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   Table of Contents - Current issue
Coverpage
June 2019
Volume 14 | Issue 2
Page Nos. 91-165

Online since Monday, July 8, 2019

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EDITORIALS  

Access to rheumatology care: How near how far p. 91
Annil Mahajan, Vishal R Tandon
DOI:10.4103/injr.injr_76_19  
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Fostering collaboration between journals: Growing together for a better future for science p. 94
Durga Prasanna Misra, Vikas Agarwal
DOI:10.4103/injr.injr_82_19  
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Musculoskeletal ultrasound in juvenile idiopathic arthritis - A future not too far p. 96
N Sajjan Shenoy
DOI:10.4103/0973-3698.260822  
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A clinical aid to precision medicine p. 98
Sakir Ahmed, Latika Gupta
DOI:10.4103/injr.injr_66_19  
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Low bone mass and its correlation in systemic sclerosis p. 100
Sri Harsha Gunna, Subhash Yadav
DOI:10.4103/0973-3698.260823  
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Anticarbamylated protein antibodies: The new clinically relevant antibody system in rheumatoid arthritis p. 102
Sajal Ajmani
DOI:10.4103/injr.injr_54_19  
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ORIGINAL ARTICLES Top

Musculoskeletal Ultrasonography in Detecting Disease Activity in Patients of Juvenile Idiopathic Arthritis: A Cross-Sectional Study p. 104
Sharad Dev, Ashish Verma, Anup Singh
DOI:10.4103/injr.injr_38_19  
Background: Musculoskeletal ultrasonography (MSUS) is a powerful tool to detect subclinical disease in juvenile idiopathic arthritis (JIA). The study was done to compare the results of clinical examination and ultrasonography (US) in identifying disease activity in joints of patients of JIA. Methods: Patients of JIA attending rheumatology clinic of a tertiary care referral center in northern India over a span of 1 year from June 2015 to June 2016 were enrolled in the study. The diagnosis of JIA was established using International League of Associations for Rheumatology 2001 criteria. Clinically determination of synovitis was compared to MSUS parameters of active disease such as synovial hypertrophy, effusion, and increased vascularity in large joints only (bilateral knee, ankle, wrist, and elbow). Results: A total of 108 patients were enrolled in a study period and 864 joints were examined. Synovitis was detected in 305 joints by clinical examination. However, US demonstrated synovitis in 502 joints (additional 209 joints). Twenty patients who were initially thought to be oligoarticular by clinical examination were later classified to polyarticular subtype on the basis of MSUS findings. A significant correlation between erosions and rheumatoid factor and anti-cyclic citrullinated peptide values was found. Conclusion: Our study found that MSUS has a definite role in assessing the disease activity in JIA patients and this modality may be considered as an adjunct in this context, as well as considered for future inclusion in classification criteria for JIA.
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Bone Mineral Density is Decreased in Patients with Systemic Sclerosis and Correlates With Serum Intact Parathormone Levels: A Cross-Sectional Study p. 109
Shefali Sharma, Aadhaar Dhooria, Tulika Singh, Varun Dhir, Arghya Chattopadhyay, Debashish Mishra, Sanjay Jain
DOI:10.4103/injr.injr_136_18  
Objective: To study bone mineral density (BMD) in Indian patients with systemic sclerosis and objectively verify whether an association exists between osteoporosis and systemic sclerosis. Methods: Adult patients suffering from systemic sclerosis (as per the 2013 American College of Rheumatology classification criteria for systemic sclerosis) attending the rheumatology clinic at Post Graduate Institute of Medical Education and Research, Chandigarh, India were recruited. BMD was measured using dual energy x-ray absorptiometry (DXA) and serum Vitamin D and iPTH levels were estimated. The 10-year probability of sustaining an osteoporotic fracture was estimated using the World Health Organisation fracture risk assessment tool with the Indian population reference. Results: 100 patients were included (89 women). Interstitial lung disease and pulmonary arterial hypertension were seen in 48 and 18 patients, respectively. Median (range) serum 25 hydroxy Vitamin D level was 17 ng/ml (3.7-225.7 ng/ml). Mean serum iPTH level was 79.6±38.1 pg/ml. 55 patients were categorized as Vitamin D deficient, 24 as insufficient, and 21 as Vitamin D sufficient. 21 patients had iPTH values above 75 pg/ml. 28% had osteoporosis of the lumbar spine while 6% had osteoporosis of the femoral neck. Serum iPTH correlated inversely with low bone mass at the hip (P = 0.023, r2 = 0.121). Low bone mass did not correlate with age, postmenopausal status, low BMI, corticosteroid use, serum 25 hydroxy Vitamin D levels, disease duration, presence of interstitial lung disease or pulmonary arterial hypertension. Conclusion: Low bone mass is highly prevalent in patients with systemic sclerosis and is associated with elevated serum iPTH levels.
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Comparison of outcome of ultrasound-guided suprascapular nerve block versus intra-articular steroid injection in adhesive capsulitis of shoulder: A randomized control trial p. 113
Davinder Kumar Verma, Osama Neyaz, Srishti Nanda, Gita Handa
DOI:10.4103/injr.injr_11_19  
Background: Adhesive capsulitis (AC) is the most common cause of shoulder pain in India. There is little consensus regarding the optimal course of treatment for AC. The aim of the present study was to compare the effectiveness of ultrasound-guided suprascapular nerve block (USNB) with intra-articular steroid injection (IASI) in AC of shoulder in providing pain relief, functional improvement, and reduction of disabilities. Settings and Design: A prospective randomized control trial at a tertiary care hospital compared a single dose of IASI with USNB in patients having shoulder pain and stiffness secondary to AC of ≥12 weeks' duration, visiting Outpatient Department of Physical Medicine and Rehabilitation. Materials and Methods: Patients in the first group were given IASI (2 ml of 40 mg/ml triamcinolone) while in the other group received USNB (4 ml of 0.5% injection bupivacaine). Home-based therapeutic exercise program for AC was advised for both the groups. The outcome measures were the Shoulder Pain and Disability Index (SPADI) and passive range of motion (ROM) (flexion, abduction, and external rotation) of the affected shoulder. Follow-up was done at 1-week, 3-week, and 6-week time-points. Results: Both domains of SPADI (pain score and disability score) and passive shoulder ROM significantly improved (P < 0.05) within both the groups at 1-week, 3-week, and 6-week follow-ups as compared to baseline. However, no statistically significant differences were found between the two groups at baseline or at follow-up (P > 0.05). Conclusion: Suprascapular nerve block is comparable in efficacy to IASI in patient with AC.
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Serum adiponectin levels in patients with rheumatoid arthritis p. 119
Ganesh Veluri, Kiranmayi S Vinapamula, P VLN Srinivasa Rao, Sirisha Kommireddy, Suchitra Musturu Manohar, Pullaiah Pasupuleti
DOI:10.4103/injr.injr_143_18  
Background and Objective: Rheumatoid arthritis (RA) is a chronic inflammatory polyarthritis of common occurrence. Adiponectin is an adipocytokine shown to exert anti-inflammatory as well as pro-inflammatory effects. Our objective was to study the serum adiponectin levels in RA and explore its association with RA disease activity. Materials and Methods: Forty RA patients (newly diagnosed n = 20, RA in clinical remission n = 20) and thirty age-, gender-, and body mass index (BMI)-matched apparently healthy controls were included. Serum adiponectin levels were measured by enzyme-linked immunosorbent assay. RA clinical remission was defined by a Disease Activity Score 28 of <2.6. Results: Serum adiponectin levels were significantly lower in RA patients compared to controls. Both groups of RA patients had lower adiponectin levels than controls. There was no difference in adiponectin levels between the two groups of RA patients. There was no association of adiponectin with disease activity or BMI. Conclusions: Serum adiponectin concentration is decreased in RA patients and was not associated with disease activity.
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Correlation of Inflammatory Markers and Disease Severity with Cardiovascular Autonomic Dysfunction in Indian Patients with Rheumatoid Arthritis p. 123
Mohan Babu Saminathan, Renuka Sharma, Arun Gogna, Anita Rani, Raj Kapoor
DOI:10.4103/injr.injr_171_18  
Background: RA is an autoimmune disease characterized by chronic systemic inflammation, affecting approximately 1% of the population. Cardiovascular disease accounts for more than 40% of mortality in RA with cardiovascular autonomic nervous system dysfunction being commonly observed. Since few studies are available regarding the status of cardiac autonomic function in RA, we planned to study the same in RA patients and correlate it with their level of inflammatory markers and disease severity. Objectives: 1. To study the heart rate variability, inflammatory markers in RA and controls. 2. To assess the correlation of inflammatory markers and disease severity with HRV. Materials and Methods: The study was conducted on 35 diagnosed cases of RA and 35 controls. Short term heart rate variability was taken as an index of autonomic function. TNF-α and IL-10 were assessed in 3 ml overnight fasting serum. Severity of RA was assessed by DAS28 score. Result: Disease severity of RA was low. LF, NN50 and RANGE were significantly decreased in RA patients. TNF-α was significantly elevated in RA patients. Correlation of TNF-α with LF/HF ratio and DAS28 with RMSSD, NN50 and HF were found to be significantly positive. Conclusion: Our findings suggest that CAD is significantly correlated with inflammatory activity and disease severity in RA. Hence, we propose that HRV may serve as an accurate tool to screen RA patients for early signs of autonomic disturbance, which can greatly help to reduce future morbidity and mortality.
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REVIEW ARTICLES Top

Safety of Cyclophosphamide Therapy in Autoimmune Rheumatic Diseases p. 127
Ramaswamy Subramanian, Himanshu Pathak, Vinod Ravindran
DOI:10.4103/injr.injr_28_19  
Cyclophosphamide (CYC) is one of the most potent antineoplastic and immunosuppressant agents. It is used as a drug of choice in many organ-threatening manifestations of systemic autoimmune rheumatic diseases (AIRDs) such as lupus nephritis, antineutrophil cytoplasmic antibody-associated vasculitis, classical polyarteritis nodosa, and myositis. It is also used in connective tissue disease-related interstitial lung disease and Behcet's disease. However, its use may be limited by the toxicities including its adverse effects on gonads in the childbearing age group, severe infections, hemorrhagic cystitis, and malignancies associated with prolonged usage. As a result, mycophenolate, azathioprine, and rituximab have gained popularity over CYC as an induction and maintenance agent in many AIRDs. However, in the event of failure of aforementioned agents in aggressive rheumatic diseases or in a resource-limited setting, the usage of CYC continues to be a useful therapeutic strategy. In this review, we have appraised the adverse effects of CYC therapy in AIRDs which would help clinicians in taking informed decisions regarding CYC usage.
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BRIEF REPORT Top

Meeting report: MyoIN – Pan-India collaborative network for myositis research p. 136
Latika Gupta, Sravan Kumar Appani, Ramya Janardana, Hafis Muhammed, Able Lawrence, Sanjiv Amin, Vineeta Shobha, Liza Rajasekhar, Ramnath Misra
DOI:10.4103/injr.injr_40_19  
Rheumatology in India, albeit old, has lagged behind in research on epidemiology and outcomes of chronic rheumatic diseases. The realization about paucity of Indian data has created the felt need for cohort-building and sustainable research. With this comes the dawn of collaborative research. Myositis is one such rare disease with considerable morbidity and mortality, where little is known about the behavior of the disease and treatment practices in the Indian setting. In recent years with the availability of myositis-specific autoantibodies, newer clinic-serologic associations have been described. Collaborative efforts in rare diseases from the Western world have yielded exemplary results. Hence, a pan-India collaborative network called MyoIN (Myositis India Collaborative Effort) was formed to collect data on patients with inflammatory myositis in a standardized format including clinical and investigational parameters both at presentation and follow up to build up a large series prospectively. This report describes the activities since the inception of this group.
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SPECIAL ARTICLE Top

Indian college of rheumatology: An idea whose time has come! p. 143
Rohini Handa, Debashish Danda, Ramnath Misra, Alakendu Ghosh
DOI:10.4103/injr.injr_68_19  
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CASE BASED REVIEW Top

Secukinumab: A safe option to treat psoriasis and psoriatic arthritis in the presence of interstitial lung disease p. 145
Raja Natarajan
DOI:10.4103/injr.injr_4_19  
Psoriasis is a commonly encountered skin condition with a significant percentage of patients developing arthritis. Psoriasis is associated with multiple comorbid conditions. However, the association of interstitial lung disease (ILD) with psoriasis is rarely reported in the literature. The therapeutic options for psoriasis and psoriatic arthritis are limited in the presence of ILD. We report a 63-year-old female with long-standing psoriasis and psoriatic arthritis with usual interstitial pneumonia pattern ILD. She developed severe arthritis and extensive psoriasis lesions which did not respond to conventional disease-modifying drugs as well as to oral phosphodiesterase inhibitor apremilast. She was planned for biological therapy. Antitumor necrosis factor therapy was not administered in view of coexistent ILD. She was treated with anti-interleukin-17 A monoclonal antibody, secukinumab 150 mg subcutaneous at 0, 1, 2, 3, and 4 weeks, followed by monthly once for 5 months for a total of ten doses. She had a resolution of skin lesions, and her arthritis went into remission. She had no clinical or radiological worsening of ILD. Spirometry showed improvement in forced vital capacity. This case report suggests that secukinumab can be safely used in psoriasis and psoriatic arthritis without worsening of underlying ILD.
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LETTERS TO EDITOR Top

Reduced Injection Site Pain with Succinate Buffer-Based Adalimumab Biosimilar (ZRC-3197) Injection (SUFFER Study): An Observational Study p. 151
Mihir Gharia, A Sudhakar
DOI:10.4103/injr.injr_154_18  
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Childhood polyarteritis nodosa: Few facts and interpretation p. 153
Sumantra Sarkar, Rakesh Mondal
DOI:10.4103/injr.injr_46_19  
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Neuropsychiatric lupus: A perpetual quandary p. 154
Vaibhav Deorari, Sujay Halkur Shankar, Neha Chopra, Prabhat Kumar
DOI:10.4103/injr.injr_162_18  
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Comment on “Improving knowledge and awareness regarding rheumatology at the undergraduate level in Indian Medical Colleges” p. 156
Subramanian Nallasivan, Yuva Vishalini, Abirami Manivannan
DOI:10.4103/injr.injr_161_18  
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IMAGES IN RHEUMATOLOGY Top

Multidrug-resistant primary cutaneous tuberculosis: A rare cause of chronic nonhealing leg ulcer in systemic lupus erythematosus p. 158
Pawan Goel, Prabhat Kumar, Shipra Agarwal
DOI:10.4103/injr.injr_58_19  
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Bilateral shoulder synovial chondromatosis: Multimodality imaging p. 161
D Suresh Kumar, Dillibabu Ethiraj, Venkatraman Indiran, Prabakaran Maduraimuthu
DOI:10.4103/injr.injr_14_19  
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Spontaneous complete re-canalization of a retinal vessel following occlusive vasculitis p. 163
Brijesh Takkar, Shorya Azad, Pradeep Venkatesh
DOI:10.4103/injr.injr_167_18  
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ERRATUM Top

Erratum: Use of coffee for alleviating methotrexate intolerance in rheumatic diseases p. 165

DOI:10.4103/0973-3698.188617  
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