Background: Previous studies have demonstrated the role of inflammation in diabetic nephropathy (DN). Neutrophil to lymphocyte ratio (NLR) rather than other white cell parameters was found to be a useful inflammatory marker to predict adverse outcomes in medical and surgical conditions. Nevertheless, the value of NLR in predicting DN has not been elucidated. Method: An observational study included 338 diabetic patients, who were followed at our clinic between 2007 and 2009. We arranged our patients into tertiles according to their 2007 NLR. The primary outcome was continuous decrease of GFR >12 mL/min between 2007 and 2009 with the last GFR <60 mL/min. Result: The lowest NLR tertile had fewer patients (2.7%) with primary outcome (i.e., worsening renal function) compared with middle and highest NLR tertiles, which had more patients with primary outcomes (8.7% and 11.5%, respectively) with a significant p-value 0.0164. When other potential confounders were individually analyzed with NLR tertile, the NLR tertiles remained a significant predictor of poor GFR outcome in the presence of other variables (hemoglobin A1C, systolic blood pressure, diastolic blood pressure, age, and congestive heart failure with p-values 0.018, 0.019, 0.017, 0.033, and 0.022, respectively). Conclusion: NLR predicted the worsening of the renal function in diabetic patients. Further studies are needed to confirm this result.

Initial presentation of invasive fungal infections such as histoplasmosis can include non-specific clinical manifestations, especially in immunocompromised patients. A high index of suspicion is required to identify atypical manifestations of these diseases, which carry a high risk of mortality, if the diagnosis is delayed or missed. We describe a case of a kidney transplant recipient with cutaneous lesions as initial manifestation of progressive disseminated histoplasmosis where a skin biopsy was crucial to an early diagnosis.

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Background Achieving a low DAS28 (disease activity score) of less than 3.2, is a common treatment goal for Rheumatoid Arthritis (RA). In clinics however, despite efforts, some patients still fail to reach treatment goals due to various barriers. Given the relatively high average disease activity level in the UAE with an average DAS28 of 4.3 (1), better understanding the barriers that exist in local clinics may yield novel information regarding how to better treat RA in the future. Objectives This study aims to better understand the factors that affect low disease activity (DAS28<3.2, LDA) and barriers in the UAE and propose a future course of action in order to improve the treatment of RA within the region. Methods Data was collected through chart reviews of 182 consecutive RA patients who were seen in a private clinic in Dubai over a 2-month period. Demographic/treatment data and DAS28 scores were collected. Patients were separated into a LDA group and a group comprised of moderate (DAS28 >3.2 and <5.1) and high disease activity (DAS 28 >5.1) (MHDA). We then examined variables that may be associated with LDA and re-examined the MHDA group for barriers such as irreversible joint damage, inability to pay for treatment, resistant disease, patient driven preferences, safety concerns and comorbidities. Results While 97 (53%) of the 182 patients had achieved the treatment target of DAS 28 <3.2, 21 (11.50%) had high disease activity and 64 (35%) had moderate disease activity. No substantial difference was found in delay to diagnosis, past methotrexate use, or rheumatoid factor or anti-CCP status between the LDA and MHDA group (Table 1). However, a significantly larger portion of LDA patients had been previously treated with sulfasalazine, SSA, (36 in LDA vs 14 in MHDA, P0.002) or were presently on biological treatments (24 vs 9, P0.013). For the 85 MHDA patients, 40 (22% of 182) exhibited resistant disease with 25 (13.7% of 182) failing their current first tier disease modifying anti-rheumatic drug (DMARD) treatment or combinations and 15 (8.2% of 182) failing current anti-TNF or biologic treatment. Notably 16 of the 25 failing DMARD treatment (40%) did not change treatment plans due to insufficient insurance. Other notable barriers were patient driven preferences (20%), non-inflammatory musculoskeletal pain (9%), and safety concerns (7%). Conclusions Over half the patients achieved the DAS28 LDA target. Factors that significantly influenced LDA were prior SSA use and current biological therapy. Among those who did not achieve target (MHDA), the most prominent barriers included resistant disease (47%) and patient driven preferences (20%). Reasons listed for resistant disease and patient-driven preference were primarily socio-economic with 40% of the resistant disease group unable to afford biological drugs and 59% of the patient-driven preference group discontinuing or refusing DMARDs against professional advice. Going forward, better educating patients on the proper use of anti-rheumatic drugs could help r...

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