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IRACON 2016: Poster Presentations

October 2016, 11(5):20-108
  2,505 322 -
New treatments for systemic lupus erythematosus
Robert George Lahita
March 2017, 12(1):48-51
New therapies for systemic lupus erythematosus are rare. This is because of the complexity of the disease and its varied presentations. There are many variables and a variety of measurement scales that must be satisfied before a new agent is approved for use in humans. Attempts are ongoing to develop biological treatments for the disease using three approaches: B cell modulation, T cell regulation and cytokine inhibition. This paper reviews the current state of these three critical areas.
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Emerging evidence-based therapies for systemic sclerosis
Jasmin Raja, Christopher P Denton
September 2016, 11(3):153-163
Systemic sclerosis (SSc) (scleroderma) is an uncommon multisystem connective tissue disease with high unmet need and mortality. There has been an improvement in overall outcome and survival over the past three decades, but it still has the highest mortality among any of the autoimmune rheumatic diseases. Progress in its management has come through more organized assessment and treatment together with the emergence of therapies that can target specific complications of the disease such as renal crisis and pulmonary arterial hypertension. In addition, there is a growing understanding of pathogenesis that allows more targeted approaches to therapy to be explored in clinical trials. In this review, several aspects of SSc management including the more targeted therapies including strategies to block specific pathways or mediators have been discussed.
  1,392 221 -
Pulmonary hypertension associated with connective tissue disease
Srinivas Rajagopala, Molly Mary Thabah
March 2017, 12(1):38-47
Pulmonary hypertension (PH) is an important cause of morbidity and mortality in connective tissue diseases (CTDs). CTDs may cause PH due to several mechanisms; pulmonary arterial hypertension, associated interstitial lung disease, neuromuscular disease, and/or sleep disordered breathing leading to hypoxia, associated thromboembolic PH, and pulmonary venous hypertension due to left ventricular dysfunction. PH can be measured on echocardiography, but the gold standard for diagnosis is right heart catheterization. PH-specific therapy in addition to immunosuppression is the most common treatment used though data are scant. In this narrative review, we discuss the epidemiologic burden, clinical presentation, evaluation, and management of PH in CTDs.
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IRACON 2016: Oral Presentations

October 2016, 11(5):2-19
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Antiphospholipid syndrome in pregnancy
Anisur Rahman
November 2016, 11(6):117-121
Antiphospholipid syndrome (APS) is an autoimmune condition, in which antiphospholipid antibodies (aPL) cause clinical features including thrombosis, fetal loss, and preterm delivery. Studies in large numbers of patients with APS show that they suffer both early and late fetal loss as well as complications of pregnancy such as preeclampsia. The fetal loss in patients with APS is not caused primarily by thrombosis, but by a number of biological effects of aPL that affect implantation of the embryo. These factors are not yet understood fully but include effects on trophoblast cell viability and migration, inflammation at the fetal-maternal interface, and activation of complement. The established management of pregnancy in patients with known obstetric APS is to give daily low-dose oral aspirin plus daily subcutaneous heparin. This gives a live birth rate of over 70%. The trials that led to this form of management being adopted were small but overall do support the use of the heparin/aspirin combination over aspirin alone. There is no definite evidence supporting the use of heparin plus aspirin in patients who are aPL-positive, but who have never suffered any problems in pregnancy. However, patients taking long-term warfarin for thrombotic APS should have this changed to heparin during pregnancy.
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Checklist prior to biologics: Indian perspective
Rajkiran Dudam, Narsimulu Gumdal
September 2016, 11(3):126-128
  1,149 285 -
Experience of biological agents usage in patients with rheumatoid arthritis from a Western Indian center
Anuj Singhal, Darshan Bhakuni, Vishal Marwaha, Vivek Hande, Garvit Bagga
September 2016, 11(3):144-148
Background: In this study the clinical outcomes of different biologics agents in patients with rheumatoid arthritis (RA) has been appraised. Methods: Nineteen RA patients with DMARD failure were administered etanercept (n = 7) or infliximab (n = 12), and 17 RA patients with TNFi failure were administered rituximab (n = 13), abatacept (n = 2), or tocilizumab (n = 2) as per 2013 EULAR guidelines. Baseline demographic details, disease duration, rheumatoid factor, and anticyclic citrullinated peptide antibody were obtained. To monitor disease activity, disease activity score 28-erythrocyte sedimentation rate (DAS28-ESR) score was obtained at baseline, and after 3 months and 6 months of therapy initiation. Results: All the groups were comparable in the baseline. Over 6 months of treatment, the reduction in disease activity, as evidenced by reduction in the mean DAS28-ESR scores was statistically significant for all patients when considered together, as well as when individual biologics were considered separately (P < 0.05 in all cases). However, there was no statistically significant difference in the magnitude of reduction in the mean DAS28-ESR scores between patients who received etanercept and infliximab in DMARD failure RA patients (P = 0.877), or between patients who received rituximab, abatacept, and tocilizumab in TNFi failure patients (P = 0.455). Conclusions: Different biologic agents showed similar efficacy in patients with RA.
  1,273 159 -
Use of art as therapeutic intervention for enhancement of hand function in patients with rheumatoid arthritis: A pilot study
Sayali Khedekar, Apurv P Shimpi, Ashok Shyam, Parag Sancheti
June 2017, 12(2):94-96
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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Rheumatoid arthritis disease activity index-5: Utility in busy clinical settings
Harpreet Singh, Vikram Singh Tanwar, Gagandeep Sukhija, Rekha Mathur, Parminder Kaur
June 2017, 12(2):72-75
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.
  1,160 162 -
Is renal biopsy always necessary to start immunosuppressive therapy in lupus nephritis?
Vasudevan Chelliah, V Balaraman, S Ilango, S Ramesh, V Kannan Bhaba, D Shivakumar
March 2017, 12(1):12-16
Objective: Most of the patients with proliferative lupus nephritis (LN) have high titer of anti-dsDNA antibody and low complement levels. In this study, we tried to predict proliferative LN with serological profile. Methods: This prospective study was conducted in fifty pateints with known systemic lupus erythematosus (SLE) with laboratory evidence of LN (proteinuria, microscopic hematuria, or increased serum creatinine). Serological profile (anti-dsDNA, C3, and C4) and renal biopsy were done in all patients. Results: Of 50 patients, 35 had Class IV (70%), 7 Class II (14%), 4 Class V (8%), and 4 had Class IV and V (8%) on renal biopsy. Totally, 39 (78%) patients had proliferative LN (Class IV and Class IV and V). The prevalence of anti-dsDNA, low C3, and low C4 was 97.1%, 68%, and 74% with LN and 97.4%, 84.6%, and 87.2% with proliferative LN (P < 0.001), respectively. About 72% (28 of 39 patients) with proliferative LN had the combination of anti-dsDNA positivity, low C3, and low C4 levels. However, whoever had the combination of anti-dsDNA positivity, low C3, and low C4 showed only proliferative LN on biopsy. Positive predictive value was 100% (P < 0.05). None of the patients with Class II or Class V (nonproliferative LN) had this combination of serology. Conclusion: In this study, it was found that proliferative LN can be predicted by serological profile alone. Thus it might be argued that immunosuppressive therapy (steroids and mycophenolate mofetil) may be started without renal biopsy in a known SLE patient with laboratory evidence of LN and positive serology; however, robust studies are required.
  1,123 158 -
Ultrasonographic evaluation of joint involvement in rheumatoid arthritis: Comparison with conventional radiography and correlation with disease activity parameters
Renu Saigal, Laxmikant Goyal, Hariram Maharia, Meenakshi Sharma, Abhishek Agrawal
March 2017, 12(1):6-11
Background: Ultrasound (US) including power Doppler (PD) are increasingly being used to evaluate joint involvement in rheumatoid arthritis (RA). Aim of this study was to evaluate joint involvement in RA by US including PD and gray scale imaging and its comparison with conventional radiographic changes and correlation with disease activity parameters. Methods: Patients with RA of less than 3.5 years disease duration were subjected to detailed clinical examination and laboratory investigations. After X-ray imaging (posterior-anterior view) of both hand joints, PD and gray scale US examination of 14 joints of both hands was performed and mean cumulative flow signal score (CFS) was calculated. Disease activity score (DAS28) was also calculated for each patient. Results: Out of total 57 patients evaluated, 54 had abnormal findings on US as compared to only 17 having radiographic abnormalities. US could detect erosions in 29 patients including all of the fourteen patients who had radiographically detectable erosions. On US evaluation, radiocarpal joint was involved most frequently. The mean CFS was 1.17 ± 1.64 in patients who were in remission (DAS28 <2.6), 3.00 ± 3.46 in patients having low disease activity (DAS28 2.6–3.2), 5.25 ± 4.22 in patients with moderate disease activity (DAS28 3.2–5.1), and 6.95 ± 3.84 in patients with high disease activity (DAS28 > 5.1). The difference in CFS among these groups was statistically significant (P < 0.01). In 5 out of 12 patients with DAS28 <2.6, i.e., in remission, CFS were high showing subclinical synovitis. Mean CFS correlated significantly with DAS28 (r = +0.42, P < 0.05); C-reactive protein (r = +0.50, P < 0.05); and erythrocyte sedimentation rate (r = +0.39, P < 0.05). Conclusions: US detected CFS which an indicator of ongoing inflammation in RA patients with clinical remission (DAS28 <2.6). US is more sensitive than conventional radiography for detection of erosions. CFS on PD had a significant correlation with markers of disease activity.
  1,098 164 -
Inflammatory rheumatic diseases in the elderly
Vikramraj K Jain, Vir Singh Negi
December 2016, 11(4):207-215
Rapid aging of world's population will translate into more elderly patients in the near future. Diagnosis of inflammatory rheumatic diseases in this age group is complicated by atypical clinical features compared to the younger onset group, nonspecific positivity of serological parameters, and confounding radiological signs. Management of these diseases also presents unique challenges in lieu of altered physiology of elderly, cognitive decline, presence of comorbidities, and altered immune system (inflammaging). Hence, this review attempts to synthesize the existing knowledge of the clinical, diagnostic, and therapeutic idiosyncrasies of inflammatory rheumatic diseases in this subgroup of population.
  1,091 166 -
Fertility and pregnancy in systemic lupus erythematosus
Alexis Jones, Ian Giles
November 2016, 11(6):128-134
Systemic Lupus Erythematosus (SLE) is a chronic multisystem autoimmune disease with a heterogeneous pattern of clinical and serological manifestations. The predilection for women, particularly of childbearing age, combined with improved survival has led to increasing numbers of women with lupus considering pregnancy. Management of pregnancy in SLE however, requires careful planning and close medical and obstetric monitoring to ensure optimal outcomes. This review, discusses possible causes of subfertility, issues regarding contraception and family planning as well as management of lupus during pregnancy and outcomes in pregnant women with SLE.
  1,027 182 -
Carcinomatous polyarthritis as a presenting manifestation of papillary carcinoma of thyroid gland
Himanshu Pathak, Ray Lonsdale, Ketan Dhatariya, Chetan Mukhtyar
September 2016, 11(3):164-166
A 61-year-old female presented with 6 months of polyarthralgia associated with constitutional symptoms. These included weight loss, night sweats, lethargy and worsening mobility and activities of daily living. There was no significant medical history. On examination, she had synovitis of multiple joints. Investigations for rheumatoid factor and anti-cyclic citrullinated peptide antibody were negative. There was an acute phase response in the form of raised erythrocyte sedimentation rate and C-reactive protein. Contrast-enhanced computed tomography showed pancreatic and right ovarian cystic lesions, which turned out to be clinically insignificant. Positron emission tomography-computed tomography demonstrated fluorodeoxyglucose avid lesion in the right hemi-thyroid. Ultrasound of thyroid gland showed a 13 mm hyporeflective, irregular, subcapsular nodule in the upper lobe with some microcalcification. Fine needle aspiration cytology was diagnostic of papillary carcinoma, confirmed on total thyroidectomy. Arthritis completely resolved within 8 weeks postoperatively. We report the first case of paraneoplastic carcinomatous polyarthritis in association with a papillary thyroid carcinoma as evidenced by a resolution of joint manifestations and laboratory markers of inflammation posttotal thyroidectomy.
  1,116 77 -
Outcome of therapy in biopsy proven lupus nephritis with cyclophosphamide or mycophenolate: Registry data from a South Indian tertiary care center
Keerthi Talari, Rajendra Varaprasad Irlapati, Megha Uppin, Liza Rajasekhar
June 2017, 12(2):76-80
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.
  1,039 116 -
Renal biopsy in lupus nephritis: To do or not to do?
Manish Rathi, Aman Sharma, Ritambhra Nada
March 2017, 12(1):2-3
  985 158 -
Test–retest reliability and correlates of 6-minute walk test in patients with primary osteoarthritis of knees
Mahamed Ateef, Sivachidambaram Kulandaivelan, Shaziya Tahseen
December 2016, 11(4):192-196
Background: In the assessment of primary osteoarthritis (OA) of knees several clinical tool including 6 minutes walk test (6 MWT) are used. The objective of this study was to to analyze the test-retest reliability of 6 MWT and its correlation with various parameters. Methods: Eighty patients (age, 56-79 years) with OA of knees met the inclusion criteria. Demographic and clinical characteristics including radiological severity of OA (by X-ray K/L grading) were recorded. Patients filled in the knee injury and osteoarthritis outcome score (KOOS) questionnaire. All patients performed 6 MWT twice with at least 48 h gap in-between. Results: Test–retest reliability of 6 MWT in primary OA knee patients was excellent with ICC 0.991 (95% confidence interval was 0.986–0.994). 6 MWT had a weak correlation with KOOS-symptom and KOOS-activities of daily living (rho = 0.397 and 0.364 respectively), a strong correlation with KOOS-pain and KOOS-sports (rho = 0.605 and 0.521 respectively), and a very strong correlation with KOOS-quality of life (rho = 0.758). It had a weak correlation with age and height (r = 0.497 and 0.302), a strong correlation with VAS, weight, and BMI (rho = −0.655, r = −0.510, and − 0.691, respectively), and a very strong correlation with disease severity (rho = −0. 849). Conclusion: 6 MWT was a reliable test and positively correlated with all KOOS subscales and negatively correlated with other parameters except height in primary OA knee.
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Do we need renal biopsy in patients with lupus nephritis? A rheumatologist's perspective
Gurmeet Singh
March 2017, 12(1):4-5
  939 98 -
Lupus pregnancies: An Indian perspective
Mithun C Mohan, Vinod Ravindran
November 2016, 11(6):135-138
There are several challenges to a successful pregnancy outcome in patients with lupus in India including unplanned pregnancies, myths and false beliefs related to lupus pregnancies and poor access to dedicated care. Pregnant lupus patients are best managed by a multidisciplinary team consisting of rheumatologist, obstetrician, and other relevant specialists. In this narrative review, we have appraised available literature on the outcomes of pregnancy among lupus patients in India, highlight the lacunae in the care of such patients, and also present perspective of this issue based on our own experience.
  853 153 -
Open-label use of Anakinra (Kineret) in the treatment of patients with osteoarthritis
Craig Davis Scoville, John Partridge Dickson
March 2017, 12(1):17-22
Background: Novel treatments for osteoarthritis (OA) are needed for patients not responding to and/or not tolerating conventional treatments. In this prospective study the usefulness of Anakinra (Kineret) in the treatment of OA was evaluated. Methods: Eleven patients with symptomatic OA were treated with Anakinra (Kineret) over a 2–3 month period. Efficacy of response was determined if patients showed >30% improvement in the Western Ontario and McMaster Universities Osteoarthritis Index and/or Australian/Canadian Osteoarthritis Hand Index scoring with treatment. Nine of the 11 patients received Kineret intra-articular (IA) injections and 2/11 patients with erosive polyosteoarthritis received Kineret 100 mg subcutaneous injections daily for 30 days. Results: One of the two patients receiving systemic administration of Kineret showed mild efficacy. A total of 21 IA Kineret injections were performed on nine patients. Only 2/5 patients receiving IA Kineret injections into small/medium-sized joints showed efficacy and only 2/5 patients receiving IA Kineret injections into large joints (knees, shoulders) showed efficacy – but those patients showing efficacy with large joints injections had >50% improvement. Conclusion: In this study it was found that patients receiving large joint injections were more likely to show greater efficacy than those receiving small joint injections. Therefore, there seems to be a possible benefit of using Kineret (150–200 mg) in the treatment of OA in large joints and may represent an alternative to IA steroid in those patients in whom steroids may be contraindicated.
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Treatment outcomes from a multiethnic lupus cohort with proliferative nephritis
Angela Pakozdi, Ravindra Rajakariar, Michael Sheaff, Debasish Pyne
September 2016, 11(3):136-143
Objective: To assess treatment responses and long-term outcomes in a multiethnic lupus cohort with proliferative lupus nephritis (LN) from a single United Kingdom (UK) center. Methods: 86 lupus patients were diagnosed with active proliferative LN between 1995 and 2015 at Barts Health, a large inner city hospital in London, UK. They were grouped by ethnicity into South Asians (Bangladeshi, Indian, Pakistani, and Sri Lankan), blacks (African Blacks and Afro-Caribbeans), and Caucasians. Remission rates were analyzed at 6 and 24 months after induction treatment with cyclophosphamide (CYC) or mycophenolate mofetil (MMF). Prognostic factors for the treatment response were identified by regression analysis. Kaplan-Meier method was applied to assess long-term renal survival and Cox proportional hazards model for risk factors for developing end-stage renal disease. Results: MMF achieved a higher remission rate in blacks compared to CYC (70% vs. 16.7%, P = 0.005) at 6 months, showed a trend in Asians (77.8% vs. 38.9%, P = 0.057), and comparable response in Caucasians (42.9% vs. 55.6%, P = 0.614). Low baseline serum creatinine was the strongest predictor for favorable treatment response (odds ratio 0.98, 95% confidence interval [95% CI]: 0.97-0.99, P = 0.045). Renal survival glomerular filtration rate (GFR >15 ml/min/1.73 m 2 ) was 79.8% and 75.6% at 5 and 10 years, lowest in blacks (60.5%) followed by Asians (86.7%) then Caucasians (88.9%) (P = 0.030). Low GFR (GFR <30 ml/min/1.73 m 2 ) on presentation was an independent risk factor for poor 10 years renal survival (hazard ratio 32.55, 95% CI: 3.70-286.64, P = 0.002). Conclusions: MMF appears to be at least as effective as CYC as an induction agent in this multiethnic cohort but there were important differences in long-term renal outcomes based on ethnic group and baseline GFR and creatinine.
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Neonatal lupus: An update
Sathish Kumar
November 2016, 11(6):139-144
Neonatal lupus erythematosus (NLE) is a syndrome that usually presents in the fetus or neonates that is caused by transplacental passage of autoantibodies from the mother. It is a clinical spectrum of cutaneous, cardiac, and systemic abnormalities observed in the newborn or infants whose mothers have autoantibodies against Ro/SSA and/or La/SSB. Congenital complete heart block is the most serious manifestation of NLE that can develop in utero or after birth. Multidisciplinary team involvement is indicated. This article will provide an overview the presentation of NLE and will review the evidence for current therapies.
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Racial differences in presentation and treatment outcome of lupus nephritis
Manish Rathi, Aman Sharma
September 2016, 11(3):124-125
  808 120 -
From the editor's desk
Vinod Ravindran
March 2017, 12(1):1-1
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