Metastatic breast cancer to the gastrointestinal tract:A case series and review of the literature

Metastatic breast cancer involving the hepatobiliary tract or ascites secondary to peritoneal carcinomatosis has been well described. Luminal gastrointestinal tract involvement is less common and recognition of the range of possible presentations is important for early and accurate diagnosis and treatment. We report 6 patients with a variety of presentations of metastatic breast cancer of the luminal gastrointestinal tract. These include oropharyngeal and esophageal involvement presenting as dysphagia with one case of pseudoachalasia, a linitis plastica-like picture with gastric narrowing and thickened folds, small bowel obstruction and multiple strictures mimicking Crohn’s disease, and a colonic neoplasm presenting with obstruction. Lobular carcinoma, representing only 10% of breast cancers is more likely to metastasize to the gastrointestinal tract. These patients presented with gastrointestinal manifestations after an average of 9.5 years and as long as 20 years from initial diagnosis of breast cancer. Given the increased survival of breast cancer patients with current therapeutic regimes, more unusual presentations of metastatic disease, including involvement of the gastrointestinal tract can be anticipated.

Estimating Benefits from Immunesuppressive Treatment in Diffuse Cutaneous Systemic Sclerosis: Data from the Canadian Scleroderma Research Group

Objective: To determine the efficacy of immunesuppressive treatment over 1 year in early diffuse cutaneous systemic sclerosis (dcSSc). Methods: dcSSc patients with less than 3 years disease duration and at least one year of data enrolled in the CSRG database were included. Regression analyses for achieving at least minimal important differences (MID) for 5 outcomes over one year were done to determine baseline predictors of change and if immunesuppressive treatment yielded the attainment of the MID. Results: 124 patients (mean age 52.3 years;79.2% female) were included. Variables associated with MID at one year were often the baseline variable and for some outcomes, age, sex, smoking, restrictive lung disease and treatment type. Treatment with immunesuppressive was not found to be associated with achieving MIDs in multivariate analyses. Conclusion: Treatment was associated with achieving a MID change at 1 year using univariate statistics, but not in multivariate models. These observational data do not support improvement with immunesuppressives over one year but there could be confounding or biases comparing with those prescribed immunesuppressives vs. those who don’t.

A Needs-Based Rheumatologist Education Program on Treating to Target in Psoriatic Arthritis and Spondyloarthropathy: Insights and Challenges

Objectives: To determine if comparative practice data and education for rheumatologists would change physician behavior for monitoring and treating psoriatic arthritis (PsA) and spondyloarthritis (SpA). Methods: Participating rheumatologists each performed a chart audit on 20 patients with PsA and SpA. Accredited education (determined by a survey and chart audits) and results of chart audits (comparing to other rheumatologists) were provided for each participant (intervention). Eight months later, a repeat chart audit by each participant was conducted on another 20 PsA and SpA patients. Changes in measurements collected, treatment given and patient characteristics pre and post intervention were analyzed. Results: Nine rheumatologists received the intervention. At baseline, most routinely monitored PsA and SpA for clinical and laboratory markers. In PsA, there was no change post-intervention in performing SJC (96%), TJC (≥91%), ESR (≥70%), CRP (≥73%), and CDAI (25%). In SpA, there were increased measurements of inflammatory markers (54% pre vs. 61% post for CRP), more NSAID use and decreased physical exam measures and HAQ but no significant changes. There were no major treatment differences pre and post intervention including NSAIDs, DMARDs and biologics. Conclusions: The rheumatologists frequently performed measurements of disease activity, did not change significantly with educational intervention so there may have been little room for improvement and many patients were already in a low disease state. Calculation of composite scores did not increase in PsA. The validity of physical exam and BASDAI as a measurement of disease activity were noted as concerns in applying a treat-to-target approach in SpA. Significance and Innovation: This study did not show a significant change in behavior for rheumatologists who had education based on care gaps and needs assessment in psoriatic arthritis and spondyloarthropathy. The rheumatologists identified that disease activity is difficult to determine with usual care in SpA and thought some measures lacked validity.

A Systematic Review of Clinical Studies Using VEGF Inhibitors in the Treatment of Macular Edema from Diabetic Retinopathy

Purpose: To synthesize the present clinical evidence of efficacy and adverse events of commonly used anti-VEGF drugs for Diabetic Macular Edema. Methods: A systematic review was undertaken from the Medline, Biosis, CINAHL, Cochrane and Web of Science databases. Grey literature that consisted of lectures, seminars and conferences was also retrieved. The cut-off date was January 1 2014. A two-stage screening process was undertaken followed by a data extraction stage using the systematic review software EPPI. These were done by two reviewers. Heterogeneous meta-analysis was performed on the primary outcome which was change in macular thickness from baseline after injection. Side effects were tabulated. Results: From 846 articles that were initially screened, 18 papers were included in the data extraction stage. For all anti-VEGF treatments, the average decrease in macular thickness was 114.4 microns (95% CI: 66.8 - 162 μM). The average decrease in thickness from Lucentis (161.9 μM) was larger than that for Avastin (96.5 μM) but this was not statistically significant (p = 0.23). The most common complications were vitreous hemorrhage, endophthalmitis and retinal detachment. Vision threatening complications were rare but were reported regularly. Conclusions: The synthesized clinical evidence to date supports both of these treatments as efficacious and safe for diabetic macular edema (DME). There is a trend toward greater efficacy for Lucentis over Avastin but this is not statistically significant and will need a head-to-head RCT to assess accurately.

The Effects of Sex on Patient Reported Outcomes in Inflammatory Arthritis and Connective Tissue Diseases

Background: It was thought that women report higher pain than men. We studied if there was a sex difference for several patient reported outcomes (PROs) in rheumatic diseases. Materials and Methods: Health Assessment Questionnaire disability index (HAQ-DI) as well as 100 mm Visual Analogue Scale (VAS) for pain, fatigue, sleep disturbance, and patient global assessment were compared cross-sectionally between the sexes for ankylosingspondylitis (AS), psoriatic arthritis (PsA), rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) and systemic sclerosis (SSc). Data were collected using standardized forms administered during routine care. Results: The sample included 136 patients (97 males) with AS, 200 (83 males) with PsA, 232 (40 males) with RA, 199 (12 males) with SLE, and 113 (17 males) with SSc. There were no significant differences in AS. There were sex differences in PsA for HAQ (0.85 females, 0.57 males;p s, 36.8 males;p s, 31.6 males;p s, 36.0 males;p s, 33.1 males;p whereas, in SSc, men had a higher global assessment (52.9 males, 38.1 females;p Conclusions: A significant sex difference was observed in PsA with females reporting worse symptoms. In SSc, global assessments were worse in males possibly due to proportionately more diffuse cutaneous SSc. Sex differences for PROs are not consistent between rheumatic inflammatory diseases in prevalent patients.