Rheumatoid arthritis and the risk of preterm birth.

During pregnancy, many diseases are correlated with different adverse outcomes. In turn, pregnancy affects the body, leading to increased disease susceptibility. This interplay between diseased states and pregnancy outcomes is illustrated in the effect of the chronic autoimmune disorder, rheumatoid arthritis (RA), and the adverse outcome, preterm birth (PTB). RA is a systemic disorder characterized by inflammation of the joints and other body organs. Joint pain and swelling are the most prominent manifestations of RA during pregnancy. However, the exact role of RA on PTB among pregnant women has yet to be established. This review highlighted the immunologic mechanisms involved in PTB in pregnant patients with RA. The immune cell population in pregnant women with RA exhibited higher activity of macrophages, dendritic cells, neutrophils, helper T (Th) 1 cells, and Vδ1 cells, but lower activity of CD4 + CD25high T regulatory (CD24 + CD25high Treg ), Th2, and Vδ2 cells. Increased pro-inflammatory cytokines IL-6, TNF-α, and IFN-γ and decreased anti-inflammatory cytokines IL-12 and IL-10 are also exhibited by pregnant patients with RA. This review also discussed factors that may predict the risk of PTB in RA. These include disease activity and severity of RA, laboratory parameters (cytokines and immune cell population), and sociodemographic factors such as ethnicity, smoking, alcohol intake, and the level of education. Current findings on the underlying immunological mechanisms of RA can help identify possible strategies to prevent PTB.

2019 revised algorithm for the management of knee osteoarthritis: the Southeast Asian viewpoint.

BACKGROUND: Since 2014, the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) algorithm for the management of knee osteoarthritis (OA) is available worldwide. AIM: Based on this document, a Southeast Asia Working Group (SEAWG) wished to see how the new ESCEO algorithm developed in 2019 was perceived by Southeast Asian experts and how it was integrated into their clinical practice. METHODS: A SEAWG was set up between members of the international ESCEO task force and a group of Southeast Asian experts. RESULTS: Non-pharmacological management should always be combined with pharmacological management. In step 1, symptomatic slow-acting drugs for osteoarthritis are the main background therapy, for which high-quality evidence is available only for the formulations of patented crystalline glucosamine sulfate and chondroitin sulfate. In step 2, oral NSAIDs are a useful option, considering the cardiovascular/renal/gastrointestinal profiles of the individual patient. Intra-articular hyaluronic acid and corticosteroids are a possible alternative to oral NSAIDs, but limited evidence is available. If steps 1 and 2 do not give adequate relief of symptoms, tramadol can be used, but its safety is debated. In general, the indications of the ESCEO algorithm are important in Southeast Asian countries, but the reimbursement criteria of local health systems are an important aspect for adherence to the ESCEO algorithm. CONCLUSION: This guidance provides evidence-based and easy-to-follow advice on how to establish a treatment algorithm in knee OA, for practical implementation in clinical practice in Southeast Asian countries.

Achievement of the target serum urate level among patients with gout treated with allopurinol or febuxostat in an arthritis clinic in the Philippines.

OBJECTIVE: Gout is an important cause of disability among Filipinos, despite measures for effective management. This study aims to determine attainment of target serum uric acid level (SUA ≤ 6 mg/dl) among patients with gout given urate-lowering therapy (ULT) over 6-12 months. METHODS: This is a single-center, prospective cohort study conducted in one adult Arthritis Clinic at the University of the Philippines-Philippine General Hospital which included 138 patients with gout (1977 ACR criteria), SUA ≥ 6 mg/dl prior to ULT, initiated on ULT (allopurinol or febuxostat), with six months minimum follow-up and with SUA determination post-treatment. RESULTS: 37.7% (52/138) and 36.2% (50/138), achieved target SUA at 6 and 12 months. The factors associated with achieving target SUA in 6 months are BMI > 25 kg/m2 [OR 6.98, 95% confidence interval (CI) 1.44-33.88, p value = .016], allopurinol dose ≥ 300 mg (OR 15.76, 95% CI 2.24-111.06, p value = .006), and baseline SUA (OR 0.52, 95% CI 0.33-0.82, p value = .005). The factors associated with achieving target SUA in 12 months are employment (OR 5.51, 95% CI 1.00-30.33, p value = .050), baseline SUA (OR 0.45, 95% CI 0.28-0.74, p value = .002), and age at onset of gout (OR 1.08, 95% CI 1.01-1.15, p value = .026). CONCLUSION: Target SUA level was not achieved at 6 and 12 months of ULT in most of this cohort. This mirrors the deficient control of gout and should urge health professionals to fully study and address the problem.

Red cell distribution width and neutrophil-lymphocyte ratio in rheumatoid arthritis.

Red cell distribution width (RDW) and neutrophil-lymphocyte ratio (NLR) are potential low-cost markers for detecting rheumatoid arthritis (RA) disease activity, but evidence on their accuracy for this purpose is conflicting. We aimed to determine the relationship between these and the Disease Activity Score of 28 joints (DAS-28) among Filipino RA patients, and to evaluate their ability to discriminate between patients with active RA and those in remission. This was a cross-sectional study done through a 7-year review of medical records of 134 adult patients with RA in a tertiary government hospital. Correlations were analyzed using Spearman analysis, and the receiver operating characteristic (ROC) curve was used to derive the sensitivity, specificity, and optimal cut-off values of RDW and NLR. Most patients were females with a mean disease duration of 7 years. Eighty-one percent (81%) had active disease using DAS-28 ESR. A weak positive correlation was found between NLR and DAS-28 and between NLR and ESR, but RDW did not correlate with either DAS-28 or ESR. The ROC analysis showed that in the differentiation of active RA and inactive RA, both RDW (area under the curve [AUC] 0.516, cut-off of ≥ 14.2% with 55.6% sensitivity and 42.3% specificity) and NLR (AUC 0.629, cut-off of ≥ 2.32 with 54.6% sensitivity and 76.9% specificity) had poor performance. NLR, but not RDW, was positively but weakly correlated with DAS-28 and ESR, making it a helpful marker of disease activity and inflammation in RA. Both NLR and RDW had low sensitivity and specificity for active RA and may not be useful in detecting disease activity.

Role of psychosocial reserve capacity in anxiety and depression in patients with systemic lupus erythematosus.

AIM: To examine the relationship between reserve capacity measures and anxiety/depression among patients with systemic lupus erythematosus (SLE) from Southern California (SoCal), United States and Manila, Philippines. METHODS: A total of 235 participants with SLE completed self-reported scales to assess anxiety/depression and psychosocial reserve capacity measures (self-esteem, optimism, personal mastery/coping skills, social support), socioeconomic status (SES) data, and Mexican SLE Disease Activity Index. Statistical analyses included independent sample t-tests, Chi-square, and point-biserial and Pearson correlations. RESULTS: Overall, participants from Manila reported lower SES than SoCal participants. Over half of Manila and SoCal participants (69% and 59.1%, respectively) reported high anxiety scores. SoCal participants had higher depression scores than Filipinos (66%, 27%, respectively, P < 0.001) despite appearing to be more resilient by exhibiting higher scores for all reserve capacity measures (P < 0.001). Participants with low self-esteem scores from both groups had higher anxiety and depression scores. SoCal participants who reported lower optimism, lower personal mastery and lower social support were more anxious and depressed, while Filipinos low on these three variables reported less depressive symptoms. CONCLUSION: Reduced psychosocial reserve capacity in individuals leads to vulnerabilities that may ultimately result in greater disease burden and psychological distress. Low self-esteem, optimism, coping and social support were associated with depression and low self-esteem was associated with anxiety for both groups. Despite the Filipino cohort's lower reserve capacity and SES, Filipino patients exhibited less depression than their SoCal counterparts, suggesting that other factors may protect them from experiencing depression.

Effectiveness and tolerability of transdermal buprenorphine patches: a multicenter, prospective, open-label study in Asian patients with moderate to severe chronic musculoskeletal pain.

BACKGROUND: We examined the effectiveness and tolerability of transdermal buprenorphine (TDB) treatment in real-world setting in Asian patients with musculoskeletal pain. METHODS: This was an open-label study conducted in Hong Kong, Korea, and the Philippines between June 2013 and April 2015. Eligible patients fulfilled the following criteria: 18 to 80 years of age; clinical diagnosis of osteoarthritis, rheumatoid arthritis, low back pain, or joint/muscle pain; chronic non-malignant pain of moderate to severe intensity (Box-Scale-11 [BS-11] pain score ≥ 4), not adequately controlled with non-opioid analgesics and requiring an opioid for adequate analgesia; and no prior history of opioid treatment. Patients started with a 5 µg/h buprenorphine patch and were titrated as necessary to a maximum of 40 µg/h over a 6-week period to achieve optimal pain control. Patients continued treatment with the titrated dose for 11 weeks. The primary efficacy endpoint was the change in BS-11 pain scores. Other endpoints included patients' sleep quality and quality of life as assessed by the 8-item Global Sleep Quality Assessment Scale (GSQA) questionnaire and the EuroQol Group 5-Dimension Self-Report Questionnaire-3 Level version (EQ-5D-3 L), respectively. Tolerability was assessed by collecting adverse events. RESULTS: A total of 114 eligible patients were included in the analysis. The mean BS-11 score at baseline was 6.2 (SD 1.6). Following initiation of TDB, there was a statistically significant improvement in BS-11 score from baseline to visit 3 (least squares [LS] mean change: -2.27 [95% CI -2.66 to -1.87]), which was maintained till the end of the study (visit 7) (LS mean change: -2.64 [95% -3.05 to -2.23]) (p < 0.0001 for both). The proportion of patients who rated sleep quality as 'good' increased from 14.0% at baseline to 26.9% at visit 6. By visit 6, the mean EQ VAS score increased by 7.7 units (SD 17.9). There were also significant improvements in patients' levels of functioning for all EQ-5D-3 L dimensions from baseline at visit 6 (p < 0.05 for all). Seventy-eight percent of patients reported TEAEs and 22.8% of patients discontinued due to TEAEs. TEAEs were generally mild to moderate in intensity (96.5%). CONCLUSIONS: TDB provides effective pain relief with an acceptable tolerability profile over the 11-week treatment period in Asian patients with chronic musculoskeletal pain. More studies are needed to examine the long-term efficacy and safety of TBD treatment in this patient population. TRIAL REGISTRATION: ClinicalTrials.gov NCT01961271 . Registered 7 October 2013 (retrospectively registered; first patient was enrolled on 28 June 2013 and last patient last visit date was 26 Apr 2015).

Disease characteristics of Filipino ankylosing spondylitis patients in Metro Manila rheumatology clinics

OBJECTIVES: The study aims to describe the disease characteristics of Filipino patients diagnosed with ankylosing spondylitis (AS) in different rheumatology clinics in Metro Manila, Philippines. METHODS: The study retrospectively reviewed the records of all Filipino AS patients aged 18 years old and above,diagnosed by the Rome Criteria and seen from January 2000 to May 2012 at the rheumatology outpatient clinic of the Philippine General Hospital and in different rheumatology clinics in Metro Manila. Demographics, joint manifestations, radiographic findings, and medications were described and tabulated. Descriptive statistics included mean and standard deviation for quantitative variables and frequency and percentage for qualitative variables. . RESULTS: Forty-seven Filipino AS patients were included in the study. The male to female ratio was 46:1. The mean age at diagnosis was 33.2 +/- 10.93 years while the mean disease duration was 7.04 +/- 4.28 years. Seven (14.8%) patients had a family history of AS while twelve (70.6%) tested positive for HLA-B27. The lumbar spine was the most commonly affected site in the majority (80.9%) of subjects. A significant number of participants (70.2%) also had peripheral joint involvement,with the knee being the most common peripheral joint involved (72.7%). In terms of imaging, sacroiliitis was found in the majority (87.5%) of patients. All patients received standard rehabilitation exercises and almost all (97.9%) were on NSAIDs. Nine (19.1%) patients each received opioids and DMARD therapy, while eight (17%) received anti-TNF therapy. CONCLUSION: Filipino patients with AS are mostly young males presenting with chronic lumbar pain and HLA-B27 positivity.The data gathered in this study may help local physicians identify AS early in affected patients, giving them access to early intervention and thereby preventing progressive structural and functional deterioration.

Clinical profile of 266 Filipino patients with rheumatoid arthritis included in the rheumatoid arthritis database and registry (RADAR) of the Philippine General Hospital.

AIM: To describe Filipino patients with rheumatoid arthritis (RA) entered in the Rheumatoid arthritis database and registry (RADAR) of the Philippine General Hospital. METHODS: Cases entered to RADAR from 2010-2012 were included. All fulfilled the 1987 American College of Rheumatology criteria for classification of RA. Included cases gave written infomed consent. Data extracted were demographics, clinical presentation, laboratory tests, treatment and disease course. Means and proportions were used for population characteristics. RESULTS: Two hundred and sixty-six cases were included. Mean age was 44 years, with 9 : 1 female preponderance and mean diagnosis time of 5 years. There was symmetrical polyarthritis with high tender and swollen joint count and mean Disease Activity Score of 28 joints, erythrocyte sedimentation rate of 5.27 (3.39, 8.13). Rheumatoid factor was positive in 2/3 of cases. Hypertension, tuberculosis and diabetes were important co-morbidities. Treatment included prednisone, non-steroidal anti-inflammatory drugs and methotrexate. At 12 months of treatment, evaluable cases (< 20%) showed improvement from high to moderate disease activity. Methotrexate average dose was 8.6 mg/week. Nine cases received biologic agents. Factors affecting treatment included access to rheumatology centers, low socioeconomic status, presence of co-morbid diseases and treatment adverse events. CONCLUSION: This study reports a cohort of Filipino RA patients seen in a government arthritis unit whose disease characteristics are similar to what is reported worldwide. This cohort differs from most studies in having a high female to male ratio, a long delay in diagnosis, and high attrition rate. Mean methotrexate dose was low and there was less access to biologic disease-modifying anti-rheumatic drugs.

Mixed connective tissue disease in Filipinos - A 13-year retrospective review of 14 cases in the Philippine General Hospital

BACKGROUND: Mixed connective tissue disease (MCTD) is a distinct autoimmune disease with overlapping features of different connective tissue diseases and a broad spectrum of presentation and prognosis. Our aim is to present the clinical profile of a cohort of Filipinos with MCTD.METHODS: Charts with diagnosis of MCTD based on the Alarcon-Segovia Criteria from the Philippine General Hospital Adult Rheumatology clinic from January 1999 to December 2011 were reviewed for demographics, clinical presentation, and management. Descriptive statistics were applied.RESULTS: Fourteen patients were identified to have MCTD. All were females. The median age at symptom onset, and at diagnosis, was 30.5, and 31.5 years, respectively, with two having juvenile onset of symptoms. Mean interval from symptom onset to diagnosis is two years. Patients are being followed up for the past mean of 3.5 years.All eight women    who wanted children were able to conceive, and among them only two had fetal losses but were negative for antiphospholipid antibodies. Chief complaint was most commonly joint pain (67%) followed by skin tightness (13%). Systemic lupus erythematosus (SLE) was the most frequent initial diagnosis (43%). Majority had initial constitutional symptoms with generalized weakness and fatigue being the most frequent (93%). Most common physical findings in different body systems are as follows: musculoskeletal - arthritis (100%); vascular - Raynaud's phenomenon (93%); cutaneous- skin tightness (71%); gastrointestinal - dental caries (57%); hematologic - anemia of chronic disease (50%); cardiopulmonary - accentuated pulmonary component of the second heart sound and right ventricular hypertrophy (21% each); neurologic - peripheral neuropathy (21%); renal - proteinuria (21%); endocrine - autoimmune thyroiditis (21%).Half have anemia of chronic disease. Only three (21%) have proteinuria and were below nephrotic range. Twelve out of 12 have elevated sedimentation rates. For serologic studies, all have speckled ANA  and very  high  titers  of  anti-U1RNP;six of six patients have  normal  rheumatoid  factor(RF) titers; one    out    of  two  have  positive  anti-Ro;two out of four have anti-Ds DNA; none of two have anti-SCL70.Majority of the chest x-rays,electrocardiograms,echocardiographs  were  normal.Three have pulmonary hypertension. One out of four has restrictive lung disease on pulmonary function test. Most are in remission and are on low-dose prednisone (79%), hydroxychloroquine (50%), nifedipine (36%) and methotrexate (21%).CONCLUSION: This is the first study that detailed clinical and laboratory features of Filipinos with MCTD diagnosed using the Alarcon-Segovia criteria. Most clinical features, disease activity, and management are concordant with international data. Possible peculiarities include fewer interstitial lung disease, esophageal dysmotility, thrombocytopenia and leucopenia, and RF titers. We intend to add newly diagnosed patients and pursue this cohort for us to better understand the course of MCTD in Filipinos that could translate to better patient care.

Correlation between disease activity, functional capacity, and health-related quality of life of Filipinos with ankylosing spondylitis

OBJECTIVE: The study aimed to evaluate the relationships between disease activity, functional capacity,  and  health-related  quality  of  life   (HRQoL) in   Filipino   patients   with   ankylosing   spondylitis (AS).METHODS: Filipino AS patients gathered from the Rheumatology Clinic of the Philippine General Hospital (PGH) and from selected tertiary hospitals  in Metro Manila who have been  diagnosed  via  the  Revised New  York  Criteria  were  included.  Disease   activity  was measured using the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), while functional capacity and HRQoL were measured using the Bath Ankylosing Spondylitis Functional  Index  (BASFI)  and Short Form (SF)-36, respectively.  Pearson's  correlation  was used to analyze  the  relationship  between  BASDAI and   BASFI,   and   between   BASDAI   and  SF-36.RESULTS: Twenty-four patients entered the study.  Mean age was 38.75 ± 12.7  years  and  mean  age  at  diagnosis  was  31 ±  12.29  years.   Symptoms  occurred for  a   mean  of   9.0  ±   6.97  years  with  mean      duration of symptom onset to  diagnosis  of  3.38  ±  5.14  years.  Study subjects had mild to moderate disease activity. Functional  capacity  was most   impaired  in   performing a full day's activities at home or at work.  HRQoL  was highest in vitality and lowest in emotional role,  with  mental health components generally showing higher scores than physical health components. Pearson's correlation showed moderate positive correlation between BASDAI and BASFI (r=0.6016, p=0.0012) and moderate negative correlation between BASDAI  and  the  physical  health  domain  (r=  -0.6916,  p=0.0001)  and mental health domain (r= -0.3575, p=0.0863)  of SF-36. However, only the first two correlations were statistically  significant.CONCLUSION: Filipino AS patients with higher disease activity have more functional disability and poorer physical  HRQoL.

A three-month follow up of musculoskeletal manifestions in chikungunya fever

BACKGROUND: Chikungunya virus (CHIKV) is a mosquito- borne  alphavirus  of  the  family  Togaviridae  transmitted  to humans by the Aedes spp. mosquitoes, causing Chikungunya   Fever  (CHIKF).OBJECTIVE: This study aims to describe the course and outcome of musculoskeletal (MSK) manifestations in patients  with  CHIKF  seen  over  a   three-month     period.DESIGN: This is a prospective descriptive  study.  Seventy  patients  with  fever,  rash,  and  arthritis  seen   at the University of the Philippines-Philippine General Hospital  and  private  arthritis  clinics  were  collected from August - December 2012.  Demographics  and course   of   arthritis   were  described.RESULTS:  Seventy   patients,   53   (68.6%)   female,   with  a mean age  of  39.2  ±13.50  were  diagnosed  with CHIKF. All cases were from the Metropolitan  Manila area. Of these, 15 (21.4%) had  family  members  affected. Twenty-four patients (34.3%) were either employed or students. The most common presenting symptoms were fever (94.3%), arthritis or athralgia  (98.6%), and rash (87.1%).  The  most  common  joint  areas involved were the ankles  (60.0%),  the  wrists (40.0%) and the small joints of the hand (51.4%). Twenty-seven (47.3%) had symmetric  arthritis.  Thirty- seven   cases   (52.9%)   had   arthralgia   or   arthritis    for at least  six  weeks.  By  the  end  of  the  follow-up  period, only four (5.7%) had persistent musculoskeletal symptoms. Age and  sex  were not  found to  be  factors in  determining  chronicity  of  arthritic  symptoms  (p   =   0.104   and   p=0.58  respectively). Of the seventy patients, 31 (44. 3%) were confirmed  cases  of  CHIKF--  29 had  (+)   CHIKV  IgM   by ELISA,  and  two   had   (+)   CHIKV   PCR.   Twenty-  one (67.7%) had  persistent  arthritis  of  at least  six  weeks. Treatment  consisted  of continuous  NSAIDs  for  at  least  two   weeks   and   some   received   steroids.  In this subgroup, age and sex were not shown to  correlate with chronic arthritis (p=0.47 and p=0.05 respectively).CONCLUSION: This report on a recent outbreak of CHIKF showed the classic triad of fever, rash,  and  arthritis.  There  was  no  correlation  between  age  and  chronicity of  arthritic  symptoms.  Sex,  likewise,  did  not  appear   to influence chronicity. The disease occurred in family clusters. Patients required continuous treatment with NSAIDs and  some  had  to  be given  steroids.  Most cases   resolved   by   12 weeks.

Second-line treatment of Filipino patients with rheumatoid arthritis included in the rheumatoid arthritis database and registry (RADAR) of the Philippine General Hospital from 1996-2010 A 2011 preliminary report

INTRODUCTION: Treatment  of  rheumatoid  arthritis  (RA) has evolved over the past  20  years, aiming at  remission with the use of disease modifying drugs (DMARDs) and recently with biologic agents. Treatment  of  Filipino  patients  with   RA   has   so   far, not  been  described  in literature.   The   University   of the Philippines-Philippine General Hospital (UP-PGH) Rheumatology Section established the rheumatoid arthritis database and registry (RADAR) to better understand   RA   as   it   affects   the   Filipino patient.OBJECTIVE: To  describe   the   treatment   received   by a cohort of Filipino  patients  with  RA  seen  in the UP-PGH and entered in the RADAR over three time  periods   from   1996   to  2000.MATERIALS AND METHODS:This   is   a   review   of   data  on treatment of all cases entered into the RADAR diagnosed   with   rheumatoid   arthritis    by    the  1987  ACR  Criteria,  between  1996   to   2010.   Cases were grouped into three five-year periods: 1996-2000 (Period  1),   2001-2005  (Period  2),   and   2006-2010  (Period3)based on initial prescription of the  drugs.  DMARDs  given were listed and trend in the rate of use was extracted. These were  then  compared  across  the three time periods.  Descriptive  statistics  using  ratios and   proportions   was   employed   on   the  data.RESULTS: Two-hundred-twenty-four (224) cases were entered  into  the  RADAR  at the  time  of  this  study   and  all  received  DMARDs.  Methotrexate (MTX)  was  the  most  common  DMARD  used  (89%).   Of   these,   75% were on MTX  monotherapy.  Hydroxychloroquine was given in 25%, with 11% on HCQ monotherapy. Combination  treatment  with  MTX  and  HCQ  was  used  in 14%  of  cases.  There  was  an   increasing   rate   of MTX use across Periods 1-3 (87%, 89% and 90%, respectively).  On the  other  hand,  a  decreasing  rate   in the  use  of  HCQ  was   noted   (43%   in   Period   1,  24%   in   Period   2,   and   21%   in   Period   3).   Only   9% of patients received biologic  agents  in combination with  MTX.CONCLUSION: This  study   reports  the   use   of   DMARDS  in a cohort of patients entered in the UP-PGH RADAR. Methotrexate monotherapy was the most common treatment used, and this increase  continued  over  the  three  observation  time   periods.   Hydroxychloroquin was used in one fourth of  patients,  and  its  use declined over the three time periods. Biologic DMARDS was rarely used, and when given, it was combined   with  MTX.

A Filipino with polyangiitis overlap syndrome and associated multiple infections

BACKGROUND: Polyangiitis overlap syndrome (POS),a systemic vasculitis not classifiable into well-defined syndromes, is  diagnosed based on combined characteristics of two or more primary systemic vasculitides, such as Takayasu arteritis  and anti-neutrophil cytoplasmic antibody (ANCA)-associated  vasculitis  (AAV), but not two AAVs. Our objective is to   present such,   with associated  multiple  infections.CASE: A  25-year-old  Filipino  female  had  six  years  of  recurrent  purpura,  debilitating  joint  pains,  hemoptysis,  rhinorrhea, epistaxis, eye redness, dyspnea,  and  abdominal  cramps. She was cachectic, had oral ulcers, bibasal  crackles,  polyarthritis,  and  generalized  purpura.   Work-up   showed   anemia,   eosinophilia  excluding   parasitism,   elevated inflammatory markers, and  positive cytoplasmic (c)-ANCA and anti-proteinase 3. There   was   chronic sinusitis on rigid rhinoscopy, middle to lower lung field  interstitial   infiltrates   on   radiographs, pulmonary vasculitis   on  chest   CT,   moderate pulmonary hypertension on  echocardiography,  but  normal  spirometry.  Skin  biopsy  showed  leukocytoclastic vasculitis without  necrotizing  granulomas.Serology showed chronic hepatitis B infection.   Pseudomonas  aeruginosa and  methicillin-resistant Staphylococcus  aureus  grew  from  bronchial  washings and   nasal   swabs,   respectively. ASO titer was high. Human  immunodeficiency  virus  infection  was  ruled  out.  She   was   diagnosed with POS,with features of two AAVs- limited granulomatosis   with   polyangiitis   (GPA)   and   Churg-Strauss   syndrome  (CSS), associated with   multiple  infections,   and  was  given naproxen and culture-guided   antibiotics  (ciprofloxacin, clindamycin, penicillin),with partial resolution of symptoms.  Prednisone   10  mg once  a  day (OD)  was   started  two weeks   after hepatitis B reactivation prophylaxis   with   lamivudine 100mg OD. Complete   resolution of skin lesions and upper airway symptoms and    inflammatory  marker  improvement  were observed after 12  weeks. She is  maintained on prednisone   5.0   mg   daily.CONCLUSION AND RECOMMENDATIONS: This   is   the   first   reported   case   of   POS   involving   two   AAVs   -   limited   GPA   and   incomplete   CSS,   associated   with   multiple   pathogens.Identifying  POS  is  important;    inability to  classify patients  into well-recognized  vasculitic  syndromes  delays  treatment.  The  infections likely  perpetuated   the   vasculitis,  and  both antimicrobials  and  immunosuppression were  necessary  to  induce   disease   remission

'Golden Kernels within the skin': disseminated cutaneous gout.

Presented in this paper is a case of a young Filipino man presenting with recurrent acute gouty flares leading to chronic tophaceous gout and unusual cutaneous manifestations (miliary gout, panniculitis, ulcerations). Unusual sites within the body (torso, shoulder, forearms, thigh) revealed multiple urate dermal deposition. Self-medication with steroids eventually led to secondary Cushing's syndrome and eventual emergence of metabolic complications.

Current considerations for the management of musculoskeletal pain in Asian countries: a special focus on cyclooxygenase-2 inhibitors and non-steroid anti-inflammation drugs.

Chronic pain is a complex problem that eludes precise definition and can be clinically difficult to diagnose and challenging to treat. In the Asia-Pacific region, prevalence estimates that chronic pain ranges from 12% to 45% of the population, with musculoskeletal, rheumatic or osteoarthritis pain making up the majority of the disease burden. Implementation of current management guidelines into routine clinical practice has been challenging and as a result, patients with musculoskeletal pain are often poorly managed. For these reasons, a multidisciplinary Chronic Pain Advisory Board of leading physicians from various Asian countries was convened to explore ways to improve treatment and compliance, especially among patients with osteoarthritis and rheumatoid arthritis. We have identified a number of unmet therapeutic needs and prioritized initiatives with the potential to contribute toward a more integrated approach to chronic pain management. Key priorities included using evidence-based interventions as recommended by current guidelines, particularly those aspects pertinent to addressing treatment priorities in Asia (e.g., patient compliance), and the incorporation of cyclooxygenase-2 inhibitors and non-steroid anti-inflammation drugs into the management algorithms for osteoarthritis and rheumatoid arthritis. Treatment must be individualized for each patient based on efficacy, side-effect profile and drug accessibility. Further studies are required to examine head-to-head comparisons among analgesics, combinations of analgesics and long-term efficacy outcomes. Our increasing understanding of the problem combined with the promise of new therapy options offers hope for improved management of musculoskeletal pain in Asian countries.

Clinical profile of Filipino patients with osteoarthritis seen at two arthritis clinics.

AIM: To describe a cohort of Filipinos with primary osteoarthritis (OA). METHOD: Charts with diagnosis of OA from two arthritis clinics (Philippine General Hospital and a private clinic) from January 2008 to May 2011, were reviewed for demographics, clinical presentation, risk factors and management. Descriptive statistics were applied. RESULTS: Eight hundred and fifty-nine (859) patients had primary OA. Female-to-male ratio was 3 : 1. Mean age at diagnosis was 63 years, onset at 59 years. Men consulted 10 months later. Mean body mass index was 27.1 kg/m(2). Women were overweight, men, obese. Co-morbid conditions included hypertension (53%), dyslipidemia (16%) and diabetes (13%). Women (94.7%) developed symptoms 12 years after menopause. One-third of patients were of low socioeconomic status. Chief complaint was pain in 92.8%. Joint findings included crepitus (70.8%) and Heberden's nodes (13.0%) for knees and hands, respectively. Commonly involved joints were knees (62.5%), knees and hands (14.3%), and generalized joint involvement (13.5%). The hip was involved in 2.9% of cases. Radiographs showed Kellgren-Lawrence score of 2 in 56.6%. Less than 25% received physical therapy. Most prescribed drugs were glucosamine sulfate (45.5%), paracetamol (42.8%) and coxibs (40.6%). Less than 8% received intra-articular treatment, or were referred for surgery. CONCLUSION: We described a large cohort of Filipino OA patients. Clinical characteristics show more women than men, with knees as the most common and hips as the least involved joints. Medical management was based on a local practice guideline. Compared to the literature, this cohort had more overweight than obese subjects and low surgical referral. A coordinated registry with orthopedics and physiatry departments is currently underway.

Correlation between Family APGAR scores and health-related quality of life of Filipino elderly patients with knee osteoarthritis.

OBJECTIVES: This study aims to describe the clinical profile of Filipino patients with knee osteoarthritis (OA) and correlate their health-related quality of life (HrQoL) with perceived family support. METHODS: This is a cross-sectional, analytical study of patients seen at the Philippine General Hospital Arthritis Clinic diagnosed with knee OA using the American College of Rheumatology classification criteria. Questionnaires for the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) v.3.1 and Family APGAR (Adaptation, Partnership, Growth, Affection and Resolve) were self-administered. Pearson's correlation, analysis of variance and Bonferroni tests were applied. RESULTS: Ninety patients with 3 : 1 female-to-male ratio, mean age of 70.14 years qualified for the study. Mean body mass index was 23.3. Mean duration of symptoms was 5.9 years. Fifty-three considered their family to be highly functional, 28 moderately dysfunctional and nine severely dysfunctional. Analysis showed that Family APGAR is moderately and inversely correlated with pain (r = -0.3373; P = 0.0002), stiffness (r = -0.3642; P = 0.0004), function (r = -0.3646; P = 0.0004) and total WOMAC scores (r = -0.3880; P = 0.0002). Likewise, there were significant differences of total WOMAC scores in the pain, stiffness and function subscales (P = 0.0076, P = 0.0032, P = 0.0165 and P = 0.0159, respectively) between patients in highly functional and severely dysfunctional families, and between highly and moderately functional families. As Family APGAR scores increased, there was significant decrease in all WOMAC subscales. CONCLUSION: We described the clinical profile of 90 elderly patients with knee OA and the relationship of HrQoL to Family APGAR scores. This paper concludes that higher Family APGAR scores in this population correlated with better HrQoL.

Prevalence of undiagnosed autoimmune thyroid disease and thyroid dysfunction in Filipino patients with autoimmune rheumatic disorders / Journal of the ASEAN Federation of Endocrine Societies

OBJECTIVES:(1) To determine the prevalence of autoimmune thyroid disease among patients with autoimmune rheumatic disorders seen at the Philippine General Hospital. (2) To determine clinical features that are associated with the occurrence of autoimmune thyroid disease in these patient.METHODOLOGY:This is a cross sectional analytical study that included 155 adult Filipinos diagnosed with an autoimmune rheumatic disorder. Clinical characteristics were recorded. Serum thyrotropin, thyroxine, triiodothyronine, anti-thyroid peroxidase antibody, anti-thyroglobulin antibody and urinary iodide excretion were determined. The prevalence of autoimmune thyroid disease was computed. Associations between clinical factors and autoimmune thyroid disease were determined.RESULTS:Overall 21.94% of the population had autoimmune thyroid disease. There was significant association between duration of the autoimmune rheumatic disorder and autoimmune thyroid disease (p-= 0.018). No significant association was noted with the other clinical factors although there was an almost significant association observed for the presence of goiter (p=0.054).CONCLUSION:Autoimmune thyroid disease commonly occurs in patients with autoimmune rheumatic disorders. As such, it is important to consider screening these patients for the coexistence of thyroid disease to help prevent the complications associated with thyroid dysfunction and avoid adding up to the morbidity of the existing autoimmune rheumatic disorder.

The epidemiology of osteoarthritis in Asia.

Worldwide, osteoarthritis (OA) is estimated to be the fourth leading cause of disability. Most of this disability burden is attributable to the involvement of the hips or the knees. OA is strongly associated with ageing and the Asian region is ageing rapidly. Further, OA has been associated with heavy physical occupational activity, a required livelihood for many people living in rural communities in developing countries. Unfortunately, joint replacement surgery, an effective intervention for people with severe OA involving the hips or knees, is inaccessible to most people in these regions. On the other hand, obesity, another major risk factor, may be less prevalent, although it is on the increase. Determining region-specific OA prevalence and risk factor profiles will provide important information for planning future cost-effective preventive strategies and health care services. An update of what is currently known about the prevalence of hip and knee OA from population-based studies conducted in the Asian region is presented in this review. Many of the recent studies have conducted comparisons between urban and rural areas and poor and affluent communities. The results of Asian-based studies evaluating risk factors from population-based cohorts or case-control studies, and the current evidence on OA morbidity burden in Asia is also outlined.