Mesenteric Panniculitis is a benign fibro-inflammatory process involving adipose tissue of the mesentery. It is characterised by fat necrosis, chronic inflammation and fibrosis, causing thickening and shortening of the mesentery. Patients may present with localised abdominal pain, abdominal mass, intestinal obstruction and ischaemic colitis. We report a case of mesenteric panniculitis causing abdominal pain in a patient with active Primary Sjögren's Syndrome. The rarity of this case makes it of interest. We review the current literature on mesenteric panniculitis and its association with connective tissue disease and inflammatory conditions. A 64-year-old Caucasian male presented in 1994 with dry mouth. A diagnosis of Primary Sjögren's Syndrome (PSS) was made on salivary gland biopsy. In 2010 he presented with an exacerbation of his eye symptoms, muscle pain and fatigue. He complained of abdominal pain and night sweating, but denied any weight loss or change in bowel habit. There was no significant past medical history other than PSS. On examination he had a small right submandibular node and mild synovitis at the right proximal interphalangeal joint and carpometacarpal joint. Examination of the abdomen showed marked umbilical tenderness but no organomegally. Blood tests at this time showed an active inflammation: CRP of 61 (NR < 5 mg/L), ESR 39 (NR < 20 mm/s), strongly positive ENA Ro and La. IgG was elevated at 18.6 (NR 5.8 -15.4), Complement was low at 0.17 (NR 0.18 -0.6). An abdominal ultrasound scan demonstrated a 6 × 3 × 3 cm area of diffuse homogenous fat encasing some mesenteric vessels in the area of focal tenderness. CT abdomen and pelvis showed oedematous mesenteric fat and lymph nodes in the jejunal small bowel mesentery, consistent with mesenteric panniculitis. Laparoscopic biopsy was discussed with the surgical team, but was felt not indicated as risk outweighed potential benefit. The patient was treated with a 9-week reducing course of oral steroids. His abdominal symptoms resolved although CT abdomen showed little improvement in mesenteric panniculitis. A review of the literature suggests that currently there is no standard treatment and management should be guided by patient symptoms. Mesenteric Panniculitis is rare; as a result evidence for treatment is limited to individual case reports. There is no clear link between symptom improvement and radiological resolution of mesenteric panniculitis. It has, therefore been suggested that follow-up imaging should be limited to those with persistent symptoms. Overall the prognosis for mesenteric panniculitis is good, up to half of patients do not require treatment, and recurrence of symptoms is uncommon.
Objectives The aim of this audit is to review new-patient referrals to a Primary Sjögren's Syndrome (PSS) clinic in the North East of England. We reviewed the referral pathway, timing from initial symptoms to referral, diagnosis and treatment, geographic distribution of referrals, whether these patients are being assessed appropriately and did they meet AECG criteria for a diagnosis of PSS. The aim is to inform service design, including education and raising awareness of the need for timely referral in these patients, setting up inter-specialty links with a view to possible combined clinics in the future, and developing a pro forma for initial assessment of these patients, with the ultimate goal to improve the standard of care for PSS sufferers Methods A list of all new suspected PSS referrals between January 2009 and September 2013 was obtained from the hospital database. Notes, including clinic letters, blood tests, x-ray reports and referral letters were reviewed. Results A Total of 169 patients were referred to the specialist clinic. Of these, 156 had been seen at least once. Of those who had not been seen, 5 patients did not attend their scheduled appointment (2.9%) and 8 had yet to receive a first appointment. Data was missing for 6 of the patients who attended the specialist clinic. Data for a total of 150 patients was analysed. The age at referral to specialist clinic ranged from 16 to 87, mean age 58.2 years. Male to female ratio 1:5. Time from initial symptoms to referral to specialist Sjögren's clinic ranged from 2 months to 252 (mean 77.2) months. Time from first presentation to a medical specialty to attendance at the specialist PSS clinic ranged from 0 to 240 (mean 41.2) months. Patients were referred from a variety of pathways. Over one third of patients were referred from primary care (50 from General Practice and 1 from dental practitioner). Two thirds were referred from secondary care, the majority of referrals from rheumatology, neurology and oral medicine. Sixty-four patients had a diagnosis of PSS confirmed as per AECG criteria. 88 (58.7%) patients had a labial salivary gland biopsy, and of these 46 were diagnosed with PSS. Time to treatment varied, in fact many patients had commenced treatment (in particular replacement therapy) prior to referral. DMARDs were commenced in 30 patients. Four patients were referred for clinical trial with rituximab/placebo due to the severity of their symptoms. Conclusions The findings from our analysis conform with the epidemiology in terms of gender bias and age at presentation. There is a significant delay from the onset of symptoms to referral. This may be due to delayed presentation by the patient (most commonly), or delayed referral. It became clear that there are key referrers (in particular ophthalmology, oral medicine and neurology) due to the nature of the disease. It may be suggested that a combined clinic involving these specialties may be both financially beneficial and result in a timely diagnosis. With current research focusing on immunomo...
BackgroundOne element of rheumatology undergraduate teaching in City Hospital Sunderland, UK traditionally involves “paper cases” delivered via small group learning and discussion. Although popular it has had poor feedback from both the students and the tutors at times especially when the tutor to student ratio is high (>1:6). With limited numbers of tutors (Consultant Rheumatologists), this issue was becoming more frequent.ObjectivesWe wished to explore alternative yet still interactive methods to highlight key learning points relating to common rheumatological conditions in a 60 minute teaching session and to make this fun and engaging.Methods30 undergraduate medical students (January 2017) were given modified teaching material for a 60 minute teaching session a week later. This material involved a partially populated Microsoft Powerpoint slideshow including prompts about a theoretical patient's clinical case in the notes section. This guided development of a clinical case presentation which covered diverse aspects of clinical care, e.g. imaging, extra-articular disease, drug side effects and disease activity scores. Clinical cases addressed systemic lupus erythematous, early rheumatoid arthritis (RA), ankylosing spondylitis and established RA. Students (groups of 2–3) received one case each were encouraged to use images and online teaching repositories to enhance their presentation. This provided the framework for a 20 minute teaching presentation which was given to their student peers at a formal teaching day 1 week later. A tutor was also present during these sessions (with a ratio of 1:10) to ensure adequate understanding of topics had been achieved and to answer any questions. Feedback was sought from the students and compared with previous “paper case” (non-modified) sessions.ResultsFeedback obtained (n=9) showed 55% of students rated the modified teaching session as “excellent” with the remainder rating it as “good”. Free-text comments included “good to have students to do the presentations so they cover relevant points” “very useful to have a quick 20 minute overview of different conditions & preparation was useful” and “lots of learning, interactive”. Additional comments included the wish for more time to cover the points in even more depth. Informal feedback from the tutors of these events was also favourable with tutors believing students had a developed a greater depth of understanding. These findings compared favourably with the previous years “paper-case” feedback (March 2016, n=13) where only 23% (n=3) of students had rated the session as “excellent” as well as free text comments emphasising wishes for more time to read through cases and smaller group discussion.ConclusionsCurrent “paper based” modalities can easily be utilized and “re-purposed” to optimize both self-directed and formal teaching components of undergraduate teaching. This can promote the understanding of complex rheumatological learning points in a relatively short period of time and allow students exposure to modalities, such as i...
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