New technology has had a huge impact on our learning opportunities. Here, Laura Horton tells Julie Bissett why time spent switching off is often the perfect moment to tune in…
Ultrasound (US) is known to be more sensitive than clinical examination in detecting synovitis in psoriatic arthritis (PsA). However, some studies found disparity between the US and clinical findings
Objectives
To assess the prevalence of synovial involvement in early PsA using clinical and sonographic assessments.
Methods
A total of 49 subjects with early PsA (CASPAR criteria) recruited in the Leeds Spondyloarthropathy Register for Research and Observation (SpARRO) study, a prospective longitudinal observational cohort, was assessed. The mean disease duration is 1.6 ±0.5 years; F:M ratio is 1.3; median SJC76 is 2 (1–2), median TJC78 is 6 (3–17); 90% of subjects had current skin psoriasis. Baseline US scan was performed on 1274 joints including bilateral wrists, MCP2–3, PIP2–3, elbows, knees, ankles & MTP 1–5. Grey Scale (GS) and Power Doppler (PD) were scored on a 0–3 semi-quantitative scale for each joint. Joints were considered clinically active if tender or swollen, and sonographically active if GS≥2 and/or PD≥1. We compared US active (yes/no) against tender (yes/no) and swollen (yes/no). The majority of the patients (88%) were DMARD naive
Results
US identified a higher proportion of subclinical synovitis among swollen rather than tender joints in subjects with early PsA. The agreement between clinical examination (tender & swollen) and US findings was high (73 & 87%) respectively. The most common sites for subclinical synovitis were MTP joints. In contrast, wrist tenderness and MTP2 swelling were the highest overestimated joints among the physical examination.
Conclusions
The prevalence of subclinical synovitis is high in early PsA. Joint swelling is more likely to correlate with PD or GS in PsA when compared to joint tenderness. As opposed to RA, where clinical tenderness correlates with subclinical synovitis, the tender joint count may not be a reliable clinical measure to assess synovitis in PsA. Possible reasons for the over-estimation of TJC in clinical examination may be the concomitant occurrence of fibromyalgia. Larger studies are needed to confirm our results.
INTRODUCTION: The role of defecation dysfunction (DD) and rectal sensitivity in opioid related chronic constipation (CC) is unknown. The purpose of this study is to evaluate the relationship between opioid use and rectal sensation, defecatory function, and balloon expulsion on physiology testing. METHODS: This was a retrospective cohort study of consecutive adult patients who underwent high-resolution anorectal manometry (HRAM) at a tertiary care center for CC. Baseline patient clinical characteristics and HRAM findings were reviewed. Rectal hyposensitivity was defined by increased rectal sensation volume for first sensation, urge, and maximal tolerance. DD was defined by impaired anal sphincter relaxation (<20% decrease from resting pressure) during strain maneuver with or without weak push, defined as inadequate rectal contraction pressure (<40 mmHg increase from baseline). Successful balloon expulsion was defined by evacuation of 50 mL balloon within 2 minutes. Statistical analyses were performed using Fisher exact or student t-test for univariate analyses and logistical or general linear regression for multivariate analyses. RESULTS: 317 patients (mean age 50.3 years; 86.8% female) were included. Patients with recent opioid use (<3 months of HRAM) had significantly increased volume for first rectal sensation (70.4 mL vs 61.5, P = 0.043), urge sensation (120.4 vs 104.5, P = 0.04), and maximal tolerance (170.2 mL vs 149.6, P = 0.0083) when compared to those without recent opioid use. No significant difference in rectal sensation was found in patients with a distant history of opioid use (>3 months) (Figure 1). Patients with recent opioid use also had increased risk of DD (63.4% vs 44.9%, P = 0.029), but no difference in failed balloon expulsion (75.9% vs 74.8%, P = 0.90). On multivariate analyses after controlling for potential confounders including history of irritable bowel syndrome (IBS), age, sex and history of abdominal or pelvic surgeries, recent opioid use (<3 months), but not distant use (>3 months), remained independently associated with increased volume for urge sensation (β-coefficient 14.3, P = 0.03) and maximal tolerance (β-coefficient 22.8, P = 0.006), and higher risk for DD (OR 1.67, P = 0.04) (Table 1). CONCLUSION: Recent opioid use was an independent risk factor for rectal hyposensitivity and DD on HRAM in patients with CC, but that effect may decrease with discontinuation of use. Anorectal physiology testing may be considered in patients on opioids with CC.
With the rapid pace of change, which only seems to be increasing, how do dental care professionals stay on top of the situation and remain in control? In this article, Laura Horton discusses how change needs to be effectively managed and communicated so that it is embraced
Introduction: Defecation requires relaxation of the external anal sphincter and puborectalis muscles, which are partially controlled by cortical inhibition of the spinal reflex. Dyssynergic defecation results from inappropriate contraction or insufficient relaxation of these muscles during evacuation. The pathogenesis remains unclear and may be subconsciously learned. Given that psychiatric comorbidities may contribute to these subconscious behaviors, thereby increasing the risk of dysfunction, we hypothesized that psychiatric disorders may be more prevalent among patients with dyssynergic defecation. Methods: This was a retrospective cohort study of consecutive patients with chronic constipation who underwent high-resolution anorectal manometry (HRAM) at a tertiary care center in 7/2013-9/2017. Patient demographics, clinical history including psychiatric diagnoses and opioid use, and HRAM data were reviewed. Dyssynergia was defined as impaired anal sphincter relaxation (<20% decrease from baseline) during strain maneuver, with or without presence of weak push, defined as decreased rectal contraction pressure (<40 mmHg increase from baseline). Statistical analyses were performed using Chisquared or student’s t-test for univariate analyses and logistic regression for multivariate analysis. Results: 303 patients (mean age: 51.1 years, 87% female) were included, with 134 (44%) having a history of psychiatric comorbidities. HRAM findings of dyssynergia were noted in 162 (53.5%) patients, subclassified as 15.8% type I, 70.3% type II, and 13.9% type IV dysfunction. Dyssynergic defecation was associated with a higher prevalence of psychiatric diagnoses (59.7% vs 40.3%, p=0.05). On subgroup analysis, both depression (28.7% vs 16.4%, p=0.03) and anxiety (21.2% vs 10.3%, p=0.04) were more common among patients with dyssynergia. The distribution of subtypes was similar between patients with psychiatric comorbidities and those without (Table 1). On multivariate analysis controlling for potential confounders, psychiatric comorbidities (OR 2.3, p=0.004) and recent narcotics (OR 2.3, p=0.04) were independently associated with dyssynergic defecation. Conclusion: A history of psychiatric comorbidities and recent narcotics use were independently associated with dyssynergic defecation on HRAM in patients with chronic constipation, and should be considered in the etiology of defecation disorders. Future studies should assess the impact of evaluating and treating these potential targets for intervention.170 Figure 1. HRAM Findings in Patients with Psychiatric Comorbidities versus Patients without Psychiatric Comorbidities
Source Citation Du C, Luo Y, Walsh S, Grinspan A. Oral fecal microbiota transplant capsules are safe and effective for recurrent Clostridioides difficile infection: a systematic review and meta-analysis. J Clin Gastroenterol. 2021;55:300-8. 33471490
'%3e%3cpath fill='%23012169' d='M0 0v30h60V0z'/%3e%3cpath stroke='%23fff' stroke-width='6' d='m0 0 60 30m0-30L0 30'/%3e%3cpath stroke='%23C8102E' stroke-width='4' d='m0 0 60 30m0-30L0 30' clip-path='url(%23b)'/%3e%3cpath stroke='%23fff' stroke-width='10' d='M30 0v30M0 15h60'/%3e%3cpath stroke='%23C8102E' stroke-width='6' d='M30 0v30M0 15h60'/%3e%3c/g%3e%3c/svg%3e)