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  Access statistics : Table of Contents
   2020| March  | Volume 15 | Issue 1  
    Online since March 30, 2020

 
 
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EDITORIALS
To Act…….or to wait for the evidence: Ethics in the time of covid-19!
Durga Prasanna Misra, Vikas Agarwal
March 2020, 15(1):3-4
DOI:10.4103/injr.injr_53_20  
  1,955 387 4
CASE BASED REVIEW
Hydroxychloroquine-induced auditory toxicity
Abhishek Patil, Yapi Jerang, John Mathew
March 2020, 15(1):53-55
DOI:10.4103/injr.injr_130_19  
A 51-year-old female with mixed connective tissue disease presented with bilateral sensorineural hearing loss. The hearing deficit was gradually progressive over a period of 6 months. On evaluation, no obvious cause for hearing was evident. Due to ototoxic potential of hydroxychloroquine, we decided to stop the drug and observe for improvement. Over time, her hearing loss stabilized, with improvement in audiometric findings. Hydroxychloroquine induced auditory toxicity is rare. Increased awareness and early recognition may minimize damage.
  2,125 181 3
REVIEW ARTICLE
Pitfalls in statistical analysis – A Reviewers' perspective
Sakir Ahmed, Aadhaar Dhooria
March 2020, 15(1):39-45
DOI:10.4103/injr.injr_32_20  
Statistics are a quintessential part of scientific manuscripts. Few journals are free of statistics-related errors. Errors can occur in data reporting and presentation, choosing the appropriate or the most powerful statistical test, misinterpretation or overinterpretations of statistics, and ignoring tests of normality. Statistical software used, one-tailed versus two-tailed tests, and exclusion or inclusion of outliers can all influence outcomes and should be explicitly mentioned. This review presents the corresponding nonparametric tests for common parametric tests, popular misinterpretations of the P value, and usual nuances in data reporting. The importance of distinguishing clinical significance from statistical significance using confidence intervals, number needed to treat, and minimal clinically important difference is highlighted. The problem of multiple comparisons may lead to false interpretations, especially in p-hacking when nonsignificant comparisons are concealed. The review also touches upon a few advanced topics such as heteroscedasticity and multicollinearity in multivariate analyses. Journals have various strategies to minimize inaccuracies, but it is invaluable for authors and reviewers to have good concepts of statistics. Furthermore, it is imperative for the reader to understand these concepts to properly interpret studies and judge the validity of the conclusions independently.
  1,885 264 1
ORIGINAL ARTICLES
The effect of neutrophil-lymphocyte ratio and thrombocyte index on inflammation in patients with periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome
Vildan Gungorer, Alaaddin Yorulmaz, Husamettin Vatansev, Sukru Arslan
March 2020, 15(1):11-16
DOI:10.4103/injr.injr_120_19  
Background: The periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome is the most common periodic fever syndrome in childhood. Its pathogenesis and etiology remain unknown. This study aimed to determine whether or not the neutrophil-to-absolute lymphocyte ratio (NLR) and thrombocyte indices could be used as subclinical inflammation markers in healthy control group children and children with PFAPA syndrome during the attacks and attack-free periods. Materials and Methods: Twenty-eight children with PFAPA syndrome that presented to our clinic were enrolled in this study. As a control group, healthy children that presented to the general pediatrics polyclinic with the exact same age and sex as the patient group were recruited. The medical records of all participants were evaluated retrospectively. Results: The leukocyte and neutrophil counts, NLRs, platelet count-to-absolute lymphocyte ratios (PLRs), and C-reactive protein levels of the patients with PFAPA syndrome during the attack period were found to be significantly higher than during the attack-free period. Similarly, during the attack period, the leukocyte and neutrophil counts, NLRs, and PLRs were significantly higher compared to the healthy control group. Patients with PFAPA syndrome during the attack-free periods were compared with the control group, and their mean platelet volume (MPV) values were significantly lower than the control group. Conclusions: MPV in PFAPA syndrome patients was significantly lower during the inflammation. We observed a significant decrease in MPV values during the attack-free period compared to the control group, suggesting that subclinical inflammation continues in the attack-free period in PFAPA syndrome.
  1,753 193 -
P-glycoprotein and/or Histone Deacetylase 2 Regulates Steroid Responsiveness in Childhood Nephrotic Syndrome
Harshit Singh, Narayan Prasad, Durga Prasanna Misra, Akhilesh Kumar Jaiswal, Vikas Agarwal
March 2020, 15(1):5-10
DOI:10.4103/injr.injr_126_19  
Background: P-glycoprotein (P-gp) overexpression in peripheral blood mononuclear cells (PBMCs) has been reported in patients with steroid-resistant nephrotic syndrome (SRNS). Glucocorticoids suppress NFκB-associated coactivator activity by deacetylation of histone by enzyme histone deacetylase (HDAC)-2. Interaction between HDAC2 activity and P-gp expression in childhood NS patients is not clear. Aim: This study aims to evaluate the role of HDAC2 and P-gp expression on PBMCs and steroid responsiveness in patients with childhood NS. Materials and Methods: Thirty-one patients were recruited at baseline (n = 31) (before initiating steroid therapy); after 6 weeks of steroid therapy, 24 patients achieved remission (steroid-sensitive NS [SSNS] n = 24 mean age, 7.96 ± 3.90), whereas seven patients were resistant to steroids (SRNS, n = 7, mean age 10.00 ± 3.55). mRNA expression of HDAC2 and P-gp and functional analysis of P-gp and enzymatic activity of HDAC2 were analyzed at baseline, and at 6 weeks of steroid treatment and at the time of relapse. Results: The expression of P-gp mRNA was significantly lower in individuals (n = 24) who achieved remission at 6-week steroid therapy as compared to baseline and those who were resistant (n = 7) to steroids (P < 0.005). Similarly, the expression of HDAC2 mRNA was significantly higher at baseline and at remission following 6-week steroid therapy as compared to their expression in those who were resistant to steroids (P < 0.005). The function of P-gp was significantly lower in NS patients who achieved remission after 6-week steroid therapy compared to baseline (P < 0.005), whereas it was not significant in resistant patients (P = 0.37). The enzymatic activity of HDAC2 was significantly higher in SSNS patients as compared SRNS patients at 6-week steroid therapy (P < 0.005). Conclusion: The expression and function of P-gp and HDAC2 may affect steroid response in NS patients. Combined therapy of steroids with P-gp inhibitor and/or HDAC2 inducers may have a rationale in management of SRNS patients.
  1,669 219 -
Depression in patients of primary knee osteoarthritis: A cross-sectional study
Pooja Dhaon, Haseeb Khan, Rana Ravneesh Singh, Mukesh Shukla
March 2020, 15(1):27-31
DOI:10.4103/injr.injr_87_19  
Aim and Objective: The aim and objective are to find the prevalence of depression and its relationship with functional status in patients with primary knee osteoarthritis (OA). Materials and Methods: The present study included 100 patients (33 males and 67 females) of primary knee OA fulfilling the American College of Rheumatology criteria. Demographic and diseases variables were recorded for all patients. Functional status was assessed using the Western Ontario and McMaster Universities Index (WOMAC), and depression was assessed using the Hamilton Depression Rating Scale (HAM-D). Results: Significant depression (HAM-D >13) was present in 19% of patients. Depression was associated with female sex and associated comorbid conditions. There was a significant positive correlation between WOMAC score and HAM-D score in all patients. Conclusion: Female patients with knee OA have associated depression, which is associated with poor functional status.
  1,645 176 -
CASE BASED REVIEW
TEN in a Case of SLE - A case based review
Shekhar Neema, Sehdev Singh, Abhishek Kumar, S Radhakrishnan
March 2020, 15(1):56-58
DOI:10.4103/injr.injr_139_19  
Systemic lupus erythematosus (SLE) is a complex autoimmune disorder of unknown etiology. Cutaneous manifestations in SLE are common, results in significant morbidity and helpful in diagnosis of underlying systemic disease. Vesiculobullous lesions in SLE are uncommon but present a diagnostic challenge. It can be a manifestation of SLE-specific or nonspecific pathology. It can also result from unrelated etiology such as drug-induced toxic epidermal necrolysis (TEN). Clinically, it is challenging to differentiate TEN-like acute cutaneous lupus erythematosus from classical TEN. We hereby present a case of TEN in SLE and discuss approach to vesiculobullous lesions in SLE.
  1,639 164 1
Essential Thrombocythemia Masquerading as Henoch–Schonlein Purpura in a 9-year-old Child
Palanisamy Sivamurukan, Sriram Krishnamurthy, CG Delhikumar, Anbazhagan Jagadeesh, Bheemanathi Hanuman Srinivas, Debdatta Basu
March 2020, 15(1):49-52
DOI:10.4103/injr.injr_115_19  
Leukocytoclastic vasculitis (LCV) is a complex group of conditions which are characterized by vascular damage and neutrophilic infiltrates. LCV in children is usually considered as a part of connective tissue diseases, autoimmune disorders, and primary systemic vasculitis such as systemic lupus erythematosus (SLE) or Henoch–Schonlein purpura (HSP). We herein describe a 9-year-old child with fever, arthritis, diffuse abdominal pain, and palpable purpura over the lower limbs, who was initially diagnosed to have HSP based on the European League Against Rheumatism criteria. He also had thrombocytosis which was attributed to HSP. The skin biopsy showed LCV, providing corroborative evidence of HSP in this setting. Due to severe abdominal pain, prednisolone was prescribed, and resolution of symptoms occurred. There was no hepatosplenomegaly, anemia, polycythemia, or lymphadenopathy at this juncture. On follow-up, however, the thrombocytosis worsened (2000 × 109/L) with appearance of a palpable spleen. Further investigations revealed essential thrombocythemia (ET) as the etiology of LCV in this child. The learning point in this case report is the emphasis on consideration of inclusion of malignancies in the spectrum of LCV in children, besides the usual differential diagnosis such as HSP or SLE, especially when accompanied by worsening thrombocytosis. ET has not been reported in the constellation of malignancies described in association with LCV in the literature.
  1,371 145 -
ORIGINAL ARTICLES
Ultrasonography of articular and periarticular structures as a relapse predictor in patients with clinically remitted rheumatoid arthritis
Mehdi Karami, Zohre Mohammadzadeh, Shadi Ebrahimian, Maryam Moradi, Sayedbonakdar Zahra
March 2020, 15(1):17-22
DOI:10.4103/injr.injr_103_19  
Introduction: Rheumatoid arthritis (RA) is an autoimmune disease causing mortality and morbidity among patients. The goal of RA treatment is remission and prevention of joint degeneration. Remission is diagnosed by physical examinations and laboratory markers. Due to the high rate of relapse, it appears that physical examination is not a sensitive method in detecting active and remitted RA patients. The aim of this study is to find whether ultrasonography (US) is an appropriate method in detecting active RA patients and estimating the relapse rate. Methods: Seventy clinically remitted RA patients were enrolled based on the Disease Activity Score in 28 joints. They underwent US to examine the presence of synovitis, tendinitis, tenosynovitis, and bursitis and were followed for 6 months regarding the relapse rate. Moreover, the predictive value of US was measured. SPSS was used for analyzing data. Results: According to the US findings, 27.1% of the clinically remitted patients had signs of active synovitis, whereas 15.7% of them showed signs of tenosynovitis, tendinitis, or bursitis. In addition, relapse was observed in 12.9% of the patients with clinical remission and was significantly higher in patients with signs of active synovitis (P < 0.05). The results also revealed that the prognostic values of US for estimating the relapse rate were 77.7% and 70.0% in terms of sensitivity and specificity, respectively. Conclusions: US is capable of detecting active synovitis among patients with clinically remitted RA and also predicts those with a higher risk of relapse within 6 months. It is also useful in identifying people with active RA, whose clinical symptoms indicate remission of the disease. Involvement of periarticular structures including tenosynovitis, tendinitis, or bursitis cannot independently predict relapse in patients with RA.
  1,307 179 -
EDITORIALS
When doing the right thing is wrong – drug efflux pumps in steroid-resistant nephrotic syndrome
Vaidehi R Chowdhary
March 2020, 15(1):1-2
DOI:10.4103/0973-3698.281583  
  1,280 205 2
ORIGINAL ARTICLES
Introduction of mini-Clinical Evaluation Exercise as a mode of assessment for postgraduate students in medicine for examination of sacroiliac joints
Anuj Singhal, Shankar Subramanian, Sonal Singh, Arun Kumar Yadav, Anup Hallapanavar, B Anjali
March 2020, 15(1):23-26
DOI:10.4103/injr.injr_106_19  
Background: Formative and subjective assessment of medical education is the need of the hour today. Mini-Clinical Evaluation Exercise (mini-CEX) and Directly Observed Procedural Skills (DOPS) are the commonly used workplace-based assessment (WPBA) tools which have been extensively studied in both undergraduate and postgraduate (PG) settings. In this study, we tried to assess the feasibility of mini-CEX and also its acceptability among PG students of internal medicine and teaching faculty for the examination of sacroiliac joints. Methods: This is an interventional study which was carried out in a government medical college in Pune, Maharashtra, India, from January to June 2019. A total of 18 1st- and 2nd-year PG students and 9 teaching faculty from the department of internal medicine participated in this study. Each student underwent five mini-CEX evaluations over a period of 6 months under different teaching faculty. Feedback was taken from both the teaching faculty and students regarding the feasibility of mini-CEX as an assessment tool. Results: A total of ninety mini-CEX exposures involving 18 PG students and nine faculty were analyzed. We found a statistically significant improvement in the domain of medical interviewing (P < 0.001), physical examination (P = 0.003), professionalism (P = 0.001), clinical judgment (P = 0.003), counseling skills (P < 0.001), and organizing efficiency (P < 0.001). Overall clinical competence improved from a scale of 5 (1.7) to 6.7 (0.8). Conclusion: The results of this study show that overall mini-CEX is an acceptable and effective assessment tool. However, regular training of assessors through workshops on the provision of effective feedback is required. Modification of the assessment form based on the feedbacks provided by teachers and students will further facilitate the implementation of this teaching tool in the curriculum.
  1,148 130 -
BRIEF REPORT
Apremilast generic for the treatment of active psoriatic arthritis: A single-center real-life experience from India
Sanjiv Amin, Aneesa Kapadia, Dhiraj Dhoot, Hanmant Barkate
March 2020, 15(1):46-48
DOI:10.4103/injr.injr_123_19  
Introduction: Apremilast has been recently introduced in the treatment of adult psoriatic arthritis (PsA) patients in India. Its efficacy and safety have been established in the landmark clinical trials; however, there is still a dearth of its real-world experience in the management of PsA in India. Materials and Methods: A retrospective cohort analysis of electronic medical records was conducted at our clinic, to study the effectiveness and tolerability of apremilast 30 mg twice a day in the management of PsA. A total of 86 patients were included in this report. Patients were classified as responders and nonresponders based on the overall physician judgment of clinical status, especially improvement of symptoms as per the disease activity in PsA (DAPSA) criteria. Results: Of the 86 patients started on apremilast, 44 patients had at least 16 weeks of follow-up assessment. Of these 44 patients, 39 were of peripheral arthritis and five were of axial spondyloarthritis. Twenty-five of 39 (64%) patients were classified as responders and 14 (36%) as nonresponders based on the DAPSA criteria. On analyzing the DAPSA scores at baseline and subsequent follow-up, there was statistically significant improvement in mean DAPSA score. Remission was seen in three patients (7.7%) and low disease activity in 16 (41%) patients at 16 weeks. Only six patients developed one or more side effects. The most common side effects were gastrointestinal symptoms. Conclusion: These results, from a real-world setting in India, confirm the effectiveness and tolerability of apremilast in PsA as seen in clinical trials.
  1,127 106 -
IMAGES IN RHEUMATOLOGY
Coexistence of fibrous dysplasia with reactive arthritis
Anupam Wakhlu, Akhil Pawan Goel, Rasmi Ranjan Sahoo, Pradyumn Singh
March 2020, 15(1):59-60
DOI:10.4103/injr.injr_138_19  
  963 230 -
ORIGINAL ARTICLES
Acro-osteolysis and its relationship with bone mineral density and peripheral vascularity in premenopausal females with systemic sclerosis
Rabab S Zaghlol, Sahar S Khalil, Rania M Almolla, Ahmed Mohamed El-Maghraby, Wafaa K Makarm
March 2020, 15(1):32-38
DOI:10.4103/injr.injr_144_19  
Objectives: To investigate the relationship between acro-osteolysis (AO), bone mineral density (BMD) and peripheral vascularity in premenopausal female patients with diffuse systemic sclerosis (dcSSc). Methods: An observational cohort study that included thirty premenopausal female patients with dcSSc. The recruited patients were categorized into two groups according to the presence of radiological signs of AO. Patients were assessed clinically, laboratory and radiologically by X-ray imaging of both hands and wrists, dual-energy X-ray absorptiometry for measuring BMD and Doppler ultrasonography for evaluation of upper limbs peripheral vascularity. Results: Overall, 80% patients had AO; comparing patients with and without AO, the former had significant increase in the frequencies of Raynaud's phenomenon, calcinosis and digital pits (88.5, 94.7, 91.7) versus (11.5, 5.3, 8.3) in the latter, respectively. Additionally, they had significantly lower distal radius BMD and higher macrovascular abnormalities at both radial and ulnar arteries ( P < 0.05). On regression analysis, the most important factors associated with AO were calcinosis (OR= 1.7; 95% CI: 1.01- 3.02; P = 0.02), Raynaud's phenomenon (OR= 3.5; 95% CI: 0.6-19.4; P = 0.003), digital pits (OR= 2.8; 95% CI: 0.9-8.8; P = 0.001), low BMD at the distal radius (OR= 1.9; 95% CI: 1.1-3.0; P = 0.002), and macrovascular changes at radial and ulnar arteries (OR = 2.2; 95% CI: 0.7-6.5; P = 0.04 and OR =1.6; 95% CI: 0.9-3.0; P = 0.05) respectively. Conclusion: Calcinosis, Raynaud's phenomenon, digital pits, vascular alterations at radial and ulnar arteries, and low BMD at the distal radius are the most important factors associated with AO in dcSSc patients.
  993 107 -
LETTERS TO EDITOR
Methotrexate does not cause interstitial lung disease
Anand Narayan Malaviya
March 2020, 15(1):61-62
DOI:10.4103/injr.injr_184_19  
  765 102 -
Response to: “methotrexate does not cause interstitial lung disease”
Wei-I Lee, Pravin Hissaria
March 2020, 15(1):63-63
DOI:10.4103/injr.injr_27_20  
  637 82 -