BackgroundThe effects of fish oil (FO) in rheumatoid arthritis (RA) have not been examined in the context of contemporary treatment of early RA. This study examined the effects of high versus low dose FO in early RA employing a ‘treat-to-target’ protocol of combination disease-modifying anti-rheumatic drugs (DMARDs).MethodsPatients with RA <12 months’ duration and who were DMARD-naïve were enrolled and randomised 2:1 to FO at a high dose or low dose (for masking). These groups, designated FO and control, were given 5.5 or 0.4 g/day, respectively, of the omega-3 fats, eicosapentaenoic acid + docosahexaenoic acid. All patients received methotrexate (MTX), sulphasalazine and hydroxychloroquine, and DMARD doses were adjusted according to an algorithm taking disease activity and toxicity into account. DAS28-erythrocyte sedimentation rate, modified Health Assessment Questionnaire (mHAQ) and remission were assessed three monthly. The primary outcome measure was failure of triple DMARD therapy.ResultsIn the FO group, failure of triple DMARD therapy was lower (HR=0.28 (95% CI 0.12 to 0.63; p=0.002) unadjusted and 0.24 (95% CI 0.10 to 0.54; p=0.0006) following adjustment for smoking history, shared epitope and baseline anti–cyclic citrullinated peptide. The rate of first American College of Rheumatology (ACR) remission was significantly greater in the FO compared with the control group (HRs=2.17 (95% CI 1.07 to 4.42; p=0.03) unadjusted and 2.09 (95% CI 1.02 to 4.30; p=0.04) adjusted). There were no differences between groups in MTX dose, DAS28 or mHAQ scores, or adverse events.ConclusionsFO was associated with benefits additional to those achieved by combination ‘treat-to-target’ DMARDs with similar MTX use. These included reduced triple DMARD failure and a higher rate of ACR remission.

BackgroundObservation charts are the primary tool for recording patient vital signs. They have a critical role in documenting triggers for a multi-tiered escalation response to the deteriorating patient. The objectives of this study were to ascertain the prevalence and incidence of triggers, trigger modifications and escalation response (Call) amongst general medical and surgical inpatients following the introduction of an observation and response chart (ORC).MethodsProspective (prevalence), over two 24-hour periods, and retrospective (incidence), over entire hospital stay, observational study of documented patient observations intended to trigger one of three escalation responses, being a MER—Medical Emergency Response [highest tier], MDT—Multidisciplinary Team [admitting team], or Nurse—senior ward nurse [lowest tier] response amongst adult general medical and surgical patients.ResultsPrevalence: 416 patients, 321 (77.2%) being medical admissions, median age 76 years (IQR 62, 85) and 95 (22.8%) Not for Resuscitation (NFR). Overall, 193 (46.4%) patients had a Trigger, being 17 (4.1%) MER, 45 (10.8%) MDT and 178 (42.8%) Nurse triggers. 60 (14.4%) patients had a Call, and 72 (17.3%) a modified Trigger. Incidence: 206 patients, of similar age, of whom 166 (80.5%) had a Trigger, 122 (59.2%) a Call, and 91 (44.2%) a modified Trigger. Prevalence and incidence of failure to Call was 33.2% and 68% of patients, respectively, particular for Nurse Triggers (26.7% and 62.1%, respectively). The number of Modifications, Calls, and failure to Call, correlated with the number of Triggers (0.912 [p<0.01], 0.631 [p<0.01], 0.988 [p<0.01]).ConclusionWithin a multi-tiered response system for the detection and response to the deteriorating patient Triggers, their Modifications and failure to Call are common, particularly within the lower tiers of escalation. The number of Triggers and their Modifications may erode the structure, compliance, and potential efficacy of structured observation and response charts within a multi-tiered response system.

In mild to moderate Parkinson's disease, gastric emptying is related to autonomic dysfunction and a determinant of the glycaemic response to oral glucose.

Background Body mass index (BMI) is associated with patient outcomes after kidney transplantation. We hypothesized that immunosuppression (IS) dosing is a contributing factor. Methods Using Australia and New Zealand Dialysis and Transplant registry data, we included all adult kidney-only transplant recipients over 2000–14 treated with prednisolone, mycophenolate and tacrolimus/cyclosporin (n = 7919). The exposure was BMI and the outcomes were time to: (i) acute rejection, (ii) fatal infection, (iii) cancer and (iv) graft; and (v) patient survival. We modelled BMI and IS dosing (in quartiles) as time-varying covariates in extended Cox models. Results Compared with a BMI of 25 kg/m2, a BMI of 35 was associated with acute rejection after adjusting for demographics and comorbidities [adjusted hazard ratio (aHR) = 1.29, 95% confidence interval (CI) 1.12–1.49]. This association virtually disappeared after correcting for IS (aHR = 1.09, 95% CI 0.93–1.29). A BMI of 35 was non-significantly associated with fewer fatal infections (aHR = 0.91, 95% CI 0.66–1.25), but this reversed after adjusting for IS (aHR = 1.54, 95% CI 1.03–2.28). Results for cancer were not significantly altered after adjusting for IS. Results for lower BMI were similarly not significantly altered though generally associated with worse outcomes. Conclusions Our findings show that the associations between high BMI, acute rejection and fatal infection after kidney transplantation were significantly altered after correcting for IS suggesting that relative under-dosing of obese patients may partially explain these associations.

Hepatic angiosarcomas are rare, deceptive and aggressive malignancies that remain notoriously difficult to diagnose and treat. This case report discusses some of the common challenges faced by clinicians, and potential clinical, radiological and histological clues to this often elusive diagnosis.