No abstract

Objective Racial and ethnic disparities in rheumatoid arthritis (RA) disease activity measures have been documented. We compared racial and ethnic differences in disease activity using multiple composite measures, including an objective measure, the multi‐biochemical disease activity (MBDA) score. Methods Data are derived from the University of California, San Francisco RA Cohort, a longitudinal observational cohort. Participants with at least one MBDA measure and self‐reported race and ethnicity were included. Multivariable linear regression evaluated the association between race and ethnicity groups and mean MBDA score, adjusting for potential confounders, including symptom duration and medication use. Sensitivity analyses substituted the Clinical Disease Activity Index (CDAI) and the Disease Activity Score‐28 joints with erythrocyte sedimentation rate (DAS28‐ESR) for the MBDA in multivariable models. Results We included 267 participants (86% female, mean age 52.7 ± 13.3 years). The majority were Latinx (n = 137; 51%), followed by Asian (n = 91; 34%). After adjustment, Latinx participants had the highest mean MBDA score (40.6 ± 2.1) compared with White participants at (32.8 ± 6.7). Black participants had the second highest mean MBDA score, followed by Asian participants (36.3 ± 5.3, 36.0 ± 2.7, respectively), although neither were significantly different from White participants. The trends observed for the CDAI and DAS28‐ESR were similar to those for the MBDA. Conclusion We found significantly higher disease activity measured by the MBDA and DAS28‐ESR in Latinx participants compared with White participants. We also found significantly higher disease activity in Asian participants compared with White participants with the DAS28‐ESR. Our findings, although limited by the small number of White participants in the referent group, suggest that RA disease activity measures may be influenced by external factors that have differential impacts by racial and ethnic group.

Macrophage activation syndrome (MAS) is a rare and potentially fatal condition characterized by excessive activation and uncontrolled proliferation of T lymphocytes and macrophages, leading to overwhelming systemic inflammation and cytokine release. MAS has been reported with viral infections, autoimmune disorders, malignancies, and medications. We describe a case of a patient with axial spondyloarthritis (axSpA) treated with adalimumab, who presented with MAS.

INTRODUCTION: Paradoxical embolus in transit is rarely identified during the work up of a stroke. We present a patient with multiple risk factors for stroke who was identified to have a thrombus crossing the interatrial septum at the time of an IV saline contrast study. CASE PRESENTATION:A 72-year-old woman with a history of diabetes, hypertension, paroxysmal atrial fibrillation, left frontal lobe stroke, and bilateral sub-segmental pulmonary emboli, presented with two months of visual hallucinations and was found to have multiple subacute infarctions affecting the right visual cortex (Fig1). Transthoracic echocardiogram (TTE) identified the etiology of her embolic strokes when a mobile 0.83 cm by 1.07 cm thrombus was seen traversing the interatrial septum from right to left with interatrial shunt following Valsalva maneuver during an IV saline contrast study (Fig2). Patient was also found to have unprovoked right mid-calf vein thrombus of indeterminate age. Diagnosis of paradoxical embolus in transit through a patent foramen ovale (PFO) associated with septal aneurysm was made. Patient did not have any new clinical event associated with the embolus and was treated with aspirin and rivaroxaban for secondary stroke prophylaxis. The decision was made not to pursue PFO closure given concern for medication non-compliance after the procedure.DISCUSSION: Paradoxical embolism is a clinically important entity1. Diagnosis often requires at least two of the following: (1) venous thrombosis, (2) arterial embolus, (3) connection between the right and left side of the heart, (4) and a traversing thrombus1. Demonstration of all of these four elements is rarely identified. Transesophageal echocardiography (TEE) is often required to explore interatrial septal anatomy after a TTE with an IV saline contrast study is performed when PFO is suspected. Identification of a paradoxical embolus during IV saline contrast study (bubble study) is even rarer, yet it establishes the stroke mechanism. Although considered a safe study with no significant residual morbidity, transient neurological symptoms have been reported with high degrees of right to left shunts2. The prevalence and clinical outcomes of paradoxical embolism during bubble study are uncertain owing to the scarcity of studies in this area3. Despite the growing evidence supporting PFO closure when it is associated with an atrial septal aneurysm or an interatrial shunt, the risk of intracranial bleeding from dual antiplatelet therapy following PFO-closure along with the risk of post-PFO atrial fibrillation makes management decision challenging and highly selective based on patient's risk factors.CONCLUSIONS: Paradoxical embolism is an uncommon, yet a clinically important entity. Identification of embolism during bubble study is exceedingly rare. Clinical outcome is uncertain warranting future studies to investigate the possibility of permanent neurological deficits.