Chronic Inflammatory Connective Tissue Diseases Research Articles

Lipedema Reduction Surgery Improves Pain, Mobility, Physical Function, and Quality of Life: Case Series Report.

Lipedema is a chronic inflammatory subcutaneous adipose-rich connective tissue disease affecting millions of women worldwide. Disproportionate fat accumulation on the extremities characterized by heaviness, tenderness, and swelling can affect function, mobility, and quality of life. Treatments include conservative measures and lipedema reduction surgery (LRS). Here, we report lipedema comorbidities and surgical techniques, outcomes measures, and complications after LRS. This is a single outpatient clinic retrospective chart review case series of comorbidities and complications in 189 women with lipedema. Bioelectrical impedance analyses, knee kinematics, gait, physical examinations, Patient-Reported Outcomes Measurement Information System, and RAND Short Form-36 questionnaires collected before and after LRS were analyzed for 66 of the 189 women. Hemoglobin levels were measured by transdermal hemoglobin monitor (Masimo noninvasive hemoglobin monitoring; Irvine, Calif.). Common comorbidities in 189 women were hypermobile joints (50.5%), spider/varicose veins (48.6/24.5%), arthritis (29.1%), and hypothyroidism (25.9%). The most common complication in 5.5% of these women after LRS was lightheadedness with a 2-g reduction or more in hemoglobin. After conservative measures and LRS in 66 women, significant improvements (P ≤ 0.0009) were found for: (1) knee flexion (10 degrees); (2) gait; (3) Patient-Reported Outcomes Measurement Information System T-score (16%); (4) mobility questions: gait velocity, rising from a chair, stair ascent; (5) RAND Short Form-36 scores: physical functioning, energy/fatigue, emotional well-being, social function, general health; (6) and Bioelectrical impedance analyses total and segmental body fat mass. LRS provided significant improvements to women with lipedema using direct physical measurements and validated outcome measures, comparable to those seen after total knee replacement.

The Role of Leptin in Systemic Lupus Erythematosus: Is It Still a Mystery?

Systemic lupus erythematosus (SLE) is a chronic inflammatory connective tissue disease with varying clinical manifestations. Recent studies have proposed that leptin may be related to SLE development. This study aims to assess current information regarding the relationship between leptin and SLE. A systematic search was done using PubMed, Google Scholar, ScienceDirect, Epistemonikos, and Cochrane Library databases. Studies published in the English language in the last 10 years were selected based on predefined eligibility criteria. The quality of the studies was evaluated using the Newcastle-Ottawa Scale and the Assessment of Multiple Systematic Reviews 2 tool.A total of 12 studies were included in this systematic review. These included systematic reviews/meta-analyses, cross-sectional studies, and case-control studies. Based on the findings of this review, we conclude thatleptin is significantly elevated in SLE patients; however, it does not seem to correlate with disease activity. The exact mechanism of leptin in the pathogenesis of the disease remains unknown and further research is needed regarding this aspect.

Mortality related to COVID-19 in patients with rheumatic and musculoskeletal diseases, first wave of the outbreak: a single-center study.

Objectives:The aim of this study was to assess the cause-specific mortality rate related to COVID-19 (CMR) in patients with rheumatic and musculoskeletal diseases (RMDs) and COVID-19 and to analyze the role of the different RMDs in their mortality risk.Methods:An observational longitudinal study was conducted during the first pandemic wave in our center. Patients with the diagnosis of RMDs and COVID-19 were included. Main outcome is the death related to COVID-19. Independent variable – type of RMDs: autoimmune rheumatic diseases (ARD), such as chronic inflammatory arthritis (CIA) and connective tissue diseases (CTD) and non-autoimmune Rheumatic Diseases (non-ARD). Survival techniques were used to estimate the CMR per 1000 patients-month with a 95% confidence interval (CI), and Cox multivariate regression analysis was run to examine the effect of ARD compared to non-ARD on mortality risk adjusted by confounders. Results were expressed by Hazard Ratio (HR) and CI.Results:Overall, 405 patients were included (642.5 patients-month). During the study period, 44 (10.86%) deaths were recorded. CMR was 68.48 (50.96–92.01). After adjusting for confounders, HR of mortality in ARD compared to non-ARD did not achieve statistical significance [HR: 1.15 (0.64–2.07)], neither CTD versus CIA nor CTD versus non-ARD. Age and certain comorbidities which are being diagnosed in March compared to April or May [HR: 2.43 (1.1–5.55)] increased the mortality risk. Glucocorticoids and disease-modifying antirheumatic drugs (DMARDs) dropped from the final model.Conclusion:In patients with RMDs and COVID-19, CMR was 6.8% patients-month. This study shows that mortality risk is higher in males, older patients, and similar between CTD, CIA, and non-ARD. COVID-19 management improved after the first month of pandemic.Plain Language Summaries Mortality related to the outbreak of COVID-19 in patients with rheumatic and musculoskeletal diseases Why was this study done? - To report the COVID-19-specific mortality rate in patients with a variety of RMDs during the first pandemic peak in a tertiary hospital in Madrid and to analyze the role of specific types of ARD and other possible factors in the risk of death related to COVID-19. What did the researchers do? - We performed a retrospective observational study during the first wave of the COVID-19 pandemic in Madrid, Spain. What did the researchers find? - In this study, neither the different diagnoses of RMDs, including CIA, CTD, or non-ARD disease or its treatment were not implicated as a potential risk of death related to COVID-19- In consonance with other studies, RMDs patients and COVID-19, older age, male sex, and certain comorbidities implied more mortality risk- Our data reflect COVID-19 severity in a particular context, time, and population. In times of the absence of COVID-19 vaccine, healthcare, social, and political measures taken to contain the coronavirus outbreak have worked properly. What do the findings mean? - The presence of comorbidities in RMDs patients represents a greater risk than the different types of RMDs themselves, in the development of COVID-19 fatal outcome. It is important to integrate the control of comorbidities in the daily management.

Biomarker profiles of endothelial activation and dysfunction in rare systemic autoimmune diseases: implications for cardiovascular risk.

Vasculopathy is an important hallmark of systemic chronic inflammatory connective tissue diseases (CICTD) and is associated with increased cardiovascular risk. We investigated disease-specific biomarker profiles associated with endothelial dysfunction, angiogenic homeostasis and (tissue) inflammation, and their relation to disease activity in rare CICTD. A total of 38 serum proteins associated with endothelial (dys)function and inflammation were measured by multiplex-immunoassay in treatment-naive patients with localized scleroderma (LoS, 30), eosinophilic fasciitis (EF, 8) or (juvenile) dermatomyositis (34), 119 (follow-up) samples during treatment, and 65 controls. Data were analysed by unsupervised clustering, Spearman correlations, non-parametric t test and ANOVA. The systemic CICTD, EF and dermatomyositis, had distinct biomarker profiles, with 'signature' markers galectin-9 (dermatomyositis) and CCL4, CCL18, CXCL9, fetuin, fibronectin, galectin-1 and TSP-1 (EF). In LoS, CCL18, CXCL9 and CXCL10 were subtly increased. Furthermore, dermatomyositis and EF shared upregulation of markers related to interferon (CCL2, CXCL10), endothelial activation (VCAM-1), inhibition of angiogenesis (angiopoietin-2, sVEGFR-1) and inflammation/leucocyte chemo-attraction (CCL19, CXCL13, IL-18, YKL-40), as well as disturbance of the Angiopoietin-Tie receptor system and VEGF-VEGFR system. These profiles were related to disease activity, and largely normalized during treatment. However, a subgroup of CICTD patients showed continued elevation of CXCL10, CXCL13, galectin-9, IL-18, TNFR2, VCAM-1, and/or YKL-40 during clinically inactive disease, possibly indicating subclinical interferon-driven inflammation and/or endothelial dysfunction. CICTD-specific biomarker profiles revealed an anti-angiogenic, interferon-driven environment during active disease, with incomplete normalization under treatment. This warrants further investigation into monitoring of vascular biomarkers during clinical follow-up, or targeted interventions to minimize cardiovascular risk in the long term.

Clinical outcomes of hospitalised patients with COVID-19 and chronic inflammatory and autoimmune rheumatic diseases: a multicentric matched cohort study

ObjectivesThe impact of inflammatory rheumatic diseases on COVID-19 severity is poorly known. Here, we compare the outcomes of a cohort of patients with rheumatic diseases with a matched control cohort...

Study of the relationship between urinary level of uromodulin, renal involvement and disease activity in patients with systemic lupus erythrematosus.

Systemic lupus erythematosus (SLE) is a multifactorial chronic inflammatory autoimmune connective tissue disease. Lupus nephritis (LN) is a common and serious complication of SLE which can progress to end-stage renal disease. Renal biopsy is the gold standard in the diagnosis and classification of LN, but since it is an invasive procedure, it is neither desirable nor applicable for all cases. This has led to the search for an alternative, noninvasive, site-specific, and immune process-related biomarkers. Uromodulin (Tamm-Horsfall glycoprotein) is the most abundant urinary protein expressed exclusively by the thick ascending limb cells and released into urine of healthy controls. Studies showed that it may act as a danger signaling molecule eliciting an inflammatory response following conditions that damage the nephron integrity and leading to uromodulin release into the interstitial space. This study aimed to assess uromodulin as a screening biomarker of tubulointerstitial involvement in patients with SLE and to elucidate its correlation with disease activity and progression. The study was conducted on 70 patients divided into two groups: control group (Group I) consisted of 20 apparently healthy volunteers of comparable age and sex to the patients' group, and 50 SLE patients (Group II) diagnosed according to the 2012 Systemic Lupus Collaborating Clinics (SLICC) classification criteria. Group II was further subdivided into 23 patients without manifestations of LN (Group II A) and 27 patients with manifestations of LN (Group II B). Urinary uromodulin level showed statistically significant difference among the studied groups, being lowest among the LN patients with a mean value 5.6 ± 3.4, in SLE patients without nephritis 9.9 ± 5.2 and 12.9 ± 4.6 in the control group. Urinary uromodulin also correlated positively with estimated glome- rular filtration rate. A negative correlation was found between urinary uromodulin and serum creatinine, 24 h urinary proteins and SLICC renal activity score. No statistically significant correlation was found between urinary uromo- dulin and SLE disease activity index. Thus, decreasing urinary uromodulin levels can be a marker for renal involvement and tubulo- interstitial nephritis in active SLE patients and a marker for chronic kidney disease and nephron loss in the absence of activity markers.

Diagnostic Pleural Fluid Cytology of Nocardial Infection in A Patient of Systemic Lupus Erythematosus

Systemic lupus erythematous is a chronic autoimmune inflammatory connective tissue disease. Infection remains the major cause of morbidity and mortality in such autoimmune disorders. Nocardia is an uncommon opportunistic pathogen. Due it its low incidence it is often missed by clinicians and pathologists. Delay in diagnosis and treatment is the major cause of dissemination and complications of this disease. Here we report a case of nocardiosis diagnosed on pleural fluid cytology smears using special stains. A known case of systemic lupus erythematous diagnosed 7 years back complained of heaviness in chest, shortness of breath and fever. Ultrasonography of chest showed pleural effusion and consolidation of underlying lung. Pleural fluid was aspirated and sent for cytology. Giemsa and Papaniculaou stained smears showed dense degenerated acute and chronic inflammatory cells in a necrotic background with negatively stained shadows which were negative for ZN and PAS stains. However, gram stain and modified ZN stain (1%H2SO4) showed positively stained clumps of long branching filamentous organism; consistent with Nocardia spp which was later confirmed by culture studies. This case highlights the importance of high index of suspicion for nocardia in cytology samples of pulmonary origin, especially in cases patients with immunosuppressed states. More so special stains like Gram’s stain and modified ZN stain in such cases can aid in a definitive diagnosis.

Panorama Des Maladies Rhumatismales A Conakry

Objective: To determine the epidemiological profile of rheumatic diseases in hospital consultation at the Ignace Deen National Hospital in Conakry (Guinea). Patients and methods: We used a cross-sectional study of participant seen in rheumatologic consultation between November 1, 2016 and November 30, 2017 at the Rheumatology Department of the Ignace Deen National Hospital in Conakry (Guinea). Rheumatic diseases were diagnosed according to the rigorous criteria. Results: We collected 1038 patients including 679 women (65.41%). The mean age of the patients was 49.88 ± 17.47 years with range of 5 and 93 years. Degenerative pathology (644 cases, 62.04%), chronic inflammatory rheumatism and connective tissue diseases (252 cases, 24.27%), periarticular pathology and canal syndromes (91 cases, 8.76%), microcrystalline arthropathies (49 cases, 4.72%), osteopathies (45 cases, 4.33%), and infectious diseases (16 cases, 1.54%) were the main disorders observed during study period. Conclusion: Most of the rheumatic diseases described in the literature have been found. The particuliarity was the relative frequency of inflammatory rheumatism and fracture osteoporosis. However, the further epidemiological studies would be needed to confirm these data.

Current treatment of systemic scleroderma

Systemic sclerosis (scleroderma) is asevere, chronic inflammatory connective tissue disease involving the skin, musculoskeletal system, and several internal organs. The heterogeneity of its presentation and course are aparticular challenge for the treating physician. As therapeutic options have improved considerably during recent years, various working groups have published consensus recommendations for the treatment of SSc. The aim of this overview is to present major aspects of these recommendations and embed them in aconcept of modern interdisciplinary care for this often still devastating disease.

Panorama of inflammatory arthropathies in rheumatologic consultations in Northern Togo.

To determine the frequency and epidemiological profile of inflammatory arthropathies seen during rheumatologic consultations in Togo. This retrospective study examined the records of patients with inflammatory arthropathy seen at a rheumatologic consultation at Kara Teaching Hospital (Northern Togo) over a four-year period. Among the 2361 patients with rheumatic disorders, 152 (6.43%) had an inflammatory arthropathy: 57.24% were men and 42.76% women. The main causes observed were: chronic inflammatory rheumatism (CIR) and connective tissue disease (49.34%), infectious arthritis (26.32%), and gout (24.34%). The mean age of the 75 patients with CIR at the onset of the disease was 40 years and the average duration of evolution was 3.11 years. The main clinical forms of CIR were rheumatoid arthritis (11 cases), spondylarthropathies (20 cases within 11 cases of reactive arthritis), connective tissue diseases (4 cases), and unclassified CIR (31 cases). Nine patients with reactive arthritis were HIV positive. The infectious arthritis was caused by a banal germ in 31 cases and by Koch bacillus in nine other cases. Gout patients (35 men and 2 women) had a mean age of 43 years at the onset of the disease, and the mean duration of the disease was 4.1 years. Gout was monoarticular in 8 cases, oligoarticular in 19 cases and polyarticular in the other 10 cases. This study demonstrates the high incidence of chronic inflammatory rheumatism in Northern Togo.

Uvéites sous biothérapies et/ou DMARDs en rhumatologie : analyse de la base de données déclarative de la pharmacovigilance nationale française

To report the characteristics of uveitis cases occurring while on biologic therapy or disease-modifying antirheumatic drugs (DMARDs) reported to the French national pharmacovigilance database. All the uveitis cases occurring in patients with chronic rheumatologic diseases, chronic inflammatory intestinal diseases or connective tissue diseases, while treated with DMARDs and/or biologic therapies between 2000and 2015and reported to the French National Pharmacovigilance Database were collected. During the study period, 32cases of uveitis were reported (15men, 17women). Two patients were treated with one DMARD alone, 24with biologic therapy alone, and six with both treatments. Anterior uveitis was diagnosed in 19patients (8cases were bilateral); intermediate uveitis was found (unilaterally) in one patient; posterior and diffuse uveitis occurred in 5and 2cases respectively. Five cases were inconclusive with regard to the anatomical type of uveitis. The uveitis was of infectious origin in 5cases: 2toxoplasmosis, 2herpes virus and 1tuberculosis. In the 27other cases, it was not possible to state whether the uveitis was associated with the underlying disease (uncontrolled) or a side effect of the biologic/DMARD treatments. The occurrence of the uveitis led to 9switches in biologic therapy and 13discontinuations of treatment (8complete discontinuations, 5discontinuations only until uveitis remission was obtained). In 4cases, the treatments were not modified. The database does not specify the ultimate course or rheumatologic disease activity at the time of the uveitis. The presence of uveitis while on biologic therapy must not be taken to indicate a therapeutic failure, especially if the ocular manifestation is isolated. In the case of uveitis occurring in patients treated with biologic therapies and/or DMARDs, infectious complications should be ruled out.

Deciphering systemic lupus erythematosus-associated serum biomarkers reflecting apoptosis and disease activity.

Systemic lupus erythematosus (SLE) is a severe chronic inflammatory autoimmune connective tissue disease. Despite major efforts, SLE remains a poorly understood disease with unpredictable course, unknown etiology and complex pathogenesis. Apoptosis combined with deficiency in clearing apoptotic cells is an important etiopathogenic event in SLE, which could contribute to the increased load of potential autoantigen(s); however, the lack of disease-specific protein signatures deciphering SLE and the underlying biological processes is striking and represents a key limitation. In this retrospective pilot study, we explored the immune system as a specific sensor for disease, in order to advance our understanding of SLE. To this end, we determined multiplexed serum protein expression profiles of crude SLE serum samples, using antibody microarrays. The aim was to identify differential immunoprofiles, or snapshots of the immune response modulated by the disease, reflecting apoptosis, a key process in the etiology of SLE and disease activity. The results showed that multiplexed panels of SLE-associated serum biomarkers could be decoded, in particular reflecting disease activity, but potentially the apoptosis process as well. While the former biomarkers could display a potential future use for prognosis, the latter biomarkers might help shed further light on the apoptosis process taking place in SLE.

Influence of biologic therapy on growth in children with chronic inflammatory connective tissue diseases.

ObjectivesConnective tissue diseases (CTD) are a heterogeneous group of chronic inflammatory conditions. One of their complications in children is the inhibition of growth velocity. Due to direct inflammation within the musculoskeletal system as well as glucocorticoid therapy, this feature is the most essential and is mainly expressed in the course of juvenile spondyloarthropathies and juvenile idiopathic arthritis (JIA). Duration of the disease, but predominantly the activity of the inflammatory process, seems to have a significant impact on the abnormal growth profile in children. Effective biological therapy leads to improvement of the patient's clinical condition and also, through the extinction of disease activity and reduction of daily doses of glucocorticosteroids (GCS), it gradually accelerates and normalizes the growth rate in children with CTD. Our objective was to evaluate the impact of biological therapy on growth in children with chronic inflammatory CTD.Material and methodsData from 24 patients with CTD treated with tumor necrosis factor-α-blockers (etanercept, adalimumab, golimumab) and an interleukin-6 receptor blocker (tocilizumab) were reviewed at the time of disease onset, biological treatment initiation and at least 12 up to 24 months onwards. The rate of growth was correlated with the daily doses of GCS, and the type and duration of biological therapy.ResultsPatient median height, measured as the change in height standard deviation score, was 0.36 ±1.07 at disease onset and –0.13 ±1.02 at biologic therapy initiation. The growth velocity accelerated in 17 patients (70.1%) during the biological treatment. Mean height-SDS improvement between biological treatment initiation up to two years was 0.51 ±0.58. In 47% of patients daily doses of GCS were reduced to 0 mg/kg/day.ConclusionsIn the treatment of CTD, biological agents restore growth velocity not only by inflammation inhibition, but also through limiting GCS daily doses.

SAT0030 Circulating Endothelial Microparticles and Endothelial Progenitors Cells in Primary SjÖGren's Syndrome: New Markers of Chronic Endothelial Damage?

BackgroundSubclinical atherosclerosis can be considered a form of systemic involvement in patients with chronic inflammatory joint and connective tissue diseases. Multiple factors, including inflammatory and immune-mediated mechanisms, have been identified...

Analysis of Clinical Symptoms and Laboratory Profiles in Children with Juvenile Idiopathic Arthritis in Malopolska Region (Poland) In the Years 2007-2010

Background: Juvenile idiopathic arthritis (JIA) is a heterogenic group of chronic inflammatory connective tissue diseases of unknown aetiology in children up to 16 years of age.Aim: The aim of this study was to analyse the incidence, clinical presentation and laboratory findings in children with JIA in Malopolska region.Materials and methods: A retrospective analysis included all children with JIA (N=251) hospitalized in the two reference rheumatology centres covering Malopolska region (Poland), between July 2007 and December 2010.Results: The annual incidence of JIA in Malopolska region was estimated at 9.5 per 100 000 children. Oligoarthritis (54.9%) was the most common category in all age groups with a tendency to decrease with age; from 71.4 % in children aged 1-6 years; 55.7% in aged 7-12 years to 39.3 % in aged 13-16 years. The frequency of polyarthritis and enthesitis-related arthritis was greater in adolescents (29.2 % and 22.5 %, respectively). HLA-B27 antigen and uveitis were most frequently found in children with enthesitis-related arthritis (58% and 18.5 %, respectively).Conclusions: The study suggests the improvement of diagnostic capacity of JIA during the last decade in Poland. In accordance with the existing data diverse clinical presentation of JIA categories and laboratory characteristics were proven.

Analysis of Clinical Symptoms and Laboratory Profiles in Children with Juvenile Idiopathic Arthritis in Malopolska Region (Poland) in the Years 2007-2010

Background: Juvenile idiopathic arthritis (JIA) is a heterogenic group of chronic inflammatory connective tissue diseases of unknown aetiology in children up to 16 years of age.Aim: The aim of this study was to analyse the incidence, clinical presentation and laboratory findings in children with JIA in Malopolska region.Materials and methods: A retrospective analysis included all children with JIA (N=251) hospitalized in the two reference rheumatology centres covering Malopolska region (Poland), between July 2007 and December 2010.Results: The annual incidence of JIA in Malopolska region was estimated at 9.5 per 100 000 children. Oligoarthritis (54.9%) was the most common category in all age groups with a tendency to decrease with age; from 71.4 % in children aged 1-6 years; 55.7% in aged 7-12 years to 39.3 % in aged 13-16 years. The frequency of polyarthritis and enthesitis-related arthritis was greater in adolescents (29.2 % and 22.5 %, respectively). HLA-B27 antigen and uveitis were most frequently found in children with enthesitis-related arthritis (58% and 18.5 %, respectively).Conclusions: The study suggests the improvement of diagnostic capacity of JIA during the last decade in Poland. In accordance with the existing data diverse clinical presentation of JIA categories and laboratory characteristics were proven.

Evaluation of pulse wave velocity in systemic lupus erythematosus, rheumatoid arthritis and Behçet's disease

Connective tissue diseases involve characteristic inflammatory lesions in the cardiovascular system, in addition to other systems. The involvement of the cardiovascular system in the course of connective tissue diseases may result in serious morbidity and mortality. Pulse wave velocity which is an indicator of arterial dilatation capacity may predict cardiovascular risk of patients. Pulse wave velocity is inversely proportional to arterial dilatation capacity. Decreased dilatation capacity leads to a reduction in arterial blood pressure and flow dynamics and impairment in coronary perfusion. In our study, we examined pulse wave velocity in frequent chronic inflammatory rheumatologic diseases: rheumatoid arthritis, systemic lupus erythematosus, and Behçet's disease. A total of 98 subjects participated in our study including 24 patients with newly diagnosed rheumatoid arthritis (4 males, 20 females; mean age 42.5 ± 11.5 years), 22 patients with newly diagnosed systemic lupus erythematosus (1 male, 21 females; mean age 35.8 ± 11.1 years), 33 patients with newly diagnosed Behçet's disease (26 males, 7 females; mean age 32.7 ± 8.0 years), and 19 healthy subjects in the control group (10 males, 9 females; mean age 36.2 ± 15.0 years). Aorta pulse wave velocity was determined by Complior Colson (Createch Industrie, Garges les Gonesses, France) device which allowed for pulse wave recording and automated measurement. Pulse wave velocity was higher in rheumatoid arthritis, systemic lupus erythematosus, and Behçet's disease groups compared to the control group. When all variables were included in the regression analysis only age was found to affect pulse wave velocity independently. Pulse wave velocity was found to be high in chronic inflammatory connective tissue diseases compared to the control group. However, no difference was found between groups. Age was determined as the most important independent variable in the regression analysis.

Proton pump inhibitors in rheumatic diseases: clinical practice, drug interactions, bone fractures and risk of infections

Platelet activation and aggregation are key elements of the pathogenesis of acute coronary syndromes, of endothelial damage in chronic inflammatory and connective tissue disease (i.e. systemic sclerosis-SSc). Patients affected by chronic inflammatory diseases as well as by connective tissue diseases such as systemic sclerosis, often have the need to take anti-platelet therapy (e.g. ASA or clopidogrel). Current consensus recommendations state that patients prescribed clopidogrel plus aspirin should receive a proton pump inhibitor (PPI) to reduce gastrointestinal bleeding. Although each single PPI has similar efficacy in many cases, differences between them should be considered when choosing a treatment regimen. Many studies show PPI and clopidogrel drug interaction, with clopidogrel non-responsiveness in about 25% of the population. Only pantoprazole, which does not inhibit CYP P450 2C19, doesn't seem to have interaction with clopidogrel or other drugs. Patients affected by systemic sclerosis have high frequency of oesophageal mucosal abnormalities and should take long-term PPI therapy. When addressing long-term therapy safety data are clearly needed. Two recent studies have reported increased hip fracture rates with long-term PPI use, raising concerns about adverse effects of this class of drugs on mineral metabolism. The use of PPIs is also associated with an increase in the risk of development of Clostridium difficile infection (CDI) and the use of PPIs during CDI treatment is associated with an increased risk of recurrence. In order to achieve the desired results and, as with all medications, PPIs should always be used appropriately taking care never to exceed correct dosage and duration. When necessary use of pantoprazole arises as one of the best possible choices.

Use of Noncontact Low-Frequency Ultrasound in the Treatment of Chronic Foot and Leg Ulcerations

A feasibility study was conducted to characterize the effects of noncontact low-frequency ultrasound therapy for chronic, recalcitrant lower-leg and foot ulcerations. The study was an open-label, nonrandomized, baseline-controlled clinical case series. Patients were initially treated with the Mayo Clinic standard of care before the addition of or the switch to noncontact low-frequency ultrasound therapy. We analyzed the medical records of 51 patients (median +/- SD age, 72 +/- 15 years) with one or more of the following conditions: diabetes mellitus, neuropathy, limb ischemia, chronic renal insufficiency, venous disease, and inflammatory connective tissue disease. All of the patients had lower-extremity ulcers, 20% had a history of amputation, and 65% had diabetes. Of all the wounds, 63% had a multifactorial etiology, and 65% had associated transcutaneous oximetry levels below 30 mm Hg. The mean +/- SD treatment time of wounds during the baseline standard of care control period versus the noncontact low-frequency ultrasound therapy period was 9.8 +/- 5.5 weeks versus 5.5 +/- 2.8 weeks (P < .0001). Initial and end measurements were recorded, and percent volume reduction of the wound was calculated. The mean +/- SD percent volume reduction in the baseline standard of care control period versus the noncontact low-frequency ultrasound therapy period was 37.3% +/- 18.6% versus 94.9% +/- 9.8% (P < .0001). Using noncontact low-frequency ultrasound improved the rate of healing and closure in recalcitrant lower-extremity ulcerations.

Systemic lupus erythematosus in pregnancy: Case report

Systemic lupus erythematosus (SLE) is a chronic inflammatory connective tissue disease commonly diagnosed after the age of 20, mostly around the age of 30 years. It is more common in women than in men, especially during the fertile period. Women with SLE are at higher risk for spontaneous abortions, intrauterine fetal death, preeclampsia and eclampsia, preterm delivery and intrauterine growth retardation. This paper is a case report of a pregnant woman with SLE complicated with preeclampsia, but it also discusses follow-up of such pregnancies.