Urinary bladder involvement in IgG4-related disease: A case-based review.

Immunoglobulin G4-related disease (IgG4-RD) is an immune-driven fibroinflammatory disease that presents as tumefactive lesions that not only commonly affects the pancreas, lacrimal and salivary glands, lung, liver and kidney but can also affect any organs. However, involvement of the urinary bladder in IgG4-RD is rarely reported. We describe a case of IgG4-RD involving the urinary bladder mimicking carcinoma and review the published literature-a 39-year-old male presented with complaints of dysuria, urgency and hesitancy. Ultrasound revealed a hyperechoic lesion protruding from the anterior of the urinary bladder wall with partial obstruction to bladder outflow, likely to be a pedunculated bladder mass with high suspicion for malignancy. A contrast-enhanced computed tomography abdomen showed a large irregular lobulated heterogeneously enhancing lesion involving the anteroinferior wall of the urinary bladder extending from mid-body up to the neck region with significant perivesical fat stranding and multiple ill-defined perivesical deposits along with hypodense soft tissue lesion in the perigastric region at the level of the body of the stomach. CT-guided perigastric and ultrasound-guided biopsy from the urinary bladder mass confirmed the diagnosis of IgG4-RD. The patient was treated with glucocorticoids. He is doing well after a 1-year follow-up without recurrence, and a repeat ultrasound showed a significant reduction in the size of the urinary bladder mass. The diagnosis of IgG4-RD should be considered in the differential diagnosis of a urinary bladder mass. High index of suspicion and prompt initiation of therapy are required to minimise residual damage and the need for surgical intervention.

Impact of COVID-19 pandemic on rheumatology trainees: an online survey.

To assess the impact of the COVID-19 pandemic on the training of rheumatology trainees. We conducted an observational cross-sectional study using an online survey-based questionnaire sent to rheumatology trainees in India. Rheumatology trainees from India, including DM/DNB residents and fellows, were included. A total of 78 trainees from 24 institutes in 12 states participated in the study. An overwhelming majority of residents (84%) felt COVID-19 Pandemic Negatively impacted their residency and their Physical (65%), Mental (74%) and Social well-being (80%); 79% of trainees felt burnt out. Majority of trainees felt the pandemic negatively impacted their training with clinical teaching (91%), Clinical examination skills (74%), current (80%) and future (70%) research opportunities suffering during the pandemic. Most had significant reduction in the overall footfall (72%) of patients in rheumatology including OPD (77%) and indoor (67%) admissions along with academics (35%), procedures (66%) and exposure to musculoskeletal ultrasound (71%). Almost 60% and 40% of trainees had OPDs, and indoor admissions stopped during COVID-19 pandemic of these 20% had OPDs, and Admissions closed for more than 6 months. 85% of participants had one or the other psychological symptoms with almost half experiencing anxiety (44%), low mood (47%) or lack of sleep (41%). We found The COVID-19 Pandemic has significantly affected the physical, social and mental well-being of Rheumatology trainees. Academic and clinical training reduced, current and future Research became difficult, disruptions in OPDs and Admissions, recurrent COVID postings and reduction in patient footfall, procedures and MSK-US have been detrimental to trainees.

Lean Mass and Disease Activity are the Best Predictors of Bone Mineral Loss in the Premenopausal Women with Rheumatoid Arthritis.

BACKGROUND AND OBJECTIVES: Factors determining bone mineral (BM) loss in rheumatoid arthritis (RA) are not well known. This study aimed to determine the occurrence and predictors of BM loss in the young premenopausal women with RA. METHODS: Ninety-six females with RA and 90 matched controls underwent clinical, biochemical, BM density (BMD), and body composition assessments. RA disease activity was assessed using disease activity score-28 (DAS-28) and hand X-ray. RESULTS: In the young premenopausal females with RA having median symptom and treatment duration of 30 (18-60) and 4 (2-12) months, respectively, with moderate disease activity (DAS-28, 4.88 ± 1.17), occurrence of osteoporosis and osteopenia was 7.29% and 25% at spine, 6.25% and 32.29% at hip, and 17.7% and 56.25% at wrist, respectively (significantly higher than controls). RA patients had lower BMD at total femur, lumbar spine (LS), radius total, and radius ultra-distal. Total lean mass (LM) and BM content were significantly lower in RA (P = 0.022 and <0.001, respectively). In RA, BMD at majority of sites (LS, neck of femur, greater trochanter, radius total, and radius 33%) had the strongest positive correlation with LM followed by body fat percent. RA patients with most severe disease had lowest BMD at different sites and lowest LM. Stepwise linear regression revealed LM followed by DAS-28 to be best predictors of BMD. RA patients receiving glucocorticoids did not have significantly different BMDs from patients not taking glucocorticoids. INTERPRETATION AND CONCLUSION: BM loss is a significant problem in the young premenopausal women with recent-onset RA. LM and disease severity were the best predictors of BMD.

Articular cartilage of knee and first MTP joint are the preferred sites to find double contour sign as an evidence of urate crystal deposition in asymptomatic hyperuricemic individuals.

BACKGROUND/OBJECTIVE: A cross-sectional study to determine the preferred sites of urate crystal deposition in asymptomatic hyperuricemic individuals by ultrasound. METHODS: In two years period twenty four asymptomatic hyperuricemic individuals (serum uric acid ≥7mg/dl) and fifty controls (serum uric acid <7mg/dl) with age more than 18 years were included in this study. Double contour sign was looked for at three articular cartilage sites (first metatarsophalangeal, tibiotalar and femoral condyle) whereas hyperechoic aggregates were looked for at one joint site (radiocarpal joint) and two tendon sites (patellar tendon and triceps tendon). The Chi-square test was used to compare the categorical variables and discrete variables were compared by one way analysis of variance. The p-value<0.05 was considered significant. RESULTS: Eight out of 24 asymptomatic hyperuricemic individuals had ultrasound evidence of urate crystal deposition in first metatarsophalangeal joint area followed by knee joint area which was detected in 6 patients. The detection rate of ultrasound abnormalities in asymptomatic hyperuricemic individuals was 45.8% with two joint area (knee and first metatarsophalangeal) and 50% with six sites assessment. Amongst controls, 16% were found to have these abnormal ultrasound findings. CONCLUSION: The highest predilection of urate crystal deposition in asymptomatic hyperuricemic individuals is the articular cartilage of Knee and first metatarsophalangeal joints. This explain the frequent clinical presentation of arthritis in these joint areas.

Ultrasonographic detection of double contour sign and hyperechoic aggregates for diagnosis of gout: two sites examination is as good as six sites examination.

OBJECTIVE: To compare ultrasound-detected abnormalities, namely double contour sign (DCS) and hyperechoic aggregates (HAGs), at two sites (knee and first metatarsophalangeal [1st MTP] joints) versus six sites (knee joint, 1st MTP joint, radiocarpal joint, talar joint, patellar tendon and triceps tendon) in gout patients. METHODS: Forty-seven clinically diagnosed gout patients and 50 subjects (serum uric acid < 7 mg/dL) as controls were included. DCS was looked for at three articular cartilage sites (first metatarsal, tibiotalar and femoral condyle), whereas HAGs were looked for at one joint site (radiocarpal joint) and two tendon sites (patellar tendon and triceps tendon). Ultrasound findings of both the groups were compared. RESULTS: Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and positive likelihood ratio (LR) of two sites ultrasound findings for gout were 87.2%, 84%, 83.7%, 85.6% and 5.5 respectively. Similar sensitivity, specificity, PPV, NPV and positive LR were observed with six sites ultrasound findings. Among controls, 16% were found to have these abnormal ultrasound findings by both two sites and six sites examinations. CONCLUSION: Screening of two sites (knee and 1st MTP) has similar sensitivity, specificity, PPV, NPV and positive LR as compared to six sites in diagnosing gout.

Performances of Clinical Disease Activity Index (CDAI) and Simplified Disease Activity Index (SDAI) appear to be better than the gold standard Disease Assessment Score (DAS-28-CRP) to assess rheumatoid arthritis patients.

BACKGROUND/PURPOSE: To compare the performance of Disease Assessment Score of 28 joints - C-reactive protein (DAS-28-CRP), Clinical Disease Activity Index (CDAI) and Simplified Disease Activity Index (SDAI) composite measures to assess status of patients with rheumatoid arthritis (RA) on methotrexate, versus DAS-28 CRP as the gold standard. METHODS: One hundred and thirty-five patients with RA as per the 2010 American College of Rheumatology/European League Against Rheumatism criteria were included in the prospective study. The disease activity was assessed at baseline and at every 6 weeks for 24 weeks, by DAS-28-CRP, CDAI and SDAI. Patients were divided into groups of remission, low, moderate and high activity on the basis of predefined cut-offs for DAS-28-CRP, CDAI and SDAI. A Spearman correlation between composite measures and inter-group comparison of the measures was performed. RESULTS: There was an excellent positive correlation between DAS-28-CRP and CDAI (linear weighted κ baseline - 0.545), DAS-28 CRP and SDAI (linear weighted κ - 0.689) at baseline. There was moderate agreement between DAS-28-CRP and CDAI (linear weighted κ final visit - 0.458) at final visit. There was moderate correlation between SDAI and DAS-28-CRP at final visit (linear weighted κ - 0.470). However, correlation between CDAI versus SDAI remained excellent at baseline and final visit. Patients in remission as per DAS-28-CRP had significantly more residual disease activity compared to SDAI and CDAI remission criteria. CONCLUSION: The study shows an excellent strong positive correlation between DAS-28-CRP, CDAI and SDAI at initial evaluation but not at final visit. SDAI- and CDAI-based remission criteria seem to be better than DAS-28-CRP-based remission criteria.

Status and Interrelationship of Zinc, Copper, Iron, Calcium and Selenium in Prostate Cancer.

Deficiency or excess of certain trace elements has been considered as risk factor for prostate cancer. This study was aimed to detect differential changes and mutual correlations of selected trace elements in prostate cancer tissue versus benign prostatic hyperplasia tissue. Zinc, copper, iron, calcium and selenium were analysed in histologically proven 15 prostate cancer tissues and 15 benign prostatic hyperplasia tissues using atomic absorption spectrophotometer. Unpaired two tailed t test/Mann-Whitney U test and Pearson correlation coefficient were used to compare the level of trace elements, elemental ratios and their interrelations. As compared to benign prostatic tissue, malignant prostatic tissue had significantly lower selenium (p = 0.038) and zinc (p = 0.043) concentrations, a lower zinc/iron ratio (p = 0.04) and positive correlation of selenium with zinc (r = 0.71, p = 0.02) and iron (r = 0.76, p = 0.009). Considerably divergent interrelationship of elements and elemental ratios in prostate cancer versus benign prostatic hyperplasia was noted. Understanding of differential elemental changes and their interdependence may be useful in defining the complex metabolic alterations in prostate carcinogenesis with potential for development of element based newer diagnostic, preventive and therapeutic strategies. Further studies may be needed to elucidate this complex relationship between trace elements and prostate carcinogenesis.

Sexual dysfunctions and lower urinary tract symptoms in ankylosing spondylitis.

AIM: To determine sexual dysfunctions and urinary symptoms in male ankylosing spondylitis (AS) patients and their association with various disease and patient factors. METHODS: In this prospective case control study conducted at a tertiary care teaching institution, 100 males with AS were compared to 100 controls using International Index of Erectile Function-15 (IIEF), International Prostate Symptom Score (IPSS), Hospital Anxiety and Depression Scale (HADS) and a global question for overall relationship with their partners. Bath AS Functional Index (BASFI), visual analogue scale pain scores, patient global assessment scale and Bath AS Disease Activity Index were also assessed in the AS group. Chi-square test, unpaired t-test and univariate and multivariate binary logistic regression analyses were used to analyze the data. RESULTS: Anxiety, depression, erectile dysfunction (ED), orgasmic dysfunction, intercourse dissatisfaction, overall sexual dissatisfaction, altered overall relationship with partner and lower urinary tract symptoms (LUTS) were significantly (P < 0.05) higher in the AS group as compared to controls. Sexual desire, severe LUTS and bothersome LUTS (quality of life score > 2) were not different (P = 0.76, 0.82 and 0.30 respectively) between the two groups. ED was associated with anxiety, depression, longer disease duration, higher BASFI and higher age in AS patients (P = 0.02, 0.001, 0.02, 0.003 and 0.001 respectively). CONCLUSIONS: AS is associated with higher incidence of sexual dysfunction in male patients. ED is associated with anxiety, depression, longer duration of disease, higher BASFI score and higher age in AS patients.

Arthritis and adult respiratory distress syndrome: unusual presentations of typhoid fever.

A middle-aged woman presented with fever of 1-month duration along with bilateral knee joint pain, swelling and difficulty in walking for 2 weeks. The patient's Typhidot test was positive for IgM antibodies. Her Widal test was negative, and blood culture and synovial fluid culture were sterile. She was started on ceftriaxone, to which her fever initially responded. However, after 4 days of treatment her disease course was complicated by relapse of fever and acute respiratory distress syndrome (ARDS). This settled with respiratory support and addition of azithromycin. Following recovery from ARDS and fever, her persistent knee arthritis responded to intra-articular methyl prednisolone instillation.

Retrograde intrarenal surgery vs extracorporeal shock wave lithotripsy for intermediate size inferior pole calculi: a prospective assessment of objective and subjective outcomes.

OBJECTIVE: To assess objective and subjective outcomes of retrograde intrarenal surgery (RIRS) and extracorporeal shock wave lithotripsy (SWL) for the treatment of intermediate size (1-2 cm) inferior calyceal (IC) stones in a prospective randomized fashion. METHODS: Between March 2011 and January 2013, 70 symptomatic adults who had isolated IC stone between 10 and 20 mm underwent RIRS or SWL by computer-generated pseudorandom assignment (1:1). Success rate, mean procedure time, hospital stay, pain score on day 1 and 2 using visual analog scale, analgesic requirement after discharge, complications, retreatment rate, auxiliary procedure, and patient-reported outcomes (using self-made nonvalidated questionnaire) were compared. RESULTS: Baseline parameters and mean stone size (SWL 16.45 ± 2.28 mm, RIRS 15.05 ± 3.56 mm; P = .0542) were comparable. Success rate was significantly higher after a single session of RIRS compared with 3 sessions of SWL (85% vs 54%; P = .008). Retreatment rate (65% vs 5.7%; P = .0001) and auxiliary procedure (45% vs 8%; P = .0009) were significantly higher in SWL. Pain score on postoperative day 1 and 2 was significantly higher in RIRS, but patients with SWL required significantly more analgesics afterward. Most of the complications were of Clavien grade I and/or II in both groups. Average time to return to normal activity and voiding symptoms were significantly higher in RIRS. Overall satisfaction score (2.17 ± 1.24 vs 2.82 ± 1.17; P = .026) was significantly higher in RIRS than SWL. CONCLUSION: For the treatment of intermediate size IC calculi, RIRS is superior to SWL in terms of objective and subjective outcomes.