The correlation of anxiety and depression with C3 and C4 Levels and systemic lupus erythematosus activity.

BACKGROUND: Anxiety and depression are psychosomatic disorders that are frequently observed in chronic conditions such as systemic lupus erythematosus (SLE). Anxiety and depression can be induced by immunological and neurotransmitter dysregulation, which is characterized by hypothalamic-pituitary-adrenal (HPA) axis dysfunction, production of proinflammatory cytokines, and activation of complement in the blood, such as C3 and C4. The causes of anxiety and depression in SLE are complex, ranging from neuropsychiatric involvement to drug adverse effects. Detecting anxiety and depression symptoms in SLE patients is critical to preventing disability from impacting quality of life. OBJECTIVE: To assess the relationship between anxiety and depression symptomatology, SLE disease activity with levels of C3 and C4 in Cipto Mangunkusumo National Hospital. METHODS: This study used a cross-sectional design. The study included 120 SLE patients from Cipto Mangunkusumo National Hospital, aged 18 to 60 years. All patients were requested to complete a Hospital Anxiety and Depression Scale (HADS) questionnaire to assess their anxiety and depression symptoms. Subjects with anxiety and depression were assessed for disease activity using the Mexican Systemic Lupus Erythematosus Systemic Disease Activity (Mex-SLEDAI), and blood samples were collected to test complement C3 and C4 levels. Spearman's correlation test was used to examine the relationship between HADS scores, Mex-SLEDAI, and C3 and C4 levels. RESULTS: The results of the study showed a very weak statistically significant negative correlation between anxiety symptoms based on HADS and C3 levels (r = -0.189; p = 0.038) and a weak correlation between anxiety symptoms and C4 levels (r = -204; p = 0.026). Depressive symptoms based on HADS revealed a very poor connection and no statistical significance with levels of C3 (r = -0.056; p = 0.546) and C4 (r = -0.068; p = 0.461). Anxiety (r = 0.06; p = 0.173) and depression (r = 0.031; p = 0.753) symptoms have a weak and insignificant positive connection with SLE activity. CONCLUSION: C3 and C4 serum levels appeared to decrease when the presence of anxious symptoms increased. There was no significant correlation in SLE disease activity between anxious and depressed patients.

Learning from the COVID-19 pandemic: health care disturbances and telemedicine as an alternative rheumatology practice in Indonesia.

BACKGROUND: Coronavirus disease 2019 (COVID-19) affects health care services. Our aim was to assess health care disruptions, treatment interruptions, and telemedicine reception regarding autoimmune rheumatic diseases (ARDs) in Indonesia. METHOD: A cross-sectional population online-based questionnaire was conducted in Indonesia from September to December 2021. RESULTS: A total of 311 ARD patients were included, of whom 81 (26.0%) underwent consultations via telemedicine during the COVID-19 pandemic. The respondents showed increased concern about their susceptibility to COVID-19 (score of 3.9/5). Approximately 81 (26.0%) avoided hospital visits, and 76 (24.4%) stopped taking the medication without medical advice. Respondents' concerns correlated with their social distancing behaviors (p value 0.000, r 0.458). Respondent concerns, behaviors, and blocked access to the hospital during the pandemic were associated with avoiding hospital visits (p value 0.014; 0.001; 0.045; 0.008). Sex was associated with stopping medication (p value 0.005). In multivariate analysis, blocked access and sex remained significant. Approximately 81 (26%) respondents who used telemedicine services during the COVID-19 pandemic as an alternative medical consultation method showed high satisfaction (3.8/5). CONCLUSION: Health care disruptions and treatment interruptions were affected by patients' internal and external factors during the COVID-19 pandemic. Telemedicine may be the best option to address barriers to health care access in Indonesia's rheumatology practice during and after the pandemic situation.

Association between Proinflammatory Cytokines and Anxiety and Depression Symptoms in Rheumatoid Arthritis Patients: A Cross-sectional Study.

Background: Rheumatoid arthritis (RA) patients have a greater prevalence of anxiety and depression. Proinflammatory cytokines are elevated in RA. We aim to evaluate the association between systemic inflammation in RA and anxiety and depression. Methods: There were 31 RA patients, 16 with active disease activity and 15 in remission state; they were assessed using the Hospital Anxiety and Depression Scale and for RA disease activity using Disease Activity Score of 28 joints (DAS28) - CRP (C-reactive protein). Serum proinflammatory cytokines were measured, including interleukin (IL)-6, IL-17, and Tumour Necrosis Factor-alpha (TNF-α). Results: Among 31 patients, ten patients showed anxiety symptoms, 19 patients showed depression symptoms, and two displayed mixed symptoms. Serum TNF-α levels were significantly higher in active disease than in the remission group (p-value 0.006). There was no association or correlation between proinflammatory cytokines to anxiety and depression symptoms in the active disease and remission groups. Conclusion: This suggests that other factors besides disease activity and state of systemic inflammation may cause anxiety and depression in RA patients.

Effects of Modified Diaphragmatic Training on Gastroesophageal Reflux Disease Questionnaire Score, Diaphragmatic Excursion, and Maximum Inspiratory Pressure in Adults with Gastroesophageal Reflux Disease After COVID-19: A Single-Blinded Randomized Control.

BACKGROUND: Although diaphragmatic training has been shown to improve gastroesophageal reflux disease (GERD) symptoms, its effectiveness in adults with GERD after COVID-19 has not been evaluated. This study examined the effectiveness of modified diaphragmatic training (MDT) on GERD questionnaire (GERDQ) score, diaphragmatic excursion, and maximum inspiratory pressure (MIP) in adults with GERD after COVID-19. METHODS: This single-blinded randomized control trial was conducted at Persahabatan Hospital from February to April 2023. The medical records of 364 patients with persistent gastrointestinal symptoms were evaluated; among these potential participants, 302 had symptoms before, and 62 after, COVID-19 infection. Fifty of these patients fulfilled the study inclusion and exclusion criteria and were randomly assigned to the intervention (n = 25) or control (n = 25) groups. Four weeks of diaphragmatic training were followed by MDT or standard diaphragmatic training. A follow-up assessment was conducted 30 days after the beginning of the training. RESULTS: The GERDQ score was significantly decreased in the pre-post-intervention group (10.44 ± 2.00 vs 1.84 ± 2.17) and the control group (8.64 ± 0.57 vs 3.32 ± 1.49), with p < 0.001. The intervention group showed significant improvements in the right diaphragmatic excursion (RDE) (44% vs 11.87%), left diaphragmatic excursion (LDE) (46.61% vs 13.62%), and MIP (75.26% vs 23.97%) compared with the control group. CONCLUSION: MDT in adults after COVID-19 with GERD enhanced diaphragmatic excursion and MIP and decreased symptoms of gastroesophageal reflux by 8.60 points of GERDQ. Respiratory symptoms and other side effects were comparable between the groups.

The Association Between Uric Acid and Symmetric Dimethylarginine Levels in Patients Undergoing Continuous Ambulatory Peritoneal Dialysis.

BACKGROUND: Uric acid (UA) levels are associated with increased risk of cardiovascular events and mortality in hemodialysis (HD) and continuous ambulatory peritoneal dialysis (CAPD) patients. In a study with a population of healthy young adults and HD there was a correlation between high blood uric acid levels and blood symmetric dimethylarginine (SDMA) level. However, in CAPD population, there are still conflicting data on the mechanism of increased risks related to uric acid levels. This study aimed to assess the association between uric acid levels and SDMA in the subjects undergoing CAPD. METHODS: This was a cross - sectional study conducted in all the adults who underwent CAPD for at least three months in tertiary hospital in Jakarta, Indonesia. Subjects already on uric lowering therapy, pregnant or lactating women, and those with a history of malignancy were excluded. Uric acid and SDMA level were measured at the same time patients controlled to outpatient clinic. Bivariate analysis was performed using the Mann - Whitney test and multivariate analysis performed using logistic regression test. RESULTS: A total of 55 subjects were included. The median level of UA was 7.30 + 1.59 mg/dl and 33 subjects (60%) had UA levels of 7 mg/dl or higher. The median SDMA level was 633.73 + 231.54 ng/mL. Subjects with UA levels > 7 mg/dl had significantly higher SDMA levels compared to subjects with UA levels < 7 mg/dl (721.58 + 220.57 vs 501.95 + 182; P < 0.001). The cut - off value of SDMA 536 ng/mL was obtained from the receiver operating characteristic (ROC) curve with sensitivity 81.8%, specificity 63.6%, PPV 77.78% and NPV 73.68%. After fully adjusted with the confounders, the determinant factors in this study were diabetes mellitus (OR: 7.844; CI95%: 1.899 - 32.395: P value: 0.004) and dyslipidemia (OR: 6.440; CI95%: 1.483 - 27.970; P value: 0.013) as risk factors. CONCLUSION: In CAPD patients, UA levels above 7 mg/dl were associated with increased SDMA levels. This study demonstrates the determinant factors regarding association between UA level and SDMA in CAPD patients were diabetes mellitus and dyslipidemia. The cut - off value of SDMA above 536 ng/mL were significant to increased risk of cardiovascular events.

Comparisons of Characteristics and Nutritional Inadequacies in Indonesian Older Adults Consuming or Refraining from Dairy Products.

BACKGROUND: Milk consumption in the Indonesian elderly population is among the lowest in the world, and two-thirds of the population are lactose intolerant. This might have an impact on energy and nutrient intakes. However, data on the prevalence of nutrient intake inadequacies in dairy users versus non-dairy users, as well as population characteristics, are lacking. Therefore we obtained data comparing nutritional inadequacies and characteristics of Indonesian older adults consuming or refraining from dairy products. METHODS: A cross-sectional study was conducted in 2021 as a part of the INA LACTASE study, involving 194 community-dwelling older adults in the outpatient geriatric clinic at Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia. We collected data on demographic and clinical characteristics as part of a routinely performed comprehensive geriatric assessment. A structured questionnaire was developed to categorize participants as dairy-or non-dairy users based on habitual dairy intake. Food records were collected to assess nutrient intakes. The prevalence of inadequacies of energy, macronutrients, and a selection of micronutrients (calcium, vitamin D, and vitamin B12) was calculated by comparing the reported mean intakes to the recommended dietary intakes of the Indonesian population (Indonesian RDA). Prevalence ratios were calculated to measure the association between dairy product consumption and the prevalence of nutrient inadequacies. RESULTS: We recruited 194 eligible participants. This study found that dairy users had a higher proportion of women, a higher monthly income, but a lower proportion of hypertension, diabetes mellitus, and dyslipidaemia in older adults consuming dairy products. We observed wide variability in energy and nutrient intakes, as well as a high prevalence of inadequacies for all dietary intake parameters, particularly micronutrients. Dairy users had a lower prevalence of micronutrient inadequacies than non-dairy users. The prevalence of vitamin D inadequacies in dairy users versus non-dairy users was 91.6% vs. 99.3% in men and 71.9% vs. 98.0% in women, respectively. Inadequate vitamin B12 intake was found in 60.6% of dairy users vs. 89.4% of non-dairy users in men and 65.5% vs.. 68.4% of women, respectively. The most pronounced difference was found in the prevalence of calcium intake inadequacies in dairy users vs. non-dairy users, which was 64.8% vs. 99.5% in men and 89.9% vs. 99.8% in women. We found statistically significant differences in the prevalence of calcium, vitamin D, and vitamin B inadequacies between dairy and non-dairy users. CONCLUSION: This study identified that dairy users had a higher monthly income and had a lower proportion of hypertension, diabetes mellitus, and dyslipidemia. In addition, we discovered a high prevalence of nutrient intakes inadequacies in Indonesian older adults, particularly among non-dairy users. Micronutrient inadequacies are major sources of concern, with statistically significant difference in calcium, vitamin D, and vitamin B12 prevalence of inadequacies.

Correlation between anti-mutated citrullinated vimentin and bone turnover markers (CTX-1 and P1NP) in patients with rheumatoid arthritis in remission and low-disease activity.

Introduction: Rheumatoid arthritis is associated with bone loss and the risk of osteoporotic fracture. Bone loss in this disease is mediated by inflammation and autoimmunity. Many studies have shown that anti-citrullinated protein antibody is capable of inducing bone loss through several mechanisms.This study aimed to determine the relationship between autoimmunity, represented by anti-mutated citrullinated vimentin (anti-MCV) in this study, and bone loss, represented by C-terminal cross-linking telopeptide of type I collagen (CTX-1), and N-terminal pro-peptide of type 1 procollagen (P1NP) in this study, in patients with rheumatoid arthritis in remission and low disease activity. Material and methods: This study enrolled 38 rheumatoid arthritis patients with disease remission and low disease activity in Cipto Mangunkusumo Hospital between August and September 2019. We collected the patients' demographic data, Disease Activity Score 28 (DAS28), and treatment history. All participants underwent blood work for anti-MCV, CTX-1, and P1NP. Results: Thirty-four of the subjects were women (89.5%), with the mean age of 40 ±7.6 years and the median disease duration of 36 months. Among the subjects, 26 patients (68.4%) were anti-MCV positive. There was no correlation between anti-MCV and CTX-1 levels (r = 0.101, p = 0.274). There was a moderate negative correlation between anti-MCV and P1NP (r = -0.449, p = 0.001). The mean difference of P1NP according to anti-MCV level also showed a significant difference (p = 0.019). Conclusions: The anti-MCV levels are not directly correlated with CTX-1 levels, indicating heterogeneity in the disease course even after inflammation has ceased. The anti-MCV and P1NP levels are moderately correlated, indicating that bone formation is resumed during the suppression of autoimmunity.

The impact of low muscle function on health-related quality of life in Indonesian women with systemic lupus erythematosus.

OBJECTIVE: There was no study aimed at evaluating the effect of muscle function on SLE patients' quality of life using the Sarcopenia Quality of Life (SarQoL) questionnaire. METHODS: This cross-sectional study recruited 61 women with SLE consecutively, muscle function was measured with Jamar handheld-dynamometer and 6-meter walk test, HRQoL was measured with Sarcopenia Quality of Life (SarQoL) questionnaire. The cut-off point for low muscle strength (<18 kg) and low gait speed (<1.0 m/s) was according to the Asian Working Group on Sarcopenia 2019 criteria. Statistical analysis was conducted with a t-test for mean difference, and linear regression was used to adjust confounders (age, protein intake, physical exercise, and disease activity). RESULTS: The subjects' mean muscle strength was 19.54 kg (6.94), and 44.3% (n = 27) was found to have low muscle strength. The subjects' mean gait speed was 0.77 m/s (0.20), and 90.3% (n = 55) was found to have low gait speed. The difference of total SarQoL score in subjects with normal and low muscle strength was found to be significant; 74.86 (9.48) vs. 65.49 (15.51) (p = 0.009), and still statistically significant after adjustments with age, protein intake, physical exercise level, and disease activity [B 0.56; 95% CI 0.08-1.03; p = 0.022]. The difference of total SarQoL score in subjects with normal and low physical performance was found to be not significant, 70.67 (11.08) vs. 70.72 (13.56) (p = 0.993). CONCLUSION: There was a significant difference in SarQoL's total score in normal compared with low muscle strength groups of Indonesian women with SLE.

Pain Reduction After Laser Acupuncture Treatment in Geriatric Patients with Knee Osteoarthritis: a Randomized Controlled Trial.

AIM: to compare the effectiveness of active laser acupuncture with placebo on reducing pain intensity and improving functional outcome in geriatric patients with knee osteoarthritis (OA). METHODS: a double-blind randomized controlled trial was conducted in geriatrics with knee OA at Medical Acupuncture Outpatient Clinic, Integrated Geriatric Outpatient Clinic, Rheumatology Outpatient Clinic of Cipto Mangunkusumo Hospital, Jakarta, during May to October 2015. Sixty two patients with knee OA were randomly assigned into two groups: active laser acupuncture group or placebo laser acupuncture group. Interventions were carried out using a gallium aluminum arsenide laser device at the ST35 Dubi, ST36 Zusanli, SP9 Yinlingquan, GB34 Yanglingquan and EX - LE - 4 Neixiyan acupuncture points on the affected knee for ten sessions of treatment, i.e. twice a week. Patients were assessed using a visual analogue scale (VAS) and Lequesne index at baseline, after four sessions, after nine sessions and at 2 weeks after the treatment had been stopped. RESULTS: the VAS scores were significantly improved in the active laser acupuncture group compared to the placebo group. The evaluation of VAS scores was carried out after four treatment sessions (mean difference: 0.39; p<0.001), after nine treatment sessions (mean difference: 37.48; p<0.001) and at 2 weeks post intervention (mean difference: 39.15; p<0.001). The evaluation also showed significant improvement of Lequesne index after four treatment sessions (mean difference: 4.68; p<0.001), after nine treatment sessions (mean difference: 5.90; p<0.001) and at 2 weeks post intervention (mean difference: 6.48; p<0.001). CONCLUSION: active laser acupuncture is effective in reducing pain.

Correlation between receptor activator of nuclear factor-κß ligand (RANKL), and osteoprotegerin (OPG) with cartilage degradation in rheumatoid arthritis patients.

AIM: to analyze the correlation between Receptor activator of nuclear factor-κß ligand (RANKL), Osteoprotegrin (OPG) serum level with cartilage oligomeric matrix protein (COMP) serum level as a marker of cartilage degradation in rheumatoid arthritis patients. METHODS: a cross-sectional study was conducted on the subjects who came to the outpatient clinic of rheumatology in Cipto Mangunkusumo Hospital. Patients were diagnosed based on the American College of Rheumatology (ACR) 1987 revised criteria. All numerical data, both primary data and data transformation were not normally distributed, so we did bivariate analysis with Spearman correlation test. RESULTS: we collected the data of 60 RA patients with majority of the subject had active disease activity (78.3%). Methotrexate was the most widely disease modifying anti-rheumatoid drug (DMARD) used, either as a single drug (51.7%) or in combination with another DMARD (25.1%). Bivariate analysis was revealed that RANKL, OPG, and OPG/RANKL serum level have no significantly correlation with COMP serum level (p=0.52; p=0.25; p=0.2, respectively). CONCLUSION: RANKL and OPG serum level, had no correlation with cartilage degradation in rheumatoid arthritis patients.

Correlation between serum methotrexate-polyglutamate 3 (MTX-PG3) level and disease activity in rheumatoid arthritis patients: A prospective cohort study.

Background: Rheumatoid arthritis (RA) is one of the most common autoimmune diseases, characterized by systemic inflammation, joint destruction and disability. Methotrexate (MTX) is used as the primary treatment for RA patients. However, the response to MTX therapy is highly varied and difficult to predict. This study sought to determine the role of MTX by measuring the MTX polyglutamate 3 (MTX-PG3) levels and the disease activity score 28 based on C-reactive protein (DAS28-CRP) of RA patients. Method: A prospective cohort study was conducted at the Rheumatology Polyclinic of Dr. Cipto Mangunkusumo General Hospital. Thirty-four patients with RA were included and followed up to 12 weeks. The RA patients were treated with MTX 10 mg per week and an increased dose of 5 mg per week every month. DAS28-CRP and MTX-PG3 level were assessed at week 8 and 12. Multivariate logistic regression analysis was used to determine the correlation between MTX-PG3 and DAS28-CRP. Result: A total of 34 RA patients were followed and the MTX was well tolerated in which no increase of serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvic transaminase (SGPT) and glomerular filtration rate (GFR) were observed. The mean scores of DAS28-CRP decreased following the MTX-treatment: 3.93, 3.22 and 2.82 at week 0, 8 and 12, respectively. In contrast, the median concentration of MTX-PG3 increased from week 8 to week 12 followed by increasing the dose of MTX. Our analysis suggested there was a moderate positive correlation between MTX-PG3 levels and DAS28-CRP score at week 8 and week 12 post-MTX treatment. Conclusion: The level of MTX-PG3 is correlated with DAS28-CRP score suggesting that MTX-PG3 could be used as an indicator to assess the disease activity in RA patients. Nevertheless, a prospective study with a higher number of patients is needed to confirm this finding.

Development of a module for the prevention of nonsteroidal anti-inflammatory drugs-associated gastrointestinal adverse reactions in the elderly at a primary health center.

BACKGROUND: The prevention of nonsteroidal anti-inflammatory drugs (NSAIDs) adverse reactions should start from the primary health center (PHC), as the first gatekeeper in community health services. However, there is no specific module available for health care professionals (HCPs) in Indonesia for the prevention of adverse drug reactions (ADR) at PHCs. NSAID is commonly used for the elderly treated at PHC in Indonesia, even though the ADR risk is well-known. OBJECTIVE: We aimed to develop a module to be used in PHC for preventing NSAID-associated upper gastrointestinal (GI) ADRs in elderly patients treated for musculoskeletal diseases. METHODS: The module was developed based on inputs from focus group discussions (FGD) among government health officers, PHC representatives, clinical pharmacologists, internal medicine and community medicine clinicians, pharmacovigilance experts, and professional organizations. A pilot implementation was conducted to test its feasibility and its effect on the HCPs' knowledge. RESULTS: Capacity building of HCPs, development of intra-HCP cooperation, as well as standard operating procedure (SOP) for the prescription of NSAID constituted important components of the module. A pilot study of the module in two PHCs showed that it was applicable with some recommendations for improvement in duration, number of participants, room space, presentation, and use of credit points as compliments. The HCPs' knowledge was improved after following the module. CONCLUSIONS: Our study showed that the module is feasible in PHC in Indonesia and useful in improving knowledge of HPC.

Clinical remission of rheumatoid arthritis in a multicenter real-world study in Asia-Pacific region.

BACKGROUND: Clinical remission is an attainable goal for Rheumatoid Arthritis (RA). However, data on RA remission rates from multinational studies in the Asia-Pacific region are limited. We conducted a cross-sectional multicentric study to evaluate the clinical remission status and the related factors in RA patients in the Asia-Pacific region. METHODS: RA patients receiving standard care were enrolled consecutively from 17 sites in 11 countries from APLAR RA SIG group. Data were collected on-site by rheumatologists with a standardized case-report form. Remission was analyzed by different definitions including disease activity score using 28 joints (DAS28) based on ESR and CRP, clinical disease activity index (CDAI), simplified disease activity index (SDAI), Boolean remission definition, and clinical deep remission (CliDR). Logistic regression was used to determine related factors of remission. FINDINGS: A total of 2010 RA patients was included in the study, the overall remission rates were 62•3% (DAS28-CRP), 35•5% (DAS28-ESR), 30•8% (CDAI), 26•5% (SDAI), 24•7% (Boolean), and 17•1% (CliDR), respectively, and varied from countries to countries in the Asia-Pacific region. Biological and targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) prescription rate was low (17•9%). Compared to patients in non-remission, patients in remission had higher rates of b/tsDMARDs usage and lower rates of GC usage. The favorable related factors were male sex, younger age, fewer comorbidities, fewer extra-articular manifestations (EAM), and use of b/tsDMARDs, while treatment with GC was negatively related to remission. INTERPRETATION: Remission rates were low and varied in the Asia-Pacific region. Treatment with b/tsDMARDs and less GC usage were related to higher remission rate. There is an unmet need for RA remission in the Asia-Pacific region.

The association between vitamin D deficiency and type 2 diabetes mellitus in elderly patients.

AIM: to identify the association between vitamin D deficiency and type-2 diabetes mellitus in elderly population. METHODS: a study was conducted at the geriatric clinic of Cipto Mangunkusumo Hospital in November 2007, with a cross-sectional design. The accessible population of our study were patients with type-2 diabetes mellitus and non-diabetes mellitus patients who visited the clinic for treatment. The subject criteria were: patients >60 years old with operational definition of type-2 diabetes mellitus, and willing to participate in the study. Data collected included characteristics, such as age, sex, education level, history of family illness, frequency of outdoor activity, duration of direct sun exposure in their outdoor activities, history of using sun protector; and the laboratory data such as 25(OH)D3 serum level, calcium and albumin serum level. Data analysis was done by Chi-Square test and multivariate analysis was performed by logistic regression technique to control some identified confounding factors. All data processing and statistical analyses were done with SPSS 11.5 for windows. RESULTS: we found a total number of 78 subjects. Of them, 40 subjects were with DM, and 38 subjects without DM. Most subjects were female (66.7%), and obese (44.9%). Direct sun exposure of most subjects was indicated by the frequency of outdoor activity of more than 3 times a week (74.4%). Duration of exposure in most subjects was less than 15 minutes (43.6%), with application of sun protector agent (56.4%). The prevalence of vitamin D deficiency was 78.2%, with a cut-off of <50 nmol/L. CONCLUSION: sex, BMI and the use of sun protectors proven as variables are associated with vitamin D deficiency. The association between vitamin D deficiency and type-2 diabetes mellitus cannot be proven statistically in our study (p=0.482; OR=0.8; CI=0.5-1.3).

Role of Secreted Frizzled-Related Protein 1 and Tumor Necrosis Factor-α (TNF-α) in Bone Loss of Patients with Rheumatoid Arthritis.

Bone loss is one of the emerging extra-articular manifestations of rheumatoid arthritis. TNF-α is the main inflammatory cytokine that can directly increase bone resorption. However, its role in bone formation is still unknown, especially related to secreted frizzled-related protein 1 (SFRP-1), an osteoblast inhibitor. This study examines the correlation between TNF-α and SFRP-1, with a bone turn over marker (CTX and P1NP). This is a cross-sectional study with 38 subjects of premenopausal female patients with RA. This study found that 60.6% of the patients were in remission or low disease activity. The median of TNF-α was 10.6 pg/mL, mean of SFRP-1 was 9.29 ng/mL, mean of CTX was 2.74 ng/mL, and the median of P1NP was 34.04 pg/ml. There is positive correlation between TNF-α and P1NP (r = 0.363, p = 0.026), also between SFRP-1 and P1NP (r = 0.341; p = 0.036). A low level of TNF-𝛼, high level of SFRP-1, high level of CTX, and low level of P1NP in this study indicate a high bone turn over process, with dominant resorption activity in premenopausal female patients with RA.

Practice Advisory on the Appropriate Use of NSAIDs in Primary Care.

Cyclo-oxygenase (COX)-2 selective and nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) are important in managing acute and chronic pain secondary to inflammation. As a greater understanding of the risks of gastrointestinal (GI), cardiovascular (CV) and renal events with NSAIDs use has emerged, guidelines have evolved to reflect differences in risks among NSAIDs. Updated guidelines have yet to reflect new evidence from recent trials which showed similar CV event rates with celecoxib compared to naproxen and ibuprofen, and significantly better GI tolerability for celecoxib. This practice advisory paper aims to present consensus statements and associated guidance regarding appropriate NSAID use based on a review of current evidence by a multidisciplinary group of expert clinicians. This paper is especially intended to guide primary care practitioners within Asia in the appropriate use of NSAIDs in primary care. Following a literature review, group members used a modified Delphi consensus process to determine agreement with selected recommendations. Agreement with a statement by 75% of total voting members was defined a priori as consensus. For low GI risk patients, any nonselective NSAID plus proton pump inhibitor (PPI) or celecoxib alone is acceptable treatment when CV risk is low; for high CV risk patients, low-dose celecoxib or naproxen plus PPI is appropriate. For high GI risk patients, celecoxib plus PPI is acceptable for low CV risk patients; low-dose celecoxib plus PPI is appropriate for high CV risk patients, with the alternative to avoid NSAIDs and consider opioids instead. Appropriate NSAID prescription assumes that the patient has normal renal function at commencement, with ongoing monitoring recommended. In conclusion, appropriate NSAID use requires consideration of all risks.

Correlation Between Tumor Necrosis Factor-α Levels, Free Fatty Acid Levels, and Soluble Vascular Cell Adhesion Molecule-1 Levels in Rheumatoid Arthritis Patients.

BACKGROUND: The mortality of Rheumatoid Arthritis (RA) is quite high, which is largely due to cardiovascular complications caused by endothelial dysfunction. One of the important inflammatory mediators that contribute to RA joints arthritis of TNF-α, also proven to play a role in endothelial dysfunction and play a role in increasing intracellular lipolysis, thus increasing circulating FFA levels. OBJECTIVES: To determine the correlation between TNF-α levels with VCAM-1 levels, correlation of TNF-α levels with FFA levels, and correlation of FFA levels with VCAM-1 levels. METHODS: Cross sectional and retrospective design studies of adult RA patients treated at Cipto Mangunkusumo Hospital (RSCM), without metabolic disturbances, acute infection, cardiovascular disorders, or other autoimmune diseases. The cross-sectional data was collected from October to November 2017, while retrospective samples were collected since August 2016. TNF-α, VCAM-1, and FFA levels were assessed by serum blood test by ELISA method. Correlation analysis is done by Pearson analysis when the data distribution is normal and with Spearman analysis when the data distribution is not normal. RESULTS: A total of 35 subjects were enrolled in the study. Most (97.1%) were women with an average age of 45.29 years, median disease duration of 48 months, and most had moderate disease activity (65.7%). No significant correlation was found between TNF-α levels and VCAM-1 levels (p = 0.677; r = +0.073). as well betwen TNF-α levels and FFA levels (p = 0.227; r = -0.21). The correlation between FFA and VCAM-1 levels showed significant correlation with negative correlation and weak correlation (p = 0.036; r = -0.355). CONCLUSIONS: (1) There was no correlation between TNF-α levels and VCAM-1 levels in RA patients; (2) There was no correlation between TNF-α levels and FFA levels in RA patients; (3) There was a negative correlation between FFA levels and VCAM-1 levels in RA patients.

The importance of assessment and management of morning stiffness in Asian patients with rheumatoid arthritis: Recommendations from an expert panel.

OBJECTIVE: In patients with rheumatoid arthritis (RA), morning stiffness is linked more to functional disability and pain than disease activity, as assessed by joint counts and markers of inflammation. As part of the Asia Pacific Morning Stiffness in Rheumatoid Arthritis Expert Panel, a group of eight rheumatologists met to formulate consensus points and develop recommendations for the assessment and management of morning stiffness in RA. METHODS: On the basis of a systematic literature review and expert opinion, a panel of Asian rheumatologists formulated recommendations for the assessment and medical treatment of RA. RESULTS: The panel agreed upon 10 consensus statements on morning stiffness, its assessment and treatment. Specifically, the panel recommended that morning stiffness, pain and impaired morning function should be routinely assessed in clinical practice. Although there are currently no validated tools for these parameters, they should be assessed as part of the patients' reported outcomes in RA. The panel also agreed on the benefits of low-dose glucocorticoids in RA, particularly for the improvement of morning stiffness. CONCLUSIONS: These recommendations serve to guide rheumatologists and other stakeholders on the assessment and management of morning stiffness, and help implement the treat-to-target principle in the management of RA.