Joint destruction in rheumatoid arthritis
Ann Rheum Dis 2011; 70: 733-9
Rheumatoid arthritis (RA) comprises synovitis, joint damage and reduced joint function. In active disease the cardinal feature is synovitis, but the inflammatory cells also invade the adjacent cartilage and bone leading to destruction of both structures and contributing to the loss of physical function, albeit by different mechanisms.
This can be, in part, irreversible. Bone destruction involves synovial osteoclasts, while cartilage damage is the result of the action of metalloproteinases from synovial fibroblasts and macrophages.
This study used data from previous pharmaceutical sponsored trials of adalimumab, etanercept, infliximab and leflunomide. These agents look to control the disease and limit joint damage.
The researchers compared the level of cartilage and bone erosive damage against function and found that contrary to the accepted wisdom, joint damage causes more functional disability than bone erosion.
Moreover, a small amount of cartilage damage can lead to a large degree of disability; this further strengthens the argument to treat RA early and aggressively.
Which NSAID in rheumatic disease?
Ann Rheum Dis 2011; 70: 818-22
NSAIDs are the backbone of treatment in chronic rheumatic diseases. They all have relatively similar efficacies, but different safety profiles.
The classic NSAIDs were known to have upper and lower GI side effects, so along came the COX-2 inhibitors with their lower GI risk. Unfortunately, these seemed to have higher cardiovascular (CV) risks so were withdrawn or had warnings put on them. Subsequently, however, this increased CV risk seemed to apply to the old NSAIDs as well.
This paper analysed the opinions of the multidisciplinary European expert panel on NSAID use.
The essence of their recommendations was when choosing a NSAID for a rheumatic disease: low GI and CV risk - any NSAID, low GI but high CV risk - naproxen and PPI.
Medium GI and low CV risk - COX-2, or any NSAID and PPI, medium GI but high CV risk - naproxen and PPI.
High GI with low CV risk - ibuprofen/diclofenac and PPI or celecoxib and PPI.
High GI and high CV risk - best avoid these drugs, but if you really have to use them, naproxen or a COX-2 and PPI could be considered. This does seem to be a useful guide.
BP in chronic kidney disease
Ann Intern Med 2011; 154: 541-8
The optimal BP target in hypertensive patients with chronic kidney disease (CKD) is apparently uncertain. This might come as a surprise to anyone who has encountered the seemingly dogmatic QOF CKD indicators.
This paper was a systematic review of trials comparing outcomes in patients with CKD against BP, with a follow up of more than one year.
The researchers found three trials that met their criteria. Analysis showed that a BP of less than 130/80mmHg was no more beneficial than one less than 140/80mmHg.
There were lower quality trials that suggested that a lower BP might be beneficial with proteinuria greater than 300mg/d.
Those treated to a lower target required most antihypertensive agents and had more adverse events. Perhaps this could be reflected in the CKD QOF targets.
Non-doctor medical termination
Lancet 2011; 377: 1155-61
One in five women worldwide choose to terminate a pregnancy and 10 per cent of these are unsafe abortions, mostly in developing countries.
As abortion cost is therefore an issue, this Nepalese-based study (where abortion is a high cause of maternal mortality), looked at cost reduction by comparing doctor-led care to midlevel (nurse or midwife) provider care for medical abortion in a rural setting.
Women up to nine weeks' gestation with no contraindications were entered into the study and given 200mg mifepristone orally followed by 800 microgram misoprostol vaginally two days later. The endpoint was complete abortion with no need for surgical termination at 30 day follow-up.
About 500 women were randomised to either doctor or midlevel care. The primary end point of complete abortion with no need for surgical termination was found to be similar in each group. No serious events were noted in the midlevel care provider group.
Midlevel care providers in the developing world, therefore, have a potentially important role in providing both safe and cost-effective access to abortion care.
Pregnancy of unknown location
BJOG 2011; 118: 693-7
A positive pregnancy test with an otherwise non-ultrasonographically visible pregnancy (not intrauterine or ectopic) is known as a pregnancy of unknown location (PUL).
These account for between 5 to 42 per cent of early pregnancy assessment unit assessments (the variation seems to be largely due to the quality of the ultrasound exam), thus accounting for a sizeable workload.
The usual scenario is a woman attending in the aftermath of a miscarriage, when the pregnancy test is still positive but little or nothing remains in the uterus.
Previous studies have shown a high rate of spontaneous resolution of PULs.
This study looked at whether a one-visit assessment strategy is safe and effective with PULs. Women with a PUL who had a serum progesterone of less than or equal to 10 nanomoles/L were discharged with no follow up.
A third of the women with PUL fell into this category. At four-week telephone follow-up, 93 per cent of these women had no further problems. This seems a safe and effective protocol.
- Dr Hunter is a GP in Bishop's Waltham, Hampshire, and a member of our team who regularly review the journals
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