Rheumatoid factor and tattoo infections

A review of this week's medical research. By GP Dr Tillmann Jacobi

Rheumatoid arthritis: elevated rheumatoid factor suggests the need for specialist referral (Photograph: Dr P Marazzi/SPL)

The significance of increased rheumatoid factor

BMJ 2012; 345: e5244

The value of rheumatoid factor as a confirmative or predictive test for rheumatoid arthritis (RA) has remained unclear for years. This Danish study checked baseline rheumatoid factor in 9,712 asymptomatic individuals from the general population and divided them into a normal level (<25IU/ml) group and several groups of elevated levels.

During 187,659 person-years, 183 individuals developed RA. The study demonstrated that in healthy individuals, a doubling in level of rheumatoid factor was associated with at least a 3.3-fold (95% CI 2.7-4) increased risk of developing RA, which was likely to be considerably higher in the long run - possibly up to 26-fold.

The highest absolute 10-year risk, 32%, was found in the group of 50-69-year-old women smokers with rheumatoid factor levels >100IU/ml. An early rheumatological opinion in elevated rheumatoid factor appears justified and useful.

Diagnostic radiation in BRCA1/2 mutations

BMJ 2012; 345: e5660

It is well known that ionising radiation generally increases the risk of breast cancer, more so if applied in childhood and adolescence. This international retrospective cohort study looked at 1,993 female carriers of BRCA1/2 mutations recruited in France, the UK and the Netherlands. It confirmed that dose-dependent exposure to diagnostic radiation before the age of 30 was associated with an increased risk of breast cancer (hazard ratio 1.9, 95% CI 1.2-3).

A history of mammography before age 30 was also associated with an overall increased risk of breast cancer (hazard ratio 1.43, 0.85-2.4) in this patient group. These results suggest very careful use of diagnostic radiation and preferably the consideration of non-ionising radiation imaging, such as MRI, as the main tool for surveillance in women under 30 with BRCA1/2 mutations.

Admission for asthmatics and non-asthmatics with flu

Eur Respir J 2012 doi: 10.1183/09031936.00015512

Influenza A infections appear to produce more severe outcomes, including death, for non-asthmatics than for asthmatics, in cases where these patients had to be hospitalised. Retrospective analysis of data on 1,520 patients admitted to 75 UK hospitals with confirmed influenza A looked at possible explanations for this.

It found that the use of steroids appears to play a determining protective part in two ways: first, most asthmatics had been using regular inhaled steroids before admission, but were also more likely to receive systemic steroids once they became unwell. Apart from this, asthmatics were more likely to present early with symptoms and therefore be admitted faster (typically within less than four days from onset of symptoms) if they appeared unwell, whereas this was often delayed in non-asthmatics. The differences regarding severe outcomes (ICU support or death) were significant (11.2% versus 19.8%), although rates of pneumonia were very similar.

Chronic kidney disease and lipid-lowering therapy

Ann Intern Med 2012; 157(4): 251-62

Many patients with chronic kidney disease (CKD) have additional cardiovascular risk factors such as hyperlipidaemia, but may not receive treatment.

This systematic review and meta-analysis of 18 RCTs looked at evidence of any impact of lipid-lowering therapy (16 studies of statins and two of a statin in combination with ezetimibe) on renal function and outcomes in patients with CKD.

Lipid-lowering therapy reduced the risk for cardiac events and mortality in these patients with CKD, just as it would in other patients without it. There were no apparent adverse effects to observe in this group. Therefore, patients with CKD and dyslipidaemia should benefit from available treatments to lower cardiovascular risk.

Risk of violence towards disabled children

Lancet 2012 Sep 8; 380: 867-9

The risk of moderately to severely disabled children becoming victims of violence and abuse is increased when compared with non-disabled children.

One of the challenges is the lack of estimates or firm data on the possible scale of the prevalence. This systematic review and meta-analysis of available observational studies published between 1990 and 2010 included 16 cross-sectional, case-control, or cohort studies.

Analysis of the data was difficult due to lack of consistency in study designs and definitions. This produced rather large variations of estimates; for example, the pooled prevalence estimates for physical violence ranged from about 13% to nearly 29% (mean approximately 27%), for sexual violence from just over 9% to nearly 19% (mean approximately 14%) and for combined violence from about 14% to 42% (mean approximately 27%).

Mycobacterial infections in newly tattooed people

N Engl J Med 2012; 367(11): 985-7

This US article considered some recent outbreaks of non-tuberculous mycobacterial skin infections in people with new tattoos.

The infections presented with red papules on grey areas and could become troublesome if not treated appropriately.

The reason for the increased infections was initially suspected to be tattoo artists' use of tap or distilled water to dilute their ink, until an outbreak strain was found in an unopened container of ink.

This led to the discovery that certain manufacturing sources distributed contaminated ink, which pointed to the challenge of quality control. The article highlighted that medical practitioners need to stay alert for tattoo-related skin infections, which may require a biopsy for diagnosis and often need prolonged macrolide treatment.

  • Dr Jacobi is a GP in York and a member of our team who regularly review the journals.

These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.

  • Discuss with your local rheumatology department if there are any specific recommendations on when to test rheumatoid factor and how to deal with borderline or elevated results in patients with minor symptoms.
  • Search for hyperlipidaemia and cardiovascular risk patients with chronic kidney disease. Check how many are on lipid-lowering medication and if there was an active decision at any point not to use this.
  • Check your knowledge of the latest child protection guidelines. Guidance from the GMC was updated this year.

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