Noninfectious Uveitis in Rheumatology: Patterns, Treatment, and Outcomes.

OBJECTIVES: The present study aimed to determine the pattern and cause of noninfectious uveitis in rheumatology practice. The secondary objective was to identify the pattern of treatment and outcomes. MATERIALS AND METHODS: This retrospective cross-sectional study was conducted in the Department of Rheumatology, National Hospital and Medical Centre, Lahore, Pakistan. After receiving consent, electronic medical records (EMRs) of all patients with a diagnosis of noninfectious uveitis (NIU) from November 2019 to January 2023 were reviewed, and a total of 52 patients labeled as having noninfectious uveitis were identified. The collected data included age at diagnosis, anatomical location of uveitis, associated systemic disease, used medications, and outcomes. All cases had been diagnosed and assessed mutually by a rheumatologist and an ophthalmologist using the International Uveitis Study Group classification system to classify the pattern of uveitis by location, clinical course, and laterality and rule out the possibility of other ophthalmologic diseases. Disease activity was defined using the Standardization of Uveitis Nomenclature (SUN) guidelines. Data was analyzed on SPSS Statistics version 23 (IBM Corp, Armonk, NY, USA). RESULTS: The mean age of the patients in this study was 36.02 ± 43.31 years, with 31 (59.6%) male patients. Anterior uveitis was the most common type observed among the patients at 55.8%, panuveitis was found in 25%, intermediate uveitis and posterior uveitis were seen in 9.6% each. Based on laterality, unilateral eye involvement was identified in 53.8% of patients. Spondyloarthritis (SpA) and idiopathic uveitis were observed in 34.6% and 28.8%, respectively. In this study, 28 (54.9%) patients were on conventional disease-modifying antirheumatic drugs (cDMARDDs), and 23 (45.1%) were on biological DMARDs. In the biologics group, 82% of patients were in remission in comparison to 60% in the cDMARDs group. CONCLUSION: To the best of our knowledge, this is the first report on noninfectious uveitis in the Pakistani population. The study concluded that anterior uveitis is the most common type of uveitis and is more common in males. Spondyloarthropathy is one of the most common underlying systemic diseases. Human leukocyte antigen (HLA)-B27 is associated more with uveitis. Biologics are more effective than cDMARDs in controlling the disease. Collaborative work between different specialties resulted in early diagnosis of underlying systemic disease, better management plans, and disease outcomes. To obtain further details on noninfectious uveitis, a population-based study is needed in Pakistan.

Prostatitis As An Initial Presentation For Granulomatosis With Polyangiitis.

Granulomatosis with polyangiitis (GPA) is an uncommon pauci-immune small-vessel necrotising granulomatous vasculitis mostly seen in age 45-60 years. We present the case of a formerly healthy 44 years old male presenting with dysuria and intermittent urinary retention for 8 months, not responding to empirical antibiotic therapy and TURP. A prostate biopsy showed necrotising granulomatous prostatitis. Urinalysis demonstrated persistent pyuria and haematuria, but cultures showed no growth. Subsequently he complained of fever, cough, dyspnoea and skin ulcers. CT of the chest showed multiple cavitatory lesions and pleural effusion. On work up, c-ANCA was positive and a diagnosis of granulomatosis with polyangiitis was established. This depicts a rarely seen presentation of prostatitis as the initial feature of GPA.

Foot Involvement as the First Manifestation in Rheumatoid Arthritis Patients in Lahore.

Objective The objective of this study was to determine the involvement of the foot as the first manifestation in rheumatoid arthritis (RA). Methods This study was conducted on 100 patients who presented to the outpatient department of the Rheumatology Department at Fatima Memorial Hospital and College of Medicine and Dentistry in Lahore, Pakistan. The period of this cross-sectional study was three months - from October 2017 to December 2017. One hundred patients aged more than 16 years, who were diagnosed as cases of RA with foot involvement, and with a disease duration of less than two years (to minimize recall bias), were enrolled for the study. Results Out of the 100 patients, 20% were male and 80% were female. The mean age of the study population was 41.16 ± 12.343 years. Foot Involvement as the first manifestation was noted in 29 (29%) of the cases. The pattern of foot involvement shows a 59% forefoot involvement, 27% hindfoot involvement, and 14% midfoot involvement. Walking difficulty was most common in forefoot involvement (71.42% of cases), followed by hindfoot involvement (20% of cases), and least common in midfoot involvement (8.57% of cases) (p=0.0001). Conclusion Foot involvement as the first manifestation is quite common in RA and should not be ignored, especially in patients with large joint involvement sparing the hands.

Diagnostic and therapeutic delay in Rheumatoid Arthritis patients: Impact on disease outcome.

OBJECTIVE: To identify factors causing diagnostic and therapeutic delay in patients with rheumatoid arthritis, and to evaluate relationship of diagnostic and therapeutic delay with disease outcome. METHODS: This cross-sectional study was conducted in Rheumatology Department, Fatima Memorial Hospital, Lahore, Pakistan, from May 2018 to July 2018. In this study 102 patients fulfilling ACR/EULAR criteria 2010 were enrolled. Lag times were calculated in months: lag-1 (delay in initial medical consultation); lag-2 (delay in consulting rheumatologists); lag-3 (diagnostic delay); lag-4 (therapeutic delay). Disease activity and functional outcome were measured by DAS28, HAQ-DI respectively. Association of lag-3 and lag-4 with HAQ-DI and DAS28 was calculated by Pearson correlation. RESULTS: Median (IQR) disease duration of study group was 6(2-10) years. Initial consultations were with; orthopedic surgeon 40(39.2%), general practitioner 27(26.5%), rheumatologist 13(12.7%), medical specialists 14(13.7%). Median (IQR) lag times in months: lag-1 (delayed initial consultation): 2(0-5), lag-2 (delay in consulting rheumatologist): 30(7.7-72), lag-3 (diagnostic delay): 12(3-48), lag-4 (therapeutic delay):18(5.7-72). Factors attributed to lag-3 (diagnostic delay) and lag-4 (therapeutic delay) (p<0.05): older Age (r= 0.2), education level(r= - 0.2), initial consultation (non-rheumatologist) (r=0.2), lag-2(r=0.8), >three doctors visited before diagnosis(r=0.6). Positive anti-CCP antibodies(r=0.2) and lag-1 (delayed initial consultation) (r=1) were associated with lag-3 (diagnostic delay) only; no association was found with positive RA factor. Significant correlation (p=<0.05) of lag-3 (diagnostic delay) was found with both DAS28(r=0.2) & HAQ-DI(r=0.2). Similarly lag-4 (therapeutic delay) also correlated with both & DAS28(r=0.2) & HAQ-DI(r=0.3) (p=<0.05). CONCLUSION: Diagnostic and therapeutic delay were associated with older age, lower education and delayed consultation with rheumatologist but not with positive RA factor. Positive anti-CCP antibodies were associated with diagnostic delay only. Diagnostic and therapeutic delay led to high disease activity and poor functional outcome in RA patients.

Prevalence of inflammatory back pain and radiographic axial spondyloarthritis in a semi-urban community of Lahore, Pakistan.

AIMS: To determine the prevalence of inflammatory back pain (IBP) and radiographic axial spondyloarthritis (SpA) in a semi-urban community of Lahore, Pakistan. METHODS: This cross-sectional household survey was designed as per the Community Oriented Program for the Control of Rheumatic Diseases (COPCORD) model. In Phase 1, the subjects were interviewed for musculoskeletal (MSK) pain in the last 7 days by clinical assistants. In Phase 2, physiotherapists identified subjects with spinal/back pain and interviewed for Assessment in Spondyloarthritis International Working Group (ASAS) criteria for IBP. In Phase 3 subjects having IBP or chronic back pain (CBP) with an age at onset ≤45 years, were assessed and further investigated. RESULTS: A total of 4922 subjects with a mean age of 35.3 ± 14.5 years, including 2770 (56%) women were surveyed in Phase 1. MSK pain in last 7 days was reported by 1407 (28.6%) of whom 1034 (21%) had spinal pain. The ASAS criteria for IBP were met in 329 (6.7%, 95% CI 6.0-7.0). In Phase 3, 222 with IBP and 83 having CBP with age at onset ≤45 years were evaluated. Out of this total of 305, 144 (2.9%) were confirmed to have IBP by rheumatologists as per at least 1 of the 3 criteria. ASAS criteria were met in 107 (2.2%, 95% CI 1.8-2.6). ASAS criteria for radiographic axial SpA were met in 47 (1%, 95% CI 0.7-1.3) of the surveyed population. CONCLUSION: Inflammatory back pain was reported in 6.7% by physiotherapists, confirmed in 3% by rheumatologists. The prevalence of radiographic axial SpA was 1%.

Association of systemic lupus erythematosus disease activity index score with clinical and laboratory parameters in pediatric onset systemic lupus erythematosus.

OBJECTIVE: To determine the association of systemic lupus erythematosus disease activity index (SLEDAI) score in pediatric onset SLE (p-SLE) with clinical and laboratory parameters. METHODS: This cross sectional observational study was conducted at Division of Rheumatology, Fatima Memorial Hospital, Lahore from November 2018 to January 2019. Total 23 patients diagnosed with p-SLE having onset of symptoms at ≤ 18 years of age, irrespective of their current age at presentation, of either gender, fulfilling criteria of 2012 Systemic Lupus International Collaborating Clinics (SLICC) criteria were enrolled. Patients' clinical symptoms and laboratory parameters were reviewed, SLEDAI scores were calculated. Collected Data were entered in proforma and analyzed on SPSS version 23. RESULTS: There were 91.3% females. Mean age at diagnosis was 11years ± 4years. At presentation patients had hematological involvement 69.6% followed by mucocutaneous symptoms 65.2% and renal involvement 21.6%. ANA by IFA was positive in all, while anti-ds-DNA was positive in 78.3% patients. SLEDAI score was ≥6 in 87% patients, average SLEDAI score was higher in patients with renal involvement (p=0.06). Elevated ESR (r=0.48, p=0.02), Anti-dsDNA (r=0.44, p=0.05) and low complement levels (p=0.03) were significantly positively correlated, while hemoglobin (r= -0.43, p=0.04) was negatively correlated with the SLEDAI score. CONCLUSION: In this study, patients with Lupus Nephritis had high SLEDAI scores. Elevated Anti-dsDNA titer, ESR, low complement levels and hemoglobin were significantly associated with high SLEDAI scores. We recommend that SLEDAI score should be calculated in p-SLE patients for stringent disease monitoring and treatment.

A rheumatology curriculum in Pakistan for empowering family physicians and fighting disability.

INTRODUCTION: Pakistan has a population of over 200 million with only 75 trained rheumatologists. To address the needs of rheumatology care, it is of paramount importance to train the primary care physician as a first line of defense. METHODS: The project "Empowering Family Physicians; fighting disability" was the recipient of a 2018 ILAR grant. This project began with development of an evidence-based curriculum using ACR Rheum2learn modules along with guidelines from international societies. A blended learning approach was chosen with nine online learning modules sandwiched between two face-to-face sessions. Participants' assessment entailed quizzes, clinical scenarios, and portfolio development all completed online, while face-to-face sessions relied upon power-point presentations and an objective structured clinical examination. Course impact was assessed with pre-course and post-course questionnaires. Overall perception of the training was evaluated through candidate feedback. RESULTS: Participants were enrolled from across the country totaling 48 health care providers (44 family physicians and 4 allied health professionals). The adherence to face-to-face sessions was 82.5% and 63.6% for the online component. The mean score for post-course assessment (mean = 2.369, SD = 0.3425) was significantly higher than for the pre-course assessment (mean = 1.792, SD = 0.4838) with statistically significant difference of, t (12) = - 7.756, p < 0.0001 (confidence interval: - 0.7390 to - 0.4149). The perception of the strategy was positive with 80% strongly satisfied with the workshops and presentations. CONCLUSION: Empowering family physicians by training them in rheumatology care can be an effective tool to fight unmet needs in access to musculoskeletal health care. We plan to offer a shortened version of the course at regular intervals.Key Points• Pakistan has a huge shortage of rheumatology care with only 75 rheumatologists caring for a population of over 200 million.• To improve access to rheumatology care,the "Empowering Family Physicians; Fighting disability" course was launched in 2018 with the help of anILAR grant.• A blended learning approach comprising of 9 online modules sandwiched between two face-to-face sessions was chosen.• A statistically significant difference between pre- and post-courseself-assessment of participantssuggests that the courseis an effective tool for teaching Family Physicians.

Frequency of Dyslipidemia in patients with Lupus Nephritis.

OBJECTIVE: To determine the frequency of dyslipidemia in patients with lupus nephritis and its association with the degree of proteinuria. METHODS: This cross-sectional analytic study included 65 patients who fulfilled the ACR (American College of Rheumatology) criteria for SLE and had renal involvement, presenting to the Division of Rheumatology, Fatima Memorial Hospital (FMH), and Lahore from 21st Sep 2016 to 20th Dec 2016. After 12 hours overnight fast their blood samples were assessed for total cholesterol (TC), triglycerides (TG), high density lipoprotein (HDL) and low density lipoprotein (LDL). Patient demographic variables (age, sex) and disease characteristics (disease duration, degree of proteinuria, steroid dose) were noted. Patients were categorized into two groups on the basis of degree of proteinuria: having proteinuria >1gm or ≤ 1gm. Data was analyzed using SPSS version 22. Individual lipid profiles were correlated with the degree of proteinuria. RESULTS: Most common lipid abnormality found in our study was hypertriglyceridemia (58.5%). Total Cholesterol and LDL-C was high in 55.4% and 30.8% subjects respectively. Low HDL was found in 21.5% subjects. Increased frequency of dyslipidemia was noticed in those subjects who had proteinuria >1gm (P value < 0.05). CONCLUSION: Dyslipidemia was observed in a high frequency in patients with lupus nephritis and was strongly associated with their degree of proteinuria.

Cognitive dysfunction in patients with Systemic Lupus Erythematosus.

OBJECTIVE: To determine the frequency of cognitive dysfunction in patients with Systemic Lupus Erythematosus in a Pakistani population, presenting at a tertiary care Rheumatology setting. METHODS: This cross-sectional study was conducted at the Division of Rheumatology, Fatima Memorial Hospital, Lahore, from March to June 2016. A total of 43 consecutive patients, who fulfilled the 2012 SLICC (Systemic Lupus International Collaborating Clinics) classification criteria for Systemic Lupus Erythematosus (SLE), were enrolled. Cognitive function was assessed using Montréal Cognitive Assessment (MoCA) questionnaire. Demographic data and disease dynamics were collected in a proforma. Cognitive dysfunction was defined as score < 26/30, adjusted for duration of formal education. SPSS version 16.0 for windows was used to analyse data and to calculate frequency of cognitive dysfunction. RESULTS: Out of 43 enrolled patients, 95.3% were females and 4.7% were males, with mean age of 28.72 ± 9.25 years and mean formal education duration of 10.98 ± 3.29 years. The mean disease duration was 24.21 ± 30.46 months. Anti-nuclear antibodies (ANA) were present in all patients and anti-ds DNA in 93% patients. Cognitive dysfunction according to MoCA score was found in 65.1% (n=28) patients. For patients with disease duration more than two years, cognitive dysfunction was found in 60% patients [p>0.05] and for duration of formal education less than 12 years in 74.1% patients [p>0.05]. CONCLUSION: In this study, two third of SLE patients had Cognitive dysfunction. Hence, there is an increasing need to recognise and initiate early therapy for this overlooked aspect of SLE with an aim to achieve better quality of life.

Pattern of initial clinical manifestations of systemic lupus erythematosus in a tertiary care hospital.

OBJECTIVE: To determine the pattern of initial clinical manifestations of Systemic Lupus Erythematosus (SLE) and to compare these features with those recorded elsewhere in Pakistan. METHODS: This cross-sectional, descriptive study was performed in the Department of Rheumatology, Fatima Memorial Hospital, Lahore, Pakistan, from November 2015 to January 2016. Sixty one patients of SLE diagnosed as per ACR (American College of Rheumatology) 1982 revised criteria, were enrolled. The patients were evaluated for the initial clinical manifestations of SLE. The information was collected on a specially designed proforma and analyzed by using SPSS version 17. RESULTS: Out of 61 patients, 49 (80.3%) were females and 12 (19.7%) males, showing a female to male ratio of 4:1. The mean age of patients was 26.2 ± 7.9 years. Fatigue was the most common presenting feature in 56 (91.8%) patients, followed by joint pains in 55 (90.2%) and fever in 54 (88.5%). Renal involvement was found in 46 (75.4%). Comparison of these presenting features was made with other studies carried out in Northern Pakistan (Islamabad) and in central Punjab (Pakistan). There were statistically significant differences in fever, fatigue and arthritis between our patients and the other two above mentioned study groups. However, comparison of renal manifestations showed significant difference only with Islamabad study, and not with previous study from central Punjab. CONCLUSION: In this study, majority of patients presented with combination of fatigue, fever, rash and arthritis. Almost three-fourth of patients had renal manifestations at initial presentation. Therefore, it is important for clinicians to have high index of suspicion for SLE, when patients present with above symptoms.

Adherence to Methotrexate therapy in Rheumatoid Arthritis.

OBJECTIVE: To determine adherence to methotrexate (MTX) therapy in patients with Rheumatoid Arthritis (RA) and to identify factors that promote either adherence or non adherence. METHODS: One hundred Rheumatoid Arthritis patients on MTX for at least two months were enrolled. Questionnaire was completed by direct interview. Details recorded were, demographics (age, sex, education, monthly income), disease duration, duration on MTX and current dose. Disease Activity Score on 28 joint counts (DAS 28) at the current visit, concomitant drugs taken and number of doses of MTX missed in the previous 8 weeks were noted. Non adherence was defined as omission of any three or more prescribed doses of MTX in previous 8 week. Patients were asked for the factors that motivated their adherence to MTX as well as factors for non adherence. Presence of side effects due to MTX was also recorded. RESULT: Non adherence was found among 23% of cases. Patients of low socioeconomic group (p <0.0001) and on MTX for longer duration (p <0.001) had higher non adherence. Non adherent patients had significantly higher disease activity as measured by DAS 28 (p<0.001). Good counseling and education by the doctor was a strong predictor of adherence (p <0.001). Lack of affordability (p <0.001); lack of availability at local pharmacy (p <0.001); lack of family support (p <0.001) and lack of awareness regarding need and importance of MTX (p < 0.001were found as significant factors for non adherence. CONCLUSION: MTX non adherence in RA is noted in about one fourth of study group. Various economical and social issues lead to non adherence but good patient education and counseling by doctor could promote adherence in this study group.

Treat-to-target approach in daily clinical practice in Pakistani patients with early Rheumatoid Arthritis.

OBJECTIVE: To determine the frequency of patients with early Rheumatoid Arthritis (RA) achieving disease remission and/or low disease activity after 6 months of treatment with conventional Disease Modifying Anti-Rheumatic Drugs (DMARDs) by using treat-to-target approach in routine clinical practice. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Division of Rheumatology, Fatima Memorial Hospital (FMH), College of Medicine and Dentistry, Lahore, from March 2011 to February 2012. METHODOLOGY: Patients with early RA defined as disease duration ² 1 year were enrolled by purposive sampling, diagnosed as per American College of Rheumatology (ACR) 1987 criteria. Treat-to-target approach was defined as per European League Against Rheumatism (EULAR) 2010 guidelines for treatment of RA with conventional DMARDs. Outcome measures of remission and low disease activity were defined as per DAS 28 score criteria. Patient response to treatment was also determined by EULAR response criteria. RESULTS: Out of 67 patients, 50 patients completed the 6 months study period, rest were lost to follow-up. All patients were started on Methotrexate and mean weekly dose at 6 months was 18.9 ± 3.8 mg. Remission was achieved in 17 (34%) and target of low disease activity was achieved in 29 (58%) of patients. EULAR good response was seen in 28 (56%), moderate response in 21 (42%) and no response to treatment in 1 (2%). CONCLUSION: By applying treat-to-target approach in early RA, achievement of clinical remission or low disease activity with conventional DMARDs is a realistic goal in routine practice.

Leflunomide in Pakistani patients with rheumatoid arthritis: prospective study in daily rheumatology practice.

INTRODUCTION: Leflunomide is a disease-modifying anti-rheumatic drug (DMARD) for rheumatoid arthritis (RA). It has been widely studied in the West but there is no available local Pakistani data. OBJECTIVE: To evaluate the efficacy and safety profile of leflunomide in Pakistani patients with RA, either alone or in combination with methotrexate. MATERIALS AND METHODS: A prospective, non-comparator, open-label study in a setting of 'care as usual' was performed. In this study, 63 consecutive RA patients on leflunomide were enrolled. Leflunomide dose was started with full loading in 5 (8%), half loading in 39 (62%) and without loading in 19 (30%) patients. Methotrexate was also used in 20 (32%) patients. Primary end-point was 20% improvement in American College of Rheumatology response criteria (ACR-20). Safety was assessed by adverse events and abnormalities in laboratory parameters. RESULTS: Out of 63 patients, 54 (85.7%) were female. Mean age was 46 ± 12.6 years. Mean disease duration was 5.1 ± 4.5 years. Fifty-two (86.6%) patients achieved ACR-20 response at 6 months; 32 (53%) achieved ACR-50 response at 6 months; 20% experienced at least one adverse event, which resolved by reducing leflunomide dose. Only seven (11%) had raised liver enzymes from baseline. CONCLUSION: This prospective study conducted in the setting of a daily rheumatology practice shows that leflunomide is an effective and safe DMARD in treatment of RA in Pakistani patients.