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   Table of Contents - Current issue
Coverpage
June 2017
Volume 12 | Issue 2
Page Nos. 67-121

Online since Friday, May 26, 2017

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FROM THE EDITORS DESK  

From the Editor's desk p. 67
Vinod Ravindran
DOI:10.4103/0973-3698.207146  
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EDITORIALS Top

Outcome assessment in rheumatoid arthritis: The patient says the best p. 68
Durga Prasanna Misra, Vikas Agarwal
DOI:10.4103/injr.injr_33_17  
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Enhancing hand function in rheumatoid arthritis: An artistic ploy p. 70
Subramanian Shankar
DOI:10.4103/0973-3698.206923  
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ORIGINAL ARTICLES Top

Rheumatoid arthritis disease activity index-5: Utility in busy clinical settings p. 72
Harpreet Singh, Vikram Singh Tanwar, Gagandeep Sukhija, Rekha Mathur, Parminder Kaur
DOI:10.4103/0973-3698.199127  
Objective: To assess disease activity using Rheumatoid Arthritis Disease Activity Index-5 (RADAI-5) in patients with rheumatoid arthritis (RA) and its correlation with Disease Activity Score using 28 joint count (DAS28) and Clinical Disease Activity Index (CDAI). Methods: One hundred patients with active RA (as per ACR 1987 criteria) were assessed for disease activity using DAS28, CDAI, and RADAI-5. Spearman's correlation coefficient (ρ) and Cronbach's alpha were measured to assess the correlation between different disease activity scores and internal consistency, respectively. Results: In the study population, 81 patients were women and 19 patients were men. Mean age of the patients was 44.4 (±11.8) years. The median scores (interquartile range) for DAS28, CDAI, and RADAI-5 were 5.6 (2.0), 26.5 (22.0), and 5.8 (3.2), respectively. RADAI-5 was found to be significantly correlated with DAS28 and CDAI (allP < 0.001). Cronbach's alpha was highest for the RADAI-5. Conclusion: RADAI-5 had a positive correlation to DAS28 and CDAI for the assessment of disease activity, and it may be a good alternative to DAS28 and CDAI in busy outdoor settings.
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Outcome of therapy in biopsy proven lupus nephritis with cyclophosphamide or mycophenolate: Registry data from a South Indian tertiary care center p. 76
Keerthi Talari, Rajendra Varaprasad Irlapati, Megha Uppin, Liza Rajasekhar
DOI:10.4103/0973-3698.199126  
Background: Cyclophosphamide and mycophenolate are the currently proposed first-line agents for induction in lupus nephritis (LN). In this study, we analysed the response rates with the three different induction regimens currently available for LN. Methods: Patients with biopsy-proven LN with data available at least till completion of induction regimen was included. Data on demography, clinical, laboratory measures, disease activity, and treatment received at baseline, at the end of induction, and until the last follow-up were retrieved. Response at the end of induction was noted. Differences between groups were analyzed using Chi-square test. Results: Eighty-three patients (75 females) with the mean age of 25 ± 8.9 years were included. The median duration of follow-up was 18 months (range: 6–153). Forty-one patients had Class IV, 19 Class III, 11 Class V, 7 Class III/IV + V, and 5 Class II LN. Forty received high-dose cyclophosphamide (HD CyC), 14 Euro-Lupus Nephritis Trial cyclophosphamide (ELNT CyC), 20 mycophenolate mofetil (MMF) for induction, while two received azathioprine, one cyclosporine, one modified ponticelli, and five with Class II nephritis received no induction. Baseline characteristics were comparable between three groups. The response rate was similar between the three groups: 30/40 in the HD CyC group, 12/14 in the ELNT CyC group, and 15/20 in the MMF group responded at the end of induction (P = 0.69). Complete response rate was higher in the individuals who received cyclophosphamide (HD CyC + ELNT CyC) as compared to MMF (17/34 vs. 2/13, P = 0.05). Univariate analysis of factors predicting response revealed only class of nephritis as a significant factor predicting response (complete or partial) at the end of induction therapy. Conclusion: In this South Indian lupus registry a complete response at 6 months in biopsy-proven LN was better with cyclophosphamide than mycophenolate.
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Erosive arthritis and anti-cyclic citrullinated peptide antibodies in systemic sclerosis p. 81
A Abdessemed, N Khaldoun, A Tahiat, R Djidjik, Y Mellal, I Allam, S Slimani, A Haddouche, N Brahimi, M Ghaffor, A Ladjouze Rezig
DOI:10.4103/injr.injr_46_16  
Background: The frequency and characteristics of erosive arthritis in systemic sclerosis (SSc) remains unclear. The aim of the study was to determine the prevalence and characteristics of erosive arthritis and to define the role of anti-CCP antibodies in the differential diagnosis of joint involvement in SSc. Methods: One hundred and fifty patients who met the 1980 American College of Rheumatology (ACR) criteria and/or Leroy and Medsger criteria for SSc were assessed. Results: Among the 150 SSc patients, 139 were women. Their median age was 45.12 ± 13.59 years and disease duration ( first non-Raynaud symptom) of 9.7 years. Of these patients, 5 patients were classified as having limited SSc, 103 as limited cutaneous SSc and 42 as diffuse cutaneous SSc. Joint involvement was characterized as arthralgia in 95 (63%) patients, arthritis in 60 (40%) patients, erosive arthritis in 21 (14%) and systemic sclerosis (SSc)-rheumatoid arthritis (RA) overlap syndrome in 7 patients. The prevalence of diffuse cutaneous involvement (50%) (P = 0.01), digital ulcers (81%) (P = 0.009), interstitial lung disease (81%) (P = 0.009) and anti-topoisomerase I antibodies (P = 0.01) was higher in patients with erosive arthritis. Anti-CCP antibodies were found in 14 of the 150 (9.4%) cases. A statistically significant association between the presence of anti-CCP antibodies and the presence of arthritis (P = 0.01), erosive arthritis (P = 0.01) and SSc-RA overlap syndrome (P < 0.05) was noted. High titers of anti-CCP antibodies were found in patients with SSc-RA overlap syndrome. Conclusion: Erosive arthritis is not rare in SSc, and it might be a marker of severe disease. Anti-CCP antibodies can be present in patients with SSc, and high titers of anti-CCP antibodies may be indicative of SSc-RA overlap syndrome.
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Immune modulation effects of curcumin in pristane-induced lupus mice p. 86
Handono Kalim, Kusworini Handono, Takhta Khalasha, Mirza Zaka Pratama, Tri Wahyudi Iman Dantara, Ayu Pramitha Wulandari, Fahimma Albinsaid, Sofi Nur Fitria, Muhammad Vardian Mahardika
DOI:10.4103/injr.injr_95_16  
Background: Curcumin, a polyphenolic compound derived from food spice turmeric has been widely used in Asian traditional medicine for its medicinal properties as antitumor, antioxidant, and anti-inflammatory properties. Meanwhile, intraperitoneal (i.p.) injection of the hydrocarbon oil pristane into normal mice leads to a lupus-like autoimmune syndrome. We aimed to investigate the effects of curcumin on systemic lupus erythematosus (SLE) clinical manifestation, adaptive immune system components, proinflammatory cytokines, and autoantibody production in pristane-induced lupus mice. Methods: Fifty female BALB/c mice, 6–8 weeks old were divided into 2 groups: Forty mice received a single i.p. injection of 0.5 cc pristane for lupus induction and ten mice as healthy controls. Starting at 16 weeks after injection, forty pristane-induced lupus mice were divided into four groups based on doses of curcumin received intragastrically: 0, 12.5, 50, and 200 mg/kg bw/day daily for 16 weeks. At 32 weeks after injection, all of mice were assessed for arthritis score, proteinuria level, body weights, adaptive immune system components (Th1, Th2, Th17, and Treg percentages) from spleen using flow cytometry; proinflammatory cytokines and autoantibody production, including interleukin-6 (IL-6), interferon-alpha (IFN-α), and antinuclear antibody (ANA) from serum using enzyme-linked immunosorbent assay. Results: Arthritis score and proteinuria level were decreased in curcumin-treated mice. However, body weights were not significantly different between the groups. The decreased of Th1, Th2, and Th17 percentages were seen after treatment with 200 mg/kg bw/day of curcumin (P = 0.031,P = 0.017, andP = 0.005, respectively). However, only slight increase of Treg percentages was seen after curcumin treatment. Treatment with 200 mg/kg bw/day of curcumin decreased serum IL-6 and IFN-α levels (P = 0.007 andP = 0.003). Furthermore, ANA levels were also decreased significantly after treatment with 200 mg/kg bw/day of curcumin (P = 0.013). Conclusion: Our findings suggested that curcumin could prove useful as a therapeutic intervention in SLE.
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BRIEF REPORT Top

Use of art as therapeutic intervention for enhancement of hand function in patients with rheumatoid arthritis: A pilot study Highly accessed article p. 94
Sayali Khedekar, Apurv P Shimpi, Ashok Shyam, Parag Sancheti
DOI:10.4103/0973-3698.199130  
Background: Conventional physiotherapy treatment for patients with rheumatoid hand emphasizes on single-plane movements and strengthening exercises directed toward improvement of function and prevention of deformities. This may be nondirective and lacks creativity and hence may predispose to a high attrition from therapy. The current study aimed to evaluate the efficacy of art as a creative therapeutic procedure for enhancement of hand functions, self-perception, and quality of life in patients with rheumatoid arthritis (RA). Methods: A single-blinded, randomized controlled pilot study was conducted on 17 participants suffering from RA. The control group received conventional physiotherapy while the experimental group received art-based intervention with bimanual projects (viz., origami, paper quelling, clay modeling, and oil painting). Both groups received intervention for 45 min daily for 4 weeks. Pre- and post-interventional assessment was done using grip and pinch strength, Grip Ability Test (GAT), Jebsen–Taylor Hand Function Test (JHFT), Australian-Canadian Osteoarthritis Hand Index (AUSCAN), Michigan Hand Outcome Questionnaire (MHQ), and Health Assessment Questionnaire (HAQ). Results: There was an improvement in hand functions (grip strength [P = 0.042], two-point pinch strength [P = 0.039], three-point pinch strength [P = 0.043], GAT [P = 0.043], JHFT [P = 0.043]), self-perception (AUSCAN [P = 0.043], MHQ [P = 0.043]), and quality of life (HAQ;P = 0.043) in art therapy patients which was similar to conventional therapy patients. Conclusion: Art is an equally effective therapeutic intervention to conventional therapy for the enhancement of hand functions, self-perception, and quality of life in patients with RA.
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REVIEW ARTICLE Top

Diagnosis and management of rheumatic manifestations of Hepatitis B, Hepatitis C and immunodeficiency Virus p. 97
Arun Ramesh Chogle
DOI:10.4103/injr.injr_96_16  
Hepatitis B, hepatitis C virus and human immunodeficiency virus infections are important causes of virally mediated arthritis. These can pose several diagnostic and therapeutic dilemmas. This review analyzes the recent publications on this topic and discusses the related issues on diagnosis and treatment.
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TOPICAL REVIEW Top

Recent evidence comparing combination of conventional synthetic disease-modifying antirheumatic drugs with biologic disease-modifying antirheumatic drugs in rheumatoid arthritis p. 104
Abhishek Zanwar, Sakir Ahmed, Durga Prasanna Misra, Vikas Agarwal, Aman Sharma, Anupam Wakhlu, Vir Singh Negi
DOI:10.4103/injr.injr_37_17  
Rheumatoid arthritis (RA) is a chronic, disabling inflammatory arthritis often treated with a variety of disease-modifying antirheumatic drugs (DMARDs), whether conventional synthetic DMARDs (csDMARDs), targeted synthetic DMARDs (tsDMARDs), or biological DMARDs (bDMARDs). Most patients with RA are seropositive, have significant disease activity at presentation to the Rheumatologist and may have erosions at the time of diagnosis, all of which are poor prognostic factors. Patients with RA are often initially started on methotrexate (MTX), with addition of other DMARDs, the usual practice in the event of failure of/suboptimal response to MTX monotherapy. Since the recent guidelines by the European League against Rheumatism favor the use of bDMARDs over the combination of csDMARDs following the failure of MTX monotherapy in patients with such poor prognostic factors, we decided to review the recent literature comparing combination csDMARDs with bDMARDs. Long-term follow-up of landmark trials such as the Behandel-Strategieëen study (10 years) and NEO-RACo study (5 years) as well as other trials supports similar efficacy of both strategies in terms of clinical and functional outcomes. Whereas some studies have shown a minor but statistically significant progression of radiographic damage in those receiving combination of csDMARDs versus those on bDMARDs, others have not, further confirmed in a recent meta-analysis. Thus, keeping in mind, the similar efficacy and better cost-effectiveness of combination of csDMARDs, this should be the preferred strategy following failure of MTX monotherapy. bDMARDs should be reserved when combination csDMARDs fail, especially in an Indian scenario where most patients are poor and a majority of healthcare is not government-sponsored.
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IMAGES IN RHEUMATOLOGY Top

Atraumatic bilateral subtrochanteric fracture in a young female with osteomalacia p. 110
Urmila Dhakad, Rasmi Ranjan Sahoo, Siddharth Kumar Das, Danveer Bhadu, Meha Sharma
DOI:10.4103/injr.injr_19_17  
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Large-vessel giant cell arteritis: A rare cause of stroke p. 112
Himanshu Pathak, Cee Yi Yong, Karl Gaffney
DOI:10.4103/injr.injr_7_17  
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LETTERS TO EDITOR Top

Splitting dose of methotrexate in the management of rheumatoid arthritis: Making a mountain out of a molehill? p. 114
Navaf Kozhippurath Mohamedali, Vinod Ravindran
DOI:10.4103/injr.injr_42_17  
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Internal medicine residents' perception of rheumatology as a subspecialty: A web-based survey p. 116
Keerthi Talari, Kirthi Theja Bommakanti
DOI:10.4103/0973-3698.202127  
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Scleroderma esophagus: A case series p. 118
Mayank Jain, Rajiv Baijal
DOI:10.4103/0973-3698.202126  
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Comment on “Ultrasonographic evaluation of joint involvement in rheumatoid arthritis: Comparison with conventional radiography and correlation with disease activity parameters” p. 120
Iftikhar Ahmad
DOI:10.4103/injr.injr_31_17  
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BOOK REVIEW Top

Pediatric rheumatology: a clinical viewpoint p. 121
Geetha Rajan, Vinod Ravindran
DOI:10.4103/0973-3698.203088  
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