Ethicon, part of Johnson and Johnson, is releasing in the U.S. its new flagship laparoscopic suturing device, the PROXISURE. It features the use of curved needles that come inside of single-use cartridges which slip onto the tip of the main device. The tip itself moves in all kinds of ways, articulating 45° in both directions and rotating 360°, all using mechanical operation. The shaft through which the tip is manipulated works through a 12 mm trocar.
Having a curved tip allows the PROXISURE to work well on flat tissues, the needle naturally extending into the tissue as it spins around the device’s tip.
The device itself, though reusable, has a limited life and has to eventually be replaced. The cartridges come with either Coated VICRYL or ETHIBOND sutures.
Thanks Hailyn for presenting this great case of a 40 yo female with a previous diagnosis of seronegative rheumatoid arthritis who presented to rheumatology clinic with new rash and ankle pain ultimately diagnosed with lupus.
Key learning points:
Use your physical exam: findings of synovitis can help narrow your differential to inflammatory causes of joint pain. Nail changes such as pitting, splinter hemorrhages, and vascular irregularities are seen in several rheumatologic conditions.
About a quarter of patients with chikungunya will develop chronic polyarthritis
Drug induced lupus most often has superficial symptoms of skin and joint findings without visceral involvement.
ESR and CRP are indirect markers of inflammation but do not always directly correlate. Lupus patients often have an elevated ESR and normal CRP due to the production of interferons that inhibit hepatocyte production of CRP.
What is the Seronegative rheumatoid arthritis?
Thanks Goop for pointing out the different terminologies used. Some people use the phrase seronegative arthritis to describe a rheumatologic cause of arthritis that has not yet been determined. Other names include arthritis NOS and palindromic arthritis. Patients with these diagnoses may go on to develop a clear rheumatologic diagnosis such as rheumatoid arthritis or lupus. Time (in addition to the appropriate serologies) is often a helpful diagnostic tool.
Characterizing joint pain: Think about the time course of symptoms, the number of joints involved, the asymmetry and size of involved joints, and if there is evidence of inflammation.
The rheumatology physical exam – synovitis and nail findings
How do I assess for synovitis on physical exam?
Look for soft tissue swelling, warmth, joint effusion, and decreased range of motion
Joints with active synovitis feel boggy and cause lss ability to feel the bone prominences of the joint
Synovitis on physical exam suggests an inflammatory cause of joint pain and can help narrow your differential
Splinter hemorrhages: seen in endocarditis, scleroderma, psoriasis, RA
Pitting: Seen in psoriasis
Get out that ophthalmoscope (or otoscope) and use some lubricant to magnify the vasculature bed of the nails
The vasculature of the nail bed normally is orderly and parallel
Patients with rheumatoid arthritis, SLE, dermatomyositis, or scleroderma the vasculature may be irregular, twisted, and dilated
Other resources for the physical of exam of the nails
The Standford 25: http://stanfordmedicine25.stanford.edu/the25/hand.html#linseys
Chikungunya: In addition to the acute illness of fever, malaise, and polyarthralgia about 25-35% of patients develop a chronic inflammatory polyarthritis.
Drug induced lupus
Common meds: procanamide, hydralazine, penicillamine, INH
Also seen with TNF-alpha inibitors which are often used to treat RA and can cloud the clinical picture in a patient with an unknown rheumatologic disease such as this patient
More often causes superficial lupus symptoms (joint pain, rash) over visceral involvement (anemia, nephritis, serositis, etc)
History of taking a known offending medication
Development of one feature of lupus
Serology: Positive ANA. Positive anti-histone antibody is strongly suggestive. You can also see a positive ANCA
Resolution of symptoms within weeks of stopping the offending agent
What is the difference between ESR and CRP?
Measures the rate at which erythrocytes suspended in plasma settle in a test tube
An indirect measure of acute phase response due to increases in fibrinogen and immunoglobulins that then affect the sedimentation rate. However, many other things besides inflammation can affect the sedimentation rate.
Most often elevated due to inflammation (rheumatologic conditions, infections, malignancy, tissue injury) but there are several non-inflammatory causes of elevated ESR including:
Causes of decreased ESR
Abnormalities in erythrocyte morphology
Produced by the liver in response to IL-6 and other cytokines
Rises and decreases more rapidly than ESR
CRP is also a sign of inflammation and when markedly elevated if often an indication of infection or systemic inflammatory diseases
Mild elevations in CRP can be a sign of low grade inflammation due to conditions such as atherosclerosis, obesity, OSA, insulin resistance, HTN
Discrepencies between ESR and CRP
Consider time course, non-inflammatory causes of elevated ESR, and low grade inflammation causing elevated CRP
Elevated ESR with normal CRP
Lupus: Often causes more marked elevations in ESR than CRP
Izzy thanks for teaching us that patients with lupus produce type 1 interferons which inhibit hepatocytes production of CRP
An elevated CRP in a patient with lupus can strongly suggest a bacterial infection over a lupus flare. The exception is lupus serositis which can large rises in CRP
Review article from BMJ on the usefulness of inflammatory markers in clinical practice: http://www.bmj.com/content/344/bmj.e454