Predictors for Dry Eye Diseases in Patients with Systemic Sclerosis

Purpose

To evaluate the prevalence of dry eye disease (DED) in patients with both limited and diffuse subtypes of systemic sclerosis (SSc) and to determine the predictive factors associated with the occurrence of DED.

Patients and Methods

This was a prospective consecutive cross-sectional study of patients with SSc. Each patient underwent a comprehensive ophthalmological evaluation. The Ocular Surface Disease Index (OSDI) was used to assess the symptoms of DED. Tear break up time (TBUT), Schirmer I and ocular surface staining (OSS) were used for objective tests. Patients were diagnosed DED using the DEW II diagnostic method which included both symptom and objective tests. The collected data of patients with and without DED were compared to find out possible associated factors. Logistic regression analysis was used to determine the effects of these factors.

Results

Eighty-four SSc patients (25 limited and 59 diffuse subtypes) were studied. The prevalence of DED in SSc patients was 52.38%. The OSDI, tear break up time (TBUT), Schirmer I and ocular surface staining (OSS) were not significantly different between SSc subtypes. Among the 46 symptomatic patients, DED was noted in 44 (52.38%). Most patients (61.4%) were mixed aqueous deficiency-evaporative dry eye type (both TBUT and Schirmer I test positive). The mean age and the median of disease duration in DED patients were higher than those without DED with statistically significant difference (P = 0.004 and 0.019).

Conclusion

DED was common in patients with SSc. The predictors for the occurrence of DED were older age and longer disease duration. Therefore, OSDI and objective tests for DED should be evaluated in all SSc patients, particularly those with older age and longer disease duration.

Role of shear wave elastography ultrasound in patients with systemic sclerosis

PURPOSE

A study of shear wave elastography (SWE) for evaluation of skin stiffness in systemic sclerosis (SSc) patients. The purpose of this study was to measure the skin stiffness and thickness in patients with scleroderma using shear wave elastography.

METHODS

Prospective data collections of skin stiffness and thickness using SWE in SSc and control groups.

RESULTS

Skin stiffness and thickness were done in 29 patients with SSc and a 29 control population using SWE on bilateral forearms. The SSc patients had thicker skin and higher stiffnesses than the control group. The mean of skin thickness and stiffness using SWE of SSc are 1.74 mm and 47.32 kPa while normal subjects were 1.5 mm and 19.5 kPa. Mean differences were 0.023 mm (95% CI 0.15-0.3, p < 0.001) and 27.82 kPa (95% CI 22.63-33.01, p < 0.001). The dorsal forearms tend to have a higher SWE than the volar forearms in SSc. No statistically significant differences between gender, age or dominancy of skin stiffness were found. SWE has a good correlation with clinical manual palpation of forearms (mRSS) with Spearman rho's of 0.550 (p = 0.002) and 0.508 (p = 0.005) of dominant and non-dominant forearms.

CONCLUSION

The application of SWE can be used for evaluation of skin involvement in scleroderma patients with good correlations with the mRSS that was used in the current patients. Furthermore, SWE is a safe technique for either diagnosis or follow up.

Skin thickness affects the result of tuberculin skin test in systemic sclerosis

Background

Skin thickness is a prominent clinical feature of systemic sclerosis (SSc), but there is no consensus on the cut-off for a positive tuberculin skin test (TST) size and the limitation of the TST for a diagnosis of tuberculosis in SSc. We aimed to identify the cut-off size of an indurated TST and the sensitivity and specificity of the test for the diagnosis of tuberculosis in SSc patients.

Methods

A cross-sectional study of 168 adult Thai SSc patients was conducted. The TST was done using 0.1 ml of purified protein derivatives via intradermal injection. The test was interpreted 72 h after testing.

Results

The median age was 57.2 years. The majority (71.8%) had the diffuse cutaneous SSc subset. All the patients had a BCG vaccination at birth, and 17 (10.1%) had a tuberculosis infection. An indurated skin reaction size of 20 mm had the highest specificity for tuberculosis (99.3%: 95%CI 96.4–100) (ROC 0.53). The skin thickness—assessed using the modified Rodnan skin score (mRSS)—had a significant negative correlation with the reaction size (Rho -0.23; p = 0.003).

Conclusion

The TST is not sufficiently sensitive for detecting TB infection in SSc patients, albeit a skin induration of ≥ 15 mm indicates a high specificity for tuberculosis infection. A high mRSS resulted in a smaller skin reaction size when using the TST, which has limited utility as a diagnostic for tuberculosis among SSc patients with severe skin thickness.

The manuscript was presented as a poster presentation at the Annual European Congress of Rheumatology EULAR 2019 Madrid 12–15 June 2019. (Ann Rheum Dis. 2019;78(suppl 2): abstract FRI0347) http://dx.doi.org/10.1136/annrheumdis-2019-eular.1456

Supplementary Information

The online version contains supplementary material available at 10.1186/s41927-022-00278-8.

Clinical outcomes of asymptomatic cardiac involvement in systemic sclerosis patients after a 2-year follow-up (extended study)

BACKGROUND

Asymptomatic cardiac involvement in systemic sclerosis (SSc) has been reported. Long-term follow-up might elucidate the clinical implications of these abnormalities. The aim was to identify the clinical outcomes of asymptomatic cardiac involvement in SSc patients after 2 years of follow-up.

METHODS

A cohort study was done at Khon Kaen University, Thailand, on adult patients with SSc who completed the preliminary study. Repeated investigations included electrocardiography, chest radiography, echocardiography, and blood tests for creatine kinase-MB, high sensitivity cardiac troponin-T, and N-terminal prohormone of brain natriuretic peptide.

RESULTS

Seventy-four of the 103 patients from the previous study were enrolled. The mean duration of follow-up was 3.1±0.9 years. Five patients developed symptomatic cardiac involvement-all of whom had pulmonary arterial hypertension (PAH). The incidence of symptomatic cardiac involvement for the combined 315 person-years was 1.6 per 100-person-years (95%CI 0.7-3.4). Fourteen patients died resulting in a mortality incidence of 4.4 per 100-person-years (95%CI 4.3-5.4). Persistent cardiac involvement was found in 35 patients for an incidence of 11.1 per 100-person-years (95%CI 8.0-15.5). Two of the patients who had persistent elevated cardiac enzyme developed PAH at a respective 3.7 and 39.4 months after the initial evaluation. None of the clinical parameters were predictive of symptomatic and persistent cardiac involvement. Only male sex was associated with mortality (hazard ratio 3.70; 95%CI 1.22-11.11).

CONCLUSIONS

Cardiac involvement in SSc can progress slowly or even be reversed. Based on a previous test, the incidence of symptomatic cardiac involvement after 2 years was low despite its being a persistent involvement. If symptomatic cardiac involvement develops, PAH is the most prevalent symptom.

Prevalence and predictive factors of osteoporosis in Thai systemic sclerosis

Systemic sclerosis (SSc) is recognized as a chronic inflammatory disease and several SSc-associated factors may increase the risk of osteoporosis and its related fractures. To determine the prevalence and predictive factors of osteoporosis in Thai SSc, a cross-sectional study was designed in adult SSc patients at Scleroderma clinic, Khon Kaen University Hospital. The prevalence of osteoporosis with the 95% confidence interval (CI) were determined and the odds ratio (OR) with 95%CI were assessed the clinical association with osteoporosis. A total of 205 SSc patients were recruited with the female to male ratio of 2.7:1. The majority of cases were diffuse SSc subset (83.4%) with a disease duration < 5 years (62.9%). The overall prevalence of osteoporosis was 29.3% (95%CI 23.1-36.0). After an age adjusted analysis, the respective prevalence of osteoporosis at lumbar spine (LS) in women and men was 26.3% and 10%, while the prevalence of osteoporosis at the femoral neck (FN) in women and men was 11% and 2.1%. Low BMI (≤ 18.5 kg/m²) and menopause were associated with osteoporosis at both the LS and FN. Using multivariate analysis, low BMI and menopause were associated with osteoporosis at LS (OR 7.78 and 5.32, respectively), while low BMI was also associated with osteoporosis at LS in pre-menopausal women. In conclusion, the prevalence of osteoporosis in Thai SSc was 29.3%. Osteoporosis at the LS is more common than FN in both men and women. Low BMI was associated with osteoporosis in overall SSc and pre-menopausal women, while only menopause was associated with osteoporosis at the FN.

Prevalence and clinical association of the presence of anti-neutrophilic cytoplasmic antibody in systemic sclerosis

INTRODUCTION

Anti-neutrophilic cytoplasmic antibody (ANCA) has been reported in systemic sclerosis (SSc). Some clinical features of SSc can also be presented with ANCA-associated vasculitis. Objectives were to determine the prevalence and clinical associations with ANCA among Thais with SSc.

MATERIAL AND METHODS

A cross-sectional study of Thai adult SSc patients was conducted. According to the sample size calculation, 185 patients were included. Clinical and laboratory tests for serology and others for evaluation of the clinical association with ANCA were done simultaneously on the study date.

RESULTS

The female to male ratio was 2 : 1. The majority had the diffuse SSc subset (71.2%). The respective prevalence of having a) at least 1 serological test for ANCA (viz., perinuclear ANCA, cytoplasmic ANCA, anti-myeloperoxidase, or anti-proteinase3), b) positive for either p-ANCA or c-ANCA, c) positive for either anti-MPO or anti-PR3, d) p-ANCA and anti-MPO and e) c-ANCA and anti-PR3 was 21.6% (95% CI: 15.9-28.3), 11.9% (95% CI: 7.6-17.4) and 13.0% (95% CI: 8.5-18.7) and 1% (95% CI: 0.1-3.9). By multivariate analysis, the erythrocyte sedimentation rate elevation was significantly associated with the presence of the antibody (OR = 11.36, 95% CI: 1.44-83.65), while elevation of high sensitivity cardiac troponin-T (hs-cTnT) was significantly associated with the presence of either p-ANCA or c-ANCA (OR = 4.25, 95% CI: 1.41-15.34). None of the patients had clinical features of systemic vasculitis.

CONCLUSIONS

Around one-fifth of SSc patients have detectible ANCA without any features of vasculitis. The presence of ANCA is associated with inflammation and myocardial injury. ANCA is not antibody specific for vasculitis in SSc.

Wand Stretching Exercise Decreases Abdominal Obesity Among Adults With High Body Mass Index Without Altering Fat Oxidation

Rationale

We designed a wand-based muscle stretching (WE) exercise program, which has become increasingly popular in physical therapy and has been used for elderly patients with adhesive capsulitis. However, studies regarding the effects of WE training on abdominal obesity and measures of cardiovascular risk factors among overweight/obese adults aged ≥55 years are rare.

Purpose

The objective of this study is to evaluate the effects of a 15-week wand stretching exercise program on waist circumference and cardiovascular risk factors in sedentary adults aged 55–70 years.

Methods

A total of 124 participants were randomly assigned to either participate in wand stretching exercise (WE) over a 15-week period or a control group (n = 62 each). Sixty participants in the WE group (26 overweight and 34 obese) and 51 in the control group (29 overweight and 22 obese) completed the study. The WE program included wand-assisted muscle stretching exercise on both the upper body and lower body for 40 min per day, 5 days per week, whereas the control group maintained their sedentary lifestyle.

Results

No significant improvements were observed in plasma glucose, insulin, and the homeostatic model assessment of insulin resistance (HOMA-IR) after exercise training. Compared with the control group, the WE group had more significant reductions in waist circumference among participants with a body mass index (BMI) < 25 kg/m² (−2.6 cm, 95% CI: −4.19 to −0.97 cm, d = 0.48) and BMI > 25 kg/m² (−2.5 cm, 95% CI: −4.1 to −0.9 cm, d = 0.59) (both P < 0.01). Furthermore, within groups, a significant increase in % fat free mass was observed after WE training. The basal metabolic rate was slightly increased, but the fat oxidation rate remained unaltered in the WE group. Improvements in low-density lipoprotein cholesterol to high-density lipoprotein cholesterol were minimal after WE. Significant reductions in high-sensitivity C-reactive protein were observed after WE only for participants with a BMI <25 kg/m².

Conclusion

The results suggest redistribution of a carbon source from the abdominal region to challenged skeletal muscle, following prolonged WE training. This abdominal fat reducing outcome of the WE is unlikely to be associated with fatty acid oxidation.

Associated factors of early-onset pulmonary hypertension and clinical difference between early- and late-onset pulmonary hypertension in Thai systemic sclerosis

OBJECTIVES

Pulmonary hypertension (PH) is a major cause of death in systemic sclerosis (SSc). Detection of early-onset PH and its associated factors would be helpful for improving patient care. Our aims were to determine the factors associated with early-onset PH and to define the differences between early- and late-onset PH among SSc patients.

METHODS

A cohort study was conducted of 409 adult SSc patients who had followed-up between January 2014 and December 2016. Early-PH is defined when the onset of PH is diagnosed within 5 years of the disease. Logistic regression analysis was applied to determine the factors associated with early-PH.

RESULTS

In 3409 person-years, we diagnosed 50 cases with PH confirmation by right heart catheterization, of whom 26 were early-PH (incidence 0.7 per 100 person-years; 95%CI:0.5-1.1). Among SSc with early-PH, 69.2% had the diffuse cutaneous SSc subset and the most common PH classification was PH due to interstitial lung disease (18 cases;69.2%). According to a logistic regression analysis, early-PH was associated with a WHO functional class (WHO-FC) II and higher, cardiomegaly according to chest radiography, and tricuspid regurgitation jet maximum velocity (TRVmax)>2.8 m/s with the respective OR of 20.12 (95%CI:1.59-255.35), 7.42 (95%CI:1.35-40.88), and 8.20 (95%CI:1.17-57.64). To contrast, early-PH had a negative association with gastrointestinal involvement (OR 0.08; 95%CI:0.01-0.56).

CONCLUSIONS

Early-PH is prevalent among SSc patients and the most common cause is interstitial lung disease. A poor WHO-FC, cardiomegaly, and a high TRVmax are associated with early-PH. Gastrointestinal involvement is a protective factor for early-PH in SSc.

Cost-utility and budget impact analysis of tocilizumab for the treatment of refractory systemic juvenile idiopathic arthritis in Thailand

OBJECTIVES

This study aimed to analyse the cost-utility and budget impact of adding tocilizumab to the standard treatment for patients with refractory systemic juvenile idiopathic arthritis (sJIA) in Thailand.

DESIGN

Economic evaluation using a decision-analytical model.

SETTING

Thailand.

PARTICIPANTS

Patients with refractory sJIA who were ≥2 years old.

METHODS

The use of tocilizumab as an add-on therapy to standard treatment was compared with standard treatment alone. A simulated health state transition model was used to estimate the lifetime costs and health outcomes from a societal perspective. Direct medical costs were collected from tertiary hospital databases while direct non-medical costs were derived from interviews. Health-related quality of life (QoL) was measured using the proxy version of three-level EuroQol five-dimensional questionnaire (EQ-5D-3L). Future costs and outcomes were discounted at an annual rate of 3%. The base case population was patients aged 9.41 years old at refractory disease onset. The results were reported as incremental cost-effectiveness ratios (ICER) in US dollar (USD). One-way and probabilistic sensitivity analysis were conducted to investigate parameter uncertainty. The 5-year budget impact was estimated from a governmental perspective.

RESULTS

The ICER of standard treatment plus tocilizumab was US$35 799 per quality-adjusted life-year (QALY) gained compared with standard treatment alone, which was not cost-effective at the threshold of US$5128 per QALY gained. The estimated 5 years budget impact was approximately US$4.8 million.

CONCLUSIONS

The use of standard treatment plus tocilizumab was not cost-effective in the Thai context, which has limited data. However, there is currently no second-line treatment for refractory sJIA in the Thai National List of Essential Medicines; thus, patients must receive higher doses of standard treatment which can cause many side effects. In contrast, tocilizumab showed obvious efficacy in clinical trials in improving treatment response and QoL. Therefore, the price of tocilizumab should be negotiated to reduce the financial impact on the healthcare system.

Cost-effectiveness of denosumab for high-risk postmenopausal women with osteoporosis in Thailand

Aims: This study assessed the cost-effectiveness of denosumab for treating postmenopausal women with osteoporosis (PMO) at high risk of fracture in Thailand.Materials and methods: A published Markov cohort cost-effectiveness model was populated with country-specific data as available and other published data as needed. The model used a societal perspective, lifetime horizon, efficacy data from network meta-analysis of trials, and included costs for direct medical and non-medical care, informal care, and osteoporosis treatments to compare denosumab to no pharmacologic treatment (calcium and vitamin D supplements only) and to oral weekly alendronate. The base case (high-risk population) included postmenopausal women with femoral neck T-score ≤-2.5, mean age 65 years at entry, and history of vertebral fracture.Results: High-risk women with osteoporosis using denosumab had the greatest number of life years and quality-adjusted life-years (QALYs) with higher reductions in hip and vertebral fracture incidence compared with patients with no pharmacologic treatment. The incremental cost-effectiveness ratio (ICER) was 119,575 Thai Baht (THB) per QALY for denosumab versus no pharmacologic treatment and 199,186 THB per QALY for denosumab versus alendronate. Among Thai postmenopausal women with high-risk of fractures, denosumab was cost-effective compared with no pharmacologic treatment at a willingness-to-pay threshold of 160,000 THB per QALY. One-way sensitivity analysis showed models were most sensitive to changes in denosumab pricing.Limitations: Data from other countries used when country-specific data were unavailable may not accurately reflect the true experience in Thailand. The model focused explicitly on hip, vertebral, and wrist fractures, and therefore provides a conservative estimate of the overall potential impact of osteoporosis-related fracture. The fracture risk was not adjusted to reflect potential changes in risk after denosumab treatment discontinuation.Conclusions: In Thailand, denosumab offers a cost-effective osteoporosis treatment option versus no pharmacologic treatment in postmenopausal women at high risk of fracture.

Clinical characteristics and outcomes of 566 Thais with systemic sclerosis: A cohort study

BACKGROUND

Most Thai patients with systemic sclerosis (SSc) have diffuse cutaneous SSc (dcSSc) unlike most Caucasians and some Asians. A longitudinal cohort study among Thai dcSSc is needed.

OBJECTIVES

We aimed to determine the overall clinical characteristics, define the clinical difference between limited cutaneous SSc (lcSSc) and dcSSc, and ascertain the mortality rate and the factors associated with mortality.

METHOD

We conducted a cohort study including 566 Thai adult SSc patients between January 2013 and June 2019. Clinical difference between lcSSc and dcSSc was investigated using generalized estimating equations (GEE).

RESULTS

Females presented more than males (356 vs 210 cases). The majority of cases were dcSSc (411; 72.6%). The median duration of disease at the time of pulmonary fibrosis (PF) detection was 2.5 years, pulmonary arterial hypertension 8.1 years, and renal crisis 4.1 years. By GEE analysis, dcSSc was significantly associated with salt-and-pepper skin, hand deformity, and every 1-point increase in modified Rodnan skin score (mRSS). A greater mortality risk was associated with age at onset >60 years (hazards ratio [HR] 5.5), a World Health Organization functional class (FC) III (HR 5.1), FC IV (HR 34.8), edematous skin (HR 11.4), early onset of PF (HR 1.7), each 5-point increase in the mRSS (HR 4.5), and ≥2 internal organ involvements (HR 10.1).

CONCLUSION

dcSSc is a common SSc subset among Thais. PF was an early complication in SSc and earlier PF detection was associated with a poorer prognosis. Elderly onset, high FC, severe skin tightness, and multiple organ involvements were associated with a greater mortality risk.

Prevalence and predictors of proton pump inhibitor partial response in gastroesophageal reflux disease in systemic sclerosis: a prospective study

Proton pump inhibitor (PPI) twice daily dosing is a standard therapy for gastroesophageal reflux disease (GERD) in systemic sclerosis (SSc) but there is no data on its response rate or the predictors of PPI-partial response GERD. Aims were to determine the prevalence of PPI-partial response GERD in SSc and to define its predictors. A prospective study was conducted in SSc patients with GERD. The patients were treated with omeprazole 20 mg bid for 4 weeks. The severity of symptom-grading by visual analogue scale (VAS) and frequency of symptoms by frequency scale for symptoms of GERD (FSSG) were assessed at baseline and 4 weeks after treatment. PPI-partial response GERD was defined as less than 50% improvement in the VAS for severity of symptom as well as acid reflux score by FSSG after treatment. According to the sample size calculation, 243 SSc-GERD patients were enrolled; of whom 166 (68.3%) had the diffuse cutaneous SSc. PPI-partial response GERD was found in 131 SSc patients (prevalence 53.9%; 95%CI 47.4–60.3). The multivariate analysis revealed that esophageal dysphagia was an only predictor the PPI-partial response GERD (OR 1.82; 95%CI 1.01–3.29) while neither SSc subset nor severity of skin tightness were significantly associated with PPI-partial response GERD. Half of the SSc patients were PPI-partial response GERD. Esophageal dysphagia was the only predictor of PPI-partial response GERD in SSc patients. Screening for dysphagia before starting GERD treatment is helpful for assessment the risk of PPI refractoriness GERD in SSc patients.

Clinical and laboratory predictions of myocardial inflammation as detected by cardiac magnetic resonance imaging in patients with systemic sclerosis: A pilot study

BACKGROUND

Cardiac magnetic resonance imaging (cardiac MRI) has high sensitivity and specificity for differentiating cardiac fibrosis from inflammation. There is no data on the clinical and laboratory association or prediction of myocardial inflammation in systemic sclerosis-a major organ involvement in systemic sclerosis (SSc).

OBJECTIVES

Our aim was to ascertain the clinical and laboratory associations with myocardial inflammation in SSc patients as detected by cardiac MRI.

METHODS

A cross-sectional study was conducted among Thai adult SSc patients who had: disease onset <4 years; a New York Heart Association functional class ≥ II; and followed up at the Scleroderma Clinic, Khon Kaen University, between June 2018 and January 2019. We excluded patients who were taking steroids and/or immunosuppressants or had a diagnosed heart disease before being diagnosed with SSc. All enrolled patients underwent cardiac MRI, and clinical and laboratory assessments the same date. Myocardial inflammation was defined by cardiac MRI per the Lake Louise Criteria.

RESULTS

A total of 30 SSc patients were enrolled. The female-to-male ratio was 1.8:1. The majority (73%) had diffuse cutaneous SSc. The respective mean age and median duration of disease was 57 ± 8 and 2.0 years (interquartile range 1.5-2.7). Myocardial inflammation was detected in 22 patients (73.3%). The multivariate analysis revealed that every 5 years of increased age at onset and every 5-point increase in the modified Rodnan skin score (mRSS) at onset was significantly associated with myocardial inflammation (odds ratio 0.47, 95% CI 0.22-0.98; and 2.64 95% CI 1.04-6.74, respectively). Neither the SSc subset, internal organ involvement, inflammatory markers, nor cardiac and muscle enzymes were associated with myocardial inflammation in SSc.

CONCLUSION

Myocardial inflammation is common in early-onset SSc. An increased risk of myocardial inflammation was associated with young age and high mRSS at onset. Cardiac MRI is the suggested evaluation for high-risk SSc patients experiencing dyspnea on exertion.

Clinical characteristics and mortality rate of Thai elderly-onset systemic sclerosis

OBJECTIVES

To identify the clinical differences and mortality rate between adult and elderly onset systemic sclerosis (SSc).

METHODS

We conducted a historical cohort study of SSc patients during January 2007-December 2011. The SSc patients were 60 and over classified as elderly onset SSc. Cox regression analysis was used to estimate the probability of survival and for assessing the factors associated with mortality.

RESULTS

The medical records of 350 SSc patients were reviewed; 53 (15.1%) had elderly onset SSc. According to the multivariate analysis, elderly onset SSc has a higher WHO functional class, more frequent weakness, more frequent hyperCKaemia, and less pulmonary fibrosis than adult onset SSc (p=0.004, 0.02, 0.02, 0.02, respectively). The incidence of mortality was 3.8 per 100 person-year with a median survival rate of 15.9 years (95%CI 12.4-17.3). The mortality rate of elderly SSc onset was significantly higher than that of adult SSc onset (HR 5.71; 95%CI 3.54-9.20). The median survival of elderly and adult onset SSc was 4.9 years and 16.1 years, respectively. The Cox regression analysis indicated that presence of digital ulcer and tendon friction rub had a respective HR of 7.39 (95%CI 1.28-42.60) and 37.23 (95%CI 2.10-659.09) for predicting mortality of elderly onset SSc.

CONCLUSIONS

Myopathy and limitation of physical activity were frequently found among elderly onset SSc over against pulmonary involvement than in adult onset SSc. Mortality of elderly onset SSc was 5.7 times higher, and median survival was 11 years shorter, than adult onset SSc.

Self-care behaviours and trajectory management by people with scleroderma in northeastern Thailand

Scleroderma, particularly systemic sclerosis, is a chronic illness that affects a person's physical, emotional, psychosocial, and spiritual dimensions. To investigate self-care deficits, health behaviours, and trajectory management of Thai people with systemic sclerosis, an exploratory case study method was used through interviews and patient records. Self-care deficit nursing theory and the chronic illness trajectory framework guided the research. Twelve patients with systemic sclerosis were purposively recruited at a hospital clinic in the northeastern region of Thailand. Thai people living with systemic sclerosis developed specific self-care agencies in each of 3 identified trajectory patterns to improve their health and well-being. By applying the theory and framework that guided the research, nurses can promote self-care behaviours and recognize situations along an illness trajectory that require intervention and management. The results extend the understanding of how people live and cope with systemic sclerosis.

Effectiveness of add-on therapy with domperidone vs alginic acid in proton pump inhibitor partial response gastro-oesophageal reflux disease in systemic sclerosis: randomized placebo-controlled trial

OBJECTIVES

Twice-daily dosing of proton pump inhibitor (PPI), the standard therapy for gastro-oesophageal reflux disease (GERD), is an effective therapy for GERD in SSc. The aim of this study was to compare the efficacy of omeprazole in combination with domperidone vs in combination with algycon in reducing the severity and frequency of reflux symptoms of PPI partial response (PPI-PR) GERD in SSc.

METHODS

Adult SSc patients having PPI-PR GERD were randomly assigned to receive domperidone plus algycon placebo or algycon plus domperidone placebo in a 1:1 ratio plus omeprazole for 4 weeks. The assessment included severity of symptom grading by visual analogue scale, frequency of symptoms by frequency scale for symptoms of GERD and quality of life (QoL) by EuroQol five-dimensions questionnaire scoring.

RESULTS

One hundred and forty-eight SSc-GERD patients were enrolled, of whom 88 had PPI-PR. Eighty cases were randomized for either domperidone (n = 38) or algycon (n = 37) therapy. The majority in both groups had the diffuse SSc subset. At the end of the study, no significant difference in symptom grading was found between groups. After treatment and compared with baseline, the severity of symptoms, frequency scale for symptoms of GERD and QoL significantly improved in both groups. Five (13.2%) and 8 (21.6%) respective cases in the domperidone and algycon groups did not respond.

CONCLUSION

The prevalence of PPI-PR GERD is common. Domperidone and algycon are equally effective treatments in combination with omeprazole. However, ∼17% of patients were non-responsive, so the effectiveness of domperidone, algycon and PPI combination therapy should be further investigated.

TRIAL REGISTRATION

https://clinicaltrials.gov (NCT01878526).

Self-assessment of skin tightness severity by scleroderma patients

AIMS

Skin tightness progression determines the severity and mortality of systemic sclerosis (SSc). The modified Rodnan skin score (mRSS) is a skin tightness assessment tool, albeit inter-physician variability is a limitation. Our objectives were to evaluate the correlation and agreement of skin tightness assessment between patient self-assessment and physician-assessment.

METHODS

A descriptive study was conducted on the masked, self-assessments of mRSS (at week 0, 4 and 12) by 23 Thai adult SSc patients seen at Srinagarind Hospital, KhonKaen University, between March 2014 and February 2015. Correlation between the physician and patient assessments was estimated using Pearson's. The intra-class correlation coefficient (ICC) and limit of agreement by Bland-Altman were determined.

RESULTS

We included 23 SSc patients (female to male ratio being 1.1:1). All had the diffuse cutaneous SSc subset. The skin thickness assessment correlation was moderate at baseline (Pearson's r = 0.68) and improved to a good correlation at week 4 and 12 (r = 0.78 and 0.86, respectively). The ICC showed good agreement (0.761) at week 0 and increased to excellent at week 4 (0.846) and 12 (0.910). The patient self-assessment score was higher than the physician assessment, which slightly decreased over time: mean difference = 4.30 (95% LOA;-9.54 to 18.14) at week 0, then 3.78 (95% LOA,-10.20 to 17.77) at week 4, and 3.16 (95% LOA,-7.78 to 14.10) at week 12.

CONCLUSION

The respective modified Rodnan skin score assessment by patient versus the physician was highly correlated with a high level of agreement. Validation of generalized patient self-assessment needs to be confirmed.

Correlation of Glomerular Filtration Rate Between Renal Scan and Estimation Equation for Patients With Scleroderma

BACKGROUND

Renal involvement in scleroderma is life-threatening. Early detection of a deterioration of the glomerular filtration rate (GFR) is needed to preserve kidney function.

OBJECTIVES

To (A) determine the correlation between (1) estimated GFR (eGFR) using 4 different formulae and (2) measured GFR (mGFR) using isotopic renal scan in Thai patients with scleroderma with normal serum creatinine and (B) to define the factors influencing eGFR.

METHOD

A cross-sectional study was performed in adult Thai patients with scleroderma at Srinagarind Hospital, Khon Kaen University, between December 2013 and April 2015. GFR was measured using the gold standard Tc-99m DTPA (Tc-99m diethylenetriaminepentaacetic acid) renal scan. We compared the latter with the eGFR, calculated using the Cockroft-Gault formula, Modification of Diet in Renal Disease (MDRD), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation and creatinine clearance equation.

RESULTS

A total of 76 patients with scleroderma (50 women and 26 men) with median age 54.8 years (interquartile range: 47.4 to 58.9) were enrolled. Mean disease duration was 5.6 ± 4.5 years. Median value of mGFR was 100.1 ± 27.6mL/minute/1.73m². There was a correlation between mGFR from the Tc-99m DTPA renal scan and the eGFR using the Cockroft-Gault formula, MDRD and CKD-EPI equation (P = 0.01, <0.001 and <0.001, respectively), but no correlation with eGFR using the creatinine clearance equation (P = 0.27). Body weight, prednisolone use and systolic blood pressure (SBP) had a negative association with mGFR (P = 0.01, 0.01 and 0.007, respectively). After multivariate analysis, SBP was the only clinical parameter that influenced mGFR (P = 0.03).

CONCLUSIONS

The Cockroft-Gault formula, MDRD study equation and CKD-EPI were useful formulae for assessing GFR in Thai patients with scleroderma. Higher SBP was associated with a lower GFR.

Causes and prevalence of inadequate pulmonary function testing among patients with systemic sclerosis

INTRODUCTION

Spirometry is a screening tool for evaluating the degree of restrictive lung disease in systemic sclerosis (SSc). Observations indicated that some patients could not complete the test. The aim of the study was to identify the prevalence, causes and clinical predictors of an inadequate pulmonary function test (PFT) in SSc.

MATERIAL AND METHODS

A cross-sectional study was performed among SSc patients over 18 years old followed up at Srinagarind Hospital, Khon Kaen, Thailand, during January 2006-December 2012. The adequacy of the PFT was based on the acceptable blow criteria as set out by the American Thoracic Society and the European Respiratory Society 2005 Standardizations of Spirometry.

RESULTS

Two hundred and forty-nine patients were included (female to male ratio was 2 : 1). The mean age at performing PFT was 51.4 ±11.1 years (range: 19.6-79.5). Median duration of disease at performing PFT was 2 years (IQR: 0.6-4.4). Inadequate PFT occurred in 73 cases (prevalence 29.3%: 95% CI: 23.6-35.0); the majority (60 cases; 82.2%) had an expiration time < 6 s and the others were due to plateau < 1 s (11 cases; 15%), air leak around mouth piece (1 case; 1.4%) and hesitation (1 case; 1.4%). Thirteen of 73 (17.8%) had an unusable graph with the overall prevalence of 5.2% (95% CI: 2.4-8.0). The factor associated with inadequate PFT was docy mass index (BMI) < 18.5 kg/m(2) (OR = 2.17: 95% CI: 1.49-3.17); the same factor was associated with an unusable graph, which was confirmed by the multivariate analysis (OR = 5.21; 95% CI: 1.60-16.95).

CONCLUSIONS

One-third of Thai SSc patients had an inadequate pulmonary function test - the majority because of inadequate time for expiring. Low BMI influenced the effectiveness of the test, leading to an incomplete graph for evaluating lung disease in SSc.

Inter- and Intra-Observer Reliability of Modified Rodnan Skin Score Assessment in Thai Systemic Sclerosis Patients: A Validation for Multicenter Scleroderma Cohort Study

BACKGROUND

Assessment of the severity of skin tightness by the modified Rodnan skin score (mRSS) for systemic sclerosis (SSc) has been found feasible, valid, and reliable. Despite being a major clinical outcome, it has not yet been validated by Scleroderma Research Group.

OBJECTIVE

To (a) determine the inter-observer variability vis-à-vis mRSS assessment by members ofthe Scleroderma Research Group before and after mRSS-assessment training by an experienced rheumatologist and (b) determine intra-observer variability.

MATERIAL AND METHOD

Between June and August 2013, we conducted a descriptive study of Thai adult SSc patients and all rheumatologists in the Scleroderma Research Group at Srinagarind Hospital, Khon Kaen University, Northeast Thailand. Eleven rheumatologists assessed the mRSS of 22 SSc patients three times (i.e., before and after training, and eight weeks after training). The intra-class correlation coefficient (ICC) and its 95% CI were estimated at week 8 after training.

RESULTS

The mean and standard deviation (SD) of mRSS for inter-observer variability analysis was slightly decreased from before training, after training (by an experienced rheumatologist), and at week 8 after training (17.3 ± 11.9, 16.5 ± 11.1, and 16.2 ± 10.3, respectively). Intra-observer variability had moderate agreement before training (ICC 0.59; 95% CI 0.38-0.78), which increased to good agreement after training and at week 8 after training (ICC 0.60; 95% CI 0.42-0.76 vs. 0.68; 95% CI 0.53-0.82, respectively).

CONCLUSION

Inter-observer variability for mRSS assessment decreased after training and the reduction persisted for eight weeks after training. The ICC rose from moderate agreement at baseline to good agreement at the end of the study. The mRSS assessment by members of the Scleroderma Research Group was reliable.

Clinical differences between Thai systemic sclerosis patients with positive versus negative anti-topoisomerase I

BACKGROUND

Anti-topoisomerase I antibody (ATA) carries an increased risk of systemic sclerosis (SSc) internal organ involvement. There have been no published comparisons of the clinical characteristics of patients positive and negative for ATA in Thailand, where the positive rate for ATA is higher than among Caucasians.

OBJECTIVE

To define the clinical differences between SSc, positive versus negative, for ATA.

METHODS

A retrospective cohort study was performed among SSc patients over 18 at Srinagarind Hospital, Khon Kaen University, Thailand, during January 2006-December 2013. SSc-overlap syndrome was excluded.

RESULTS

Two hundred and ninety-four SSc patients were included (female : male 2.5 : 1). The majority (68.6%) were the diffuse cutaneous SSc subset (dcSSc). ATA was positive in 252 patients (85.7%), among whom 71.7% had dcSSc and 28.2% limited cutaneous SSc (lcSSc). Using a multivariate analysis, hand deformity had a significantly positive association with ATA (odds ratio [OR] 7.01; 95% CI 1.02-48.69), whereas being anti-centromere (ACA) positive had a negative association (OR 0.17; 95% CI 0.03-0.92). After doing a subgroup analysis of the SSc subset, the median duration of disease at time of pulmonary fibrosis detection among ATA positive dcSSc was significantly shorter than the ATA negative group (1.05 vs. 6.77 years, P = 0.01). Raynaud's phenomenon (RP) at onset was significantly more frequent in lcSSc sufferers who were ATA negative than those who were ATA positive (90.5% vs. 56.9%, P = 0.005).

CONCLUSIONS

A high prevalence of ATA positivity was found among Thai SSc patients and this was associated with a high frequency of hand deformity, ACA negativity, a short duration of pulmonary fibrosis in dcSSc and a lower frequency of RP in lcSSc.

The short-term effect of gloving in combination with Traditional Thai Massage, heat, and stretching exercise to improve hand mobility in scleroderma patients

BACKGROUND

Systemic sclerosis (SSc) is a chronic, multisystem connective tissue disorder characterized by autoimmune activation, microvascular endothelium damage, and excessive collagen proliferation. The most affected hand presents claw hand deformity and microvascular disease. Deformed hands can cause functional disability and decrease the quality of life. A daily home program can improve mobility of scleroderma patients.

OBJECTIVE

We sought to determine the effect of a daily home exercise program on hand mobility among scleroderma patients.

MATERIALS AND METHODS

This was a randomized control trial. Twenty-eight participants were divided into two groups, both of which received the same daily home treatment: Group 1 with gloves (n = 14) and Group 2 without gloves (n = 14). The 2-week daily home program combined traditional Thai massage (TTM) with stretching exercises and heat. Hand mobility was assessed using hand mobility in scleroderma (HAMIS). The study was conducted in patients who were already on vasodilator drugs.

RESULTS

Both groups showed a significant improvement in hand mobility after 2 weeks of daily home exercise program (P < 0.05). Wearing the glove, however, resulted in better thumb mobility.

CONCLUSIONS

A daily home exercise program improved hand mobility among patients with scleroderma and wearing gloves may improve thumb mobility.

Atypical morphological characteristics and surface antigen expression of Burkholderia pseudomallei in naturally infected human synovial tissues

Abstract Burkholderia pseudomallei is the causative agent of melioidosis, a disease that frequently runs a protracted course and is very difficult to eradicate. The mechanisms that this organism uses to escape from host defense mechanisms and antibiotics are not well understood. The aim of the study was to compare the morphological characteristics and surface antigen expression of B. pseudomallei in naturally infected human synovial tissues with the characteristics of bacteria grown in culture media. Immunoelectron microscopic study was performed in four synovial biopsies taken from four B. pseudomallei septic arthritis patients. Colonies of pathogenic B. pseudomallei collected from culture media were used as positive controls. Polyclonal antibody to whole cell B. pseudomallei was used as a primary antibody. Complete bacteria-like particles were demonstrated both extracellularly and intracellularly in all four synovial specimens. The intracytoplasmic location of B. pseudomallei and mononuclear phagosome containing microcolony-like structures were demonstrated. B. pseudomallei found in the synovial membrane samples were mostly atypical, with fewer cytoplasmic electron lucent granules. Immunogold staining of bacterial surface antigens was weaker than staining of positive controls. We demonstrated atypical forms of B. pseudomallei and evidence for suppression of its surface antigens in naturally infected human synovial tissues. This adaptation may help bacteria to survive despite host immune surveillance and treatment with antibiotics.

Clinical characteristics and mortality in systemic sclerosis: a comparison between early- and late-referred diseases

OBJECTIVE

To determine if there is any significant difference in the clinical characteristics and mortality between early-and late-referred systemic sclerosis (SSc).

MATERIAL AND METHOD

An historical cohort study was performed among referred-SSc patients at Srinagarind Hospital between January 2006 and December 2010. 'Early referrals'occurred during the edematous phase while 'late referrals' occurred after that.

RESULTS

Forty two percent of the SSc cases (229 of 543) were referred; 108 (47.2%) were early-referrals. Early referrals were for proper management (49.1%) and diagnosis (41.7%), whereas the majority of late referrals (79.3%) were for proper management, followed by additional investigations (10.7%). The respective median duration of disease at referral between early and late was 3.7 (IQR 2.6-5.6) and 20.7 months (IQR 12.2-37.4). Joint contracture, cardiac involvement and pulmonary fibrosis presented more frequently among late-referrals (p < 0.001, p = 0.03 and p = 0.04, respectively). The respective mortality rate among early- vs. late-referrals was 15.1 (95% CI 10.0-21.8) vs. 23.0 (95% CI 15.8-32.3) per 100 person-year Two-thirds of deaths were associated with the disease, pulmonary fibrosis being most common among both early- and late-referrals (50 and 42.7%, respectively).

CONCLUSION

The number of early vs. late referrals was comparable and cardiopulmonary involvement and joint contracture were common presentations in late-referrals. Late-referral was associated with high mortality commonly from pulmonary fibrosis.

Features and outcomes of hospitalized Thai patients with pyogenic arthritis: analysis from the nationwide hospital database

BACKGROUND

Pyogenic arthritis (PA) is still a problematic arthritic disease that requires hospitalization.

OBJECTIVE

To study the epidemiological characteristics and predictors of treatment outcomes for Thai patients hospitalized with PA.

MATERIALS AND METHODS

The nationwide hospital database from the 2010 fiscal year was analyzed. Patients 18 years of age onward, who had primary diagnosis of pyogenic arthritis, were included in this study.

RESULTS

There were a total of 6242 PA admissions during 2010. It was ranked third among hospitalized musculoskeletal patients after osteoarthritis (OA) and gouty arthritis. The estimated prevalence of PA was 13.5 per 100 000 adult population. Geographic distributions of PA was related to the population density of each region; however it seemed more frequent in the northern and northeastern regions of Thailand. The prevalence increased with age, 3.6 and 43.6 per 100 000 in young adults and the elderly, respectively. Among the 2877 co-morbidities coded, diabetes was the most common, followed by crystal-induced arthritis, existing other foci of infections (urinary tract infection, skin and soft tissue infections and pneumonia) and pre-existing chronic joint diseases (OA,rheumatoid arthritis), respectively. Overall hospital mortality rate was 2.6%. Poorer outcomes were found among patients with chronic liver disease and other existing foci of infections.

CONCLUSIONS

The prevalence of hospitalized PA is still modest in Thailand, showing the highest prevalence in the advanced age group. Diabetes was the most commonly co-morbidity found; however, poorer outcomes were noted among patients with chronic liver disease and existing multiple sites of infections.

Low prevalence of contraceptive counseling at Srinagarind hospital, Thailand among women of reproductive age with systemic lupus erythematosus

OBJECTIVE

Unplanned pregnancy in women with SLE can have grave complications both for the child and the woman. We studied the prevalence of contraceptive counseling among women of reproductive age with SLE at a university hospital in Northeast Thailand.

METHODS

Recruited: 125 women with SLE, between 15 and 50 years, followed up at the Rheumatology Clinic. A questionnaire was administered and the results analyzed to identify the prevalence of contraceptive counseling.

RESULTS

The majority of women with SLE had had their reproductive goals evaluated (76.00%, 95% CI 66-83) and received contraceptive counseling (72%). Among the SLE patients at risk for pregnancy, only one-third used effective contraception and one-fifth of those did not have any background knowledge about SLE and pregnancy. Contraceptive counseling was more frequently given to women who had had a previous pregnancy or who were already concerned about SLE as related to pregnancy.

CONCLUSION

The majority of SLE patients had at one time or other received contraceptive counseling, but some reported not grasping the gravity. The survey results presented herein suggest that a multidisciplinary team is needed to improve patient knowledge regarding SLE as it affects on pregnancy and relatedly contraceptive counseling.

Pattern of skin thickness progression and clinical correlation in Thai scleroderma patients

BACKGROUND

Skin thickness progression in scleroderma (SSc) varies in daily clinical practice observation.

OBJECTIVES

To define the pattern of skin thickness among Thai sufferers of SSc and to ascertain the clinical correlation with each skin pattern.

METHODS

A 3-year follow-up cohort was performed on patients over 15 years of age in Khon Kaen, Thailand, between January 1, 2005 and December 31, 2006. The progression of skin thickness equals the modified Rodnan skin score at the end minus the score at onset divided by the duration of the disease.

RESULTS

SSc cases (117) were included and the female-to-male ratio was 70:47. The mean age at onset was 49.8 years (range 24.4-75.5). The most common skin patterns were: (i) 'slow progression to peak then slow regression' (77 cases; 65.8%); followed by (ii) 'continuous slow progression' (37; 31.6%); (iii) 'continuous intermediate progression' (2; 1.7%); and (iv) 'slow progression to peak then intermediate regression' (1; 0.9%). The respective mean peak skin score and duration of disease at peak skin score was 19.8 points (range 4-45) and 20.3 months (range 1.0-42.2). Only telangiectasia at onset and contracture of joint(s) were related to 'continuous slow progression' of skin thickness with P=0.001 and P=0.042, respectively. Neither SSc subsets nor internal organ involvement were correlated with skin thickness pattern.

CONCLUSION

The most common skin pattern in Thai SSc was 'slow progression to peak then slow regression'. Telangiectasia at onset and contracture of joint(s) were predictive of continuous progressive skin thickness in the first 3 years.

Prevalence and risk factor for symptomatic avascular necrosis development in Thai systemic lupus erythematosus patients

BACKGROUND

Avascular necrosis (AVN) has been reported in systemic lupus erythematosus (SLE) and most SLE patients suffer from this problem.

OBJECTIVES

To study the prevalence of AVN in Thai SLE patients and to determine the risk factors for developing AVN.

METHODS

A retrospective study was performed, between January 1, 1995 and August 31, 2005, on patients over 15 years of age in Khon Kaen, Thailand.

RESULTS

The medical records of 736 SLE patients were reviewed. The female to male ratio was 15.4:1. The prevalence of AVN was 8.8%. The average age at the time of AVN detection was 27 years (range, 18-54) and the average duration of disease 69 months (range, 12-112). All cases were AVN of the hip joint. The factors correlated with AVN included: long duration of disease, history of previous septic arthritis in the ipsilateral hip to the AVN development, hematological involvement, gastrointestinal involvement, arthritis and cutaneous vasculitis. After regression analysis, hematological involvement and long duration of disease were associated with AVN with a respective odds ratio of 3.13 (95% CI 1.13-8.54) and 1.01 (95% CI 1.00-1.02). Neither high-dose steroid nor antimalarial treatment were correlated with AVN in our study and 4.6% (n = 3) of patients had never received steroid therapy during the follow-up period.

CONCLUSION

Prevalence of symptomatic AVN was 8.8% in our SLE patients. A longer duration of disease and hematological involvement were associated with AVN development.

Incidence rate and causes of infection in Thai systemic sclerosis patients

BACKGROUND

Infection is a common cause of death in systemic sclerosis (SSc) but despite immunosuppressant therapy, there are few reports of opportunistic infection.

OBJECTIVES

To estimate the incidence of infection, to determine the etiologic organism, and to assess the risk factors for infection among Thai SSc patients.

METHODS

A historical cohort analysis was conducted on patients over 15 years of age, diagnosed with SSc, who attended the Scleroderma Clinic at Srinagarind Hospital, Khon Kaen, Thailand, between January 1, 2005 and December 31, 2006.

RESULTS

The medical records of 117 SSc patients were reviewed. The female-to-male ratio was 1.5 : 1.0. Of the total 310 person-years under observation, 63 events of infection occurred. The incidence rate of infection was 20.3 per 100 person-years (95% CI 15.6-26.0) and the incidence rate of major infection was 11.0 per 100 person-years (95% CI 8.4-16.5). The mean age and mean duration of SSc at the time of infection was 50.1 ± 11.1 years (range, 25.2-76.6) and 12.9 ± 10.4 months (range, 0.5-34.6), respectively. Urinary tract infection was the most common infection (23.8%). Opportunistic infection was found in one case (esophageal candidiasis). Esophageal dysmotility was significantly related to major infection (odds ratio [OR] 3.22). There was a clinical association between aspiration pneumonia and esophageal dysmotility (OR 1.23), as well as non-strongyloidiasis diarrhea and gastrointestinal involvement (OR 2.28). One person died due to severe bacterial aspiration pneumonia.

CONCLUSIONS

Infection is not uncommon among SSc patients; however, opportunistic infection is rare, despite immunosuppressant therapy. Esophageal dysmotility increases the risk of major infection, particularly of aspiration pneumonia.

Survival rate among Thai systemic lupus erythematosus patients in the era of aggressive treatment

BACKGROUND

The major cause of death in systemic lupus erythematosus (SLE) is due to the disease activity itself or infection. It is uncertain whether the treatment approach during the last decade prolonged survival in SLE.

OBJECTIVE

Our objective was to identify the causes of death and the factors predictive of mortality and to calculate the survival rate among SLE patients.

METHOD

We conducted a retrospective study of SLE patients followed up at Srinagarind Hospital, Khon Kaen University, Thailand, between January 1, 1996 and August 31, 2005. Cox regression analysis was used to estimate the probability of survival and assessing factors associated with death. The medical records of 749 SLE patients were reviewed; 66 patients died during the follow-up period.

RESULTS

The mortality rate was 1.2 per 100 person-years. The 5- and 10-year survival rate among our SLE patients was 93% and 87%, respectively. The mean age at death was 34.08 ± 11.75 years and the median disease duration was 48 (1-336) months. One-third of the cases were referred from a local hospital more than 1 month after onset and were associated with a significantly higher risk of mortality than cases referred earlier (P = 0.047). The most common causes of death were opportunistic pulmonary infections and neuropsychiatric lupus. Factors predictive of mortality included: (i) major organ flare more than four times per year; (ii) age at onset > 50 years; (iii) high-dose steroid use and/or immunosuppressive therapy at onset and within 2 weeks prior to death; and (iv) concomitant diabetes mellitus. Protective against mortality was antimalarial use.

Right ventricular systolic pressure assessed by echocardiography: a predictive factor of mortality in patients with scleroderma

BACKGROUND

Pulmonary arterial hypertension (PAH) is a well-known complication of systemic sclerosis (SSc). Doppler echocardiographic screening for the detection of PAH (by measuring right ventricular systolic pressure [RVSP]) is therefore recommended for all patients with SSc. However, the validity of RVSP as a predictor of mortality in patients with SSc is not well established.

HYPOTHESIS

Doppler-determined PAH identifies a high-risk subset of patients with SSc with decreased survival.

METHODS

We performed echocardiography in 155 consecutive patients with SSc between May 2005 and July 2006 and tested the value of an RVSP level of ≥36 mm Hg to predict mortality. Cox proportional hazards model was used to examine the individual relationship between each variable and the mortality rate.

RESULTS

Tricuspid regurgitant jets for RVSP determination were quantified in 129 patients (82.6%), of which 47 (36.4%) had RVSP ≥36 mm Hg. The median follow-up time was 34 months. The 1-, 2-, and 3-year survival rates were significantly lower among SSc patients with RVSP ≥36 vs ≤36 mm Hg (82%, 78%, and 67% vs 98%, 90%, and 86%, respectively, P < 0.01 by Wilcoxon test). In a multivariate analysis including echocardiographic and clinical variables, only an RVSP ≥36 mm Hg and a New York Heart Association III/IV class were associated with increased mortality; the respective Cox hazard ratios were 2.22 (95% confidence interval [CI]: 1.01-4.89, P = 0.048) and 4.77 (95% CI: 2.09-10.90, P = 0.000).

CONCLUSIONS

Our results indicate that Doppler RVSP identifies a high-risk subset and supports the use of Doppler RVSP as a screening test in patients with SSc who may warrant early treatment of their PAH.

Synovial fluid adenosine deaminase activity to diagnose tuberculous septic arthritis

There are reports of a correlation between high adenosine deaminase (ADA) levels in body fluid and tuberculosis (TB) infection, but none have evaluated synovial fluid ADA and TB arthritis. The objectives of this study were to determine the proper cut-off level for synovial fluid adenosine deaminase (SF-ADA) and the sensitivity and specificity of SF-ADA to diagnose TB arthritis. Between January 2006 and December 2007, SF-ADA were determined using the modified Giusti's method on patients over 15 years of age with clinically suspected TB arthritis or having an unknown etiology of their arthritis. Synovial fluid culture for TB was performed in all patients as a gold standard test. Forty cases were included in the study, with a female to male ratio of 1.7:1 and a mean age of 52.3 +/- 17.4 years (range, 16-80). The median duration of symptoms was 60 days. The prevalence of TB arthritis was 16.7% (6 cases) while the remaining cases were rheumatoid arthritis (8), non-TB bacterial septic arthritis (3), and miscellaneous (23). The mean SF-ADA levels in patients with TB arthritis and non-TB arthritis were 35.7 +/- 10.4 (range, 20-51) and 15.4 +/- 9 (range, 2-34) U/1, respectively. The cut-off value for the diagnosis of TB arthritis was 31 U/1, with a sensitivity of 83.3% (95% CI 35.9-99.6), a specificity of 96.7% (95% CI 82.8-99.9) and an agreement Kappa of 0.8 (p < 0.001). SF-ADA levels higher than 31 U/1 were highly correlated with a diagnosis of TB arthritis, with a high sensitivity and specificity. SF-ADA may be considered as a less invasive and time-consuming diagnostic tool for TB arthritis.

Clinical features of tuberculous septic arthritis in Khon Kaen, Thailand: a 10-year retrospective study

Tuberculous septic arthritis is difficult to diagnose. A retrospective analysis was done on patients over 15 years of age who attended Srinagarind Hospital, Khon Kaen, Thailand, between January 1, 1997 and December 31, 2006, whose synovial fluid culture was positive for Mycobacterium tuberculosis. The medical records of 77 patients were reviewed; one-third were in their sixth decade. Comorbid disease was found in 33 cases (42.9%), with systemic sclerosis being the most common (9 cases) followed by diabetes mellitus (5 cases) and chronic kidney disease (5 cases). Chronic monoarthritis was the most common presentation (34 cases) followed by acute monoarthritis (20 cases). More than half of the polyarticular involvements were disseminated tuberculosis. The knee was the most commonly affected joint (36.4%). Sixty percent had delayed diagnosis due to an incorrect diagnosis. Abnormal chest radiography and blood eosinophilia were found in 40 and 57.3% of cases, respectively. Synovial fluid and synovial tissue staining for acid-fast bacteria were positive in 30 and 40% of cases, respectively. A caseous granuloma was present in 57.5% of cases and non-specific synovitis in 12%. Sixty-three percent had bone erosions. Tuberculous septic arthritis should be considered in patients who present with acute or chronic monoarthritis, and who have an abnormal chest radiograph or eosinophilia. Polyarticular involvement was commonly related to having disseminated tuberculosis and may indicate systemic involvement of tuberculous infection.

Effect of once a week endurance exercise on fitness status in sedentary subjects

OBJECTIVE

To study whether 3-months aerobic exercise training at moderate intensity once a week can increase fitness status in healthy sedentary young men.

MATERIAL AND METHOD

Randomized controlled study was performed in 37 sedentary young men, 18 to 25 years old. The exercise group (19) was assigned to work on bicycle ergometry at 60% of maximal effort, once a week for 12 weeks. The control group (18) lived a normal life style. Before and after training, aerobic fitness (VO2(max)), resting heart rate, lipid profile, and isokinetic power and strength of shoulder and knee were evaluated.

RESULTS

In the exercise group, there was a significant increase in most fitness parameters compared with control, VO2(max) (19.7%), isokinetic power and strength of shoulder and knee (14.9%), and resting heart rate decreased (7.4%).

CONCLUSION

Moderate-intensity training once a week for at least 12 weeks was sufficient to increase aerobic fitness in sedentary young men. This low frequency of exercise training may be used to encourage sedentary individuals for more compliance with physical activity.

Pregnancy and disease outcome in patients with systemic lupus erythematosus (SLE): a study at Srinagarind Hospital

BACKGROUND

Systemic lupus erythematosus (SLE) is a multi-system involvement autoimmune disease that commonly occurs in childbearing age women. During pregnancy and postpartum period, disease activity may be severe or unchanged. Disease flare during pregnancy consistently affects pregnancy outcome.

OBJECTIVE

To study pregnancy outcomes and predictive factor for disease flare during pregnancy in SLE patients.

MATERIAL AND METHOD

Retrospective descriptive study was performed The study population was pregnant SLE patients who were treated between January 1997 and December 2006 at Department of Obstetrics-Gynecologic and Medicine, Srinagarind Hospital, Khon Kaen University, Thailand.

RESULT

The medical records of37 pregnant SLE patients were reviewed Of these, 33 cases gave delivery at Srinagarind Hospital. Mean age was 27.3 +/- 3.26 years, and mean disease duration was 59.67 +/- 38.62 months. Mostly SLE was established before pregnancy; about 10% SLE were firstly recognized during pregnancy During pregnancy, the disease activity was defined active in about two third (25 cases) of the patients. In most cases (60%), disease activity was continued from the pre-pregnancy period. The most common manifestations during pregnancy were lupus nephritis, hemolytic anemia, cutaneous rash, and arthritis respectively. In 40% (10 patients), SLE was severely active but could be controlled with high doses of corticosteroid, two of these required immunosuppressant. Overall live-birth in SLE patients who delivered at Srinagarind Hospital was 72.7%. Among this group, premature labor and intrauterine growth retardation were more commonly found in the patients who had active SLE than who had disease remission throughout pregnancy period with ratio of 4:1 and 7:1 respectively. Pregnancy lost (27.3%) was due to abortion (6 cases) and dead fetus in utero (DFIU; 2 cases) Termination of pregnancy was performed in 10 patients. Indications were severe active lupus (6 cases), DFIU (2 cases), and premature rupture of membrane (1 case). Pregnancy outcome was the best in patients who had inactive disease throughout pregnancy (75%) and worse in groups of patients whose disease flared up (54.5%) or emerged (50%) during pregnancy.

CONCLUSION

Even contraception was routinely advised in treating SLE patients, getting pregnant during active disease was eventually found. Lupus nephritis was the most common manifestation. Overall live-birth was 72.7%. Pregnancy lost was due to abortion and dead fetus in utero. Pregnancy outcome was worse in SLE patients who had disease flares up or emerging during pregnancy.

D-dimer and pulmonary arterial hypertension in systemic sclerosis

BACKGROUND

Micro-vascular thrombus is a common pathological finding in pulmonary artery hypertension. The association between plasma D-dimer, a marker of thrombus formation, and pulmonary artery hypertension (PAH) in patients with systemic sclerosis is unknown.

OBJECTIVE

To assess the correlation of the level of plasma D-dimer and pulmonary artery pressure in patients with systemic sclerosis.

MATERIAL AND METHOD

One hundred and twenty nine patients with systemic sclerosis between 19 and 75 years of age (mean, 48 +/- 11.3) entered the study. Plasma D-dimer was determined using immunoturbidimetric assay (D-dimer plus, Dade Behring Inc., Newark, USA). Pulmonary artery pressure was estimated by Doppler echocardiography. PAH was considered present if the Doppler echocardiography-estimated right ventricular systolic pressure (RVSP) exceeded 36 mmHg.

RESULTS

Forty-seven patients (36.4%) had PAH according to Doppler echocardiography including 32 (68.1 %) mild (RVSP, 36-45 mmHg), nine (19.1%) moderate (RVSP, 46-55 mmHg), and six (12.8%) severe PAH (RVSP > or = 56 mmHg). No significant correlation was found between plasma D-dimer and RVSP (r = 0. 02, p = 0. 82).

CONCLUSION

The present study demonstrated that the D-dimmer level is not associated with the level of pulmonary artery pressure in patients with systemic sclerosis, indicating that microvascular thrombosis may not play a significant role in the pathogenesis of PAH in patients with systemic sclerosis.

Acute lupus hemophagocytic syndrome: report of a case and review of the literature

The authors reported a case of systemic lupus erythematosus (SLE) with an unusual presentation. The patient presented with acute febrile illness along with progressive pancytopenia related to increasing hemophagocytic activity of histiocytes in the bone marrow. Concomitant polyarthritis, myositis, nephritis, high titer of antinuclear factor (1:2,560) and positive test for anti-DNA antibody made him fit the diagnostic criteria of SLE. No definite evidence of associated infections was confirmed by bacteriologic, serologic and viral studies. He did not respond to empiric antibiotic therapy but dramatically responded to corticosteroid treatment. Therefore, diagnosis of acute lupus hemophagocytic syndrome was made. The clinical presentation, laboratory diagnosis, and management of the patient are discussed and the literature was reviewed and presented.

Bucillamine Induces the Synthesis of Vascular Endothelial Growth Factor Dose-Dependently in Systemic Sclerosis Fibroblasts via Nuclear Factor-κB and Simian Virus 40 Promoter Factor 1 Pathways

The pathogenesis of systemic sclerosis (SSc) is characterized by activation of the immune system, impaired angiogenesis, and activated dermal fibroblasts. The effects of the immunosuppressive agent bucillamine (SA 96) on fibroblasts and angiogenic factors have not been examined. SA 96, and particularly its metabolite SA 981, increased the levels of vascular endothelial growth factor (VEGF) mRNA and protein dose-dependently in dermal fibroblasts from patients with SSc and healthy control subjects without influencing cell viability. SSc fibroblast cultures showed consistently a higher inducibility of VEGF than cultures from healthy control subjects. Preincubation with the SP-1 inhibitor mithramycin as well as blockade of nuclear factor (NF)-kappaB signaling with pyrrolidine dithiocarbamate treatment and IkappaB transfection reduced significantly the transcription of VEGF, indicating that both transcription factors contribute to the activation of VEGF by SA 981. Specific binding of NF-kappaB protein to its binding site after treatment with SA 981 was confirmed by electrophoretic mobility shift assay. In contrast, SA 981 did not influence the stability of VEGF mRNA as analyzed with actinomycin D assays. The study provides evidence for a role of NF-kappaB in the transcriptional regulation of the VEGF gene. SA 96 might have positive aspects on the impaired angiogenesis in patients with SSc.

Tuberculous pyomyositis

Tuberculosis, caused by Mycobacterium tuberculosis is a common infection both in immunocompromised and normal hosts. Its clinical manifestation can by divided as pulmonary and extrapulmonary form. Pyomyositis caused by M. tuberculosis is extremely rare. The authors report 2 patients, one with underlying dermatomyositis, and the other with polymyositis. The diagnosis was delayed according to nonspecific symptoms and masking effect of steroid therapy, which led to complications. Microscopy and culture of the pus confirmed the diagnosis. Surgical drainage was done and antituberculous therapy was given. The patient with dermatomyositis was complicated by drug induced hepatitis and died but the other was cured. Tuberculous pyomyositis should be considered in patients who are immunocompromised hosts.

Kikuchi-Fujimoto's disease, histiocytic necrotizing lymphadenitis, mimicking systemic lupus erythematosus

Kikuchi-Fujimoto's disease (KFD) or histiocytic necrotizing lymphadenitis is a self-limiting condition characterized by fever, neutropenia and lymphadenopathy. It is rarely associated with systemic lupus erythematosus (SLE). The authors reported a case of Kikuchi's necrotizing lymphadenitis who presented with fever, generalized lymphadenopathy, moderate leukopenia, polyarthritis, vasculitis-like lesions and oral ulcers compatible with SLE but serologic tests for autoimmune disease were all negative. The clinical symptoms resolved spontaneously within 3 months without any treatment. Because there is an association between KFD and SLE, great care should be taken with a patient who presents with either KFD or SLE.

Quinolones and Salmonella septic arthritis

Salmonella septic arthritis is an infrequent infectious disease but can cause progressive joint destruction resulting in disability. The authors retrospectively reviewed cases with culture proved Salmonella septic arthritis in Srinagarind Hospital, Khon Kaen from 1994 to 2000. There were 23 episodes in 16 cases; all had underlying diseases and a history of steroid abuse or steroid and immunosuppressive therapy. Systemic lupus erythematosus was the most commonly found underlying disease (56%). Salmonella group D and group B were isolated in 13 and 3 cases. Most first episodes had acute onset of monoarthritis. The antibiotics used as initial treatment of the first episodes were beta lactam, cotrimoxazole or quinolones. There were 8 cases with disabled sequelae and 7 cases with relapse. For 13 evaluable first episodes, relapse occurred in 3 cases in the cephalosporin/penicillin and 4 cases in the cotrimoxazole treated group but none in the quinolones. Six relapse cases were treated successfully with quinolones as well as one with cotrimoxazole. Although 5 relapse cases treated with quinolones had previous progressive joint destruction or avascular necrosis, there was no further joint damage after re-treatment with quinolones. In conclusion, quinolones were more effective than beta-lactams and cotrimoxazole for the treatment of Salmonella septic arthritis to prevent relapse and progressive joint destruction.