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   Table of Contents - Current issue
September 2020
Volume 15 | Issue 3
Page Nos. 149-254

Online since Thursday, September 3, 2020

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Journal metrics: Different from author metrics p. 149
Chengappa Kavadichanda
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The true meaning of plagiarism p. 155
Sakir Ahmed, Prajna Anirvan
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Platelet-rich plasma therapy for knee osteoarthritis: The jury is still out p. 159
Nilesh Nolkha
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Blaming the peer reviewer: Don't shoot the messenger!! p. 162
Durga Prasanna Misra, Vikas Agarwal
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Comparison of intra articular autologous platelet-rich plasma with steroids in osteoarthritis knee: Experience from a North Indian tertiary care center p. 165
MN Arjun, Vivek Vasdev, Kunal Kishore, Arun Hegde, Krishnan Shanmuganandan, Abhishek Kumar, Uday Bhanu Kovilapu, Roopa Shivashankar
Background: Intra-articular (IA) platelet-rich plasma (PRP) is a promising treatment option for knee osteoarthritis (OA). It accelerates the process of healing, ligament repair, cartilage regeneration, and bone formation when given in supraphysiological doses. The aim of this study was to compare the efficacy of IA PRP versus IA methylprednisolone acetate (MPA) in patients with knee OA. Methods: Open labeled prospective observational study was conducted on 60 patients with Kellgren-Lawrence Grade 2 and 3 OA knee, who fulfilled the ACR classification criteria for knee OA. Thirty patients were given IA PRP (6 ml) and 30 received IA methyl prednisolone (80 mg) at baseline line, which was repeated at 12 weeks. The primary endpoint was an improvement in Western Ontario and McMaster Universities Index (WOMAC) and 100 mm Visual Analog Scale (VAS) pain at 24 weeks postinjections. Results: The mean change in VAS pain and total WOMAC score from baseline to 24 weeks was 32.9 ± 12.1, 31.8 ± 14.7 for PRP group, and 12.9 ± 5.9, 7.5 ± 5.5 for MPA group, which was statistically significant (P < 0.0001). Conclusions: Treatment with IA PRP showed sustained improvements in WOMAC and VAS scores compared to IA steroids. PRP is an effective treatment for functional status and pain in moderate knee osteoarthritis.
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Perception about social media use by rheumatology journals: Survey among the attendees of IRACON 2019 Highly accessed article p. 171
Sakir Ahmed, Latika Gupta
Background: Rheumatology journals are exploring social media presence, though currently less than a third have dedicated social media editors. Methods: A survey was conducted among the attendees of the Indian Rheumatology Association annual meet 2019 held at Puducherry, to assess the attitudes and perceptions of a target audience. Results: There were 111 respondents, 90 practicing rheumatology and 21 from allied fields. Around threequarters (76.6%) have never subscribed to hard copies of any journal and 65% followed at least one medical journal on at least one social media platform; 87% preferred visual cues for learning and 95% felt the need for visual abstracts to promote articles on social media. Two-thirds (64%) felt that Altmetrics® might reflect the impact of an article better than the number of times it is cited. Conclusion: Thus, the survey strengthened the felt need of rheumatology journals to have a presence on the social media. This presence ought to be supported by a strategy, including the active use of visual abstracts.
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Evaluation of a new biomarker 14-3-3 Eta protein in diagnosis of rheumatoid arthritis p. 175
Lakshmi Deepika Yarlagadda, Rachel Jacob, D Liza Rajasekhar, Krishna Mohan Iyyapu, Sai Baba S S. Kompella, Vijaya Bhaskar Madrol, NN Sreedevi, Siraj Ahmed Khan, Noorjahan Mohammed
Context: The lack of sensitivity and specificity of the existing diagnostic markers in Rheumatoid arthritis (RA) stimulates the search for new biomarkers to improve diagnostic sensitivity especially in seronegative cases. Aims: To estimate the levels of 14-3-3 η in RA cases, to assess the positivity of 14-3-3 η in seronegative RA and to correlate rheumatoid factor (RF) positivity with 14-3-3 η positivity in seropositive RA. Settings and Design: This was cross sectional case control study by the Departments of Biochemistry and Rheumatology and clinical immunology. Subjects and Methods: A total of 61 RA cases and 20 healthy controls were included. Erythrocyte sedimentation rate, high sensitivity C reactive protein, RF, anti-citrullinated peptide antibodies (CCP) and 14-3-3 η protein were estimated. RA cases were further classified as seropositive (n = 23) and seronegative (n = 38) based on the positivity of either RF or anti-CCP result. Statistical Analysis: Prism 7 (GraphPad Software Inc.). Results: The median levels of 14-3-3 η (ng/ml) in cases (0.66 [0.2–1.1]) were significantly high compared to controls (0.1 [0.07–0.28]), P < 0.0001. It had a sensitivity of 74% and specificity of 90% at >0.3 ng/ml. 14-3-3 η showed statistically significant difference between seronegative cases and controls (P = 0.0003). The sensitivity and specificity of RF and anti-CCP were 33% and 85% and 37% and 90% respectively. The combination of 14-3-3 η, RF and anti-CCP showed sensitivity and specificity of 85.4% and 100% respectively with area under the curve 0.927. Conclusions: Our study demonstrated that serum levels of 14-3-3 η were significantly higher in cases compared to controls. Seronegative RA cases showed 14-3-3 η positivity in 71% of cases. 14-3-3 η appears to be a useful and highly specific marker in RA.
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The clinical and immunological profiles of systemic lupus erythematosus patients from Assam, North-East India p. 181
Debashree Talukdar, Akash Protim Gogoi, Daisy Doley, Rebecca R Marak, Sanjeeb Kakati, Vandana Pradhan, Anita H Nadkarni, Shashi Baruah
Objective: The objective of this study is to document the clinical and immunological profiles of systemic lupus erythematosus (SLE) patients from the Upper Assam region and to evaluate the relevance of autoantibody combinations on the clinical presentation of SLE. Materials and Methods: One hundred and forty-five SLE patients were enrolled in the study. Anti-nuclear antibody (ANA) profiles and titers of autoantibodies were determined using the ANA blot and enzyme-linked immunosorbent assay, respectively. The patients were clustered based on autoantibody titers and clinical features among the clusters were compared. Results: Mucocutaneous (87.59%), hematological (69.65%), renal (58.03%), and musculoskeletal (50.34%) manifestations were the common clinical complications, whereas anti-double stranded deoxyribonucleic acid (dsDNA) antibody was noted in 62.76% of the patients. Patient clustering using autoantibody titers revealed that the cluster with a combination of high titers of anti-dsDNA, anti-nucleosome (Nuc), and anti-ribosomal P (Rib-P) antibody had complex disease presentation with higher frequencies of oral/nasal ulcer, serositis, musculoskeletal, hematological, and central nervous system manifestations. Conclusion: The most common clinical features of the SLE patients were mucocutaneous, hematological, renal and musculoskeletal manifestations, and anti-dsDNA antibody was the most frequent autoantibody. A combination of high titers of anti-dsDNA, anti-Nuc, and anti-Rib-P antibodies showed association with disease complexity but not the combinations of autoantibodies against extractable nuclear antigens.
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Neutrophil-to-lymphocyte ratio: A biomarker for predicting systemic involvement in iga vasculitis p. 187
Rintu Merin George, Arun C Inamadar, Ajit B Janagond
Context:“IgA vasculitis, is an immune complex mediated, self limited cutaneous small vessel vasculitis, characterized by palpable purpurae, arthralgia or arthritis, gastrointestinal and/or renal involvement.” Systemic involvement is considered to be the presence of gastrointestinal (GI) and/or renal involvement in IgA vasculitis patients. Neutrophil-to-lymphocyte ratio (NLR) is a relatively cost-effective and easily obtainable laboratory parameter integrating information on two immune pathways to provide a superior predictive ability over other inflammatory parameters regarding systemic involvement. Aims: The aim of the study was to assess the predictive value of NLR with regard to the systemic involvement in IgA vasculitis. Subjects and Methods: This was a hospital-based cross-sectional study of patients diagnosed with IgA vasculitis, irrespective of age, between 2017 and 2019. Results: The study consisted of 33 patients with a mean age of 33.52 ± 19.78 years. Joint involvement was observed in 52% (17), whereas systemic manifestations in the form of renal involvement were present in 7 (21%), GI in 19 (57.6%), and renal and/or GI in 22 (66.7%) patients. NLR was found to be significantly associated with GI manifestations (P < 0.001). Optimal cutoff value of NLR for predicting systemic involvement was 3.25, with a specificity of 100% and sensitivity of 59%. Conclusions: NLR can be considered as a biomarker for predicting systemic involvement in IgA vasculitis, presenting with only cutaneous with/without joint manifestations.
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Ultrasonographic measurement of the peroneal and tibial nerves in patients with rheumatoid arthritis with symptoms or signs of polyneuropathy: A cross-sectional study p. 192
Serdar Kaymaz, Hakan Alkan, Uǧur Karasu, Veli Çobankara
Background: Drug toxicity, vasculitis, entrapment neuropathy, and amyloidosis are among the various different reasons of peripheral neuropathy in rheumatoid arthritis (RA). We aimed to determine the cross-sectional areas (CSA) of the peroneal and tibial nerves in patients with RA who had neuropathic symptoms, and to determine a cutoff value for peroneal and tibial nerves CSA by ultrasonography (USG) to diagnose polyneuropathy (PN) in patients with RA. Materials and Methods: Sixty-nine patients with RA and thirty healthy controls were included in this cross-sectional study. According to nerve conduction study (NCS) test, patients with RA were divided into two groups, diagnosed as having PN or not. Demographic data, laboratory findings, CSA of bilateral peroneal and tibial nerves, NCS values, and painDETECT (PD-Q) scores of all patients were assessed. Disease duration, disease activity score 28, duration of neuropathic symptoms, and Health Assessment Questionnaire of patients with RA were also determined. Results: No statistically significant difference was found among the groups in terms of age, gender, and laboratory findings. However, a statistically significant difference was found among these three groups in comparison with PD-Q, NCS values, and nerve CSA (P < 0.05). Seropositivity was statistically higher in the group with PN. When peroneal nerve CSA cutoff value was taken as 20 mm2, sensitivity and specificity values were 96.6% and 79.6%, respectively, for the diagnosis of PN (area under the curve [AUC] = 0.962). When tibial nerve CSA cutoff value was taken as 8.5 mm2, the sensitivity and specificity values were 93.1% and 71.6%, respectively, for the diagnosis of PN (AUC = 0.897). Conclusion: USG can be used as a noninvasive diagnostic modality in the assessment of RA-associated PN.
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Determinants of self-care behaviors in patients with knee osteoarthritis based on the theory of planned behavior in Iran p. 201
Mohammad Ali Morowatisharifabad, Sakineh Gerayllo, Zohreh Karimiankakolaki, Ali Dehghan, Hossein Soleymani Salehabadi, Hossein Fallahzadeh
Introduction: Knee osteoarthritis (OA) is one of the most prevailing causes of knee joint pains depending on age and one of the main reasons for functional deficiency. As patients are in need of effective self-care plans in promoting health, so that, this study was conducted with an aim to study the determinants of self-care behaviors in the patients with knee OA referring to clinical centers of Yazd city based on theory of planned behavior (TPB). Methods: The cross-sectional study was performed on 235 patients who referred to the health-care centers of Yazd city. A questionnaire was developed and used to collect the data based on TPB constructs. Data were analyzed using SPSS 18 software and by the statistical tests of correlative coefficient, Chi-square, and linear regression at 0.05 significance level. Results: This study was conducted on 235 patients. Based on the results of Pearson correlation test, the self-care behaviors of knee OA had a statistically significant positive correlation with all constructs of the TPB (P < 0.05). Following data analysis, the constructs of the TPB predicted 8% of the variance of intention and 16.2% of the variance of OA self-care behaviors. Conclusion: According to the results, the TPB can be suitable for explaining knee OA self-care behavior. Furthermore, recurrent training can be effective in promoting behavioral intention of patients in self-care.
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Autoinflammatory diseases: Emerging phenotypes p. 207
Gummadi Anjani, Surjit Singh, Amit Rawat
Autoinflammatory diseases (AIDs) are a heterogeneous group of genetically inherited disorders involving genes regulating innate immune response. The genetic basis of several AIDs has been characterized and many new syndromes have been identified in the past few years. This review focuses on some of the common AIDs encountered in clinical practice.
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Convalescent plasma therapy in severe coronavirus disease-2019: A narrative review Highly accessed article p. 217
Rasmi Ranjan Sahoo, Kasturi Hazarika, Prashant Bafna, Manesh Manoj, Anupam Wakhlu
Passive immunotherapy using whole blood or plasma from recovered patients is a potential therapeutic strategy for infections with no known drug therapy or prophylactic vaccines. Much before, the concept of transfusing neutralizing antibodies through convalescent blood or plasma was established; this modality demonstrated its effectiveness in containing the havoc caused by diphtheria and tetanus during the early 20th century. Convalescent blood products were effective in reducing the mortality risk when administered early in the disease course during the deadliest pandemic of Spanish flu in 1918. Even in the antibiotic era, the use of passive immunization strategy continued to expand with promising results against measles, Ebola, Argentine hemorrhagic fever, and Zika viruses. It was also effective in reducing the mortality and viral load in severe acute respiratory syndrome, H5N1, H1N1, and Middle East Respiratory Syndrome. Convalescent plasma administration carries the risk of anaphylactic reactions, transfusion-related acute lung injury, and transfusion-associated circulatory overload, but these are extremely rare. The impact of the recent coronavirus disease 2019 is enormous with significant morbidity and mortality. Until, a specific antiviral therapy or an effective vaccine is made available, the consideration for use of convalescent blood products, especially plasma, is warranted. Conceptual and observational wisdom often blossoms among therapeutic penury.
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Chronic granulomatous disease presenting with foot abscess caused by Serratia marcescens and autoimmune dactylitis p. 223
Sunil V Kapur, Jitendra S Oswal, Vibha Bafna, Vijay Viswanathan
Chronic granulomatous disease (CGD) is an inherited neutrophil phagocytic function disorder leading to recurrent infections, granuloma formations, and rarely autoimmune diseases. We report a case of genetically proven autosomal recessive CGD in a child with a mutation in NCF2 gene resulting in p67phox defect presenting with foot abscess caused by Serratia marcescens and autoimmune dactylitis at the same time. The case emphasizes the importance to consider a primary immunodeficiency in patients with musculoskeletal manifestations who develop unusual or opportunistic infections. We also hope awareness among pediatricians may lead to increased recognition of the autoimmune manifestations of CGD.
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Myositis as initial presentation of sarcoidosis: A rarity p. 226
Mayank Gupta, Lalit Duggal, Neeraj Jain, Bhavya Chintala
Sarcoidosis is a multisystem chronic inflammation characterized by noncaseating granulomas with internal organ involvement. Lung and lymph nodes are most commonly affected with muscles are involved in up to 3% of patients. Here, we discuss a 39-year-old male patient consulted in rheumatology OPD with chief complaints of localized swelling over the left calf since 6 months. Routine blood investigations were normal. Magnetic resonance imaging of the left thigh muscles was done which was suggestive of features of inflammatory myositis. Muscle biopsy was suggestive of epithelioid granulomas, more in favor of sarcoidosis. Contrast-enhanced computed tomography chest revealed symmetrical nodules in upper lobes of both lungs. We made a diagnosis of granulomatous myositis secondary to sarcoidosis. Steroids and azathioprine were started. The patient responded well to treatment and muscle swelling subsided.
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An unusual presentation of IgG4-related disease p. 229
Upreti Rohit, Hegde Arun, Sengupta Prashant, Gupta Vikas, Jain Anurag, Kovilapu Uday Bhanu
IgG4-related disease (IgG4-RD) is an emerging disease concept that was first recognized in the 21st century. It has since then been attracting substantial attention in many fields of medicine as it tends to involve either synchronously or metachronously, various organs, including the pancreas, bile duct, lacrimal gland, salivary gland, and many others. This umbrella diagnosis now successfully explains a substantial number of disorders, which were previously regarded as “idiopathic.” Reports of the manifestations of IgG4-RD in the head and neck are extremely rare. Otologic manifestations have been reported, but only a handful of cases are available in literature that have been confirmed by immunohistopathology. We, herein, present a case of IgG4-RD of the middle ear, which manifested as a growth in the left mastoid and middle ear cavity, and became symptomatic with symptoms of chronic otitis media in the left ear, and was subsequently diagnosed to have IgG4-RD.
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Gout in premenopausal women and in pregnancy – A case-based review p. 234
Lubna Khurshid, Suraj Chaudhari, Sanjiv Kapoor, Anand Narayan Malaviya
Gout is uncommon in reproductive age group. In this report, two women with gout are presented, one of whom became pregnant while under treatment. The causes of gout in premenopausal age and challenges of managing gout flares in pregnancy are discussed.
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An unusual cause of recurrent meningitis in a 17-year-old girl p. 239
K Nikitha, Sachin Sureshbabu, P Anoof
We present the report of a 17-year-old girl, with a history of recurrent headaches, diagnosed as meningitis on two occasions 2 years apart. She was extensively evaluated for all systemic and local causes of the same, which was finally diagnosed as Sjogren's syndrome (SS). SS presenting with recurrent, aseptic meningitis as the only manifestation in the pediatric age group is a very rare occurrence.
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Leflunomide induced drug reaction with eosinophilia and systemic symptoms: A lesser known entity p. 242
Deepak Vashisht, Madhab Durga Tripathy, Sunmeet Sandhu, Rohit Kothari, Surbhi Vashisht, Arun Hegde
Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe cutaneous adverse reaction to drugs with varied clinical manifestations. Diffuse morbilliform rash with facial edema and systemic involvement in the form of lymphadenopathy, eosinophilia and hepatic involvement are the commonest clinical presentation. Features mimicking Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS-TEN), sepsis, Kawasaki disease andhyper-eosinophilic syndrome can cause immense diagnostic dilemma. We report a case of DRESS which is unique as the triggering drug being leflunomide that has rarely been reported and atypical presentation wherein exfoliative dermatitis and erythema multiforme like lesions which evolved sequentially. A 56-year-old lady, a known case of rheumatoid arthritis on treatment, developed diffuse exanthematous rash over body with fever and hepatic dysfunction, a month after administration of leflunomide. She was diagnosed as DRESS partially managed with steroids to rebound back a week later with severe and atypical manifestations. The uniqueness of the case lies in the fact that DRESS resulted after an uncommon incriminating drug and polymorphic presentation appearing sequentially, besides, highlighting the need of slow tapering of steroids.
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Look beyond the eye: A rare case of retinal neovascularization in Takayasu arteritis p. 245
Divyalakshmi Kaiyoor Surya, Cynthia Arunachalam
A young 18-year-old girl presented with gradually painless progressive diminution of vision in the left eye for 4 months. Her best-corrected visual acuity was 6/36 Left eye. Clinical examination showed anterior segment ischemia and extensive peripheral retinal avascularity with neovascularization. Fundus fluorescein angiography confirmed the findings of ischemia with nonperfusion. Systemic evaluation showed feeble upper limb pulses and nonrecordable blood pressure. Computed tomography angiogram showed signs of inflammatory aortitis involving the left common carotid artery. All the findings were consistent with Takayasu arteritis. The patient was treated with systemic immunosuppressant and showed good response to therapy with regression of neovascularization. oculus sinister that is
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Spondylodiscitis in ankylosing spondylitis: Andersson lesion p. 247
BN Shiva Prasad, HA Karthik Urala
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Usefulness of hydroxychloroquine for COVID-19: Does answer lie in timing to start? p. 249
Mohan Gurjar, Vikas Agarwal
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A rare case of primary antiphospholipid antibody-associated chorea in a child p. 250
Sunil V Kapur, Jitendra S Oswal
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Prevalence of thyroid dysfunction in patients with systemic lupus erythematosus: A descriptive cross-sectional study p. 252
Mahmood Dhahir Al-Mendalawi
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Fill in the blanks of fibromyalgia with inflammation! p. 253
Ilke Coskun Benlidayi
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