Introduction: Patients affected by autoimmune pathologies such as rheumatoid arthritis require surgery for various reasons. However, the systemic inflammatory nature of these disease processes often ...necessitates therapy with disease-modifying antirheumatic drugs (DMARDs). Alteration of these agents in the perioperative period for surgery requires a careful risk-benefit analysis to limit disease flares, infection rates, and secondary revisions. We therefore queried North and South American practices for perioperative management of DMARDs in patients undergoing elective spine surgery.Methods: An institutional review board-approved pilot survey was disseminated to spine surgeons regarding how they managed DMARDs before, during, and after spine surgery.Results: A total of 47 spine surgeons responded to the survey, 37 of whom were neurosurgeons (78.7%) and 10 orthopedic surgeons (21.3%). Of the respondents, 80.9% were from North America, 72.3% were board-certified, 51.1% practiced in academic institutions, and 66.0% performed 50-150 spine surgeries per year. Most respondents consulted a rheumatologist before continuing or withholding a DMARD in the perioperative period (70.2%). As such, a majority of the spine surgeons in this survey withheld DMARDs at an average of 13.8 days before and 19.6 days after spine surgery. Of the spine surgeons who withheld DMARDs before and after spine surgery, the responses were variable with a trend toward no increased risk of postoperative complications.Conclusions: Based on the results of this pilot survey, we found a consensus among spine surgeons to withhold DMARDs before and after elective spine surgery.
To describe the differences in clinical characteristics and outcome between adult- and childhood-onset biopsy-proven IgA vasculitis (IgAV) in North America.
Patients with IgAV diagnosed from January ...1, 1997, through December 31, 2016, were retrospectively identified. Data were abstracted from direct medical record review. Kaplan-Meier methods were used to estimate survival rates.
A total of 243 patients with IgAV were included (227 93.4% white, 141 58.0% male); 174 patients were adults (≥21 years), and 69 were younger than 21 years. Compared with patients younger than 21 years, adults at baseline more frequently had ulcerative skin lesions (19 10.9% vs 1 1.4%; P=.02) and nephrotic-range proteinuria (21 of 96 21.9% vs 1 of 38 2.6%; P=.007) but less commonly had abdominal pain (59 33.9% vs 42 60.9%; P<.001), ischemic gastrointestinal tract involvement (18 10.3% vs 14 20.3%; P=.04), and arthralgias (66 37.9% vs 42 60.8%; P<.001). During 389 person-years of follow-up, 29 deaths were observed. Five-year survival rates for patients aged younger than 21, 21 to 50, and 51 years or older were 100%, 94%, and 40%, respectively. In comparison to data from the United States life tables for whites, patients 51 years or older at diagnosis had a greater than 7-fold increased risk of mortality (standardized mortality, 7.60 95% CI, 5.01-11.06; P<.001).
IgA vasculitis in adults is associated with more severe skin/kidney involvement and poorer renal outcome. Among adults with IgAV, patients aged 51 years or older at diagnosis have significantly higher mortality (P<.001).
Key Clinical Message
Erdheim‐Chester Disease is a multi‐systemic condition characterized by non‐Langerhans histiocytic infiltration. Cardiovascular involvement with pseudotumoral infiltration of the ...right atrium is present in approximately one‐third of patients and may be asymptomatic. Although retroperitoneal fibrosis is common, perinephric dystrophic calcification has not been previously described.
Erdheim‐Chester Disease is a multi‐systemic condition characterized by non‐Langerhans histiocytic infiltration. Cardiovascular involvement with pseudotumoral infiltration of the right atrium is present in approximately one‐third of patients and may be asymptomatic. Although retroperitoneal fibrosis is common, perinephric dystrophic calcification has not been previously described.
Background
In preparation for surgery, patients being treated with disease-modifying antirheumatic drugs (DMARDs) are recommended to either continue or withhold therapy perioperatively. Some of these ...drugs have known effects against bone healing, hence the importance of adequately managing them before and after surgery.
Objective
We aim to assess the current evidence for managing conventional synthetic and/or biologic DMARDs in the perioperative period for elective spine surgery.
Methods
A systematic review of four databases was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The included manuscripts were methodically scrutinized for quality, postoperative infections, wound healing characteristics, bone fusion rates, and clinical outcomes.
Results
Six studies were identified describing the management of conventional synthetic and/or biologic DMARDs. There were 294 DMARD-treated patients described undergoing various spine surgeries such as craniovertebral junction fusions. Three of the studies involved exclusive continuation of DMARDs in the perioperative window; one study involved exclusive discontinuation of DMARDs in the perioperative window; and two studies involved continuation or discontinuation of DMARDs perioperatively. Of patients that continued DMARDs in the perioperative period, 13/50 patients (26.0%) had postoperative surgical site infections or wound dehiscence, 2/19 patients (10.5%) had delayed wound healing, and 32/213 patients (15.0%) had secondary revision surgeries. A fusion rate of 14/19 (73.6%) was described in only one study for patients continuing DMARDs perioperatively.
Conclusions
The available published data may suggest a higher risk of wound healing concerns and lower than average bone fusion, although this may be under-reported given the current state of the literature.
Bisphosphonates, Bone and Joint Pain Villatoro-Villar, Michel; Kwoh, C. Kent
Current osteoporosis reports,
08/2021, Letnik:
19, Številka:
4
Journal Article
Recenzirano
Purpose of Review
Bisphosphonates (BPs) have an established role in a number of diseases including osteoporosis, but the role of BPs for treating symptomatic conditions other than bone metastases is ...less clear. We review recent data on the efficacy of BPs in the treatment of symptomatic bone and joint pain with osteoarthritis (OA) as an example.
Recent Findings
Although controversial, BPs have been reported to improve pain ratings, imaging features, and inflammatory markers in patients with arthritis, more specifically OA. It is possible that their effects in periarticular bone strongly influence the complex inflammatory process within the joints. Recent data also suggests that they can potentially impact synovial and synoviocytes and macrophages. Although more studies are needed to define their contribution in clinical practice, increasing evidence suggests they hold an important function, especially in conditions with periarticular bone involvement such as OA.
Summary
Although BPs are indicated primarily for prevention and treatment of osteoporosis, they can also have potential effects on the inflammatory process of other conditions, including OA. Improvements in pain scale ratings, periarticular findings through imaging, and inflammatory response suggest their potential extra-osteoporotic properties.
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