The Cost-Effectiveness of and Adherence to Disease-Modifying Antirheumatic Drug (DMARD) Therapy in Rheumatoid Arthritis Patients in a Tertiary Care Teaching Hospital in Uttarakhand, India.

Objective This study was conducted with the aim of evaluating the cost-effectiveness of and adherence to treatment in patients on disease-modifying antirheumatic drug (DMARD) therapy for rheumatoid arthritis (RA) in a tertiary care teaching hospital in Uttarakhand, India. Methodology This prospective observational study was conducted on 150 rheumatoid arthritis patients presenting to the Rheumatology Outpatient Department (OPD) receiving DMARD therapy (approval number AIIMS/IEC/18/160). The patients were followed up for an average of 10.7 weeks and received drugs in four regimens with methotrexate (MTX) (Regimen 1) having the least contribution with a mean of 46.05 Rs, methotrexate + hydroxychloroquine (MTX + HCQ) (Regimen 2) with 174.15 Rs, methotrexate + hydroxychloroquine + leflunomide (MTX + HCQ + Lef) (Regimen 3) with Rs 371.70, and methotrexate + hydroxychloroquine + leflunomide + biological DMARD adalimumab (MTX + HCQ + Lef + bDMARD adalimumab) (Regimen 4) with 17,349.4 Rs. The cost of drug therapy was assessed by calculating the cost of therapy per month for each patient, and adherence was assessed using the Morisky-Green-Levine Scale (MGLS) at the follow-up visit. Results The overall mean cost of DMARD treatment was 205.81 Rs. The overall DMARD therapy cost-effectiveness was Rs 878.14 for a unit change of Disease Activity Score (DAS28). The most cost-effective treatment came out to be Regimen 1 with the least cost of 290.9 Rs for a unit change of DAS28, and the least cost-effective was Regimen 4 with 65,661.8 Rs for a unit change of DAS28. At follow-up, among all subjects of the study, 49 (32.7%) subjects showed high adherence, 71 (47.3%) subjects showed medium adherence, and 30 (20%) subjects showed low adherence. Accordingly, the maximum number of participants fell in the category of medium adherence, i.e., 71 (47.4%). Conclusion Our study concluded that the cost burden varied according to the number of DMARDs being given to the patient. The double-drug therapy of methotrexate + hydroxychloroquine had a maximum "high adherence." On a whole, the majority of patients had "medium adherence" to therapy.

A Case-Based Review of Arthritis Robustus.

Rheumatoid arthritis (RA) commonly presents as a chronic additive symmetric inflammatory polyarthritis involving the small and large joints. Rarely do patients present with few or no clinical symptoms, despite apparent signs of inflammation. This condition, known as arthritis robustus, typically occurs in elderly males who are manual laborers with an active lifestyle. It is essential to diagnose arthritis robustus and start treatment promptly to avoid the development of deformities and other complications in the future.

Evaluation of prescription practices in rheumatoid arthritis at the rheumatology clinic in a tertiary care teaching hospital in Uttarakhand: A cross-sectional study.

OBJECTIVE: This study was aimed to analyze the prescription pattern of disease modifying anti-rheumatic drug (DMARD) therapy in patients with rheumatoid arthritis (RA) in a tertiary care teaching hospital in Uttarakhand, India. METHODOLOGY: This cross-sectional study was conducted in 150 RA patients who were given DMARD therapy. Patient's demographic details, drugs prescribed with their dosage and administration routes and the usage of complementary and alternative medicine (CAM) therapy were recorded to study the prescription pattern. RESULTS: Overall, 4 DMARDs were prescribed in all the studied patients: Methotrexate (n = 150), hydroxychloroquine (n = 35), leflunomide (n = 5), and adalimumab (n = 1). Single DMARD therapy with methotrexate was prescribed to 110 (73.3%) followed by double therapy with methotrexate + hydroxychloroquine in 35 (23.3%), triple therapy (methotrexate + hydroxychloroquine + leflunomide) in 4 (2.7%) and triple therapy with biological DMARD (methotrexate + hydroxychloroquine + leflunomide + adalimumab) in 1 (0.7%) patient. Adjuvant therapy drugs included: Prednisolone (n = 150), folic acid (n = 150), naproxen (n = 150), calcium (n = 150), vitamin D (n = 150) and indomethacin (n = 40). Of the total, 61.4% patients also took complimentary alternative medicine (CAM) therapy. CONCLUSION: Our study concludes that the most commonly prescribed DMARDs in our setting, to patients of RA, in descending order of frequency were methotrexate, followed by hydroxychloroquine, leflunomide and lastly adalimumab. A total of five adjuvant medications were commonly prescribed to all patients. There was a high prevalence of self-medicated CAM therapy in the majority of these patients.

Tuberculous vasculitic lung mass: Unique presentation of a common disease.

Tuberculosis is a common disease but it keeps on surprising with its unique presentations. It has been reported as lung mass but here we are reporting a case of Tuberculosis presented as vasculitic lung mass. A 61 years old female, known case of hypertension and secondary Sjogren syndrome, on treatment, presented with history of mild dyspnea and generalised weakness with incidental finding of Right hilar mass on chest X-ray undergoes a CECT thorax and CT guided biopsy. Histopathology contrary to expectations revealed granulomatous vasculitis with no microbiological evidence of TB, responded to antitubercular treatment and there was almost complete regression of the lesion after 6 weeks of ATT.

Falciparum malaria-induced acute pancreatitis.

Falciparum malaria is one of the most common causes of acute febrile illness in India and frequently presents as severe malaria also known as complicated malaria or cerebral malaria with associated multiple organ failure. Acute pancreatitis secondary to malaria is very rare complication. Here we are presenting a case of severe falciparum malaria with acute pancreatitis.

Rising visceral leishmaniasis in Holy Himalayas (Uttarakhand, India) - A cross-sectional hospital-based study.

BACKGROUND: Apart from the rarity of the visceral leishmaniasis (VL) cases in high altitude (>2000 ft), the combination triad of VL, hemophagocytic lymphohistiocytosis (HLH) syndrome, and Himalayas is rarely being reported. Here, we studied the triad in the Himalayan region, attending a single tertiary care hospital over a period of 2 years. METHODS: The study was a cross-sectional analysis of case records of seven confirmed VL patients. A systematic master chart review analyzed the demographic, clinical, laboratory, treatment, and outcome details of these patients. RESULTS: These cases were diagnosed as VL by clinical findings and confirmed by rk-39 anti-body and demonstration of LD bodies in bone marrow smears. All cases without any travel history to endemic regions presented with prolonged fever (>1 months duration), anorexia, weight loss, and having hepatosplenomegaly and bi-or pan-cytopenia. All cases were having HLH, confirmed based on the HScore system (online calculation), and liver injury having transaminitis. Kidney involvement was seen in 27% cases. All cases improved with liposomal amphotericin-B, but one had cardiac arrest after blood transfusion reaction. CONCLUSION: Clinician of the non-endemic zone should suspect VL in patients with fever of unknown origin and have a high suspicion in cases of HLH and liver involvement and vice versa. Kidney involvement is seen in one-third of the VL cases. Liposomal amphotericin-B is recommended in this region. The leishmaniasis prevalent in these areas should further be subject to comparison with endemic parts, and a large-scale study is needed to find the reason of the rising vector from the holy Himalayas.

A cytosol derived factor of Group B streptococcus prevent its invasion into human epithelial cells.

Group B streptococcus (GBS) or Streptococcus agalactiae, is an opportunistic pathogen causing a wide range of infections like pneumonia, sepsis, and meningitis in newborn, pregnant women and adults. While this bacterium has adapted well to asymptomatic colonization of adult humans, it still remains a potentially devastating pathogen to susceptible infants. Advances in molecular techniques and refinement of in vitro and in vivo model systems have elucidated key elements of the pathogenic process, from initial attachment to the maternal vaginal epithelium to penetration of the newborn blood-brain barrier. Still, the formidable array of GBS virulence factors makes this bacterium at the forefront of neonatal pathogens. The involvement of bacterial components in the host-pathogen interaction of GBS pathogenesis and its related diseases is not clearly understood. In this study we demonstrated the role of a 39 kDa factor from GBS which plays an important role in the process of its invasion. We found a homogeneous 39 kDa factor from the cytosol of GBS after following a combination of sequential purification steps involving molecular sieving and ion exchange chromatography using ACTA-FPLC system. Its N-terminal sequence showed a homology with xenobiotic response element type transcriptional regulator protein, a 40 kDa protein of Streptococcus. This factor leads to inhibition of GBS invasion in HeLa and A549 cells. This protein also showed sensitivity and specific cross reactivity with the antibodies raised against it in New Zealand white rabbits by western immunoblotting. This inhibitory factor was further confirmed tolerant for its cytotoxicity. These results add a novel aspect to bacterial pathogenesis where bacteria's own intracellular protein component can act as a potential therapeutic candidate by decreasing the severity of disease thus promoting its invasion inhibition.