RheumNow Podcast - Scurvy And Mechanics (2 - 1-19) Save
RheumNow Podcast - Scurvy And Mechanics (2 - 1-19) by Dr. Cush
Transcription
Welcome to the RheumNow podcast. It's the 02/01/2019. I'm Jack Cush, executive editor of rheumnow.com. What happens when pirates get scurvy? What happens when women with autoimmune disease get mechanic's hands?
What are they doing under the car? And lastly, what happens when RA patients get periodontal disease? We're gonna cover that today. Our first report is on scurvy, and it comes from MMWR and the CDC where they have a interesting report of an outbreak of scurvy in the Sudanese in Africa. And obviously, this is related to diet, nutrition, poor health conditions in that environment.
And I bring it up because it's a reminder that scurvy is still a public health problem around the world. It's still a problem here in The United States. I had a great case to present as a hoot, as a, you know, outsmart the panel kind of thing last year of scurvy that my partner Doctor. Dow diagnosed in a woman who had GI complaints and gingival complaints and joint complaints and elevated CR, sedate and CRP and her husband ratted her out and said she had the world's worst diet. You know, she ate chicken McNuggets and gummy bears and nothing else.
And sure enough, she had no vitamin C and she had scurvy. Well, I presented this to a panel only to get upstaged by a pediatrician who presented three cases of scurvy to the panel as well. And yet even though they had been primed and educated on scurvy and then when I presented my case of scurvy, nobody got it. Suggesting that it's hard to identify these people, but you have to think about it. It's very common in younger people, adolescents, young adults who have these hard diets, like I said, you know, chicken McNuggets and or only the sort of monotonous diets or a fad diet gone wrong, obviously with no vegetables and no fruits.
But you should look for the symptoms and they're often musculoskeletal with mucosal and bleeding and gingival kind of things. So arthralgias, frank arthritis, encephalitis, lethargy, fatigue, gingival pain and bleeding, gingival hyperplasia, they have some skin lesions, they can get chest pain, they can get purpur in their skin, they have poor wound healing, they may have deep myalgic and bone kinds of pain and it can even have elevated sed rates and CRPs. So you should look for these, they're not that uncommon. Scurvy, yes, in your backyard. So an interesting study looked at five seventy six, patients with autoimmune disease, and tried to identify the frequency of mechanics hands.
Now mechanics hands as you know is sort of a roughen, scaly hyperkeratotic, digital lesion that has been linked mostly with the anti synthetase syndrome and the inflammatory myopathies. However, in this particular cohort, almost six hundred patients, seventeen percent of patients had mechanics hands. They were mostly seen in guess what? Wrong. MCTD, fifty percent of patients came from MCTD, thirty five percent came from dermatomyositis, fifteen percent came from primary systemic sclerosis, fifteen percent from undifferentiated undifferentiated disease, and fourteen percent from Sjogren's.
None with lupus had MC had these mechanic hands. So that means UCTD and MCTD, I like UCTD as a diagnosis instead of MCTD. MCTD, I think is a diagnosis on its way to something else unified by an RNP antibody. So that makes up two thirds of patients with mechanics hands. So these mechanic hands patients, they were very, very likely to have abnormal, nail fold capillaroscopy.
They were more likely to have Raynaud's, they were more likely to be joe one positive, and again, as I said, abnormal capillaroscopy. So, it's interesting to note that the range there is different than what you might have normally have been taught being related to dermatomyositis, polymyositis. A UK, cohort study looked at patients with hemochromatosis, specifically the ones who had HFE gene rearrangement testings looking for the C29A2Y mutation. They found that when patients were homozygous for that mutation and you looked at men with that, the odds of actually having a hemochromatosis went up like four eleven fold, the odds ratio of four eleven. Patients with that rearrangement and who are homozygous were likely to have not just hemochromatosis but liver disease, RA, osteoarthritis, and diabetes, a two to three to fourfold increased risk of those.
So the purpose of study was to look at if you have the gene and you were thought to have hemochromatosis, what other diseases co associate with this? And RA, diabetes, OA, and obviously the liver disease. Much more common, of course, was those who had these heterozygous mutations for the HFE gene, and they were way more common, but they were also less likely to be symptomatic and actually they had very modest amounts of morbidity which was very different than those who are homozygous. Interesting an interesting study looks at the association between periodontal disease and rheumatoid arthritis. Now we've heard this story before, I'll just give you some numbers, a hundred and eighty seven RA patients, a hundred fifty seven without RA or inflammatory disease.
When periodontal periodontitis was present, the adjusted odds ratio of having periodontal disease, if you had RA, was twenty four higher. The presence of periodontal disease in inflammation, in what looks like infection, but it's really just inflammation, also is significantly associated with RA disease activity. What I'm looking to see and I haven't yet found is show me someone who treats the periodontal disease and their RA gets better. Or show me someone who treats the RA and their periodontal disease goes away. There's some hints of that out there.
These are causative associations. They actually have a very similar this is the pathology, the biology, the cytokine profile of the synovium and the joint is almost the same as the periodontal tissues. And is this a microbiome issue or, is there truly a good link here? We need some more cause and effect studies, I think. A study of almost seven hundred and fifty thousand patients, in Southern Sweden shows that almost a quarter of the osteoarthritis patients in Southern Sweden are using opioids, and it's basically twofold higher than those who don't have hip or knee osteoarthritis, suggesting that even outside The United States, this is a big issue.
And the question is, do they need it? We do know there are plenty of studies that show that opioids are no better than simple analgesics like acetaminophen or even low dose Tylenol and then other studies not related to opioids but showing that turmeric is as good ibuprofen in managing osteoarthritis, suggesting that sometimes the frustration of managing those patients, especially near the end, is riddled with the use of opioids, which comes with a new risk and a higher risk of things that you may not want to exhibit or put upon your patients. An interesting study of 100 kids with Takayasu's finds that there's a three percent mortality in the first year of that disease. It's low, but it's not totally unnoticeable. There is a fifty percent chance of significant morbidity in the first five years.
So these patients can be sick, they can be hard to manage. In their cohort kids, course, 14 years of age was the mean age, three quarters of them were females. Things to look for hypertension, blood pressure discrepancy between the limbs, bruits and fifty percent hypertension seventy percent, pulse deficits in thirty eight percent. The, artery involvement that was found in the kids renal arteries in two thirds, aorta and 43% subclavian forty four percent carotid and forty three percent. That's the profile of the ugly but easy to treat Takayasu syndrome.
You got to make the diagnosis though. Today's, actually yesterday's New England Journal article on oral or IV antibiotics for bone and joint infections. A 2324 multicenter UK study looked at almost a thousand patients who after they had their surgery or the initiation of antibiotics were followed, and specifically looked at whether they were treated with IV antibiotics for six weeks or oral antibiotics for six weeks. There's not a lot of breakdown here on types of infections, the types of antibiotics. The base is meant to be a non inferiority study and guess what?
You're looking out at one year and the outcomes at one year, the failure rates were exactly the same between the IV group, almost fifteen percent, fourteen point six, and the oral group thirteen point two. Those are not significant differences, suggesting that the, I think the dictum that patients should get IV antibiotics for six weeks has been challenged by this cohort study. I do think we need more studies to be totally comfortable using oral antibiotic therapy as long term therapy after a bone or joint infection. There's an interesting article that we posted from MedPage today about the risk of inflammatory bowel disease in secukinumab patients. It's sort of a meta analysis of their seven thousand three hundred patients with either psoriasis, psoriatic arthritis or ankylosing spondylitis, showing that the event rate for IBD IBD is with secukinumab is basically about two per thousand, and zero point two per one hundred patient years looking at almost ninety six ninety six thousand patient years of experience.
As you know, the numbers tend to be a little bit lower there for psoriasis, tend to be a little bit higher for ankylosing spondylitis. These are very rare events. There are a few cases in which patients had pre existing, inflammatory bowel disease who received the IL-seventeen inhibitor and did have some flares. But again, I don't, I mean, I asked patients if they have inflammatory bowel disease, but I would not defray useful therapy because of an incredibly low risk. I mean, we give biologics all the time with an even higher risk of developing an SIE, a serious infectious event.
So those are the real numbers and you can find them on the website. A study from the ASBMR, the American Society for Bone and Mineral Research was a task force that was challenged with finding out what the actual benefit was to these vertebral augmentation procedures. We're talking specifically about balloon kyphoplasty and cement vertebroplasty. And in the end, looking at the analyses and the data out there shows that these are not any better than placebo with regard to reduction in pain. There's a little bit of a shocker because I don't know about you.
I do see patients with vertebral collapse and acute pain from that. And the idea is that if you can show a relatively new onset, vertebral compression fracture, one of these procedures may provide significant benefit with regard to pain and long term pain, and I've seen that happen. But this analysis of control data suggests it may not be happened. I think that we're going to now be maybe be a little bit more cautious about using these, especially in patients who you know not to have, or you can't be certain as to the acuteness of the fracture. And I think you're gonna have to talk to the experts that do these procedures at your center about this data and how it's gonna affect your practice.
Lastly, a report in yesterday's or today's room now about an update on pregnancy. There was one about infertility and some disappointment there. I'll just tell you the data about the second report which comes from the Otis registry where they followed four ninety women mostly with RA, almost one hundred with JIA and looked at whether they discontinued the TNF inhibitor once they became pregnant. A quarter of these of this cohort discontinued TNF inhibitor before week twenty, forty one percent use the TNF inhibitor beyond week twenty and thirty four percent did not use a TNF inhibitor at all during pregnancy. They showed that stopping the drug before week twenty was not associated with any worsening, or a significant worsening compared to the other two groups of their, inflammatory arthritis.
Of course, it's incredibly important to keep the inflammatory arthritis under control to have the best possible outcomes for the fetus and the baby. They didn't report about birth outcomes in a study, although they did collect the data, I assume it's going to be part of another study. But the idea is that once patients do get pregnant, they could in fact stop their TNF inhibitor. One of the problems in this particular study is at enrollment disease activity was low to minimal in over sitting like seventy two or seventy three percent of patients. That's pretty high compared to most cohort studies looking at pregnancy.
So yes, it makes sense if patients are doing very, very well and are well controlled at the time they achieve pregnancy, it makes sense to stop the biologic. However, it does not make sense to stop the biologic if they have active inflammatory disease. So we know they can continue to take, especially the TNF inhibitors throughout the pregnancy and do very well as far as the maternal and the fetal outcomes are not going to be affected by TNF inhibitors. That's it for this week at RheumNow. Make sure you can go to the website and, click on these links and read a little more.
We'll see you next week on the RheumNow podcast. Tell your friends to sign up and give us a good ranking on iTunes.
What are they doing under the car? And lastly, what happens when RA patients get periodontal disease? We're gonna cover that today. Our first report is on scurvy, and it comes from MMWR and the CDC where they have a interesting report of an outbreak of scurvy in the Sudanese in Africa. And obviously, this is related to diet, nutrition, poor health conditions in that environment.
And I bring it up because it's a reminder that scurvy is still a public health problem around the world. It's still a problem here in The United States. I had a great case to present as a hoot, as a, you know, outsmart the panel kind of thing last year of scurvy that my partner Doctor. Dow diagnosed in a woman who had GI complaints and gingival complaints and joint complaints and elevated CR, sedate and CRP and her husband ratted her out and said she had the world's worst diet. You know, she ate chicken McNuggets and gummy bears and nothing else.
And sure enough, she had no vitamin C and she had scurvy. Well, I presented this to a panel only to get upstaged by a pediatrician who presented three cases of scurvy to the panel as well. And yet even though they had been primed and educated on scurvy and then when I presented my case of scurvy, nobody got it. Suggesting that it's hard to identify these people, but you have to think about it. It's very common in younger people, adolescents, young adults who have these hard diets, like I said, you know, chicken McNuggets and or only the sort of monotonous diets or a fad diet gone wrong, obviously with no vegetables and no fruits.
But you should look for the symptoms and they're often musculoskeletal with mucosal and bleeding and gingival kind of things. So arthralgias, frank arthritis, encephalitis, lethargy, fatigue, gingival pain and bleeding, gingival hyperplasia, they have some skin lesions, they can get chest pain, they can get purpur in their skin, they have poor wound healing, they may have deep myalgic and bone kinds of pain and it can even have elevated sed rates and CRPs. So you should look for these, they're not that uncommon. Scurvy, yes, in your backyard. So an interesting study looked at five seventy six, patients with autoimmune disease, and tried to identify the frequency of mechanics hands.
Now mechanics hands as you know is sort of a roughen, scaly hyperkeratotic, digital lesion that has been linked mostly with the anti synthetase syndrome and the inflammatory myopathies. However, in this particular cohort, almost six hundred patients, seventeen percent of patients had mechanics hands. They were mostly seen in guess what? Wrong. MCTD, fifty percent of patients came from MCTD, thirty five percent came from dermatomyositis, fifteen percent came from primary systemic sclerosis, fifteen percent from undifferentiated undifferentiated disease, and fourteen percent from Sjogren's.
None with lupus had MC had these mechanic hands. So that means UCTD and MCTD, I like UCTD as a diagnosis instead of MCTD. MCTD, I think is a diagnosis on its way to something else unified by an RNP antibody. So that makes up two thirds of patients with mechanics hands. So these mechanic hands patients, they were very, very likely to have abnormal, nail fold capillaroscopy.
They were more likely to have Raynaud's, they were more likely to be joe one positive, and again, as I said, abnormal capillaroscopy. So, it's interesting to note that the range there is different than what you might have normally have been taught being related to dermatomyositis, polymyositis. A UK, cohort study looked at patients with hemochromatosis, specifically the ones who had HFE gene rearrangement testings looking for the C29A2Y mutation. They found that when patients were homozygous for that mutation and you looked at men with that, the odds of actually having a hemochromatosis went up like four eleven fold, the odds ratio of four eleven. Patients with that rearrangement and who are homozygous were likely to have not just hemochromatosis but liver disease, RA, osteoarthritis, and diabetes, a two to three to fourfold increased risk of those.
So the purpose of study was to look at if you have the gene and you were thought to have hemochromatosis, what other diseases co associate with this? And RA, diabetes, OA, and obviously the liver disease. Much more common, of course, was those who had these heterozygous mutations for the HFE gene, and they were way more common, but they were also less likely to be symptomatic and actually they had very modest amounts of morbidity which was very different than those who are homozygous. Interesting an interesting study looks at the association between periodontal disease and rheumatoid arthritis. Now we've heard this story before, I'll just give you some numbers, a hundred and eighty seven RA patients, a hundred fifty seven without RA or inflammatory disease.
When periodontal periodontitis was present, the adjusted odds ratio of having periodontal disease, if you had RA, was twenty four higher. The presence of periodontal disease in inflammation, in what looks like infection, but it's really just inflammation, also is significantly associated with RA disease activity. What I'm looking to see and I haven't yet found is show me someone who treats the periodontal disease and their RA gets better. Or show me someone who treats the RA and their periodontal disease goes away. There's some hints of that out there.
These are causative associations. They actually have a very similar this is the pathology, the biology, the cytokine profile of the synovium and the joint is almost the same as the periodontal tissues. And is this a microbiome issue or, is there truly a good link here? We need some more cause and effect studies, I think. A study of almost seven hundred and fifty thousand patients, in Southern Sweden shows that almost a quarter of the osteoarthritis patients in Southern Sweden are using opioids, and it's basically twofold higher than those who don't have hip or knee osteoarthritis, suggesting that even outside The United States, this is a big issue.
And the question is, do they need it? We do know there are plenty of studies that show that opioids are no better than simple analgesics like acetaminophen or even low dose Tylenol and then other studies not related to opioids but showing that turmeric is as good ibuprofen in managing osteoarthritis, suggesting that sometimes the frustration of managing those patients, especially near the end, is riddled with the use of opioids, which comes with a new risk and a higher risk of things that you may not want to exhibit or put upon your patients. An interesting study of 100 kids with Takayasu's finds that there's a three percent mortality in the first year of that disease. It's low, but it's not totally unnoticeable. There is a fifty percent chance of significant morbidity in the first five years.
So these patients can be sick, they can be hard to manage. In their cohort kids, course, 14 years of age was the mean age, three quarters of them were females. Things to look for hypertension, blood pressure discrepancy between the limbs, bruits and fifty percent hypertension seventy percent, pulse deficits in thirty eight percent. The, artery involvement that was found in the kids renal arteries in two thirds, aorta and 43% subclavian forty four percent carotid and forty three percent. That's the profile of the ugly but easy to treat Takayasu syndrome.
You got to make the diagnosis though. Today's, actually yesterday's New England Journal article on oral or IV antibiotics for bone and joint infections. A 2324 multicenter UK study looked at almost a thousand patients who after they had their surgery or the initiation of antibiotics were followed, and specifically looked at whether they were treated with IV antibiotics for six weeks or oral antibiotics for six weeks. There's not a lot of breakdown here on types of infections, the types of antibiotics. The base is meant to be a non inferiority study and guess what?
You're looking out at one year and the outcomes at one year, the failure rates were exactly the same between the IV group, almost fifteen percent, fourteen point six, and the oral group thirteen point two. Those are not significant differences, suggesting that the, I think the dictum that patients should get IV antibiotics for six weeks has been challenged by this cohort study. I do think we need more studies to be totally comfortable using oral antibiotic therapy as long term therapy after a bone or joint infection. There's an interesting article that we posted from MedPage today about the risk of inflammatory bowel disease in secukinumab patients. It's sort of a meta analysis of their seven thousand three hundred patients with either psoriasis, psoriatic arthritis or ankylosing spondylitis, showing that the event rate for IBD IBD is with secukinumab is basically about two per thousand, and zero point two per one hundred patient years looking at almost ninety six ninety six thousand patient years of experience.
As you know, the numbers tend to be a little bit lower there for psoriasis, tend to be a little bit higher for ankylosing spondylitis. These are very rare events. There are a few cases in which patients had pre existing, inflammatory bowel disease who received the IL-seventeen inhibitor and did have some flares. But again, I don't, I mean, I asked patients if they have inflammatory bowel disease, but I would not defray useful therapy because of an incredibly low risk. I mean, we give biologics all the time with an even higher risk of developing an SIE, a serious infectious event.
So those are the real numbers and you can find them on the website. A study from the ASBMR, the American Society for Bone and Mineral Research was a task force that was challenged with finding out what the actual benefit was to these vertebral augmentation procedures. We're talking specifically about balloon kyphoplasty and cement vertebroplasty. And in the end, looking at the analyses and the data out there shows that these are not any better than placebo with regard to reduction in pain. There's a little bit of a shocker because I don't know about you.
I do see patients with vertebral collapse and acute pain from that. And the idea is that if you can show a relatively new onset, vertebral compression fracture, one of these procedures may provide significant benefit with regard to pain and long term pain, and I've seen that happen. But this analysis of control data suggests it may not be happened. I think that we're going to now be maybe be a little bit more cautious about using these, especially in patients who you know not to have, or you can't be certain as to the acuteness of the fracture. And I think you're gonna have to talk to the experts that do these procedures at your center about this data and how it's gonna affect your practice.
Lastly, a report in yesterday's or today's room now about an update on pregnancy. There was one about infertility and some disappointment there. I'll just tell you the data about the second report which comes from the Otis registry where they followed four ninety women mostly with RA, almost one hundred with JIA and looked at whether they discontinued the TNF inhibitor once they became pregnant. A quarter of these of this cohort discontinued TNF inhibitor before week twenty, forty one percent use the TNF inhibitor beyond week twenty and thirty four percent did not use a TNF inhibitor at all during pregnancy. They showed that stopping the drug before week twenty was not associated with any worsening, or a significant worsening compared to the other two groups of their, inflammatory arthritis.
Of course, it's incredibly important to keep the inflammatory arthritis under control to have the best possible outcomes for the fetus and the baby. They didn't report about birth outcomes in a study, although they did collect the data, I assume it's going to be part of another study. But the idea is that once patients do get pregnant, they could in fact stop their TNF inhibitor. One of the problems in this particular study is at enrollment disease activity was low to minimal in over sitting like seventy two or seventy three percent of patients. That's pretty high compared to most cohort studies looking at pregnancy.
So yes, it makes sense if patients are doing very, very well and are well controlled at the time they achieve pregnancy, it makes sense to stop the biologic. However, it does not make sense to stop the biologic if they have active inflammatory disease. So we know they can continue to take, especially the TNF inhibitors throughout the pregnancy and do very well as far as the maternal and the fetal outcomes are not going to be affected by TNF inhibitors. That's it for this week at RheumNow. Make sure you can go to the website and, click on these links and read a little more.
We'll see you next week on the RheumNow podcast. Tell your friends to sign up and give us a good ranking on iTunes.
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