Pilot studies have indicated that peroral endoscopic myotomy (POEM) might be a safe and effective treatment for achalasia. We performed a prospective, international, multicenter study to determine ...the outcomes of 70 patients who underwent POEM at 5 centers in Europe and North America. Three months after POEM, 97% of patients were in symptom remission (95% confidence interval, 89%–99%); symptom scores were reduced from 7 to 1 ( P < .001) and lower esophageal sphincter pressures were reduced from 28 to 9 mm Hg ( P < .001). The percentage of patients in symptom remission at 6 and 12 months was 89% and 82%, respectively. POEM was found to be an effective treatment for achalasia after a mean follow-up period of 10 months. Clinical Trials Gov Registration number: NCT01405417.
Mycophenolate mofetil (MMF) has been long used in the treatment of systemic lupus erythematosus (SLE). Further studies are warranted to investigate its long-term use in maintenance treatment of lupus ...nephritis (LN). The purpose of this study was to describe our practice experience using MMF with regard to its indications, safety, tolerability, and treatment efficacy. We sought to identify rates of renal remission, flare and progression to end-stage renal disease (ESRD).
In this retrospective chart review, we identified all patients treated with MMF between 1999 and 2019. Descriptive statistics were used to identify occurrence of remission, occurrence of flares, progression to ESRD, and occurrence of adverse effects.
One hundred and one patients were treated with MMF for a mean duration of 69 months. The most common indication was LN (90%). Among patients with LN, 60% achieved complete remission and 16% achieved partial remission at one-year follow-up. Ten patients flared while on maintenance therapy and seven patients flared after treatment was discontinued. Of the 40 patients who were treated for at least five years, one patient developed a flare. Of the 13 patients who were treated for at least 10 years, none developed a flare. One patient on maintenance therapy progressed to ESRD. The most common adverse effects were leukopenia (9%), nausea (7%) and diarrhea (6%).
Maintenance treatment with MMF constitutes an effective long-term treatment for lupus nephritis. Our practice demonstrates its tolerability over many years with few adverse effects, prevention of renal flares, and a low progression rate to ESRD.
Background
Conflicting reports exist regarding the racial and the gender distribution of rheumatoid arthritis–related interstitial lung disease (RA-ILD). In a major population study of predominately ...Whites, RA-ILD was reported mainly among smoker middle-aged men. However, recent data suggest that the disease is that of elderly women. Our study aimed to assess the prevalence and identify the gender differences and clinical characteristics of RA-ILD in a predominantly Black population.
Methods
Cross-sectional analysis of data obtained from the records of 1142 patients with RA diagnosis by ICD codes of which 503 cases met the inclusion criteria for the study. Eighty-six patients had chronic respiratory symptoms of cough and dyspnea and were further assessed by our multidisciplinary group of investigators. Thirty-two subjects with an established diagnosis of rheumatoid arthritis met the diagnostic criteria for interstitial lung disease.
Results
Of the 32 patients with RA-ILD, mean age was 62.6 ± 2.2 (± SEM), 93.7% were females, and 89% Blacks with a BMI = 29.2 (Kg/m
2
). Usual interstitial pneumonia (UIP) was found in 24/32 (75%) of the cases. Seventy-two percent of the RA-ILD patient had seropositive RA. Smoking history was reported in 31.3% of the cohort, gastroesophageal reflux disease (GERD) in 32.3%, and cardiovascular disease (CVD) risk factors in 65.6%.
Conclusion
Our study indicates RA-ILD among Blacks is predominantly a disease of elderly females with higher rates of GERD and CVD risk factors. Further studies are needed to identify the pathogenetic differences accounting for the gender distribution of RA-ILD among Black and White populations.
Key Points
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First study to assess ILD among predominantly Black RA patients.
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The prevalence of RA-associated ILD was 6.36%, affecting mostly women in their sixth decade with seropositive disease.
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COPD was the most common airway disease among non-RA-ILD Black population.
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GERD was found in approximately one-third of patients with RA-associated ILD versus one-fifth of those RA patients without any lung disease.
Rheumatoid arthritis (RA) patients have an increased risk of malignancy with postulated risk factors that include chronic inflammation, smoking and the use of immunosuppressants have been postulated ...as drivers of higher malignancies rates. Our study aimed to describe the prevalence and type of malignancies encountered in an urban, predominantly Black RA patient population.
Cross sectional analysis of 1142 patients with RA diagnosis by ICD-codes of which 501 cases met the inclusion criteria for the study. Blacks accounted for 88.4% of the study population. Fifty-six patients had cancer recorded in their medical records and these cases were further reviewed for tumor type, timing of diagnosis and patient clinical characteristics.
The cancer prevalence was 11.2% (56/501) in our Black RA population being studied. Mean age at cancer diagnosis was 59.9 ± 5.2 for the patients who developed cancer before RA diagnosis and 58.25 ± 16.02 for those who developed malignancy after RA diagnosis. There were 18 breast cancers, 4 colon and 4 cervical cancers; for lung, multiple myeloma, thyroid, squamous cell carcinoma and pancreas there were 3 cases each; for endometrial, Non-Hodgkin's lymphoma, meningioma and prostate, 2 cases each and 1 each for urinary bladder, esophageal adenocarcinoma, lymphoma, glioblastoma, liver, Hodgkin's lymphoma, sarcoma, ovary and renal cell carcinoma. No differences were found in years of RA duration, joint erosion, joint space narrowing or SENS score except for significantly higher ESR among the cancer group and RF seropositivity in the non-cancer group.Therapeutic modalities were not significantly different between the cancer and no cancer groups.
Breast cancer was the most prevalent malignancy among our Black RA population. Further studies are needed to identify the contributing factors to the malignancy risk of breast cancer in our Black RA population and whether it is gender-related since RA is more prevalence in women.
Rheumatoid arthritis (RA) patients have nearly twice the risk of cardiovascular disease (CVD) compared to the general population. We aimed to assess, in a predominantly Black population, the ...prevalence of traditional and RA-specific CVD risk factors and therapeutic patterns. Utilizing ICD codes, we identified 503 RA patients ≥18 years old who were seen from 2010 to 2017. Of them, 88.5% were Black, 87.9% were women and 29.4% were smokers. CVD risk factors (obesity, diabetes, hypertension, dyslipidemia) were higher than in previously reported White RA cohorts. Eighty-seven percent of the patients had at least one traditional CVD risk factor, 37% had three or more traditional CVD risk factors and 58% had RA-specific risk factors (seropositive RA, >10 years of disease, joint erosions, elevated inflammatory markers, extra-articular disease, body mass index (BMI) < 20). CV outcomes (coronary artery disease/myocardial infarction, heart failure, atrial fibrillation and stroke) were comparable to published reports. Higher steroid use, which increases CVD risk, and lesser utilization of biologics (decrease CV risk) were also observed. Our Black RA cohort had higher rates of traditional CVD risk factors, in addition to chronic inflammation from aggressive RA, which places our patients at a higher risk for CVD outcomes, calling for revised risk stratification strategies and effective interventions to address comorbidities in this vulnerable population.
Background: There is controversy among surgeons regarding the treatment of inguinal hernias. Despite the potential advantages of laparoscopic inguinal hernia repair (LIHR) in appropriate clinical ...situations, many surgeons do not use this technique. The purpose of this 2-part project was to: (1) using a population-based analysis, report practice patterns among Quebec surgeons for the treatment of inguinal hernias and identify factors that may be associated with the choice of operative approach; and (2) using a survey, describe perceived indications for LIHR, and identify barriers to its adoption and educational needs of surgeons. Methods: (1) The population-based analysis used RAMQ and MED-ECHO administrative databases to identify patients who have undergone an inguinal hernia repair between 2007 and 2011 in Quebec, Canada. A generalized linear model was used to identify predictors associated with the selection of a laparoscopic approach. (2) The survey was web-based and was sent to general surgeons and residents. The 33-item survey was divided into 4 sections: demographics, utilization of techniques, management based on 11 clinical scenarios, and educational needs and barriers to LIHR. Results: (1) 49,657 inguinal hernias were repaired over the four-year study period by 478 surgeons. Eight percent of repairs were performed using a laparoscopic approach. LIHR was used to repair 28% of bilateral hernias, 10% of recurrent hernias, 6% of unilateral hernias, and 4% of incarcerated hernias. 268 (56%) surgeons did not perform any laparoscopic repairs, and 11 (2%) surgeons performed more than 100 repairs. These 11 surgeons were responsible for performing 61% of all laparoscopic cases. (2) 697 general surgeons and 206 general surgery residents responded to the survey. 280 (46%) of these surgeons never perform LIHR. Of these surgeons, 70% consider the benefits of laparoscopy to be minimal, 59% said they lack the requisite training, and only 26% are interested in learning. Surgeons (70%) and residents (73%) agreed that the best educational method would be a course followed by expert proctoring. Conclusion: Surgeons remain divided on the utility of laparoscopic surgery for inguinal hernia repair. Half of Quebec's surgeons and half of the surveyed surgeons never perform LIHR. Educational programs need to be implemented for surgeons who want to learn and who have a sufficient volume of procedures to overcome the learning curve.
Contexte: Le traitement chirurgical des hernies inguinales fait l'objet d'une controverse parmi les chirurgiens. Bien que les avantages potentiels d'une réparation laparoscopique d'une hernie inguinale (RLHI) soient connus, la communauté chirurgicale n'a pas tout à fait adopté cette pratique. Le but de ce projet en 2 parties était de: (1) à l'aide d'une analyse représentative de la population dresser un bilan sur les tendances des pratiques de traitement des chirurgiens québécois sur une hernie inguinale et afin d'identifier les facteurs pouvant influencer le choix de l'approche chirurgicale; et (2) à l'aide d'un sondage, identifier les indications perçues d'une RLHI ainsi que pour identifier les obstacles à son adhésion et aux besoins éducatifs des chirurgiens. Méthodes: (1) L'analyse représentative de la population utilise la base de données administratives de la RAMQ ainsi que la base de données MED-ÉCHO afin d'identifier les patients qui ont subi une réparation d'une hernie inguinale entre 2007 et 2011 au Québec. Un modèle linéaire généralisé a été utilisée afin d'identifier les variables explicatives associées au choix de l'approche laparoscopique. (2) L'enquête a été réalisée à l'aide d'une application Web et a été envoyée aux chirurgiens généralistes et aux médecins résidents. Ce sondage portant sur 33 points était divisé en quatre sections: la démographie, l'utilisation de techniques, une gestion basée sur onze scénarios cliniques et les besoins éducatifs et les obstacles à une RLHI. Résultats: (1) 49 657 hernies inguinales ont été réparées au cours de la période d'étude de quatre ans par 478 chirurgiens. Huit pour cent des réparations ont été effectuées en utilisant une approche laparoscopique. La RLHI a été utilisée pour réparer 28% des hernies bilatérales, 10% des hernies récidivantes, 6% des hernies unilatérales, et 4% des hernies incarcérées. 268 (56 %) des chirurgiens n'ont pas effectué les réparations laparoscopiques, et 11 (2 %) des chirurgiens ont effectué plus de 100 réparations. Ces 11 chirurgiens étaient chargés d'effectuer 61% de tous les cas de laparoscopie. (2) 697 chirurgiens généraux et 206 résidents en chirurgie générale ont répondu à l'enquête. 280 (46 %) de ces chirurgiens n'effectuent jamais de RLHI. Parmi ces chirurgiens, 70% considèrent que les avantages de la laparoscopie sont mineurs, 59% ont dit qu'ils n'ont pas la formation requise, et seulement 26% sont intéressés à en apprendre davantage. Les chirurgiens (70%) et les résidents (73%) étaient d'avis que la meilleure méthode d'apprendre serait de suivre un cours suivi d'une surveillance par un expert. Conclusion: Les chirurgiens demeurent partagés quant au recours à la chirurgie laparoscopique pour réparer une hernie inguinale. La moitié des chirurgiens québécois et la moitié des chirurgiens interrogés n'ont jamais réalisé de RLHI. Des programmes d'enseignement doivent être implantés pour les chirurgiens souhaitant apprendre et surmonter la courbe d'apprentissage.
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