Red cell distribution width and neutrophil-lymphocyte ratio as inflammatory markers in patients with rheumatoid arthritis.

Introduction: The aim was to study the red cell distribution width (RDW) and neutrophil-lymphocyte ratio (NLR) as inflammatory markers and their correlation with clinical disease activity parameters in patients with rheumatoid arthritis (RA). Material and methods: This observational cross-sectional study included 100 randomly selected patients with RA. Disease Activity Score with 28-joint counts and erythrocyte sedimentation rate (DAS28-ESR) was taken as a marker of disease activity. The diagnostic value of NLR and RDW in RA was assessed. Results: The majority (51%) of cases showed mild disease activity. The mean NLR in cases was 3.88 ±2.59. Mean RDW was 16.25 ±2.49%. Neutrophil-lymphocyte ratio significantly correlated with ESR (p = 0.026), severity of pain (p = 0.013), osteoporosis (p = 0.014) and radiographic joint erosions (p = 0.048), but not with DAS28-ESR (p > 0.05) and C-reactive protein (CRP) (p > 0.05). Red cell distribution width showed a significant correlation only with NLR (p = 0.009). The positive predictive values of NLR and RDW for disease activity were 93.3% and 90% and the negative predictive values were 20% and 16.7% respectively. For NLR, the area under the curve (AUC) was 0.78 (p = 0.001) and at a cut-off value of 1.63, the diagnostic sensitivity was 97.7% and specificity 50%. For RDW, the AUC was 0.43 (p = 0.40) and at a cut-off value of 14.52, the diagnostic sensitivity was 70.5% and specificity 41.7%. The sensitivity and specificity of NLR were higher than those of RDW. A significant difference was seen between the AUC of NLR and RDW (p = 0.02). Conclusions: Neutrophil-lymphocyte ratio is a valuable inflammatory marker in patients with RA, but RDW is not useful in this regard.

Scrub typhus in Uttarakhand & adjoining Uttar Pradesh: Seasonality, clinical presentations & predictors of mortality.

BACKGROUND & OBJECTIVES: Scrub typhus is a re-emerging mite-borne rickettsiosis, which continues to be underdiagnosed, with lethal consequences. The present study was conducted to determine the seasonality, clinical presentation and predictors of mortality in patients with scrub typhus at a tertiary care teaching hospital in northern India. METHODS: Scrub typhus was suspected in patients attending the hospital as per the standard case definition and serological evidence was obtained by performing an IgM ELISA. RESULTS: A total of 284 patients with scrub typhus from urban and rural areas were seen, predominantly from July to November. The most common clinical presentation was a bilateral community-acquired pneumonia (CAP), which resembled pneumonia due to atypical pathogens and often progressed to acute respiratory distress syndrome (ARDS). An acute undifferentiated febrile illness (AUFI) or a febrile illness associated with altered sensorium, aseptic meningitis, shock, abdominal pain, gastrointestinal bleeding or jaundice was also seen. Eschars were seen in 17 per cent of patients, and thrombocytopenia, transaminitis and azotaemia were frequent. There were 24 deaths (8.5%) caused predominantly by ARDS and multi-organ dysfunction. The mortality in patients with ARDS was high (37%). ARDS [odds ratio (OR)=38.29, 95% confidence interval (CI): 9.93, 147.71] and acute kidney injury (OR=8.30, 95% CI: 2.21, 31.21) were the major predictors of death. INTERPRETATION & CONCLUSIONS: The present findings indicate that scrub typhus may be considered a cause of CAP, ARDS, AUFI or a febrile illness with multisystem involvement, in Uttarakhand and Uttar Pradesh, especially from July to November. Empiric therapy of CAP may include doxycycline or azithromycin to ensure coverage of underlying unsuspected scrub typhus.

Echocardiographic evaluation of diastolic dysfunction in rheumatoid arthritis - a case-control study.

OBJECTIVES: To assess left ventricular diastolic dysfunction (LVDD) and its predictors in rheumatoid arthritis (RA). METHODS: This cross-sectional case-control study assessed 100 RA patients and 100 healthy controls for LVDD by M-mode, two-dimensional, colour Doppler echocardiography. RESULTS: RA patients had higher prevalence of LVDD than controls (43% vs. 14%; p < 0.001). LVDD had significant association with duration (p = 0.033), severity of disease activity (p < 0.0001), Steinbrocker stage and functional class (p < 0.0001 each) and non-adherence to treatment (p = 0.047). Peak of late diastolic (A) mitral flow velocity and isovolumic relaxation time (IVRT) were higher (p < 0.05 each), whereas left ventricular ejection fraction, peak of early diastolic (E) mitral flow velocity and E/A ratio were lower (p < 0.05 each) in RA patients than in controls. Deceleration time (DT) was not significantly different in the two groups (p = 0.623). E/A ratio had significant correlation with anti-cyclic citrullinated peptide antibody (ACPA) (r = 0.233, p = 0.019) and age (r = 0.203, p = 0.042). IVRT had significant negative correlation with ACPA (r = -0.196, p = 0.044), while DT had significant correlation with Disease Activity Score with 28-joint (DAS28) counts (r = 0.244, p = 0.014). ACPA was an independent predictor of E/A ratio (p = 0.031). DAS28 was the only independent predictor of LVDD (odds ratio [OR] = 6.01; p = 0.007). CONCLUSIONS: LVDD occurred commonly in RA patients and depended on severity of disease activity.

Model for end-stage liver disease score versus Maddrey discriminant function score in assessing short-term outcome in alcoholic hepatitis.

BACKGROUND AND AIMS: The Maddrey Discriminant Function (mDF) score and the Model for End-Stage Liver Disease (MELD) score are standard prognostic scores for predicting disease severity and mortality in alcoholic hepatitis (AH).This prospective study compared the MELD score and the mDF score as predictors of short-term outcome in AH. METHODS: The admission MELD score and the mDF score were assessed in 47 patients with a diagnosis of AH in the Himalayan Institute Hospital, Dehradun, India and the concordance (C) statistics of the two scores for 28-day mortality were determined and compared. RESULTS: Both the MELD score and the mDF score on day 1 were significantly higher in non-survivors than in survivors (P = 0.0001 each). The C-statistic for 28-day mortality for the MELD score was 0.91 (P < 0.0001, 95% confidence interval [CI] 0.79-0.97) and for the mDF score 0.90 (P < 0.0001, 95% CI 0.78-0.97). There was no significant difference between the C-statistics of the two scores (P = 0.83, 95% CI -0.07 to 0.09). For predicting 28-day mortality, the optimal MELD score of > 19 (sensitivity 91.6% and specificity 85.7%) corresponded to the mDF score of > 52.8 (sensitivity 91.6% and specificity 82.8%). CONCLUSIONS: Both the MELD score and the mDF score at admission were strong and equally good predictors of 28-day mortality in patients with AH, but the optimal mDF score corresponding to optimal MELD score was higher than the conventional one. Thus, MELD score may be used as an alternative to mDF score for predicting short-term mortality in AH with an advantage.

Prevalence and patterns of peripheral neuropathy in patients of rheumatoid arthritis.

BACKGROUND: Rheumatoid arthritis (RA) is an autoimmune disorder characterized by involvement of multiple small and large joints with multisystem extra-articular manifestations. Peripheral neuropathy is known extra-articular manifestation of RA with the incidence of around 39.19% as per previous studies. Early diagnosis and treatment of peripheral neuropathy has been shown to improve both physical and functional disabilities of patients with RA. OBJECTIVES: The primary objective was to study prevalence and patterns of peripheral neuropathy in patients with RA. The secondary objective was to study demographic, clinical parameters, disease severity, and extra- articular manifestations in patients with RA with and without peripheral neuropathy. MATERIALS AND METHODS: Consecutive patients of RA were recruited. Detailed clinical examination and electrophysiological tests were done to diagnose peripheral neuropathy. The demographic and clinical parameters were noted and tabulated. Student's t-test was used to analyze continuous variable, whereas Chi-square test was used for analysis of categorical variables. RESULTS: Of 89 patients with RA, 75.28% (n = 67) patients had peripheral neuropathy electrophysiologically, whereas 20.89% (14 patients of 67) had superficial touch sensory loss on examination. Subclinical neuropathy was present in 50.74% (n = 34) of patients. Statistically significant association between the presence of neuropathy and age of the patients, disease duration, use of disease-modifying antirheumatoid drugs, disease severity (disease activity score-28), and presence of subcutaneous nodules (P < 0.05). CONCLUSION: Patients with RA, especially elderly patients, should undergo electrophysiological testing to rule out peripheral neuropathy. Electrophysiological study is a diagnostic and gold standard tool to diagnose subclinical neuropathy in patients with RA. Presence of peripheral neuropathy in these patients has been found to be significantly associated with deteriorating health status, pain scores, and presence of extra-articular manifestations.

Gray Scale and Power Doppler Ultrasonographic Findings in the Assessment of Disease Activity and Their Correlation with Disease Activity Parameters in Rheumatoid Arthritis.

OBJECTIVES: To study the utility of gray scale and power Doppler ultrasonography in assessing the disease activity and correlation of ultrasonographic findings with disease activity parameters in Rheumatoid Arthritis (RA). MATERIALS AND METHODS: This cross-sectional study was conducted on 100 RA patients diagnosed as per 2010 classification criteria. Rheumatoid Factor (RF), serum Anti-cyclic Citrullinated Peptide Antibodies (ACPA), Erythrocyte Sedimentation Rate (ESR), C-reactive Protein (CRP), disease activity score with 28-joint counts and ESR (DAS28-ESR), Visual Analogue Scale (VAS) for global disease activity and Gray Scale Ultrasonography (GSUS) and Power Doppler Ultrsonography (PDUS) scores in hands and wrists were determined. RESULTS: Of 100 RA patients with clinically active arthritis, GSUS detected disease activity in all and PDUS in 95 (95%) patients. Of total 2200 joints assessed, disease activity was seen by clinical assessment in 51.31% (1116/2200), GSUS in 57.36% (1262/2200) and PDUS in 48.36% (1064/2200) joints. For detecting active arthritis, clinical assessment showed 79.5% sensitivity and 76.2% specificity while GSUS showed 100% sensitivity and 82.5% specificity using PDUS as a gold standard. GSUS findings of synovitis, joint effusion and bone erosions and PDUS score showed significant correlations with the swollen joint count, tender joint count, ESR and DAS28- ESR (p<0.05 each) but not with VAS, CRP, RF and ACPA (p>0.05 each). Multivariate analysis showed that swollen joint count was independently associated with synovitis (p=0.029) and tender joint count with PDUS score (p=0.036). CONCLUSIONS: GSUS and PDUS findings are useful in ascertaining the disease activity and correlate with clinical disease activity in joints in RA.

Association of anti-cyclic citrullinated peptide antibodies with clinical and radiological disease severity in rheumatoid arthritis.

OBJECTIVE: This study assessed an association of anti-cyclic citrullinated peptide antibodies (ACPA) with clinical and radiological disease severity in patients with rheumatoid arthritis (RA). MATERIALS AND METHODS: Fifty patients diagnosed with RA as per 2010 revised American College of Rheumatology/ European League Against Rheumatism (ACR/EULAR) classification criteria were included in this cross-sectional study. Serum levels of ACPA, C-reactive protein (CRP) and rheumatoid factor (RF), erythrocyte sedimentation rate (ESR), disease activity score with 28-joint counts and ESR (DAS28-ESR), patient's global assessment of disease activity using visual analogue scale (PtGA-VAS), modified health assessment questionnaire score (M-HAQ) and radiological damage in hands and feet (modified Larsen score) were determined. RESULTS: ACPA were positive in 48 (96%) and RF in 44 (88%) patients. Mean Larsen score was 19.82 ± 17.11 and mean DAS28-ESR 6.39 ± 1.59. A significant correlation of ACPA levels was seen with RF (p=0.03) and Larsen score (p=0.02) but not with DAS28-ESR (p=0.17) and M-HAQ (p=0.81). A significant correlation was seen between Larsen score and disease duration (p<0.0001), age (p=0.04), DAS28-ESR (p=0.001) and M-HAQ (p<0.0001). Multivariate analysis showed that painful joint count (p=0.003), ESR (p<0.001) and PtGA-VAS (p=0.009) were independently associated with clinical disease activity severity. Disease duration (p=0.01), ACPA levels (p=0.004) and DAS28-ESR (p=0.03) were independently associated with radiological joint damage. CONCLUSION: Serum ACPA levels correlate significantly with radiological severity of RA but not with clinical disease severity and are independently associated with radiological outcome.

Initial default among sputum-positive pulmonary TB patients at a referral hospital in Uttarakhand, India.

BACKGROUND: Initial default is a serious issue which can enhance the transmission of TB. We determined the magnitude of and the causative factors for initial default among sputum-positive pulmonary TB (PTB) patients. METHODS: In this prospective study, 2310 patients attending a referral hospital in Uttarakhand state, north India, with presumptive TB were investigated and 555 patients with sputum-positive PTB were followed-up for initiation of anti-TB treatment (ATT) during 2010-2012. The patients not confirmed as having started ATT were considered initial defaulters. RESULTS: Initial default was seen in 120 (21.6%) patients comprising 22 (18.3%) defaulters during diagnosis and 98 (81.6%) defaulters after referral for directly observed treatment, short-course (DOTS). The initial default rate was significantly higher among patients from rural areas than urban areas, illiterate patients than literate patients and smokeless tobacco-users than non-users (p<0.05 for all). The main reasons for initial default among patients referred for DOTS were limited trust in DOTS (n = 44, 44.8%), adverse effects of previous ATT (n = 41, 41.8%), dissatisfaction with health services (n = 38, 38.7%), local deaths while taking DOTS (n = 28, 28.5%), advice by others against DOTS (n = 25, 25.5%), disbelief in the diagnosis (n = 18, 18.3%) and patient death before starting treatment (n = 4, 4.0%). CONCLUSION: A high initial default rate was seen among patients with PTB. There is an urgent need to promote public awareness to lower the initial default rate.

Plasmodium vivax malaria complicated by acute kidney injury: experience at a referral hospital in Uttarakhand, India.

BACKGROUND: Acute kidney injury (AKI) is a serious complication of Plasmodium vivax malaria, worsening its prognosis. METHODS: This prospective study assessed the incidence, clinical spectrum, prognostic factors and outcome of AKI in P. vivax malaria. During 2010-2011, 195 patients with vivax malaria diagnosed by positive peripheral blood film and rapid malaria test were studied for AKI using RIFLE criteria. RESULTS: AKI occurred in 63 patients (32%), with maximum RIFLE class R (Risk), class I (Injury) and class F (Failure) in 27 (43%), 23 (37%) and 13 (21%) patients, respectively. AKI was associated with oliguria/anuria (48%), anaemia (70%), thrombocytopenia (84%), hepatic dysfunction (48%), gastrointestinal manifestations (33%), acute respiratory distress syndrome (ARDS) (14%), cerebral malaria (6%), disseminated intravascular coagulation (8%) and shock (11%). All 63 patients with AKI received artesunate and 12 (19%) received quinine after failure of response to artesunate. Fourteen patients (22%) underwent haemodialysis. Patients with maximum RIFLE class R, I and F had mortality rates of 3.7%, 4.3% and 30.7%, respectively. Poor prognostic factors were delayed diagnosis, anaemia, severe AKI, shock, ARDS, need for ventilatory support, raised serum transaminases and metabolic acidosis. CONCLUSIONS: AKI is now common in vivax malaria and has significant mortality. Its early recognition and management can improve the outcome.