Tab Application Banner
  • Users Online: 301
  • Home
  • Print this page
  • Email this page
Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Reader Login
Export selected to
Endnote
Reference Manager
Procite
Medlars Format
RefWorks Format
BibTex Format
  Citation statistics : Table of Contents
   2020| December  | Volume 15 | Issue 4  
    Online since December 18, 2020

 
 
  Archives   Previous Issue   Next Issue   Most popular articles   Most cited articles
 
Hide all abstracts  Show selected abstracts  Export selected to
  Cited Viewed PDF
EDITORIALS
Introducing open researcher and contributor identifier and publons: The digital transformation
Sham Santhanam
December 2020, 15(4):255-257
DOI:10.4103/injr.injr_191_20  
  2 1,543 109
CASE BASED REVIEW
Pneumonia complicated by SARS-coV-2 infection in three patients with ankylosing spondylitis who are on anti-TNF therapy: Case-based review
Serdar Kaymaz, Ugur Karasu, Veli Çobankara, Hakan Alkan, Firdevs Ulutas
December 2020, 15(4):341-346
DOI:10.4103/injr.injr_221_20  
The mortality rate for the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic is increasing worldwide with each passing day. The risk factors for mortality include advanced age and comorbidities. It is still uncertain whether biological agents pose a risk for the progression of SARS-CoV-2. Although there are studies suggesting the use of biological agents in the literature, there are also studies suggesting the discontinuation of biological agents during SARS-CoV-2. In this study, we aimed to determine whether anti-tumor necrosis factor (anti-TNF-α agents) therapy, which is one of the biological agents commonly used in rheumatology clinics, has an effect on the clinical course of SARS-CoV-2 infection, and to review the literature. We searched the MEDLINE/PubMed and SCOPUS databases until the date of August 15, 2020, using the following keywords: SARS-CoV-2 and anti-TNF-α agents. We reviewed abstracts and retrieved the relevant articles. We reported the clinical manifestation and disease course of SARS-CoV-2 pneumonia in three patients with ankylosing spondylitis who were receiving anti-TNF-α agents. All patients in our case series had a mild course similar to the most cases reported in the literature.
  1 1,534 126
ORIGINAL ARTICLES
Effectiveness and safety of secukinumab in axial spondyloarthritis and psoriatic arthritis: A retrospective analysis of its real-world usage from India
Sham Santhanam, Hema Murugesan, Thilagavthy Nambi, Raja Natarajan, Kavitha Mohanasundaram
December 2020, 15(4):261-266
DOI:10.4103/injr.injr_82_20  
Background: Although secukinumab has become available in India since mid-2016, there is no published data on its usage in axial spondyloarthritis (axial SpA) and psoriatic arthritis (PsA). In this study, we analyzed the real-world usage of this drug to assess the effectiveness and safety in axial SpA and PsA. Methods: All patients with active axial SpA or PsA who had received secukinumab as a biological disease-modifying antirheumatic therapy either as a primary or as a secondary biological therapy covering the period between August 2017 and February 2020 from five Indian centers were included in the study. Whereas Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) 50 and Ankylosing Spondylitis Disease Activity Score (ASDAS) C-reactive protein (CRP) improvement were used to assess the treatment response in axial SpA, DAS 28ESR was used for PsA. The data were retrospectively analyzed. Results: Out of 45 patients included in the study, 27 had axial SpA and 18 had PsA. Disease duration (median [interquartile range]) was 60 (96) months in axial SpA and 54 (108) in PsA. In axial SpA, out of 21 patients who had completed at least 6 months of therapy, 19 demonstrated a BASDAI 50 response and 20 reported good response as per ASDAS CRP (15, low disease activity and 5, inactive disease). In PsA, 14 patients had completed at least 6 months of therapy and 8 of them went in remission and another 4 achieved low disease activity. Adverse events were few (2, upper respiratory tract infection; 1 pneumonia; 3, uveitis; and leukocytoclastic vasculitis in 1) with no tuberculosis reported. Conclusion: In its real-life usage to treat both active axial SpA and PsA, secukinumab was found to be effective and safe.
  1 2,063 155
Beliefs and outlook toward medications in Indian patients with very early rheumatoid arthritis: Cross sectional survey
Sakir Ahmed, Arup Mahapatra, Basanta Kumar Behera, Prasanta Padhan
December 2020, 15(4):298-303
DOI:10.4103/injr.injr_3_20  
Introduction: Beliefs toward medicine influences drug compliance in rheumatoid arthritis (RA). Studies on attitudes toward medicine are available for established RA, where the disease itself could have altered the beliefs. Similar studies are not available for early RA. Thus, we surveyed patients with very early RA to determine their initial outlook toward medicines. Methods: Two hundred and fifty patients fulfilling the American College of Rheumatology/European League against Rheumatism 2010 criteria for RA, who had developed arthritis within the past 3 months were surveyed using the Beliefs about Medicines Questionnaire (BMQ). For the BMQ subsets (specific necessity, specific concern, general overuse, and general harm), more than scale midpoint is considered high. Depending on these scores, patients were classified as indifferent, accepting, sceptical, or ambivalent. Correlations of these scores with age, sex, time to presentation, education, occupation, and income were calculated. Results: Mean (±standard deviation) age of the cohort was 47.6 (±13.4) years with 88.4% (221) being females. Twelve (4.8%) had a high specific necessity, while 31 (12.4%) had a high specific concern score. General overuse and general harm scores were high in 248 (99.2%) and 246 (98.4%) patients, respectively. Thus, 242 (96.8%) patients were classified as indifferent, 4 (1.6%) accepting, 4 (1.6%) sceptical, and none as ambivalent. There was no statistically significant correlation between these scores and sex, age, educational status, occupation, or income. Multivariate analysis showed that persons with high specific concerns about medicines, educated to secondary level, being a student or having a desk job tended to present earlier. Conclusion: General harm and overuse scores were high, but patients had low scores on the scales specific for RA medication. Thus, most of them were classifiable as “indifferent” unlike as in previous studies on established RA.
  1 1,497 99
CASE BASED REVIEW
Kimura disease: A rare presentation in the rheumatology clinic
Malay Kumar, Arun Hegde, Gunjan Dwivedi, Prashant Sengupta, Kovilapu Uday Bhanu
December 2020, 15(4):347-353
DOI:10.4103/injr.injr_132_20  
Kimura disease (KD) is a rare chronic inflammatory disorder of unknown cause, primarily seen in young Asian males. The disease is characterized by painless subcutaneous swelling in head and neck region, accompanied by regional lymphadenopathy and frequent salivary gland enlargement. Blood and tissue eosinophilia, and elevated immunoglobulin E (IgE) levels, are common associations. Characteristic histopathological findings of biopsy specimens obtained from the subcutaneous swellings or lymph nodes include eosinophilic infiltrates, follicular hyperplasia, and proliferation of postcapillary venules. The course is usually waxing and waning, albeit benign. Early diagnosis may spare the patient from unnecessary invasive procedures. We herein, describe a case of KD in an 18 years old male, who presented with subcutaneous swelling in the both cheek (right more than left) in 2014, underwent multiple surgical interventions for the same, before being reassessed and finally diagnosed as KD in 2020, based upon peripheral blood eosinophilia, raised serum IgE levels and histopathological findings. He subsequently made a good recovery on oral steroids.
  - 878 75
Common variable immunodeficiency: An uncommon cause of bronchiectasis, granulomatous disease, chronic liver disease, and enteropathy – Case report and review of literature
Veena Shamsudeen, Arun Hegde, Uday Bhanu Kovilapu, Nisha Verma, Anurag Jain
December 2020, 15(4):354-358
DOI:10.4103/injr.injr_157_20  
Common variable immune deficiency (CVID) is a primary immunodeficiency syndrome, characterized by a defective B cell function. Although there is no age or gender predilection, it is usually diagnosed between the second and fourth decades of life. The clinical features are diverse and include recurrent infections and autoimmune and granulomatous diseases, along with an increased risk of malignancies. Respiratory involvement occurs commonly in the form of recurrent upper and lower respiratory tract infections (LRTI), at times resulting in bronchiectasis. Gastrointestinal involvement may manifest either in the form of an infectious diarrhea due to parasites such as Giardia lamblia and bacteria such as Campylobacter jejuni, or as a noninfectious enteropathy resembling coeliac disease or inflammatory bowel disease. Some patients develop a granulomatous disease manifesting with noncaseating granulomas, especially of lymph nodes, skin, lung, spleen, and liver. Nearly 20%–25% of cases develop autoimmune complications such as autoimmune hemolytic anemia and immune thrombocytopenia. Hepatic involvement can occur in the form of abnormal biochemistry, nodular degenerative hyperplasia, and cirrhosis of liver. Treatment of infection, and replacement of immunoglobulins, remains the mainstay of management of CVID. Herein, we describe the case of a 48-year-old female, who initially presented to our hospital with recurrent bouts of upper and LRTI, along with small-bowel diarrhea, and progressively developed generalized lymphadenopathy and ascites, before being finally diagnosed by the rheumatologist, as a case of CVID, with associated CVID-related enteropathy, granulomatous disease, and chronic liver disease. She was managed with immunoglobulin replacement therapy, along with hydroxychloroquine and steroids with good response.
  - 885 80
Adult-onset Still's disease: A great masquerader triggered by hepatitis A infection
Jhasaketan Meher, Keshao B Nagpure, Md Sabah Siddiqui, AM Vishnu Dev
December 2020, 15(4):359-361
DOI:10.4103/injr.injr_155_20  
Adult-onset Still's disease (AOSD) is a rare inflammatory disorder of unknown etiology. The varied clinical presentation of the disease mimicking many other diseases makes it difficult to diagnose. Various infectious triggers in a genetically susceptible host have been described in literature. We report a case of a 25-year-old female who presented with fever, rash, and arthralgia and diagnosed to be AOSD triggered by hepatitis A infection after excluding other differentials. She was managed with corticosteroids with dramatic response and continued to be in remission even after steroid withdrawal.
  - 878 56
CASE REPORTS
Simultaneous presentation of malignant acanthosis nigricans and palmar fasciitis with polyarthritis syndrome in a patient of ovarian neoplasm: A rare manifestation
Jayati Dave, Sunanda Mahajan, Ankita Maheshwari, Abhishek Gupta
December 2020, 15(4):362-365
DOI:10.4103/injr.injr_99_20  
Malignant acanthosis nigricans (MAN) is a paraneoplastic dermatosis associated most commonly with an underlying intra-abdominal malignancy. It may manifest either with or before the development of the malignancy prompt diagnosis of such paraneoplastic syndrome is often instrumental in early diagnosis of occult malignancy. Palmar fasciitis and polyarthritis syndrome is a rare disease characterized by palmar fasciitis, symmetric synovitis of the hands, fibrosis, and flexion contractures. We present a case of a 48-year-old female who presented with complaints of bilateral contracture of hands with diffuse hyperpigmentation over body folds, face, and trunk suggestive of MAN. On investigation, she was found to have ovarian carcinoma. The hand contracture was thought to be due to palmar fasciitis with polyarthritis syndrome. The patient underwent total abdominal hysterectomy with bilateral total salpingo-oophorectomy with subtle improvement in acanthosis nigricans.
  - 1,461 69
Extrapulmonary sarcoidosis presenting as myositis: A rare case
Niraj Bohania, Sumeet Singla, Jagriti Nahata, Pijush Kanti Nandi, Seema Daksh, S Anuradha
December 2020, 15(4):366-369
DOI:10.4103/injr.injr_4_20  
Sarcoidosis is a multisystem disease with dominant pulmonary involvement (90%). Isolated extrapulmonary involvement is less common. Skeletal muscle (1-2%) involvement is even rare. We report a 40 year old lady presented with easy fatigability, low grade fever for 5-6 months and generalized myalgias. Examination revealed pallor, a receding hair line, hepatomegaly and proximal muscle weakness. Investigations revealed anemia, hypercalcemia and raised serum ACE level. During hospital stay patient developed right sided hemiparesis (acute vasculitic infarct in left parietal cortex). A FDG-PET scan was done which revealed that the muscles of upper and lower limbs showed diffuse, heterogenous areas of increased FDG avidity suggestive of myositis. Final diagnosis of extrapulmonary sarcoidosis (presenting as myositis along with CNS vasculitis and hypercalcemia) was made. Patient showed marked improvement in her symptoms with immunosuppressive therapy. This case is a rare manifestation of extrapulmonary sarcoidosis and emphasizes the role of FDG-PET in diagnosing these cases.
  - 1,283 75
EDITORIALS
Corrections in biomedical literature: Errata, expressions of concern, and retractions
Keerthi Talari, Vinod Ravindran
December 2020, 15(4):258-260
DOI:10.4103/injr.injr_303_20  
  - 853 71
IMAGES IN RHEUMATOLOGY
Role of fine-needle aspiration cytology in the diagnosis of erosive polyarticular tophaceous gout
Sonu Kalyan, Anuj Dhull, Priyanka Khuttan
December 2020, 15(4):370-371
DOI:10.4103/injr.injr_167_19  
  - 654 66
Chronic regional multifocal osteomyelitis: A diagnosis of exclusion
Abhijeet Taori, Divya Malpani
December 2020, 15(4):372-373
DOI:10.4103/injr.injr_119_20  
  - 1,381 73
LETTER TO EDITOR
IgG4 related disease in a middle-aged male having HLA-B27 positive unilateral sacroiliitis
Arun R Chogle
December 2020, 15(4):374-374
DOI:10.4103/injr.injr_145_20  
  - 674 62
LETTERS TO EDITOR
Immunoglobulin G4-Related disease, constitutional symptoms, human leukocyte antigen b27 positivity, and sacroiliitis – Reply
S Verma, L Khurshid, PR Voleti, AN Malaviya
December 2020, 15(4):375-375
DOI:10.4103/injr.injr_211_20  
  - 604 53
Arthritis as a distinctive atypical clinical presentation of COVID-19
Prabhat Agrawal, Ruchika Garg, Anjana Pandey, Ashish Gautam
December 2020, 15(4):376-377
DOI:10.4103/injr.injr_196_20  
  - 959 67
ORIGINAL ARTICLES
Clinical profile of adults and children with reactive arthritis in India – A cohort study
Koshy Nithin Thomas, Anamika Kumari Anuja, Latika Gupta
December 2020, 15(4):304-309
DOI:10.4103/injr.injr_126_20  
Background: An evolving clinicodemographic spectrum is reported in reactive arthritis (reA) with the changing microbial profile in recent times. Moreover, understanding of chronic disease patterns is limited due to widespread beliefs of a self-limiting nature. We thus assessed the clinical profile of a cohort of acute reA and compare them with chronic reA. Methods: A hospital-based study of prevalent triggers and demographic features, articular and extra-articular manifestations, and radiological findings was undertaken in children and adults with reA at a tertiary care center in northern India. Results: Sixty-eight cases (8 juvenile, 41 acute, and 27 chronic) of age 26 years (18–34, M:F 5.8:1) and disease duration 36 (19–60) days were enrolled. Enteritis was the most common preceding trigger (37, 54%), followed by genitourinary infection (25, 36%), irrespective of gender. The clinical spectrum mirrored previous descriptions, with arthritis in most (95%), enthesitis in 33%, and conjunctivitis and circinate balanitis being the most common extra-articular features (8% each). Numerous cases (n = 7) did not fulfill the Braun's criteria at the current visit though a high representation of sacroiliitis was noted (20%, 12%) in acute as well as chronic reA. Enthesitis was more common in the acute reA (P = 0.018) and mucocutaneous features occurred only at inception. Otherwise, the clinical profile was similar in cases triggered by urethritis and enteritis, and in children as compared with adults. Conclusion: These observations of varied spectrum of reA assume larger importance in light of the emerging concept of a unified clinic-pathologic spectrum of spondyloarthritis.
  - 1,253 96
Clinical profile of juvenile idiopathic arthritis from a tertiary care hospital in Northern India
Arun Hegde, Suchi Acharya, Kavita Singh, Uday Bhanu Kovilapu
December 2020, 15(4):310-316
DOI:10.4103/injr.injr_137_20  
Background: Juvenile idiopathic arthritis (JIA) is the most common rheumatological disorder in children with wide variation in its clinical profile. Objective: The aim is to study the clinical, laboratory, radiological, and treatment profile of children with JIA attending the rheumatology clinic of a tertiary care hospital in Northern India. Methods: In this prospective observational study, we analyzed the clinical, serological, radiological, and treatment profile of 56 consecutive JIA patients attending our hospital between January 2013 to December 2016. Results: Out of 56 children, 38 (67.8%) were boys and 18 (32.2%) were girls. Five (8.9%), 15 (26.8%), 16 (28.5%), and 20 (35.7%) children had oligoarticular, systemic-onset JIA (SOJIA), polyarticular JIA, and enthesitis-related arthritis (ERA), respectively, with male: female ratios being 0.67:1. 6.5:1, 0.45:1 and 9:1, respectively. Mean age at disease onset was 6.7 ± 4.3 (mean ± standard deviation), 6.6 ± 4.5, 6.0 ± 2.6, and 10.4 ± 3.2 years in SOJIA, polyarticular, oligoarticular and ERA, respectively. Arthritis was present in all patients. Fever, lymphadenopathy, hepatosplenomegaly, and rash were exclusive to patients with SOJIA. Uveitis and anti-nuclear antibody (ANA) positivity (3.5% each) were rare findings. Knee was the most common joint involved in all subtypes except SOJIA, where the wrist was most commonly involved. All children with SOJIA and polyarticular JIA required conventional synthetic disease-modifying anti-rheumatic drugs. Seven children with SOJIA, six children with polyarticular JIA and six children with ERA received biological disease-modifying anti-rheumatic drugs, in view of refractory disease. Conclusion: JIA-ERA, followed by polyarticular JIA, were most common subtypes of JIA in our study. The knee is the most common joint to be involved. Uveitis and ANA positivity are rare findings in our subsets of children.
  - 1,297 124
Serum levels of neutrophil gelatinase-associated lipocalin, kidney injury molecule-1, and cystatin-C in renal artery stenosis: A pilot study
Raghunandan Prasad, Reeta Choudhary, Anuradha Singh, Surabhi Agarwal, P Kaushik, Kritika Singh, Rajanikant R Yadav, Amar Singh Yadav, Dharmendra Singh Bhadauria, Hira Lal
December 2020, 15(4):317-322
DOI:10.4103/injr.injr_163_20  
Background: The present pilot study evaluated the potential of newer renal biomarkers (neutrophil gelatinase-associated lipocalin [NGAL], cystatin-C [Cys-c], and kidney injury molecule-1 [KIM-1]) in estimating subclinical renal injury due to renal artery stenosis (RAS). Materials and Methods: A total of 13 patients of magnetic resonance angiography confirmed RAS and 14 normotensive healthy controls were enrolled in the study after obtaining ethics approval and informed consent. Serum was collected from participants to check for serum levels of NGAL, KIM-1, and Cys-c by quantitative enzyme immunoassay. The data of RAS patients were compared and analyzed against the data of healthy controls. Results: sNGAL, sKIM-1, and sCys-c values in RAS patients showed rising trend as compared to normal healthy control; however, the difference in their values was not statistically significant. This could be due to small and heterogeneous sample size. However, statistically significant difference was noted in the values of sNGAL and sCys-c between healthy controls and RAS patients with abnormal serum creatinine. This difference in the values of these biomarkers was also statistically significant between RAS patients with normal and elevated serum creatinine. Conclusion: In RAS patients, sNGAL, sCys-c, and sKIM-1 seem to have potential as an early biomarker of kidney injury.
  - 934 61
Axial spondyloarthritis in India: determining the delay in diagnosis, impact on work productivity, and attitude of patients toward treatment
Kamini Narendra Reddy, Asawari Raut, Pravin Patil
December 2020, 15(4):267-274
DOI:10.4103/injr.injr_190_19  
Background: Axial spondyloarthritis (axSpA) primarily affects young, working demographics, and impacts on work productivity. Here, we aimed to determine the delay in diagnosis of axSpA, assess the impact on work productivity, and explore patients' perception of available treatment options. Methodology: A cross-sectional study was conducted on 100 axSpA patients who fulfilled the ASAS criteria. Ethical approval was obtained. Data regarding disease duration, delay in diagnosis, and other demographics were collected using an investigator-designed questionnaire. Disease activity, quality of life, and loss in work productivity were determined using standardized scales. Results: Median disease duration and delay in diagnosis were 5 years (interquartile range [IQR]: 2.0, 10.0) and 2 years (IQR: 0.5, 5.0), respectively. Median Bath Ankylosing Spondylitis Disease Activity Index, Bath Ankylosing Spondylitis Function Index, Bath Ankylosing Spondylitis Global, and Ankylosing Spondylitis Quality of Life scores were 4.15, 3.00, 4.00, and 8.00 respectively. Three different specialists were visited by 58% of the patients before reaching a rheumatologist. An incorrect clinical impression was made in 69% of the patients before consultation with the rheumatologist. Median presenteeism and impact on work productivity reported were 20% and 20.34%, respectively. Eight percent of the patients had to cease employment due to debilitating consequences of axSpA. Daily activities were affected up to 40%. A misconception that “allopathic medications cause side effects in all axSpA patients” was held by 58% of the patients and 25% of the patients believed that doctors deliberately conceal side effects of medications. Conclusion: A patient referral pathway for axSpA should be established to avoid the visits to multiple specialists. AxSpA not only reduces work productivity but also leads to work disability. There is a need to address the patient's concerns regarding modern medicine so that their health-seeking behavior is improved.
  - 2,558 117
Prevalence of low bone mineral density in ankylosing spondylitis, correlation with disease activity, and serum sclerostin levels
Anupam Wakhlu, Akhil Pawan Goel, Puneet Kumar
December 2020, 15(4):275-281
DOI:10.4103/injr.injr_144_20  
Background: Ankylosing spondylitis (AS) involves pathological new bone formation in the cortical zone of vertebrae and excessive loss of trabecular bone in the center of the vertebral body causing osteoporosis (OP). OP expressed as reduced bone mineral density (BMD) is a common complication in AS. Tumor necrosis factor-α (TNF-α) causes induction of Dickkopf-1 and sclerostin, which downregulates bone formation by inhibiting wingless proteins and bone morphogenic proteins. Materials and Methods: Fifty AS patients were compared with an equal number of age- and sex-matched controls. Various biochemical and radiological parameters of disease activity were calculated. BMD was measured at antero-posterior (AP) lumbar spine, neck of femur, and lateral lumbar spine using the dual-energy X-ray absorptiometry. Serum sclerostin, TNF-α, interleukin-17A (IL-17A), and IL-22 levels were measured using commercial enzyme-linked immunosorbent assay kits. Results: Mean BMD at various sites was significantly lower in patients. Patients with OP and low BMD at AP and lateral spine were 38% and 72%, respectively; at neck of femur, 20% and 68% of patients had OP and low BMD, respectively. Neck of femur BMD had significant positive correlation with Bath's ankylosing spondylitis disease activity index. Serum sclerostin levels were significantly higher in patients and had significant negative correlation with modified Stoke's ankylosing spondylitis spinal score. Conclusion: Low BMD is a significant complication in AS, and more prevalent in spine as compared to femur. Neck of femur BMD varies significantly with disease activity. Low sclerostin plays a significant role in the formation of syndesmophytes.
  - 1,337 97
Myeloid-related proteins 8/14 failed to act as theragnostic biomarker in axial spondyloarthritis patients on combination disease-modifying anti-rheumatic drugs therapy
Arvind Ganapati, Jayakanthan Kabeerdoss, Mahasampath Gowri, Belavendra Antonisamy, Debashish Danda
December 2020, 15(4):282-285
DOI:10.4103/injr.injr_223_20  
Background: Reports signifying the utility of myeloid-related proteins (MRP) 8/14 in axial spondyloarthritis (AxSpA) as a theragnostic biomarker are scarce. Objectives: Evaluating the utility of serum MRP 8/14 (baseline levels and change from baseline to 3 months) in AxSpA as a predictor of Assessment of SpondyloArthritis International Society (ASAS) 20 response at 6 months post combination disease-modifying anti-rheumatic drugs (DMARD) therapy. Methods: Serum MRP 8/14 was assayed using enzyme-linked immunosorbent assay platforms (R&D systems, USA) at baseline in 83 AxSpA patients satisfying ASAS 2009 criteria meeting the predefined eligibility criteria; treated with a combination of methotrexate, sulfasalazine at optimum tolerated doses with on-demand nonsteroidal anti-inflammatory agents and 30 healthy age-matched controls. Repeat measurement was done at 3 months in 60 patients. Results: Median MRP 8/14 levels in AxSpA patients was 3.00 (3.96) μg/ml compared to 2.3 (3.29) μg/ml in controls (P = 0.2). Median baseline MRP 8/14 levels in ASAS 20 responders at 6 months (n = 36) was 3.6 (4.1) μg/ml compared to 2.4 (4.8) μg/ml in nonresponders (n = 35) (P = 0.4). Median △ (baseline to 3 months) MRP 8/14 levels in ASAS 20 responders at 6 months (n = 33) was – 1 (−2.7) μg/ml compared to − 0.2 (−3.8) μg/ml for nonresponders (n = 27) (P = 0.5). Among the 83 patients with 138 disease activity assessments at baseline and 3 months post therapy, median MRP 8/14 in active disease (bath ankylosing spondylitis disease activity index [BASDAI] ≥4) (n = 112) was 2.2 (3.8) μg/ml, compared to 2 (2.3) μg/ml (P = 0.5) in inactive disease (BASDAI < 4) (n = 26). Conclusion: Serum MRP 8/14 did not serve as a theragnostic biomarker in our cohort of AxSpA patients treated with combination DMARDs and on-demand NSAIDs.
  - 970 82
Clinical efficacy and safety of tocilizumab in the treatment of seropositive rheumatoid arthritis patients in India
Abhishek Kumar, Darshan Singh Bhakuni, K Shanmuganandan, Arun Hegde, Vivek Vasdev, MN Arjun, Kunal Kishore
December 2020, 15(4):286-291
DOI:10.4103/injr.injr_98_20  
Background: Tocilizumab (TCZ) is a human interleukin (IL)-6 receptor (IL-6R) antibody which competitively inhibits IL-6 signal transduction. Clinical efficacy and safety of TCZ in the treatment of rheumatoid arthritis (RA) and other autoimmune conditions have been established. However, there is a lack of data on its use in the Indian population. Objective: The objective was to study the clinical efficacy and safety of TCZ in Indian patients with seropositive RA. Patients and Methods: This was a prospective, observational single-center study conducted at a tertiary care rheumatology center. All patients were more than 16 years of age, fulfilled the American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) classification criteria for RA, and had at least moderate disease activity as measured by disease activity score-28 joints erythrocyte sedimentation rate (DAS28-ESR) ≥3.2 at enrollment while on at least two disease-modifying antirheumatic drugs. Patients with latent tuberculous infection were excluded from the study. Six doses of TCZ were administered at 8 mg/kg body weight dose at four weekly interval and clinical response was assessed at each visit. Results: All 30 patients enrolled completed the study. Baseline DAS28-ESR was 5.03 (SD0.39) which improved to 2.4 (△-2.6; 95% confidence interval: 2.30–3.04; P < 0.005) after 24 weeks. A total of 19 (63.3%) patients achieved remission (DAS-28 ESR < 2.6) at 24 weeks, while 25 (83.3%) patients showed a good EULAR response. No serious adverse effect was noted in any of the patients. Conclusions: TCZ is an effective and safe option for the treatment of seropositive RA.
  - 1,226 94
The effects of educational status and comorbidity on routine assessment of patient index data 3 and its correlation with disease activity score 28 and clinical disease activity index
Kubilay Sahin, Cem Ozisler, Nesibe Karahan Yesil, Fulya Dortbas, Ahmet Omma, Zeynep Ozbalkan Aslar, Yasar Karaaslan
December 2020, 15(4):292-297
DOI:10.4103/injr.injr_25_20  
Background: Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory disease which leads to significant morbidity. Formal quantitative swollen and tender joint count and indices like disease activity score 28 (DAS28) and clinical disease activity index (CDAI) are very specific for measuring disease activity. Routine assessment of patient index data 3 (RAPID3) is a patient-reported outcome measure used for the assessment and follow-up of RA which can be completed in 10 s. We aimed to determine the effects of patient educational status and comorbidity on RAPID3 and its correlation with DAS28 and CDAI. Methods: A total of 246 RA patients (80.1% female; mean age: 53.2 years) followed up for 3 years were asked to fill out RAPID3 questionnaires, and DAS28 and CDAI were calculated. Patients were subdivided according to disease severity as Group A (remission-minimal disease activity) and Group B (moderate–severe disease activity). The duration of disease, medications, educational status, comorbidity, and medical history were recorded. Results: The mean duration of disease was 8.44 years. Of the patients, 27.2% were illiterate and the mean education time was 4.9 years. The 47.6% of the patients had a comorbid disease. The correlation of RAPID3 with DAS28 and CDAI scores was statistically significant (P < 0.001). Similarly, educational status and the presence of comorbidity did not affect this correlation (P < 0.001). The kappa analysis showing compliance of RAPID3 with DAS28 and CDAI scores was also significant (P < 0.001). Conclusion: RAPID3 is an index which shows a perfect correlation with DAS28/CDAI and can be used routinely for follow-up of RA patients and for decision-making for treatment. It can provide quantitative data with DAS28/CDAI in busy outpatient clinics not only in patients with different educational levels but also in patients with comorbid diseases.
  - 802 64
REVIEW ARTICLE
The impact of obesity on disease activity and other health outcome measures in rheumatoid arthritis
Ankur Dalal, Rizwan Rajak
December 2020, 15(4):333-340
DOI:10.4103/injr.injr_41_20  
Obesity is a common risk factor for noncommunicable diseases such as hypertension and diabetes. It is believed to be a state of low-grade inflammation. Rheumatoid arthritis (RA) is the most prevalent chronic inflammatory arthritis, and obesity is thought to influence its development through adipokines. However, the exact impact of obesity on the disease course of RA is not well understood. This nonsystematic literature review is, therefore, carried out in an effort to understand about how do the obesity affects disease activity (DA) and other health outcome measures in patients with RA. The reviewed evidences suggest that obesity if at all predispose than mostly to the sero-negative RA. Overall, the reviewed data show that obesity may increase DA, but not the radiological joint damage and mortality in patients with RA. However, few evidences also suggest that obesity by itself may actually increase the level of inflammatory markers rather than underlying disease process. These contradictory observations show a definite requirement of further research in this regard and until then weight reduction through reducing fat over lean body mass can be recommended in patients with RA to improve their DA, disability, quality of life, and general cardiovascular status.
  - 1,390 87
REVIEW ARTICLES
Role of neuroimmunomodulation by vagus nerve stimulation in rheumatoid arthritis: Are we heading towards a drug-free era?
Prasan Deep Rath, Swetal Pandey, Rahul Bisaralli
December 2020, 15(4):323-332
DOI:10.4103/injr.injr_92_20  
Progressive clinical research in the field of neuroimmunomodulation has formed a base for the development of a new therapeutic paradigm for various inflammatory diseases, including rheumatoid arthritis (RA). One of the most common mechanisms is electrical vagus nerve stimulation of inflammation. The role of the vagal nerves in activation of various immune responses through preclinical and clinical evidence has established its role in assisting the control of inflammation and improving survival in the infectious and inflammatory disorders through efferent as well as afferent vagal pathways that regulate the peripheral inflammation via the central nervous system. Another mechanism is the neural inflammatory reflex that regulates innate and adaptive immune responses and also inhibits the production of a vital inflammatory therapeutic target molecule, known as tumor necrosis factor, for RA. This review discusses the multifactorial and multidimensional interactions between neurons and immune cells, the mechanisms of the nervous system which are responsible for the regulation of inflammation, the impact of cholinergic pathways on inflammation, and the evidence supporting the role of various bioelectronic devices in vagus nerve stimulation.
  - 816 83