Clinical medicine (London, England)
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Case Reports
Images of the month: Lower-back pain in a young man with HLA B27 - not always spondyloarthritis!
Presence of human leucocyte antigen (HLA) B27 in a patient with lower-back pain should not be considered synonymous with axial spondyloarthritis. Other causes of back pain should be ruled-out by careful evaluation. Lumbosacral transitional vertebra is a common congenital malformation of spine which frequently leads to mechanical back pain. ⋯ Etanercept was stopped and he was started on physiotherapy protocol for transitional vertebra, with which he improved remarkably. This case highlights the need for greater awareness among clinicians about lumbosacral transitional vertebra, a finding which is frequently missed. Presence of HLA B27 can be coincidental, as in our case.
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Phosphodiesterase inhibitors (such as sildenafil) and endothelin receptor antagonist, bosentan, are effective for digital ulcer disease in systemic sclerosis (SSc-DU) and are endorsed in international treatment recommendations. Commissioning of high-cost drugs, such as bosentan, however, differs across devolved nations of the UK. We report a multicentre service evaluation project to examine 'real world' management of SSc-DU before and following the 2015 UK Scleroderma Study Group (UKSSG) guidance, across south-west (SW) England and Wales. ⋯ Between 2015-2017, sildenafil use for SSc-DU increased in SW England while remaining stable in Wales. Bosentan use for SSc-DU after 2015 in SW England increased, while remaining stable and proportionately lower in Wales. These findings demonstrate that differing commissioning guidance across devolved nations of the UK seems to contribute to geographic variation in patient care.
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Immunoglobulin G4-related disease (IgG4-RD) is a complex multisystem fibro-inflammatory disorder, requiring diagnostic differentiation from malignancy and other immune-mediated conditions, and careful management to minimise glucocorticoid-induced toxicity and prevent progressive organ dysfunction. We describe the experience of the first inter-regional specialist IgG4-RD multidisciplinary team meeting (MDM) incorporating a broad range of generalists and specialists, held 6-weekly via web-link between Oxford University Hospitals NHS Foundation Trust and University College London Hospitals NHS Foundation Trust. Over 3 years, there were 206 discussions on 156 patients. ⋯ Management was changed in the majority of patients (74%) with the treatment escalation recommended in 61 cases, including 19 for rituximab. Challenges arose from delays and misdiagnosis, cross-specialty presentation and the management of sub-clinical disease. Our cross-discipline IgG4-RD MDM enabled important diagnostic and management decisions in this complex multisystem disorder, and can be used as a model for other centres in the UK.