Correlation of Hypothyroidism With Disease Activity Score-28 in Patients of Rheumatoid Arthritis.

Introduction Rheumatoid arthritis (RA) is a chronic autoimmune disorder with variable disease course including periods of flares and remissions. High disease activity in terms of disease activity score-28 (DAS-28) results in significant morbidity. Hypothyroidism is found to be associated with higher DAS-28 scores in RA. This study is planned to determine overt and subclinical hypothyroidism and its correlation with the DAS-28 score in patients with RA. Methodology This study was conducted from June 2021 to March 2022 at the department of rheumatology and immunology at Shaikh Zayed Hospital, Lahore, Pakistan. Inclusion criteria were any male and female patients aged between 18 and 70 years. The blood samples of diagnosed patients with RA were sent for thyroid function tests (thyroxine [FT4], thyroid-stimulating hormone [TSH]), and erythrocyte sedimentation rate (ESR), and the patients were categorized as overt hypothyroidism, subclinical hypothyroidism, and non-hypothyroid. The collected data were analyzed on Statistical Package for the Social Sciences (SPSS) version 24.0 (IBM Corp., Armonk, NY). Results The mean age of patients was 38.18 ± 9.78 years. The mean duration of symptoms was 14.65 ± 1.04 months. There were 182 (91%) females and 18 (9%) males. The mean number of swollen joints was 2.26 ± 2.8, and the mean number of tender joints was 4.16 ± 5.11. Sixty patients (30%) had high disease activity, i.e., DAS-28 score > 5.1. Fifty-seven patients (28.5%) with RA had subclinical hypothyroidism, and 19 patients (9.5%) had overt hypothyroidism. Pain visual analog scale (VAS) and DAS-28 were significantly higher in hypothyroid patients. Conclusion It was concluded that patients of RA with concomitant hypothyroidism had increased disease activity with increased tender joints. Thyroid function tests should be included in the clinical evaluation of RA patients. The evaluation of thyroid functional status must be done during screening in RA patients. This will detect thyroid disorders earlier, with early treatment initiation and possibly a better prognosis.

Frequency and predictors of pulmonary hypertension in patients with Systemic Lupus Erythematosus.

OBJECTIVE: To determine the frequency and predictors of pulmonary hypertension in patients with Systemic Lupus Erythematosus in a Pakistani population, presenting at a tertiary care hospital. METHODS: This cross-sectional study was conducted at the Department of Rheumatology, Shiekh Zayed Hospital, Lahore from March to June 2018. A total of 97 patients, who fulfilled the Systemic Lupus Erythematosus (SLE) criteria of American College of Rheumatology (ACR) 1992 were enrolled. Pulmonary Arterial Hypertension (PAH) was measured by calculating pulmonary arterial systolic pressure through echocardiography by a single consultant cardiologist. Disease characteristics and demography was collected in a self-administered proforma. PAH was defined as mean pulmonary arterial pressure of 25mmHg or above by calculating with a formula. SPSS version 20 was used for analysis of data. RESULTS: Out of 97 patients, 89.7% (n=87) were females and 10.3% (n=10) were males, with mean age of 31.29± 8.824 years. The mean disease duration was 24.21 ± 30.46 months. PAH was found in 23.3% (n=23) patients, including 19 females and 4 males. On further analysis of data, Raynaud phenomenon, rheumatoid factor and nephritis were assessed as predictors of PAH and all of these showed statistical significance for presence of PAH as per Chi-square test (p<0.05). CONCLUSION: In this study, 23.3% SLE patients showed evidence of PAH and positive statistical significance was found between predictors like Raynaud phenomenon, rheumatoid factor, nephritis and presence of PAH. So it is imperative to detect PAH early and start prompt treatment to achieve better quality of life.

Case report of a lupus patient with a severe flare and miliary tuberculosis: need for proper guidelines for management.

Systemic lupus erythematosus (SLE) is an autoimmune disease that is frequently treated with high doses of corticosteroids and other immunosuppressive drugs. Thus patients with SLE are at increased risk for infections with several pathogens including Mycobacterium tuberculosis. There are no established guidelines available for treatment of tuberculosis in SLE patients with high disease activity due to lack of relevant studies and management based more on physician expertise. We report a case of a young SLE patient with high disease activity index (SLEDAI19) as evidenced by the presence of a vasculitic rash, non-healing ulcer on forearm and proteinuria of >1 g/d along with miliary tuberculosis. She was treated with intravenous methylprednisolone pulse up to 3 g and antituberculous therapy, but the result was a fatal outcome. This case report emphasizes the need for formal guidelines for co-management of active tuberculosis and SLE with high disease activity.

Cardiovascular risk score in Rheumatoid Arthritis.

OBJECTIVE: To determine the 10-year Cardiovascular risk score with QRISK-2 and Framingham risk calculators in Rheumatoid Arthritis and Non Rheumatoid Arthritis subjects and asses the usefulness of QRISK-2 and Framingham calculators in both groups. METHODS: During the study 106 RA and 106 Non RA patients age and sex matched participants were enrolled from outpatient department. Demographic data and questions regarding other study parameters were noted. After 14 hours of fasting 5 ml of venous blood was drawn for Cholesterol and HDL levels, laboratory tests were performed on COBAS c III (ROCHE). QRISK-2 and Framingham risk calculators were used to get individual 10-year CVD risk score. RESULTS: In this study the mean age of RA group was (45.1±9.5) for Non RA group (43.7±8.2), with female gender as common. The mean predicted 10-year score with QRISK-2 calculator in RA group (14.2±17.1%) and Non RA group was (13.2±19.0%) with (p-value 0.122). The 10-year score with Framingham risk score in RA group was (12.9±10.4%) and Non RA group was (8.9±8.7%) with (p-value 0.001). In RA group QRISK-2 (24.5%) and FRS (31.1%) cases with predicted score were in higher risk category. The maximum agreement scores between both calculators was observed in both groups (Kappa = 0.618 RA Group; Kappa = 0.671 Non RA Group). CONCLUSION: QRISK-2 calculator is more appropriate as it takes RA, ethnicity, CKD, and Atrial fibrillation as factors in risk assessment score.

Evaluation of anti-CCP antibody for diagnosis of rheumatoid arthritis.

BACKGROUND: Rheumatoid arthritis is a common, world wide, systemic disease that affects mainly joints. Rheumatoid factor is the only marker to diagnose rheumatoid arthritis; however these antibodies are present in other disorders and even in up to 15% of the healthy population. Many auto antibodies have been reported to diagnose rheumatoid arthritis e.g. APF and AKA, etc. but they are not specific and due to tedious laboratory procedure, they have not been generally adopted. Anti-CCP antibodies have been reported for their high sensitivity and specificity. This study was planed to determine the prevalence of anti-CCP antibodies and RA factor in clinically diagnosed patients of rheumatoid arthritis. METHODS: Anti-CCP antibody was determined by ELISA technique and RA-factor was done by latex agglutination method. RESULTS: Forty five patients, 36 female and 9 male, were recruited for this study. Twenty-five (55.6%) patents were positive for anti-CCP antibodies while 20 patients were negative for anti-CCP antibodies and comparison between anti-CCP positive and anti-CCP negative was statistically significant (p = < 0.01). Thirty-one (68%) patients were seropositive (SPRA) for RA while 14 (31%) patients were seronegative (SNRA). Among SPRA patients, 18 were positive for anti-CCP antibody and among 14 SNRA patients, 7 patients had anti-CCP antibody and the difference between these two groups was not statistically significant. CONCLUSIONS: Anti-CCP antibody and RA-factor should be used concomitantly to diagnose RA.

An index of depression in patients with chronic nonspecific musculoskeletal pain.

BACKGROUND: The present study was undertaken to derive an index of depression in patients with chronic non-specific musculoskeletal pain and to determine correlation between these two parameters. METHOD: The study was carried out at the Shaikh Zayed Hospital Lahore from November 2001 to May 2002 and included 36 patients with pain for at least 4-24 weeks duration; an equal number of healthy people acted as controls. Depression was assessed among subjects by administering the General Health Questionnaire (GHQ) to patients and controls and obtaining their GHQ scores. Pain assessment was performed in patients by scoring the total number of pain sites on digital palpation to provide a Total Pain Score (TPS). RESULTS: Patients differed significantly from controls in their GHQ scores (patients 20.47 +/- 7.19, controls 3.11 +/- 1.89 respectively, p<0.001). The GHQ score and the TPS score correlated significantly in patients (r=0.517, p=0.001). CONCLUSIONS: Patients with chronic non-specific musculoskeletal pain suffer from significant levels of depression, in direct correlation to their pain.

Uric acid profile in patients with chronic nonspecific musculoskeletal pain.

BACKGROUND: The present study was undertaken to determine the uric acid profile in patients with unexplained chronic musculoskeletal complaints, and to establish any possible causal role for altered uric acid profile in such patients. METHOD: A comparative study of 36 patients and 36 controls of both sexes and ages between 25-60 years was carried out at Shaikh Zayed Hospital, Lahore from November 2001-May 2002. Patient included were those who had at least 4-24 weeks duration of complaints. Uric acid profile for serum uric acid, uric acid excretion, uric acid clearance and total uric acid production was done. Additional tests included renal functions test, liver function test, cardiac enzymes, haematology and serology to exclude other underlying causes of complaints. RESULTS: Mean serum uric acid levels were higher in patients as compared to controls (p = 0.05), with 9 (25%) patients showing hyperuricemia. Uric acid clearance (female patients 5.86 +/- 0.42 ml/min, female controls 8.06 +/- 0.24 ml/min) and daily uric acid excretion (female patients 412.38 +/- 28.52 mg/24 hours, female controls 487.79 +/- 18.64 mg/24 hours) in female patients was significantly lower than control females (P = 0.034 and P < 0.001 respectively). Twenty patients (55.55%, 3 males and 17 females) were classified as under excretors of uric acid, while there were no under excretors in the control group (p < 0.001). CONCLUSION: We conclude that abnormalities of uric acid profile, particularly under excretor status may be an underlying biochemical abnormality in a significant number of patients. Female patients appear more predisposed to abnormal uric acid profile such as hyperuricemia and under excretor status.