoriasis, and the impact on their body image. Ninety Finnish patients completed an internet self-reported questionnaire in June 2016. Fifty-two percent (48/90) had one tattoo or more (mean number of three tattoos, range 1-20). They were younger than non-tattooed patients (p = 0.001). Of these, 27.6% experienced a KP on their tattoos from 1 week to 15 to 20 years after tattooing. Among those, 30% reported an acute flare-up of psoriasis within the first weeks after tattooing. They were more likely to have a history of KP. Less than 7% reported a psoriasis flare-up on another part of the body after tattooing. Eighty-two percent stated that their tattoo(s) had a positive effect on their body image. KP on tattoos is not particularly frequent in patients with psoriasis. Tattooing has a bolstering effect on body image and should not be a contraindication. However, patients need proper counseling before receiving tattoos.

Exhaled nitric oxide levels to guide treatment for adults with asthma.

Asthma guidelines aim to guide health practitioners to optimise treatment for patients so as to minimise symptoms, improve or maintain good lung function, and prevent acute exacerbations or flare-ups. The principle of asthma guidelines is based on a step-up or step-down regimen of asthma medications to maximise good health outcomes using minimum medications. Asthma maintenance therapies reduce airway inflammation that is usually eosinophilic. Tailoring asthma medications in accordance with airway eosinophilic levels may improve asthma outcomes such as indices of control or reduce exacerbations or both. Fractional exhaled nitric oxide (FeNO) is a marker of eosinophilic inflammation, and as it is easy to measure, has an advantage over other measurements of eosinophilic inflammation (for example sputum eosinophils). To evaluate the efficacy of tailoring asthma interventions based on exhaled nitric oxide (FeNO), in comparison to not using FeNO, that is management based on clinical symptoms (with or without spirometry/peak flow) or asthma guidelines or both, for asthma-related outcomes in adults. We searched the Cochrane Airways Group Specialised Register of Trials, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and reference lists of articles. The last searches were undertaken in June 2016. All randomised controlled trials (RCTs) comparing adjustment of asthma medications based on exhaled nitric oxide levels compared to not using FeNO, that is management based on clinical symptoms (with or without spirometry/peak flow) or asthma guidelines or both. We reviewed results of searches against predetermined criteria for inclusion. We independently selected relevant studies in duplicate. Two review authors independently assessed trial quality and extracted data. We contacted study authors for further information, receiving responses from four. We included seven adult studies; these studies differed in a variety of ways including definition of asthma exacerbations, FeNO cutoff levels used (15 to 35 ppb), the way in which FeNO was used to adjust therapy, and duration of study (4 to 12 months). Of 1700 randomised participants, 1546 completed the trials. The mean ages of the participants ranged from 28 to 54 years old. The inclusion criteria for the participants in each study varied, but all had a diagnosis of asthma and required asthma medications. In the meta-analysis, there was a significant difference in the primary outcome of asthma exacerbations between the groups, favouring the FeNO group. The number of people having one or more asthma exacerbations was significantly lower in the FeNO group compared to the control group (odds ratio (OR) 0.60, 95% confidence interval (CI) 0.43 to 0.84). The number needed to treat to benefit (NNTB) over 52 weeks was 12 (95% CI 8 to 32). Those in the FeNO group were also significantly more likely to have a lower exacerbation rate than the controls (rate ratio 0.59, 95% CI 0.45 to 0.77). However, we did not find a difference between the groups for exacerbations requiring hospitalisation (OR 0.14, 95% CI 0.01 to 2.67) or rescue oral corticosteroids (OR 0.86, 95% CI 0.50 to 1.48). There was also no significant difference between groups for any of the secondary outcomes (FEV1, FeNO levels, symptoms scores, or inhaled corticosteroid doses at final visit).We considered three included studies that had inadequate blinding to have a high risk of bias. However, when these studies were excluded from the meta-analysis, the difference between the groups for the primary outcomes (exacerbations) remained statistically significant. The GRADE quality of the evidence ranged from moderate (for the outcome 'exacerbations') to very low (for the outcome 'inhaled corticosteroid dose at final visit') based on the lack of blinding and statistical heterogeneity. Six of the seven studies were industry supported, but the company had no role in the study design or data analyses. With new studies included since the last version of this review, which included adults and children, this updated meta-analysis in adults with asthma showed that tailoring asthma medications based on FeNO levels (compared with primarily on clinical symptoms) decreased the frequency of asthma exacerbations but did not impact on day-to-day clinical symptoms, end-of-study FeNO levels, or inhaled corticosteroid dose. Thus, the universal use of FeNO to help guide therapy in adults with asthma cannot be advocated. As the main benefit shown in the studies in this review was a reduction in asthma exacerbations, the intervention may be most useful in adults who have frequent exacerbations. Further RCTs encompassing different asthma severity, ethnic groups in less affluent settings, and taking into account different FeNO cutoffs are required.

Product Differences in Intra-articular Hyaluronic Acids for Osteoarthritis of the Knee

Background: Knee osteoarthritis (OA) is a common and often disabling joint disorder among adults that may result in impaired activity and daily function. A variety of treatment options are currently available and prescribed for knee OA depending on the severity of the disorder and physician preference. Intra-articular hyaluronic acid (IA-HA) injection is a treatment for knee OA that reportedly provides numerous biochemical and biological benefits, including shock absorption, chondroprotection, and anti-inflammatory effects within the knee. Clarity is needed as to whether the available IA-HA products should be considered for therapy as a group or whether there are significant differences in the products that need to be considered in treatment of OA of the knee. Purpose: To determine whether there are differences in efficacy and safety with respect to intrinsic properties of available IA-HA injections for knee OA. Study Design: Meta-analysis. Methods: A comprehensive literature search of the Medline, EMBASE, and PubMed databases was conducted for all existing randomized trials of IA-HA. The primary outcome measure analyzed was the mean pain score at the reported follow-up nearest to 26 weeks after injection. Pooled efficacy and safety results were recorded for subgroupings of HA product characteristics. Results: A total of 68 studies were included for analysis. Products with an average molecular weight ≥3000 kDa provided favorable efficacy results when compared with products of an average molecular weight <3000 kDa. Products with a molecular weight ≥3000 kDa demonstrated significantly fewer discontinuations due to treatment-related adverse events than did ≤1500 kDa counterparts, while trial discontinuation rates were similar between biological fermentation–derived HA products and avian-derived HA. The results did not demonstrate a significant difference in the occurrence of effusion across molecular weight subgroups. Additionally, biological fermentation–derived HA had a significantly smaller incidence of effusion than did avian-derived HA. Biological fermentation–derived HA demonstrated fewer acute flare-ups at the injection site than did avian-derived HA products, while high-molecular-weight products demonstrated the highest rate of injection site flare-up. Conclusion: Despite similarities, IA-HA products should not be treated as a group, as there are differences in IA-HA products that influence both efficacy and safety. In the available literature, IA-HA products with a molecular weight ≥3000 kDa and those derived from biological fermentation relate to superior efficacy and safety—factors that may influence selection an IA-HA product for OA of the knee.

Psoriasis and leprosy: A rare co-occurence

Occurence of psoriasis and leprosy in a single patient is extremely rare with very few cases reported. Better knowledge of the pathogenesis of these two diseases has led to some understanding of this rare association. We report such an association in one of our patients. We also report the therapeutic dilemma faced in treating lepra reaction with steroids while preventing the acute flare-up of psoriasis.

Use of mesenchymal stem cells in the combination therapy of ulcerative colitis

To compare results of treatment in patients with moderate and severe ulcerative colitis (UC), receiving standart anti-inflammatory therapy (second group) and its combination with bone marrow-derived mesenchymal stromal cells (MSC) (first group). Complex therapy of UC acute flare-up, including MSC did not influence on reccurence frequency, remission duration and mean value of clinical and endoscopic activity indices during 1 year of follow-up: in 1 group UC flare-up occurred in 2 (16.7%) patients, in 2 group--in 3 patients (30%). RR was 0.3 (95% CI 0/08--1.36; p=0.2; x2=1.47). After 2 years of follow-up risk of UC exacerbation in 1 group was 3 times lower than in the 2 group (p=0.03). Mean duration of remission in the 1 group was 22 months, in the 2 group--17 months (p=0.049). After 3 years of follow-up remission duration in the 1 and 2 groups were 22 and 22 months, respectively (p=0.66). Activity Index according to Rachmilevich in the 1 group was 4.75+/-1.13 points, in the 2--8.1+/-1.1 points (p=0.001). MSC application increases efficacy of anti-inflammatory treatment in patients with acute exacerbation of UC.

How do patients and professionals differentiate between intra-articular joint bleeds and acute flare-ups of arthropathy in patients with haemophilia?

The overlap in symptoms between joint bleeds and flare-ups of haemophilia arthropathy (HA) creates difficulties in differentiating between the two conditions. Diagnosis of haemarthrosis is currently empirically made based upon clinical presentations. However, no standard diagnostic criteria are available. To offer appropriate treatment, rapid and accurate diagnosis is essential. Additionally, adequate differentiation can decrease health costs significantly. The aim of this study was to identify signs and symptoms to differentiate between an intra-articular joint bleed and an acute flare-up of HA in patients with haemophilia and make an initial proposal of items to include in a diagnostic criteria set. Six focus group interviews with a total of 13 patients and 15 professionals were carried out. The focus groups were structured following the Nominal Group Technique (NGT). The most important signs and symptoms used to differentiate between joint bleeds and HA were (i) course of the symptoms, (ii) cause of the complaints, (iii) joint history, (iv) type of pain and (v) degree of impairments in range of motion. This qualitative study provides insight into signs and symptoms that are currently used to differentiate between joint bleeds and flare-ups of HA. Results of this study can be used to develop a valid and standardized clinical diagnostic criteria set to differentiate between these two conditions. Further research is necessary to validate the signs and symptoms found in this study.

Opsoclonus-myoclonus syndrome in adults: a report of two cases

Background: Opsoclonus-myoclonus syndrome (OMS) is a rare movement disorder characterized by chaotic multidirectional eye movements, myoclonus and less frequently cerebellar ataxia. OMS affects as few as 1 in 10,000,000 people per year. Case reports: We present two cases of female Caucasian patients aged 19 and 60 years respectively who developed OMS following a febrile illness. In both cases OMS starts with an acute flare-up of physical symptoms within days. The neurologic examination revealed opsoclonus, myoclonus and ataxia. Both women had normal magnetic resonance imaging of the brain. The results of routine laboratory tests were normal. In both cases, cerebrospinal fluid examinations was consistent with aseptic meningoencephalitis and showed cell-protein association (lymphocytic pleocytosis and protein elevation). The oligoclonal IgG band was negative. Cytomegalovirus, Epstein-Bar virus, Varicella-zoster virus, borrelia, coxsackie, enterovirus, streptococcal infection, syphilis, herpes simplex virus-1 and -2, human immunodeficiency virus or hepatitis were negative in the serological tests. The thyroid function tests, the tests for anti-nuclear and anti-neuronal antibodies were within normal limits. Malignancy was not detected on positron-emission tomography-CT. After therapies including a combination of intravenous methylprednisonolon, intravenous ceftriaxon, acyclovir and clonazepam, both patients gradually improved and had recovered. After a 12-month follow-up, both women had no neurological sequelae. We have obtained approval of both patients. Conclusion: OMS is associated with multiple etiologies. The most common etiologies are idiopathic, paraneoplastic and infectious disorders. OMS may occur in patients with aseptic brainstem encephalitis. The exact immunopathogenesis and pathophysiology of OMS are uncertain.

Hyperuricemia and gout in solid-organ transplant: update in pharmacological management.

Hyperuricemia is a common comorbid condition experienced by up to 28% of kidney transplant recipients. These patients are at elevated risk of acute flare-ups of gout because of transplant-specific risk factors such as impaired renal function, chronic contributing pharmacotherapy (eg, calcineurin inhibitors, diuretics), and associated comorbid conditions. After transplant, treatment is often complicated by drug-drug interactions, renal impairment, and toxic effects of drugs with the use of first-line recommended agents. A number of therapeutic options remain available for transplant recipients, including dose modifications of historic agents and newer pharmacotherapeutic options. Notably, the Kidney Disease Improving Global Outcomes guidelines address the management of hyperuricemia and gout, but these guidelines were last published in 2009, and new data and treatment options have emerged since then. The management of hyperuricemia and acute and chronic gout is described, including the use of novel agents including urate oxidases, interleukin 1 inhibitors, and human urate transporter 1 inhibitors and alternative immunosuppressive therapy strategies.