Prevalence and factors associated with flares following COVID-19 mRNA vaccination in patients with rheumatoid arthritis, psoriatic arthritis and spondyloarthritis: a national cohort study

OBJECTIVE

To determine prevalence and factors associated with flares post Coronavirus disease 2019 (COVID-19) mRNA vaccination in patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA) and spondyloarthritis (SpA).

METHODS

A retrospective multi-centre study was conducted (January 2021 to February 2022). Data were collected during index visit, defined as first post-vaccine visit in which the patient had a physician-defined flare, or if at least 3 months had elapsed since first vaccine dose, whichever came first. Factors associated with flares were identified using mixed effects Cox regression and expressed as hazard ratio (HR) and 95% confidence interval (CI).

RESULTS

Total of 2377 patients were included (1563 RA, 415 PsA and 399 SpA). Among patients with RA, PsA and SpA, 21.3%, 24.1% and 21.8% experienced a flare respectively. Of those who experienced a flare, only 10.2%, 11.0% and 14.9% were severe in patients with RA, PsA and SpA respectively. Patients with low or moderate/high disease were more likely to flare compared to those in remission in patients with RA only (HR: 1.68, 95% CI 1.22-2.31; HR: 2.28, 95% CI 1.50-3.48, respectively). Receiving the Moderna vaccine was associated with a higher HR of flare compared to the Pfizer vaccine in patients with PsA only (HR: 2.21, 95% CI 1.20-4.08). Patients who had two vaccine doses were found to be less likely to flare (HR: 0.08, 95% CI 0.06-0.10). HRs of flares were not significantly different among RA, PsA and SpA.

CONCLUSION

About one-fifth of patients experienced a disease flare post COVID-19 mRNA vaccination, but most flares were non-severe. Patients with active disease prior to vaccination should be monitored closely for disease flares, especially in patients with RA.

Recommendations for enhanced primary series (third dose) COVID-19 vaccination for people with rheumatic diseases: Chapter of Rheumatologists, College of Physicians, Singapore

Introduction

This review aims to provide evidence-based recommendations for an enhanced primary series (third dose) coronavirus disease 2019 (COVID-19) vaccination in people with rheumatic diseases (PRDs) in the local and regional context.

Methods

Literature reviews were performed regarding the necessity, efficacy, safety and strategies for enhanced primary series COVID-19 vaccination in PRDs. Recommendations were developed based on evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Evidence was synthesised by eight working group members, and the consensus was achieved by a Delphi method with nine members of an expert task force panel.

Results

Two graded recommendations and one ungraded position statement were developed. PRDs have impaired immunogenicity from the COVID-19 vaccine and are at an increased risk of postvaccine breakthrough severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and poor clinical outcomes, compared to the general population. We strongly recommend that PRDs on immunomodulatory drugs be offered a third dose of the messenger RNA (mRNA) vaccine as part of an enhanced primary series, after the standard two-dose regimen. We conditionally recommend that the third dose of mRNA vaccine against SARS-CoV-2 be given at least 4 weeks after the second dose or as soon as possible thereafter. There is insufficient data to inform whether the third mRNA vaccine should be homologous or heterologous in PRDs.

Conclusion

These recommendations that were developed through evidence synthesis and formal consensus process provide guidance for an enhanced primary series COVID-19 vaccination in PRDs.

Diffuse alveolar haemorrhage in systemic lupus erythematosus: A multicentre retrospective study in Singapore

OBJECTIVE

Diffuse alveolar haemorrhage (DAH) is a rare but life-threatening complication of systemic lupus erythematosus (SLE). We describe the clinical characteristics, treatment and survival outcomes of SLE patients with DAH in Singapore.

METHODS

We conducted a retrospective review of the medical records of SLE patients with DAH hospitalised in 3 tertiary hospitals between January 2007 and October 2017. Patient demographics, clinical characteristics, laboratory, radiologic and bronchoscopic findings, as well as the treatments, were compared between survivors and non-survivors. Survival rates were analysed between the various treatment groups.

RESULTS

A total of 35 patients with DAH were included in this study. Majority of them were female (71.4%) and of Chinese ethnicity (62.9%). Median age was 40.0 years (IQR: 25-54), with a median disease duration of 8.9 months (IQR: 0.13-102.4). Haemoptysis was the most common clinical presentation, and majority had concomitant cytopaenia and lupus nephritis. All patients received high dose glucocorticoids; 27 (77.1%), 16 (45.7%) and 23 (65.7%) received cyclophosphamide (CYP), rituximab (RTX), and plasmapheresis (PLEX), respectively. Twenty-two patients required mechanical ventilation with a median duration of 12 days. Overall mortality rate was 40%, with a median survival time of 162 days. Twenty-six patients (74.3%) achieved remission, with an overall median time to remission of 12 days (IQR: 6-46) after diagnosis of DAH. Patients on triple therapy (CYP, RTX and PLEX) had a median survival of 162 days as compared to 14 days in patients on PLEX alone (p = .0026).

CONCLUSIONS

The overall mortality of DAH in SLE patients remained high. There were no significant differences in patient demographics or clinical characteristics between the survivors and non-survivors. However, better survival appears to be associated with treatment with cyclophosphamide.

Post-mRNA vaccine flares in autoimmune inflammatory rheumatic diseases: Results from the COronavirus National Vaccine registry for ImmuNe diseases SINGapore (CONVIN-SING)

BACKGROUND

Studies of flares of autoimmune inflammatory rheumatic diseases (AIIRD) after COVID-19 mRNA vaccination are limited by small sample size, short follow up or at risk of selection bias.

METHODS

A national retrospective cohort study of consecutive AIIRD patients ≥12 years old, across 8 hospitals who received at least one dose of a COVID-19 mRNA vaccine. Patients were included from the date of 1st vaccine dose and censored at the time of flare or on the date of the clinic visit at least 3 months from cohort entry, whichever came first. Predictors of flare were determined by Cox proportional hazards analysis.

FINDINGS

4627 patients (73% Chinese, 71% female) of median (IQR) age 61 (48, 70) years were included; 42% Rheumatoid arthritis, 14% Systemic lupus erythematosus and 11% Psoriatic arthritis. 47% were in remission, 41% low disease activity, 10% moderate disease activity and 1% in high disease activity. 18% patients flared, of which 11.7% were within the 3-month period of interest. 11.8% patients improved. Median (IQR) time-to-flare was 60 (30, 114) days. 25% flares were self-limiting, 61% mild-moderate and 14% severe. Older patients (53-65 years and >66 years) had a lower risk of flare [HR 0.6 (95% CI 0.5-0.8) and 0.7 (0.6-0.8) respectively]. Patients with inflammatory arthritis and with active disease had a higher risk of flare [HR 1.5 (1.2-2.0) and 1.4 (1.2-1.6), respectively]. Treatment with conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs), immunosuppression and prednisolone was also associated with an increased risk of flare [HR 1.5 (1.1-2), 1.2 (1.1-1.4) and 1.5 (1.2-1.8) for prednisolone ≤7.5 mg respectively].

INTERPRETATION

There was a moderately high rate of AIIRD flares after mRNA vaccination but also improvement in several patients. Severe flares and hospitalisation were rare. Thus, vaccination remains safe and highly recommended.

The Impact of the Off-site Monitoring Clinic (Virtual Monitoring Clinic) on the Practice of Outpatient Rheumatology in a Tertiary Centre during the COVID-19 Pandemic

The ongoing pandemic in Singapore is part of a global pandemic caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). To control the spread of COVID-19 and prevent the healthcare system from being overwhelmed, ‘circuit breaker’ measures were introduced between 7 April and 1 June 2020 in Singapore. There is thus a crucial need for innovative approaches to the provision and delivery of healthcare in the context of safe-distancing by harnessing telemedicine, especially for patients with chronic diseases who have traditionally been managed in tertiary institutions. We present a summary of how the Virtual Monitoring Clinic has benefited the practice of our outpatient rheumatology service during the COVID-19 pandemic. The virtual consultations address the need for safe-distancing by limiting face-to-face appointments and unnecessary exposure of patients to the hospital where feasible. This approach ensures that the patients are monitored appropriately for drug toxicities and side-effects, maintained on good disease control, and provided with patient education. Keywords: Chronic rheumatic diseases, health services, medication delivery service, severe acute respiratory syndrome coronavirus 2, telemedicine

Evaluation of a bilingual questionnaire-based assessment on hearing in children with speech delay

INTRODUCTION

To correlate the score obtained using a bilingual (Malay and English) 14 points questionnaire in the detection of hearing loss at the University of Malaya, Medical Centre (UMMC), Kuala Lumpur, Malaysia over a 9 month period.

METHODS

This is a prospective instrument correlation study done on 93 children aged 1-4 years of age with speech and language delay for at least 3 months. Hearing status was confirmed using otoacoustic emissions, pure tone audiometry and brainstem evoked response (BSER). Hearing status was then compared to the 14-point questionnaire final scores and is statistically correlated.

RESULTS

There were 26 patients, 15 males (58%) and 11(42%) females who were diagnosed to have hearing loss. The average age of presentation was 2.49 and conductive hearing loss accounted for about 74% of cases of hearing loss. The mean questionnaire score obtained through our patients was 3.83±1.987. Discriminant analysis suggests that a questionnaire score of above 4 was indicative that the child was suffering from hearing loss.

CONCLUSION

Our study suggests that the low-cost bilingual (Malay and English) questionnaire can be used to detect hearing loss in the Malaysian population and could potentially be useful in rural health centres to help detect hearing loss and to determine the urgency of referral to a tertiary health centre.

An evaluation of the effectiveness of teaching anatomy to rheumatologists through combined musculoskeletal sonoanatomy and human cadaveric dissection

Objective

Our aim was to evaluate the effectiveness of teaching anatomy through combined musculoskeletal sonoanatomy and human cadaveric dissection for rheumatologists practising musculoskeletal US.

Methods

The principal focus was on scanning and then dissecting relevant musculoskeletal structures. Outcomes measured included confidence levels and objective knowledge. A mixed-methods approach of evaluation and descriptive statistical data analysis was performed.

Results

The change in confidence ratings by delegates after the teaching event as represented by the mean difference (s.d.) (s.e.m.) for identification of surface anatomy was 1.846 (1.281) (0.355), with Student’s paired t = 5.196 and P=0.000223. The mean difference (s.d.) (s.e.m) for performing IA injections was 1.538 (1.266) (0.351), with Student’s paired t = 4.382, P=0.001, and for recognizing sonoanatomical structures it was 1.769 (1.235) (0.343), with Student’s paired t  = 5.165 and P= 0.000235. There was a significant increase in correct identification of anatomical and sonoanatomical knowledge in the pre- and post-course assessments. Rotator cuff interval region improved from 13 to 73%, P  = 0.004; knee tendons insertion sites from 47 to 93%, P  = 0.016; and muscles not adjacent to joints from 27 to 93%, P  = 0.002.

Conclusion

Dissection of joints enabled a three-dimensional relational mind map of the relevant regions of the human body, producing clarity in understanding regional relational topographic anatomy and sonoanatomy. The combination of US and cadaveric dissection improved learners’ satisfaction, confidence and knowledge in areas where soft tissue complaints are common, which is likely to lead to accurate early diagnosis and cost-conscious, better overall care.

An evaluation of the Virtual Monitoring Clinic, a novel nurse-led service for monitoring patients with stable rheumatoid arthritis

OBJECTIVES

To study clinical and patient reported outcomes for the Virtual Monitoring Clinic (VMC), a remote nurse-led telemonitoring service for monitoring Rheumatoid Arthritis (RA) patients treated with disease-modifying antirheumatic drugs (DMARDs).

METHODS

Patients with stable RA enrolled in the VMC were followed up prospectively. The primary outcomes evaluated at 1-year follow-up were: Disease Activity Score-28 (DAS28), Routine Assessment of Patient Index Data 3 (RAPID3), and patient satisfaction assessed using an 11-point Likert scale.

RESULTS

Of the 251 patients enrolled, 186 completed 1-year of follow-up. There was a 2.3% (n = 450) reduction in the annual workload from the rheumatology specialist outpatient clinic as a result of the VMC. Statistically significant improvement was seen in the mean patient satisfaction score (7.70-8.16, P ≤ 0.001), with 61.5% of patients opting for the VMC alternating with rheumatology outpatient clinic visits as their preferred mode of follow-up vis-à-vis standard care. There was a marginal increase in mean DAS28 and RAPID3 scores from 2.56 to 2.78 (P < 0.05) and 5.28 to 6.03 (P < 0.05), respectively. However, given that at 1-year follow-up more than half (72.0% and 63.4% based on DAS28 and RAPID3) of the patients' disease activity had improved or remained stable, and was in remission or low activity (73.1% and 53.2% based on DAS28 and RAPID3), the VMC seemed to maintain a stable RA disease activity for the majority of patients.

CONCLUSIONS

The VMC is an effective and well-accepted novel approach for the management of patients with stable RA.

Back to the basics: Understanding joint swelling and tenderness at the wrist in rheumatoid arthritis through the use of ultrasonography

AIM

To compare ultrasound-detected inflammation with clinical manifestations at the wrist in rheumatoid arthritis (RA).

METHOD

Wrists assessed serially by assessors blinded to ultrasound findings were categorized into 4 groups: 1 = S0T0 (not swollen; not tender); 2 = S0T1 (not swollen; tender); 3 = S1T0 (swollen; not tender); 4 = S1T1 (swollen; tender). Ultrasound synovitis and tenosynovitis were graded semi-quantitatively (0-3) and dichotomously (0 or 1), respectively. The (a) power Doppler (PD), gray-scale (GS) and combined (PD + GS) ultrasound (CUS) scores and (b) their positivity (score > 0) were analyzed using a general linear repeated measures mixed model (a) assuming Gaussian errors and (b) with binary distribution and logit link, respectively. Pairwise comparisons among wrist groups were performed within context of the models.

RESULTS

In 122 wrist assessments (baseline = 64; 3 months = 58) from 32 treated RA patients (87.5% female; mean disease duration 42.8 months), significant differences among groups for (a) scores were: 4 vs 1 (PD, P = 0.0031; GS, P = 0.0159; CUS, P = 0.0045), 4 vs 2 (PD, P = 0.0176; GS, P = 0.0160; CUS, P = 0.0074), and 4 vs 3 (CUS, P = 0.0374); and (b) positivity were: 4 vs 1 (PD, P = 0.0007), 4 vs 2 (PD, P = 0.0234), and 3 vs 1 (PD, P = 0.0202). No significant differences in results were found for groups 2 vs 1. No significant effects were attributable to differences in wrist side or follow-up visit.

CONCLUSION

Ultrasound detected substantial inflammation when wrist joint swelling and tenderness are both present. Joint swelling without tenderness is associated with significantly more frequent PD detection. Without swelling, joint tenderness is not associated with a significantly greater degree of ultrasound-detected inflammation.

Greater rheumatoid arthritis joint improvement with more subjects achieving response across improvement categories using novel versus existing ultrasound methods

We compared the change in joint inflammation and the proportion of subjects achieving threshold levels of improvement using the existing methods employing ultrasonography on pre-determined joint sites versus novel methods. These novel methods select the most affected joints based on (i) ultrasonography-the Individualized-Ultrasound (IUS) method, or (ii) ultrasonography and clinical joint assessment-the individualized-Composite-Ultrasound (ICUS) method. Mean 3-month change in total inflammation score (ΔTIS) and 95% CI was computed for each method on 24 RA subjects initiated or escalated on treatment. Individual improvement in TIS per subject, calculated as the 3-month ΔTIS divided by the maximum possible TIS score expressed as a percentage, was used to obtain the proportion of subjects achieving response across improvement categories. Mean 3-month ΔTIS was significantly greater (p values ranging from 0.0003 to 0.0026) for novel versus existing methods using 12- and 7-joint approaches. Using 12-joint approach, percentages of subjects in improvement categories ≥5%, ≥10%, ≥15% and ≥20% were, respectively, 50, 37.5, 12.5 and 8.3% for IUS; 58.3, 37.5, 12.5 and 8.3% for ICUS; and 16.7, 0, 0 and 0% for the existing method. Using 7-joint approach, the respective category percentages were 62.5, 37.5, 25 and 12.5% for IUS; 62.5, 41.7, 16.7 and 8.3% for ICUS; and 12.5, 4.2, 4.2 and 0% for the existing method. Novel ultrasound methods are more likely to detect improvement in joint inflammation, with more subjects achieving response across improvement categories, thereby representing a substantial advantage over the existing methods. However, this requires confirmation in larger RA cohorts.

Novel joint selection methods can reduce sample size for rheumatoid arthritis clinical trials with ultrasound endpoints

OBJECTIVES

To determine whether novel methods of selecting joints through (i) ultrasonography (individualized-ultrasound [IUS] method), or (ii) ultrasonography and clinical examination (individualized-composite-ultrasound [ICUS] method) translate into smaller rheumatoid arthritis (RA) clinical trial sample sizes when compared to existing methods utilizing predetermined joint sites for ultrasonography.

METHODS

Cohen's effect size (ES) was estimated (ES^) and a 95% CI (ES^L, ES^U) calculated on a mean change in 3-month total inflammatory score for each method. Corresponding 95% CIs [nL(ES^U), nU(ES^L)] were obtained on a post hoc sample size reflecting the uncertainty in ES^. Sample size calculations were based on a one-sample t-test as the patient numbers needed to provide 80% power at α = 0.05 to reject a null hypothesis H₀ : ES = 0 versus alternative hypotheses H₁ : ES = ES^, ES = ES^L and ES = ES^U. We aimed to provide point and interval estimates on projected sample sizes for future studies reflecting the uncertainty in our study ES^S.

RESULTS

Twenty-four treated RA patients were followed up for 3 months. Utilizing the 12-joint approach and existing methods, the post hoc sample size (95% CI) was 22 (10-245). Corresponding sample sizes using ICUS and IUS were 11 (7-40) and 11 (6-38), respectively. Utilizing a seven-joint approach, the corresponding sample sizes using ICUS and IUS methods were nine (6-24) and 11 (6-35), respectively.

CONCLUSIONS

Our pilot study suggests that sample size for RA clinical trials with ultrasound endpoints may be reduced using the novel methods, providing justification for larger studies to confirm these observations.

Dichotomous versus semi-quantitative scoring of ultrasound joint inflammation in rheumatoid arthritis using novel individualized joint selection methods

The aim of the study is to compare the responsiveness of two joint inflammation scoring systems (dichotomous scoring (DS) versus semi-quantitative scoring (SQS)) using novel individualized ultrasound joint selection methods and existing ultrasound joint selection methods. Responsiveness measured by the standardized response means (SRMs) using the DS and the SQS system (for both the novel and existing ultrasound joint selection methods) was derived using the baseline and the 3-month total inflammatory scores from 20 rheumatoid arthritis patients. The relative SRM gain ratios (SRM-Gains) for both scoring system (DS and SQS) comparing the novel to the existing methods were computed. Both scoring systems (DS and SQS) demonstrated substantial SRM-Gains (ranged from 3.31 to 5.67 for the DS system and ranged from 1.82 to 3.26 for the SQS system). The SRMs using the novel methods ranged from 0.94 to 1.36 for the DS system and ranged from 0.89 to 1.11 for the SQS system. The SRMs using the existing methods ranged from 0.24 to 0.32 for the DS system and ranged from 0.34 to 0.49 for the SQS system. The DS system appears to achieve high responsiveness comparable to SQS for the novel individualized ultrasound joint selection methods.

Utility of ultrasonography in guiding modification of disease modifying anti-rheumatic drugs and steroid therapy for inflammatory arthritis in routine clinical practice

OBJECTIVE

To determine the utility of ultrasonography in guiding modification of disease-modifying anti-rheumatic drug (DMARD) and steroid therapy for inflammatory arthritis (IA) in routine clinical practice.

METHODS

In this retrospective study, we analyzed DMARD and steroid use in IA patients referred to a rheumatologist-led ultrasound clinic. Power Doppler (PD) vascularity and greyscale (GS) synovial hypertrophy joint findings were categorized as positive/negative for each patient. The erythrocyte sedimentation rate (ESR) was used as a measure of disease activity.

RESULTS

We assessed single visit data for 46 adult IA patients: 67.4% (n = 31) rheumatoid arthritis (RA), 15.2% (n = 7) psoriatic arthritis, 10.9% (n = 5) spondyloarthritis, and 6.5% (n = 3) undifferentiated IA. The mean ESR was 28.8 mm/h. Thirty-seven patients with both GS and PD ultrasound results were subsequently analyzed. All patients (n = 10) escalated and/or initiated on DMARD and 9/10 patients escalated or initiated on steroids were PD and GS positive. Six of seven patients with dose reduction and/or cessation of DMARDs and five of seven patients with dose reduction or cessation of steroids were PD negative. Of six patients who were GS positive and PD negative, three had dose reduction and/or cessation of DMARDs, while four had dose reduction of steroids; none of the six patients had DMARD/steroid escalation.

CONCLUSION

By clarifying joint inflammation in an IA cohort with overall low ESR, ultrasonography of physician-selected joints can improve clinical assessment, resulting in treatment modification. Positive PD findings were particularly influential, while the clinical significance of GS positivity alone requires further investigation.

Novel Ultrasound Joint Selection Methods Using a Reduced Joint Number Demonstrate Inflammatory Improvement when Compared to Existing Methods and Disease Activity Score at 28 Joints

OBJECTIVE

A pilot study testing novel ultrasound (US) joint-selection methods in rheumatoid arthritis.

METHODS

Responsiveness of novel [individualized US (IUS) and individualized composite US (ICUS)] methods were compared with existing US methods and the Disease Activity Score at 28 joints (DAS28) for 12 patients followed for 3 months. IUS selected up to 7 and 12 most ultrasonographically inflamed joints, while ICUS additionally incorporated clinically symptomatic joints.

RESULTS

The existing, IUS, and ICUS methods' standardized response means were -0.39, -1.08, and -1.11, respectively, for 7 joints; -0.49, -1.00, and -1.16, respectively, for 12 joints; and -0.94 for DAS28.

CONCLUSION

Novel methods effectively demonstrate inflammatory improvement when compared with existing methods and DAS28.

Achieving consensus in ultrasonography synovitis scoring in rheumatoid arthritis

OBJECTIVE

Ultrasonography is sensitive for synovitis detection but interobserver variation in both acquisition and image interpretation is still a concern. The objective was to assess if a short collegiate consensus would improve inter-observer reliability in scoring of synovitis.

METHODS

Eight rheumatologists (Singapore) participated in a 1-day consensus meeting divided into: (i) still-image interpretation and consensus followed by; (ii) image acquisition and interpretation, according to definitions and synovitis scoring rules endorsed by Outcome Measures in Rheumatology (OMERACT) and TUI (Targeted Ultrasound Initiative). Interobserver reliability of semiquantitative scoring in B-mode, Power Doppler (PDUS) and European League Against Rheumatism (EULAR)-OMERACT PDUS composite score was assessed by intraclass correlation co-efficient (ICC). Agreement at the joint region level was calculated using prevalence-adjusted-biased-adjusted-kappa (PABAK).

RESULTS

For B-mode still images, ICC was good at 0.75 (95% CI 0.66-0.82) while for PDUS images this was excellent at ICC = 0.88 (95% CI 0.83-0.92) with ICC improving by 12% for B-mode and 13% for PDUS respectively. During image acquisition and interpretation, B-mode scoring showed ICC = 0.75 (95% CI 0.66-0.84) while for PDUS the ICC was lower at 0.59 (95% CI 0.48-0.72). The ICC for OMERACT PDUS composite synovitis scoring was good at 0.77 (95% CI 0.68-0.85). At the joint level, agreement varied with PABAK being excellent in the small joints of the hands but poor to fair in the wrists, elbows, ankles and metatarsophalangeal joints, and no agreement at the knees (PABAK range -0.34 to 0.85).

CONCLUSION

A consensus meeting was useful in improving interobserver variation in US synovitis scoring of still images, but image acquisition and interpretation especially in non-hand joints require further standardization.

Disease patterns of rheumatology outpatients seen in a tertiary hospital serving a multi-ethnic, urban Asian population in Singapore

AIMS

To describe the spectrum of diseases seen in an outpatient setting in the Singapore General Hospital, the largest tertiary referral centre in Singapore.

METHODS

In this cross-sectional study, medical records of patients scheduled for an appointment at the rheumatology specialist outpatient clinics over a 4-month period (10 August 2010-31 December 2010) were reviewed. Primary diagnoses documented by the attending physician at the latest visit were recorded.

RESULTS

Among 4180 patients (29.5% male; mean [SD] age: 53.5 [15.1] years; 77.0% Chinese, 8.0% Malay, 8.8% Indian and 6.2% others), the spectrum of diseases seen was as follows [disease - definite n (%), probable n (%)]: Arthritis: rheumatoid arthritis - 958 (22.9%), 68 (1.6%); osteoarthritis - 452 (10.8%), 39 (0.9%); crystal arthritis - 417 (10.0%), 18 (0.4%); spondyloarthritis - 227 (5.4%), 61 (1.5%); psoriatic arthritis - 158 (3.8%), 9 (0.2%); other inflammatory arthritis - 153 (3.7%), 94 (2.2%); Connective tissues diseases: systemic lupus erythematosus - 412 (9.9%), 26 (0.6%); vasculitis - 105 (2.5%), 22 (0.5%); Sjögren's syndrome - 81 (1.9%), 32 (0.8%); overlap syndromes - 73 (1.8%); scleroderma - 50 (1.2%), 4 (0.1%); undifferentiated connective tissue diseases - 45 (1.1%), 106 (2.5%); myositis - 41 (1.0%), 12 (0.3%); antiphospholipid syndrome - 22 (0.5%), 7 (0.2%); polymyalgia rheumatica - 16 (0.4%); Others: soft tissue rheumatism - 155 (3.7%); osteoporosis - 61 (1.5%); other non-rheumatologic conditions - 189 (4.5%); other rheumatologic conditions - 67 (1.6%).

CONCLUSION

Rheumatoid arthritis, osteoarthritis and crystal arthritis were the three most common rheumatological diseases seen in a tertiary referral centre serving a multi-ethnic urban Asian population in Singapore.

Discordant assessment of lupus activity between patients and their physicians: the Singapore experience

Patients with systemic lupus erythematosus often assess their disease activity differently from their physicians. We studied the factors associated with this discordance. The data provided by 534 systemic lupus erythematosus patients were analyzed. We compared the physician and patient assessments of lupus activity on a visual-assessment scale from the same visit. We collected clinical data and scores from MOS 36-Item Short-Form Health Survey, Systemic Lupus Erythematosus Quality-of-Life Questionnaire, Rheumatology Attitudes Index, Systemic Lupus Erythematosus Disease Activity Index, and revised Systemic Lupus Activity Measure. Patients tended to score their disease activity higher than do their physicians, when these factors were present: poorer general health assessment, presence of thrombocytopenia, hypertension and urinary sediments, and difficulty in carrying groceries. Physicians tended to score the disease activity higher than do the patients in these circumstances proteinuria, hemolysis, use of azathioprine or cyclophosphamide, tiredness, photosensitivity, higher revised Systemic Lupus Activity Measure score, casturia, and patient report of being more easily ill than are other patients. There was only moderate correlation between the discordance in the baseline and the subsequent visits. The physician assessment of disease activity at baseline correlated better with an objective measure of disease activity (revised Systemic Lupus Activity Measure) in the subsequent visit than the patient assessment. In conclusion, discordance in the perception of disease activity between patients and physicians may be amenable to intervention.

Septic Monoarthritis and Osteomyelitis in an Elderly Man Following Klebsiella pneumoniae Genitourinary Infection: Case Report

Introduction: Klebsiella pneumoniae septic arthritis and osteomyelitis, albeit uncommon in adults, are important sites of disseminated infection. Many case reports have shown K. pneumoniae as a cause of nosocomial transmitted septic arthritis in neonates and children. We report a rare case of an elderly patient with K. pneumoniae genitourinary infection spreading to the liver and other extra hepatic sites like the prostate and peripheral joint. Clinical Picture: The patient presented with a short history of general malaise, fever and urinary symptoms, associated with an acute monoarthritis of the ankle. On admission, he was in septic shock. Investigations suggested an infective cause, as evidenced by raised total white cell count and pyuria. K. pneumoniae was cultured from both urine and ankle synovial fluid. Imaging confirmed multiple liver and prostatic abscesses, as well as osteomyelitis of the foot bones adjacent to the ankle. Treatment: Treatment in this case included surgical drainage of the affected joint and surrounding soft tissue structures, in addition to a 6-week course of systemic antibiotics. Outcome: The patient had good clinical response following treatment. In addition, we noted a normalisation of his laboratory parameters and resolution of the intraabdominal and pelvic abscesses. Conclusion: This case emphasises the importance of timely and accurate diagnosis followed by appropriate treatment in disseminated K. pneumoniae infection to prevent significant morbidity and mortality. Key words: Arthritis, Infectious, Klebsiella infections, Liver abscess

Septic monoarthritis and osteomyelitis in an elderly man following Klebsiella pneumoniae genitourinary infection: case report

INTRODUCTION

Klebsiella pneumoniae septic arthritis and osteomyelitis, albeit uncommon in adults, are important sites of disseminated infection. Many case reports have shown K. pneumoniae as a cause of nosocomial transmitted septic arthritis in neonates and children. We report a rare case of an elderly patient with K. pneumoniae genitourinary infection spreading to the liver and other extra hepatic sites like the prostate and peripheral joint.

CLINICAL PICTURE

The patient presented with a short history of general malaise, fever and urinary symptoms, associated with an acute monoarthritis of the ankle. On admission, he was in septic shock. Investigations suggested an infective cause, as evidenced by raised total white cell count and pyuria. K. pneumoniae was cultured from both urine and ankle synovial fluid. Imaging confirmed multiple liver and prostatic abscesses, as well as osteomyelitis of the foot bones adjacent to the ankle.

TREATMENT

Treatment in this case included surgical drainage of the affected joint and surrounding soft tissue structures, in addition to a 6-week course of systemic antibiotics.

OUTCOME

The patient had good clinical response following treatment. In addition, we noted a normalisation of his laboratory parameters and resolution of the intraabdominal and pelvic abscesses.

CONCLUSION

This case emphasises the importance of timely and accurate diagnosis followed by appropriate treatment in disseminated K. pneumoniae infection to prevent significant morbidity and mortality.

Development and preliminary validation of a systemic lupus erythematosus-specific quality-of-life instrument (SLEQOL)

OBJECTIVES

Systemic lupus erythematosus (SLE), a chronic illness with an unpredictable and variable course, profoundly affects the quality of life (QOL). General health questionnaires are used to assess QOL in SLE, but a disease-specific instrument could offer enhanced responsiveness and content validity. We detail the steps we took to develop and validate a new SLE-specific QOL instrument, SLEQOL.

METHODS

Rheumatology professionals nominated items that they felt were important determinants of QOL of SLE patients. One hundred SLE patients were asked to assess the importance and frequency of occurrence of these items and to suggest those that had not been listed. Item reduction was performed using Rasch model and factor analyses to create a new questionnaire in English. This final questionnaire was administered to a cohort of 275 patients to study its psychometric properties.

RESULTS

Fifty-one items covering a wide range of QOL concerns were identified. The patients' responses led to the elimination of 11. The new questionnaire of 40 items was found to have Cronbach's alpha of 0.95 and to consist of eight domains covering physical, mental and social QOL issues. It has good test-retest reliability, poor to fair cross-sectional correlation with the SF-36, with poor correlation with lupus activity or damage indices. The SLEQOL was more responsive to change than the SF-36.

CONCLUSIONS

We have developed a new 40-item SLEQOL in English and showed that it is valid for use in SLE patients in Singapore. It offers better content validity and responsiveness to change than the SF-36.

Simultaneous regulation of plasmid replication and heterologous gene expression in Escherichia coli

An expression plasmid in which plasmid DNA replication and heterologous gene expression can be simultaneously regulated was constructed to avoid derepression prior to induction. This was achieved by placing a pBR322 origin of replication immediately downstream of an anthranilate synthase-human epidermal growth factor fusion gene (trpE-hEGF), both under the control of the promoter from the tryptophan biosynthetic operon. Regulation of plasmid copy number ensured tight repression of the trp promoter prior to induction. Upon induction, plasmid copy number increased up to six-fold and the fusion protein accumulated to approximately 12% of total cell protein. Induction experiments with a series of plasmid derivatives with sequentially lower copy numbers revealed that accumulation levels of the TrpE-hEGF fusion protein post-induction correlated well with plasmid copy number. Plasmid constructs where the native trp promoter had been replaced by derivatives deleted of the attenuator resulted in high levels of hEGF accumulation in the tryptophan-free medium prior to induction. Nevertheless, up to two-fold increase in TrpE-hEGF accumulation levels were obtained using the constructs lacking the attenuator compared to those bearing the native trp promoter.