Abstract Background We present a rare case of NeuroBehcet’s-related intracranial hypertension without cerebral venous thrombosis (NBrIHwCVT), occurring as the first presentation of NeuroBehcet’s. In ...addition, we describe the novel use of subcutaneous tocilizumab for this indication. This is followed by a review of the literature on this topic. Case The patient was a 28-year-old lady of Southern Chinese origin with a known history of Behcet’s disease with oral ulcers and ocular findings for which she was on mycophenolate mofetil and adalimumab. She presented with a headache and bilateral disc swelling associated with an intracranial pressure (ICP) of > 40cmH20. There were no structural lesions or cerebral venous thrombosis (CVT) on imaging. Initial lumbar puncture had raised leucocytes and protein. We discuss diagnostic challenges given persistently elevated ICP despite subsequent non-inflammatory cerebrospinal fluid (CSF) profiles and non-response to acetazolamide. She eventually showed a response to immunosuppressant therapy in the form of pulsed methylprednisolone, cyclophosphamide and subsequently subcutaneous tocilizumab, supporting the diagnosis of NBrIHwCVT. Complete normalization of ICP remains challenging. Her disease course was severe, unusual for her ethnicity. Literature review We identified 34 patients (including ours) from 14 publications. We found that the majority of NBrIHwCVT patients were young (average age of 34 years), with a slight female preponderance. Of the 17 cases in the literature with available data on CSF profile, none had raised leucocytes whilst one patient had elevated protein. Patients were generally treated with steroids and occasionally azathioprine, in line with the suspected autoimmune pathophysiology. Of 22 patients with data on outcome, six (27%) were noted to have recurrence of symptoms generally occurring a few months later. Conclusion As demonstrated by this case, NBrIHwCVT can present with BD with raised ICP even if there is no prior history of NB, central Asian ethnicity, cerebral venous thrombosis or features of inflammation on the CSF. We demonstrated how novel use of Tocilizumab may have a role in the management of NBrIHwCVT. Based on our literature review, patients were more likely to be young, female, display a non-inflammatory CSF picture, be treated with steroids and harbour a possibility of recurrence.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Chinese herbal medicine (CHM) has been shown to be effective in autoimmune rheumatic diseases, but harmful herb-drug interactions might be inherent. We aim to review the evidence regarding herb-drug ...interactions between immunosuppressive drugs used in autoimmune rheumatic diseases and CHM.
We searched PubMed, EMBASE and CINAHL from inception till 30 April 2023 using keywords that encompassed ‘herb-drug interactions’, ‘herbs’ and ‘immunosuppressants’. Articles were included if they contained reports about interactions between immunosuppressive drugs used in the treatment of rheumatic diseases with CHM. Level of evidence for each pair of interaction was graded using the algorithm developed by Colalto.
A total of 65 articles and 44 unique pairs of interactions were identified. HDIs were reported for cyclophosphamide, cyclosporine, tacrolimus, methotrexate, mycophenolic acid, glucocorticoids, sulfasalazine, tofacitinib and biologic disease-modifying antirheumatic drugs. Among these, cyclosporine (n = 27, 41.5%) and tacrolimus (n = 19, 29.2%) had the highest number of documented interactions. Hypericum perforatum had the highest level of evidence of interaction with cyclosporine and tacrolimus. Consumption reduced the bioavailability and therapeutic effects of the drugs. Schisandra sphenanthera had the highest level of evidence of interaction with tacrolimus and increased the bioavailability of the drug. Majority of the articles were animal studies.
Overall level of evidence for the included studies were low, though interactions between cyclosporine, tacrolimus, Hypericum perforatum and Schisandra sphenanthera were the most and well-documented. Healthcare professionals should actively enquire about the concurrent use of CHM in patients, especially when drugs with a narrow therapeutic index are consumed.
•Chinese herbal medicine (CHM) might cause harmful herb-drug interactions.•Interactions of cyclosporine and tacrolimus with H. perforatum had the highest level of evidence.•Interactions of tacrolimus with S. sphenanthera had the highest level of evidence.•Consumption affected the bioavailability and therapeutic effects of the drugs.
Abstract
Background
Empathy is pivotal to effective clinical care. Yet, the art of nurturing and assessing empathy in medical schools is rarely consistent and poorly studied. To inform future design ...of programs aimed at nurturing empathy in medical students and doctors, a review is proposed.
Methods
This systematic scoping review (SSR) employs a novel approach called the Systematic Evidence Based Approach (SEBA) to enhance the reproducibility and transparency of the process. This 6-stage SSR in SEBA involved three teams of independent researchers who reviewed eight bibliographic and grey literature databases and performed concurrent thematic and content analysis to evaluate the data.
Results
In total, 24429 abstracts were identified, 1188 reviewed, and 136 included for analysis. Thematic and content analysis revealed five similar themes/categories. These comprised the 1) definition of empathy, 2) approaches to nurturing empathy, 3) methods to assessing empathy, 4) outcome measures, and 5) enablers/barriers to a successful curriculum.
Conclusions
Nurturing empathy in medicine occurs in stages, thus underlining the need for it to be integrated into a formal program built around a spiralled curriculum. We forward a framework built upon these stages and focus attention on effective assessments at each stage of the program. Tellingly, there is also a clear need to consider the link between nurturing empathy and one’s professional identity formation. This foregrounds the need for more effective tools to assess empathy and to better understand their role in longitudinal and portfolio based learning programs.
Background
Prior studies reported conflicting results regarding differences in Assessment of SpondyloArthritis (ASAS) Health Index (HI) scores between radiographic axial spondyloarthritis (r-axSpA) ...and non-radiographic axial spondyloarthritis (nr-axSpA). Country-level variations in disease activity were also observed. Hence, this study aimed to compare the ASAS HI scores between r-axSpA and nr-axSpA in Singapore, and determine factors associated with poorer ASAS HI scores.
Methods
This was a cross-sectional evaluation of baseline data from a prospective cohort study in Singapore General Hospital, from January 2018 to March 2023. Patients aged 21 years and above who were clinically diagnosed with axial spondyloarthritis (axSpA) based on the 2009 ASAS criteria were included. Sociodemographic variables, clinical variables and patient-reported outcomes were collected. Univariable and multivariable linear regression were performed to identify variables associated with ASAS HI scores. Variables with p-value of <0.10 were included in the multivariable regression. A p-value of <0.05 was considered significant.
Results
Of the 331 patients, 265 (80.0%) and 66 (20.0%) had r-axSpA and nr-axSpA respectively. The median (IQR) age in r-axSpA was 40.0 (30.0-53.0) years, higher than nr-axSpA 34.0 (25.0-47.0) years, p<0.01. There was a higher proportion of males in r-axSpA (80.4%) than nr-axSpA (65.2%), p=0.01. Patients with r-axSpA had a longer disease duration 6.8 (1.8-14.0) years than nr-axSpA 1.1 (0.2-5.4) years, p<0.01. More patients with r-axSpA (90.2%) were positive for HLA-B27 than nr-axSpA (69.7%), p<0.01. Differences in ASAS HI scores were not statistically significant between r-axSpA and nr-axSpA 4.0 (2.0-6.8) vs 5.5 (1.1-8.5), p=0.12. Post multivariable regression, nr-axSpA (Formula: see text: 0.70, 95% CI: 0.09, 1.32, p=0.02), BASDAI (Formula: see text: 0.18, 95% CI: 0.01, 0.35, p=0.04), BASFI (Formula: see text: 0.47, 95% CI: 0.30, 0.65, p<0.01) and HADS-Depression scores (Formula: see text: 0.11, 95% CI: 0.01, 0.21, p=0.04) were positively associated with ASAS HI. Higher SF36-PCS (Formula: see text: −0.11, 95% CI: −0.14, −0.08, p<0.01) and SF36-MCS (Formula: see text: −0.07, 95% CI: −0.10, −0.04, p<0.01) were negatively associated with ASAS HI (Table 1).
Conclusion
Patients with nr-axSpA were associated with poorer overall health and functioning as compared to r-axSpA. Higher disease activity, poorer physical function, poorer mental health status and more depressive symptoms were associated with worse health and functioning.
Immunoglobulin G4-related disease (IgG4-RD) was not recognised as a systemic condition until 2003, when extra pancreatic manifestations were identified in patients with autoimmune pancreatitis. Since ...then, IgG4-RD has been described to involve virtually every organ system. It is highly responsive to immunosuppressants but can have detrimental effects if left untreated. Early recognition of the disease is, therefore, critical. The diagnosis of IgG4-RD is frequently challenging owing to its non-specific clinical manifestations, indolent nature and broad differential diagnoses. Although histopathological examination remains the cornerstone of diagnosis, imaging plays an important role in establishing extent of disease and identifying areas suitable for biopsy.
18
F-Fluorodeoxyglucose (
18
F-FDG) positron emission tomography/computed tomography (PET/CT) has been demonstrated to be useful in assessing organ involvement, guiding biopsy and monitoring disease response. The
18
F-FDG PET/CT scan is highly sensitive and able to evaluate multiorgan involvement in a single examination, a key advantage over conventional imaging modalities. A potential pitfall is its low specificity. As such, detailed knowledge of the imaging findings in IgG4-related disease is required to avoid misdiagnosis. This pictorial review aims to depict the diverse spectrum of imaging findings of IgG4-RD and the key imaging features to distinguish it from other important differential diagnoses.
Evolving individual, contextual, organizational, interactional and sociocultural factors have complicated efforts to shape the professional identity formation (PIF) of medical students or how they ...feel, act and think as professionals. However, an almost exclusive reliance on online learning during the COVID-19 pandemic offers a unique opportunity to study the elemental structures that shape PIF and the environmental factors nurturing it. We propose two independent Systematic Evidence-Based Approach guided systematic scoping reviews (SSR in SEBA)s to map accounts of online learning environment and netiquette that structure online programs. The data accrued was analysed using the clinically evidenced Krishna-Pisupati Model of Professional Identity Formation (KPM) to study the evolving concepts of professional identity. The results of each SSR in SEBA were evaluated separately with the themes and categories identified in the Split Approach combined to create richer and deeper 'themes/categories' using the Jigsaw Perspective. The 'themes/categories' from each review were combined using the Funnelling Process to create domains that guide the discussion. The 'themes/categories' identified from the 141 included full-text articles in the SSR in SEBA of online programs were the content and effects of online programs. The themes/categories identified from the 26 included articles in the SSR in SEBA of netiquette were guidelines, contributing factors, and implications. The Funnelling Process identified online programs (encapsulating the content, approach, structures and the support mechanisms); their effects; and PIF development that framed the domains guiding the discussion. This SSR in SEBA identifies the fundamental elements behind developing PIF including a structured program within a nurturing environment confined with netiquette-guided boundaries akin to a Community of Practice and the elemental aspect of a socialisation process within online programs. These findings ought to be applicable beyond online training and guide the design, support and assessment of efforts to nurture PIF.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
The Short Form 36 Health Survey (SF-36) is a popular health-related quality of life (HrQoL) tool. However, few studies have assessed its psychometric properties in patients with spondyloarthritis ...(SpA). We therefore aimed to assess the reliability and validity of the SF-36 in patients with SpA in Singapore. Cross-sectional data from a registry of 196 SpA patients recruited from a dedicated tertiary referral clinic in Singapore from 2011 to 2014 was used. Analyses were guided by the COnsensus-based Standards for the selection of health Measurement INstruments framework. Internal consistency reliability was assessed using Cronbach’s alpha. Construct validity was assessed through 33 a priori hypotheses by correlations of the eight subscales and two summary scores of SF-36 with other health outcomes. Known-group construct validity was assessed by comparison of the means of the subscales and summary scores of the SF-36 of SpA patients and the general population of Singapore using student’s
t
tests. Among 196 patients (155 males (79.0 %), median (range) age: 36 (17–70), 166 Chinese (84.6 %)), SF-36 scales showed high internal consistency ranging from 0.88 to 0.90. Convergent construct validity was supported as shown by fulfillment of all hypotheses. Divergent construct validity was supported, as SF-36 MCS was not associated with PGA, pain and HAQ. Known-group construct validity showed SpA patients had lower scores of 3.8–12.5 when compared to the general population at
p
< 0.001. This study supports the SF-36 as a valid and reliable measure of HrQoL for use in patients with SpA at a single time point.
ObjectivesTo evaluate the association between anxiety, depression and resilience with overall health and functioning in axial spondyloarthritis (axSpA).DesignCross-sectional evaluation of baseline ...data from a prospective cohort study, with recruitment from January 2018 to March 2021.SettingOutpatient clinic in a tertiary hospital in Singapore.ParticipantsPatients aged 21 years and above who were diagnosed with axSpA.Outcome measuresThe Hospital Anxiety and Depression Scale (HADS) was used for assessing anxiety and depression, 10-item Connor Davidson Resilience Scale (CD-RISC-10) for resilience, Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) for disease activity, Bath Ankylosing Spondylitis Functional Index (BASFI) for functional limitation and Assessment of SpondyloArthritis International Society Health Index (ASAS HI) for overall health and functioning. Univariable and multivariable linear regression analyses were performed to assess the association between anxiety, depression and resilience with health and functioning.ResultsWe included 296 patients in this study. The median (IQR) score for HADS-Anxiety was 5.0 (2.0–8.0), with 13.5% and 13.9% having borderline abnormal and abnormal anxiety, respectively. The median (IQR) score for HADS-Depression was 3.0 (1.0–7.0), with 12.8% and 8.4% having borderline abnormal and abnormal depression, respectively. The median (IQR) CD-RISC-10 score was 29.0 (23.0–32.0) while the median (IQR) ASAS HI score was 4.0 (2.0–7.0). Apart from BASDAI, BASFI and disease duration, anxiety and depression were associated with overall health and functioning (β: 0.12, 95% CI 0.03, 0.20; β: 0.20, 95% CI 0.09, 0.31) in the multivariable linear regression. Level of resilience was not associated with health and functioning.ConclusionAnxiety and depression, but not resilience, were associated with poorer health and functioning. Clinicians could consider routinely screening for anxiety and depression in their patients, especially in patients with more severe symptoms.
The use of social media in health care may serve as a beneficial tool for education, information dissemination, telemedicine, research, networking, and communications. To better leverage the benefits ...of social media, it is imperative to understand the patterns of its use and potential barriers to its implementation in health care. A previous study in 2016 that investigated social media use among young clinical rheumatologists (≤45 years) and basic scientists showed that there was substantial social media use among them for social and professional reasons. However, there is a limited inquiry into social media use in different areas of rheumatology, such as spondyloarthritis.
We aimed to explore the motivations, barriers, and patterns of social media use among an international group of experts in spondyloarthritis.
We distributed a web-based survey via email from March 2021 to June 2021 to 198 members of the Assessment of Spondyloarthritis International Society. It contained 24 questions about demographic characteristics, patterns of current social media use, and perceptions of utility. Univariable and multivariable logistic regression analyses were performed to identify the characteristics associated with use trends.
The response rate was 78.8% (156/198). Of these, 93.6% (146/156) of participants used at least one social media platform. Apart from internet-based shopping and entertainment, the use of social media for clinical updates (odds ratio OR 6.25, 95% CI 2.43-16.03) and research updates (OR 3.45, 95% CI 1.35-8.78) were associated with higher social media consumption. Among the respondents, 66% (103/156) used social media in a work-related manner. The use of social media for new web-based resources (OR 6.55, 95% CI 2.01-21.37), interaction with international colleagues (OR 4.66, 95% CI 1.21-17.90), and establishing a web-based presence (OR 4.05, 95% CI 1.25-13.13) were associated with higher levels of consumption for work-related purposes. Time investment, confidentiality concerns, and security concerns were the top 3 challenges to a wider adoption of social media.
Most respondents (103/156, 66%) use social media in a work-related manner. Professional development, establishing a web-based presence, and international collaboration were associated with higher use. Challenges to social media adoption should be addressed to maximize its benefits.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Background
Near-peer mentoring is a process where a mentor is close to the social, professional, or age level of the mentee. Near-peer mentors are better able to interact with and understand the ...struggles of students.
Objective
The aim of the programme was to increase confidence of students in the final year examination.
Methods
Following a needs analysis of final-year medical students, a near-peer mentoring programme was designed using peer-assisted learning framework. In the programme conducted between November 2019 and March 2020, trained Internal Medicine junior residents were assigned to students grouped according to the examination domains they most needed improvement in. Pre- and post-intervention data on students’ confidence in each of the examination domains using a 5-point Likert scale (1: Not confident at all and 5: Very confident), mock examination scores and feedback on the programme were collected.
Results
Fifty-one students were enrolled. Thirty-one students completed the post-programme survey, of which 71.0% felt more confident in the final year examination. Of the twenty-eight students who completed both the pre- and post-programme survey, 78.6%, 78.6% and 60.7% of them showed an increase in confidence in the communications, physical examination and history component of the examination, respectively. There was no association found between confidence level and examination performance.
Conclusion
A personalized near-peer mentoring programme is effective in increasing confidence of students in examinations and serves as a platform for residents to hone their skills as mentors. Its role as part of the medical school curriculum is worth exploring.
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