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Medscape
6 days ago
- General
- Medscape
Fibrosis-4 Index Finds New Role in Rheumatoid Arthritis
Up to 20% of patients with rheumatoid arthritis (RA) had abnormal fibrosis-4 (FIB-4) index values, reflecting an indeterminate to high risk for liver fibrosis; a significant correlation was seen with insulin resistance but not with disease activity. METHODOLOGY: Researchers conducted a cross-sectional study to calculate FIB-4 index values in patients with RA and assess their relationship with disease characteristics and cardiovascular comorbidities. They recruited 465 adults with RA (mean age, 55 years; 81% women) between 2019 and 2021, all of whom had a disease duration of at least 1 year and were taking ≤ 10 mg/day of prednisone or an equivalent dose. The FIB-4 index was calculated using an equation considering age, platelet count, and alanine aminotransferase and aspartate aminotransferase levels, with the risk for fibrosis classified as low, indeterminate, or high on the basis of defined cutoff values. Participants underwent evaluations for disease activity, complete lipid profiles, the presence of metabolic syndrome, anthropometric parameters, and insulin resistance using the Homeostatic Model Assessment, as well as carotid ultrasound to detect subclinical carotid atherosclerosis. Cardiovascular risk was estimated using t he Systematic Coronary Risk Evaluation-2 (SCORE2) tool. TAKEAWAY: SCORE2 classified 66% of patients with RA as having low cardiovascular risk, 28% as having moderate cardiovascular risk, and 6% as having high cardiovascular risk; the prevalence of cardiovascular risk factors was generally high. FIB-4 values indicated an indeterminate risk for fibrosis in 18% of patients with RA and a high risk in 1%, whereas 81% had a low risk. Several factors, including age ( P < .001), cardiovascular risk measured by SCORE2 ( P < .001), and metabolic syndrome ( P = .008), showed positive correlations with FIB-4 values; however, in multivariable analysis, the presence of hypertension, insulin resistance indices, and statin use maintained significant positive associations. < .001), cardiovascular risk measured by SCORE2 ( < .001), and metabolic syndrome ( = .008), showed positive correlations with FIB-4 values; however, in multivariable analysis, the presence of hypertension, insulin resistance indices, and statin use maintained significant positive associations. Disease activity (measured by multiple scores), acute phase reactants, and the presence of rheumatoid factor or anti–citrullinated protein antibodies showed no significant association with FIB-4 values, whereas the presence of erosions at recruitment was associated with FIB-4 ( P = .044). IN PRACTICE: "This index may serve as a surrogate marker for CV [cardiovascular] risk and insulin resistance in patients with RA," the authors concluded. SOURCE: This study was led by Iván Ferraz-Amaro, Hospital Doctor Negrín, Las Palmas de Gran Canaria, Spain. It was published online on May 21, 2025, in Rheumatology . LIMITATIONS: The cross-sectional design of this study prevented the establishment of causal relationships between variables. Data on hepatic ultrasound or liver biopsy were lacking. Information on cumulative methotrexate use was not collected. DISCLOSURES: This study was supported by a grant from Instituto de Salud Carlos III and additional funds from the European Union. Two authors reported receiving grants or research support and consultation fees from speaker bureaus associated with several pharmaceutical and healthcare companies, including AbbVie, Roche, and GSK.
Medscape
13-05-2025
- Health
- Medscape
Unusual Case of Psychosis Linked to Adrenal Tumour
In older patients, elevated blood pressure is often observed during visits to general practitioners. However, if it is not measurable, this should raise particular concerns. If a psychotic episode also occurs, prompt action is needed. Bastien Picut and his colleagues at Valais Hospital in Sion, Switzerland, reported an unusual case of a 60-year-old woman with decompensated metabolic syndrome and psychosis caused by a typical adrenal cortical carcinoma (ACC; adrenocortical oncocytic neoplasm, ACON). The Patient and Her History The woman presented to the hospital with symptoms of refractory arterial hypertension, accompanied by dizziness, headaches, and asthenia, and a weight gain of 20 kg within a span of 6 months. Despite maximal antihypertensive therapy, her systolic blood pressure remained at approximately 160 mmHg. Findings and Diagnosis Examination revealed the onset of type 2 diabetes, requiring immediate insulin, and mixed hyperlipidaemia associated with hypokalaemia and hypernatremia. While hospitalised under geriatric care, the patient experienced a psychotic breakdown characterised by persecutory delirium, noncritical visual hallucinations, and mistrust of contacts associated with anxiety. A comprehensive laboratory analysis was performed. Liver function tests were abnormal, with significantly elevated levels of gamma-glutamyl transpeptidase, total bilirubin, alanine aminotransferase, aspartate aminotransferase, and alkaline phosphatase. Additionally, hypernatremia (149 mmol/L) was noted (normal range, 135-145 mmol/L). The calcium and ammonia levels were normal at 2.31 mmol/L and 36 μmol/L, respectively. Urine analysis revealed proteinuria, ketonuria, urobilinogen, and haematuria. The levels of dehydroepiandrosterone sulphate and urinary catecholamines, including metanephrine, normetanephrine, and methoxytyramine, were marginally elevated. Following the initial evaluation, an ultrasound was performed, revealing a large, bilobed retro-pancreatic mass near the left kidney and para-aortic region. Subsequent abdominal CT confirmed a bilobed left adrenal mass measuring 8 × 5 cm and 1.8 × 2.2 cm, which was vascularised without calcifications. The CT scan ruled out the presence of any locoregional or distant spread of the disease. The differential diagnosis of pheochromocytoma was considered. Radiological findings and elevated urinary metanephrines, suggesting the secretion of catecholamine precursors. No other causes for the elevated urinary catecholamines were identified. Prior to the intervention, the patient was medically managed with haloperidol (1 mg orally three times daily) and clomethiazole (192 mg orally twice daily as needed) for psychiatric decompensation. For diabetes management, metformin 500 mg orally three times daily, linagliptin 5 mg orally, and insulin glargine 30U subcutaneously were administered. Hypertension was managed with metoprolol (50 mg), spironolactone (25 mg), lisinopril (20 mg), and doxazosin (4 mg) orally. Subsequently, laparoscopic left adrenalectomy was performed without intraoperative complications. The patient required adrenergic support until the fourth postoperative day. Additionally, all antihypertensive medications were discontinued, except for beta blockers. Discussion This is the first ACON case described in the literature with such an atypical clinical presentation, according to the authors. Psychotic manifestations of ACC have been previously described; however, they are associated with cortisol-secreting ACC as part of Cushing syndrome. Furthermore, the doctors could not conclusively determine whether the tumour was a pure non-secreting ACON. The clinical presentation resembled Cushing syndrome, and hypokalaemia could be attributed to vasospasm from secondary hyperaldosteronism. Aldosterone secretion from the tumour could not be clearly assessed due to the ongoing use of antihypertensive medications (beta blockers, spironolactone, calcium channel blockers, and angiotensin-converting enzyme inhibitors). This may have affected the aldosterone-renin ratio, leading to a potentially false-negative assessment. The variable clinical presentation and the lack of sensitivity and specificity of preoperative diagnostic procedures, such as imaging in aggressive malignant diseases, make adrenocortical oncocytic neoplasms a significant challenge for clinicians.
