COVID-19 et maladies auto-immunes dans un centre de traitement des épidémies à Dakar / COVID 19 and autoimmune diseases in an outbreak treatment center in Dakar

Introduction : Les patients présentant une affection systémique ont un risque accru d'infections. Leur prise en charge au cours de la pandémie au COVID19 constitue un défi qui doit prendre en considération plusieurs aspects. Nous rapportons les caractéristiques épidémiologiques, cliniques, et évolutives des patients COVID positifs suivis pour une maladie auto-immune (MAI). Patients et méthode : étude rétrospective, descriptive et analytique menée au centre de traitement des épidémies du centre hospitalier universitaire (CHU) Le Dantec de Dakar durant les périodes du 30 Avril au 30 Octobre 2020 puis du 30 Décembre 2020 au 30 Avril 2021. Etaient inclus tous les dossiers des patients suivis pour une maladie systémique hospitalisés pour COVID-19 confirmée à la RT-PCR. Résultats : treize patients étaient inclus dans l'étude, composés de 8 femmes et de 5 hommes. L'âge moyen était de 59 ans [16 à 74 ans]. Il s'agissait de 8 cas de maladies auto-immunes systémiques (MAIS) : polyarthrite rhumatoïde (n=3 ; 37,5%), Sjögren primitif (n=2 ; 25%), lupus systémique, dermatomyosite, arthrite à cellules géantes chacun 1 cas (12,5%) et 5 cas de maladies auto-immunes spécifiques d'organes (MASO) : maladie de Basedow (n=1 ; 20% de MASO), thyroïdite de Hashimoto (n=1 ; 20%), myasthénie (n=1 ; 20%), diabète de type 1 (n=1 ; 20%) et maladie de Biermer (n=1 ; 20%). Les formes cliniques étaient modérées (6 cas ; 46,1%), sévères (2cas ; 15,4%) et critiques (2cas ; 15,4%). Huit patients (8/13) avaient au moins une comorbidité associée. Deux décès (2/13) étaient notés. Conclusion : il n'a pas été trouvé une augmentation des complications sévères dues au COVID-19 chez les patients suivis pour une maladie auto-immune. Leur pronostic n'est pas différent de celui de la population générale.

Assessment of pharmacist's knowledge on use of non-steroidal anti-inflammatory drugs in hypertensive patients with co-morbid arthritis and pharmaceutical services rendered in Ibadan, Nigeria

Background: hypertension and arthritis are two co-morbid diseases that require pharmaceutical care (PC) services. Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used for treatment of arthritis.Objectives: The study evaluated the knowledge of pharmacist on the use of NSAIDs in this set of patients and the PC services rendered to them. Methods: structured tested questionnaires were distributed to pharmacists working in public hospitals and community pharmacies in Ibadan metropolis. The questionnaire elicited information on the demographics of respondents, identification of drug related problems and ways of resolving them, knowledge on pharmacotherapy of arthritis and hypertension. Data was analysed with descriptive analysis using statistical package for the social sciences (SPSS) version 16 for windows.Results: a total of 165 questionnaires were distributed with 124 properly filled and returned giving a response rate of 75.2%. Majority (64.5%) were females, the mean year of graduation of the respondents was 9.12years and 50.8% practice as Community pharmacists. Common PC activities include; counseling (84.4%), monitoring of patients B.P (53.3%), blood glucose measurement (53.3%), monitoring patient's using available laboratory results (44.3%). Majority (85.5%) resolved side effects complaint from patients by reassuring the patients that side effect will subside as therapy continues while 77.4% took full medication history and 65.3% consulted physician for a change of medication. Majority (88.7%) agreed that they encountered prescriptions containing NSAIDs for arthritis in their practice. Good numbers of the respondents had no idea of what measure to take when a patient diagnosed of arthritis and hypertension was prescribed NSAIDs if the blood pressure was control or when it was uncontrolled. Few 16.9% and 8.9% indicated they monitored B.P of such patients with controlled or uncontrolled B.P, while more than half (55.6%) of the respondent indicated that COX2 inhibitor are safer in hypertension as compared to COX1 and that NSAIDs effects on hypertension is dose dependent. Most(77.4%) of them indicated that NASIDs can exacerbate hypertension while 55.6% indicated that NSAIDs can induce hypertension. Conclusion: Respondents' knowledge of the pharmacotherapy with antihypertensives and NSAIDs use in patients with hypertension co-morbid arthritis need to be improved. Good and well established pharmacist physician relationship, refresher courses and remuneration of pharmacist for the PC services will also improve services provided by the pharmacist

Connective Tissue Diseases: Challenges of management among Nigerians

Contrary to previous assumptions, Connective Tissue Diseases (CTD) are increasingly being reported among Africans, Nigerians inclusive. The clinical presentations are mostly similar to patterns described in other parts of the world, though with few differences. The management is patterned, as universally done, but drugs such as the biologics are infrequently used because of the prohibitive cost. The challenges of management arise mainly from a poor understanding of the spectrum, presentation and management of CTD as well as the non-affordability of the required drugs. The superstitious belief that these poorly-understood conditions are due to 'spiritual attacks' further compounds the problem of late presentation and sometimes accounts for the high morbidity and mortality. Continuing training of rheumatologists will enhance the understanding and management of rheumatological diseases

Psoriatic Arthritis: An Assessment of Clinical; Biochemical and Radiological Features in a Single-Centre South African Cohort

BACKGROUND:Although psoriatic arthritis (PsA) is a well-documented clinical entity; epidemiological; clinical and radiological studies of South African (SA) patients are scarce.OBJECTIVES:To assess clinical; biochemical and radiological features in a single-centre SA cohort.METHODS: We conducted a prospective assessment of the clinical; biochemical and radiological features of 384 consecutive patients with PsA seen at the rheumatology clinic at Prince Mshiyeni Memorial Hospital; Durban; SA; between January 2007 and December 2013. Patients were assessed at enrolment and 6 months after enrolment. They were classified into five groups as described by Moll and Wright; being entered into the group that best described the clinical manifestations. Clinicopathological characteristics recorded at enrolment were age at the time of examination; racial background; personal and family medical history; age and symptoms at the onset of PsA; pattern of joint involvement; joint pain; and the relationship between joint pain and the onset of PsA.RESULTS:Of the patients; 59.1% had a polyarticular presentation indistinguishable from rheumatoid arthritis; 19.0% had distal interphalangeal involvement; 9.1% had spondyloarthropathy; 11.9% had oligoarthritis and 0.9% had arthritis mutilans. The epidemiological trends (male/female ratio 1.45:1; mean age at onset of arthritis 50.2 (standard deviation 11.8) years; female preponderance in the polyarticular group and male preponderance in the spondyloarthropathy and oligoarticular groups) were similar to trends published elsewhere. A notable characteristic of our cohort was the complete absence of black South Africans with PsA.CONCLUSIONS:The complete absence of black South Africans with PsA is interesting. We anticipate that our findings will prompt genetic studies to isolate both protective and susceptibility genes for further elucidating PsA

Infliximab; an Anti-TNF-Alpha Agent; Improves Left Atrial Abnormalities in Patients with Rheumatoid Arthritis: Preliminary Results : Cardiovascular Topic

Background : Rheumatoid arthritis (RA) is associated with increased cardiovascular morbidity and mortality. In the current prospective study; we addressed the impact of RA on left atrial (LA) function and electrical remodelling. Further; we tried to demonstrate the effects of infliximab; an anti-TNF-alpha agent; on echocardiographical LA abnormality in RA patients with preserved left ventricular (LV) ejection fraction. Methods: We compared 38 female RA patients without clinical evidence of heart disease and 30 female controls without RA and clinical evidence of heart disease. Further; we compared RA patients receiving infliximab and increasing doses of prednisolone over a three-month period. At baseline and post treatment; this study assessed (1) LA and LV parameters using conventional and speckle tracking echocardiography (STE); and (2) electrocardiographic P-wave changes. Results: The values of C-reactive protein (CRP); isovolumic relaxation time (IVRT); A wave; and deceleration time (DT) were significantly higher in RA patients compared to the control group (p 0.05); whereas E/E' and E/A values were found to be lower (p 0.05) in RA patients. E/E' values were lower in prednisolone- compared to infliximab-treated patients (p 0.05). After three months of infliximab and prednisolone treatment; CRP and disease activity score (DAS 28) values decreased in both groups (p 0.05); and Duke activity status index (DASI) increased (p 0.05). Maximal left atrial volume index (LAVImax); pre-contraction left atrial volume index (LAVIpreA) and maximum P wave (Pmax) of the RA patients were higher compared to the control group (p 0.05); whereas LA global strain was found to be lower (p 0.05). There was no difference in Pmax values between groups before and after the treatment period. E/E'; LAVImax and LAVIpreA values of infliximab-treated patients decreased and LA global strain increased after three months of therapy compared to baseline (p 0.05). At baseline in both treatment groups; E/E' and LA global late diastolic strain rate were lower in prednisolone- compared to infliximab-treated patients (p 0.05). Conclusion: There was echocardiographic LA abnormality in these RA patients. In this patient group there was also a meaningful increase in maximum P wave assessed by

Rheumatoid Arthritis Disease Progression in a South African Cohort:Bayesian Multistate Chronic Disease; Dynamic Modelling

The primary goal of this article is to model the forces (rates) of recovery; relapse and mortality for patients started on rheumatoid arthritis (RA) standard treatment and the effect of adjusting for body functionality. A four state model inclusive of the absorbing state death was fit to these data. A consequence of an improved health is better body functionality; which was measured using a health assessment disability index (HAQ-DI). The modelling was done using a member of the generalised additive mixed models (GAMMs) which utilise nonparametric functions adjusting for over-dispersion and correlation. Based on the results we advocate that patients should be treated until the disease activity score is in remission or lowest possible to enable greater physical functionality whilst alleviating disability and mortality due to RA

Exercise Prescription in the Management of Rheumatoid Arthritis

"Background: Over the last few years; the types of exercises prescribed for patients with rheumatoid arthritis (RA) have changed. There is also increasing knowledge on the physical status and physical activity levels of these patients. This article aims to give an overview of the physical status; physical activity levels and appropriate exercise prescription for patients with RA. Method: A literature search was conducted of scientific journals and text; including Medline and PubMed (1980-2012). Literature was selected for its in-depth data and well researched information. Key search terms included ""RA and exercise therapy""; as well as ""physical activity levels and physical status of patients with RA"". Results: The literature indicated that RA has a major impact on physical and psychological health. Over the past decade; there has been growing evidence of the health benefits of physical activity for patients with RA. Despite this evidence; patients with RA are less physically active than the general population. The types of exercises prescribed for patients with RA have changed from the traditionally prescribed isometric and range-of-motion exercises. However; proper choice and appropriate utilisation of exercise is essential in order to provide a therapeutic effect. Conclusion: Although pharmacological interventions have largely improved RA management; exercise therapy remains an important part of treatment. Despite the known benefits of physical activity and exercise; patients with RA are less physically active than the general population."

Consultation Outcomes for Musculoskeletal Conditions at two Community Health Centres in Cape Town

"Objectives: To compare the proportion of patients with documented diagnoses and management plans when they presented with musculoskeletal complaints at two community health centres (CHCs) using two models of care: one with a rheumatology outreach service and the other with none. Secondly; to describe the profile of patients with rheumatoid arthritis (RA) who attended the CHC with the outreach service. Design: Cross-sectional. Subjects: A group of 59 patients at each CHC were compared regarding engagement of their musculoskeletal complaints by doctors and clinical nurse practitioners (CNPs). Secondly; 24 RA patients who attended Heideveld CHC were profiled. Results: A comparison of the ""overall engagement"" between the two CHCs [risk difference (RD) -0.06; 95 confidence interval (CI): -0.17-0.05; odds ratio (OR) 0.79; 95 CI: 0.51-1.24; chi-square 0.82; p-value 0.36] was not significantly different. Comparison between doctors (RD -0.05; 95 CI: -0.05-0.08; OR 0.80; 95 CI: 0.46-1.40; chi-square 0.41; p-value 0.52) was also not significantly different. The comparison between the CNPs at the two CHCs was statistically significant (RD 0.30; 95 CI: 0.14-0.45; OR 8.37; 95 CI: 1.05-66.60; Fisher's exact test 0.01); but the CI around OR was large. Patients with RA had a mean age of 60 years; an average of two co-morbidities and an average of three annual clinic visits. Eighty-three per cent resided in the drainage area of the clinic. Conclusion: There was no significant difference in engagement between the CHCs. The potential that CNPs seemed to show of being positively influenced by the outreach service should be further researched. Patients with RA had comorbidities that required management at primary healthcare level."

Reliability of Anti-Cyclic Citrullinated Peptide Antibodies (Anti-CCP) for the Diagnosis of Rheumatoid Arthritis as Compared to that of Rheumatoid Factor Test

Background: Rheumatoid factor (RF) is commonly used for diagnosis of rheumatoid arthritis (RA). RF positivity is nonspecific for diagnosis of RA because it can be detected in 3-5of normal individuals. Recent studies indicated that anti-Cyclic-Citrullinated protein (Anti-CCP) antibodies are more specific to diagnose rheumatoid arthritis and have the capacity to diagnose RA in early stages of the disease; or even before the onset of the disease when the arthritis is undifferentiated. Objectives: This study has been conducted to assess the reliability and specificity of anti- CCP in the Sudanese as an indicator of RA. Patients and methods: In this study; patients were diagnosed as RA patients according to the American College of Rheumatology (ACR) criteria. To get further insight on the sensitivity and specificity of Anti-CCP test as compared to that of RF test in the diagnosis of RA; analysis of samples obtained was perform negative rate reached 21.2. Although anti-CCP test is more accurate compared with RF; it may sometimes fail to diagnose some patients with rheumatoid antibodies were scarce

Superior Detection of Pathogens in Synovial Fluid by the Bactec 9240 Peds Plus/F System Compared to the Conventional Agar-based Culture Method

To improve culture yield in cases of possible septic arthritis; we compared culture of joint fluid aspirates on conventional agar-based media to culture in Bactec 9240 Peds/Plus F blood culture bottles with and without the addition of fastidious organism supplement (FOS). Over a period of 21 months; we analysed 123 synovial fluid samples and isolated 20 pathogens. The Bactec methods proved superior by yielding more pathogens than the conventional culture method (p=0.074). However; this method also yielded more contaminants within the first three days of incubation (p=0.027). All contaminants detected after three days of incubation were the result of overgrowth on conventional method agar plates. The Bactec methods provided clinicians with a positive pathogen result one day earlier than the conventional counterpart (p=0.001). Four isolates of Neisseria gonorrhoeae were only cultured with the Bactec method. No significant benefit was demonstrated by supplementing blood culture bottles with FOS. We recommend that whenever infection by fastidious organisms is suspected; synovial fluid aspirates should be cultured using automated blood culture systems to increase the culture yield and to decrease the time to detection

Superior Detection of Pathogens in Synovial Fluid by the Bactec 9240 Peds Plus/F System Compared to the Conventional Agar-Based Culture Method

Abstract:To improve culture yield in cases of possible septic arthritis; we compared culture of joint fluid aspirates on conventional agar-based media to culture in Bactec 9240 Peds/Plus F blood culture bottles with and without the addition of fastidious organism supplement (FOS). Over a period of 21 months; we analysed 123 synovial fluid samples and isolated 20 pathogens. The Bactec methods proved superior by yielding more pathogens than the conventional culture method (p=0.074). However; this method also yielded more contaminants within the first three days of incubation (p=0.027). All contaminants detected after three days of incubation were the result of overgrowth on conventional method agar plates. The Bactec methods provided clinicians with a positive pathogen result one day earlier than the conventional counterpart (p=0.001). Four isolates of Neisseria gonorrhoeae were only cultured with the Bactec method. No significant benefit was demonstrated by supplementing blood culture bottles with FOS. We recommend that whenever infection by fastidious organisms is suspected; synovial fluid aspirates should be cultured using automated blood culture systems to increase the culture yield and to decrease the time to detection

Outcome of Management of Non-Gonococcal Septic Arthritis at National Orthopaedic Hospital; Enugu; Nigeria

Septic arthritis is an acute bacterial infection of a synovial joint. It is an orthopaedic emergency that can lead to morbidity or mortality if not properly treated. The fundamental issues in the management of septic arthritis include the duration of antibiotic therapy; the mode of joint drainage and the role of physiotherapy. There is paucity of local data on septic arthritis in Nigeria. The study was carried out at the National Orthopaedic Hospital; Enugu; a regional trauma and orthopaedic center with wide catchments area covering at least three geopolitical zones of Nigeria.The objective of the study is to describe the pattern and distribution of non-gonococcal septic arthritis; the causative organisms; and the outcome of management of this condition at Enugu; Nigeria and make recommendations on the antibiotic therapy. A retrospective study of all the patients that presented at the National Orthopaedic Hospital Enugu with Non-gonococcal septic arthritis between January 1997 and December; 2006 was done. The patient's case notes were retrieved from the Medical Record Department. Information extracted and analyzed included demographic data; joints affected; cultured organisms; antibiotic sensitivity pattern; duration of parenteral and oral antibiotics therapy; complications and follow-up period. Patients with incomplete records; immunecompromised patients and those with subjacent osteomyelitis were excluded from the study. Forty-three patients were seen within the period and 40 had analyzable data. The age range was 1 month to 39 years; with a mean age of 10.2 years. Twenty-one patients (52.5) were males and 19 (47.5) were females. The hip joint was the most commonly affected (47.5). Staphylococcus aureus was the most common organism (50); followed by Coliforms (42.5). Most patients (75) had parenteral antibiotics for 3-5 days; while 77.5of patients received oral antibiotics for 2-4 weeks. All the patients had arthrotomy and joint irrigation within 48 hours of admission. Complications were recorded in 11 patients (27.5). Fixed flexion deformity was the commonest complication (17.5). No mortality was recorded. Septic arthritis is an orthopaedic emergency. Early diagnosis and prompt treatment with appropriate antibiotics and surgical drainage are the keys to a successful outcome. In our environment (Enugu); the coliforms are competing favourably with staphylococcus aureus as causative agents of septic arthritis. Short term parenteral antibiotics of 3 - 5 days seems to be as effective as the 1 - 2 weeks therapy in the non-immune compromised patients and in cases not complicated by juxtarticular osteomyelitis or presence of prosthetic implants

Review of the Cardiovascular Safety of COXIBs Compared to NSAIDS : Review Article

There is no doubt that NSAiDs and CoXiBS are the mainstay for managing pain and inflammation in arthritis. overall; at therapeutically equivalent doses; both NSAiDs and CoXiBs provide equivalent analgesic and anti-inflammatory efficacy. However; the gastrointestinal risk associated with NSAiDs is considerable. More recently; the cardiovascular risk associated with NSAiDs and CoXiBs has become a concern. Most patients; particularly the young; can benefit from NSAiDs without the risk of serious adverse gastrointestinal or cardiovascular events. However; patients with a previous history of serious gastrointestinal complications and the elderly; who could be at risk; do require alternatives. CoXiBs have significant benefits over NSAiDs in reducing the incidence of serious gastrointestinal complications (perforations; ulcers and gastric bleeding). Currently two oral CoXiBs are available; celecoxib and lumiracoxib; and one parenteral CoXiB; parecoxib. Celecoxib has been on the market for longer and has the largest body of evidence. The older NSAiDs; such as meloxicam; with preferential CoX-2 inhibition do not have good long-term evidence of reducing the incidence of serious gastrointestinal complications. However; these agents do have evidence of tolerability; ie; reducing the less-serious gastrointestinal effects; mainly dyspepsia. The South African Rheumatoid Arthritis Association's guidelines; amended in November 2005 recommend CoXiBs for elderly patients ( 60 years) with previous gastropathy and those on warfarin and / or corticosteroids; providing they do not have contra-indications. However; caution is advised when prescribing CoXiBs for patients with risk factors for heart disease. These recommendations are very similar to those made by the National institute for Clinical Excellence (NiCE). in addition; it should be noted that for those patients without any cardiovascular complications but with gastrointestinal risk factors or on aspirin; it may be necessary to add a proton pump inhibitor (PPi). PPis; however; provide little benefit for bleeding and ulceration of the lower intestine. one consequence of this low-grade bleeding is anaemia and a general feeling of malaise in patients with rheumatic disease. Current evidence suggests that CoXiBs such as rofecoxib and celecoxib do not increase small intestinal permeability and that celecoxib does not cause lower intestinal bleeding and may be of benefit to those patients with lower gastrointestinal complications. In patients at risk for cardiovascular complications; both NSAiDs and CoXiBs have been shown to increase the risk of myocardial infarctions (Mi); hypertension and heart failure. Studies comparing CoXiBs and non-specific NSAiDs should; however; be interpreted with caution. one needs to take into account the underlying baseline cardiovascular risk of the populations being compared. CoXiBs appear to be prescribed preferentially to patients who were at an increased risk of cardiovascular events compared with patients prescribed non-specific NSAiDs. When the overall risk of cardiovascular complications is relatively low and an anti-inflammatory agent is required; choice because of its lower cardiovascular toxicity potential compared to NSAiDs and other CoXiBs

Mini Review - Chloroquine has not Disappeared

Chloroquine (CHQ); an antimalarial; is also used as an anti-inflammatory drug for systemic lupus erythematosus and rheumatoid arthritis (RA). Hydroxychloroquine (HCQ) reduces the frequency of organ involvement and disease flares; and relieves skin and joint symptoms. CHQ reduces the immunologically-mediated inflammation of the joints. HCQ and combination therapies have a significant benefit on synovitis; pain and physical disability on RA. We advocate the investment of resistance Plasmodium prevalence determina-tions in countries beset by malaria; and to match thereafter the quantity of persons administered CHQ. Follow-up investigations are essential to diagnose and prevent visual damage

Muscle strengthening and rheumatoid arthritis

Rheumatoid arthritis often cripples its victims. Signs and symptoms of the disease are inflammation of joints; pain; tenderness weakness and atrophy of muscles. The cause is not fully understood. The two forms that exist are the acute and chronic. Literature reveals that while the acute form would respond more to drugs and heat therapy; the chronic form responds more to a programme of muscle strengthening through resistive exercises isotonic and isometric. The physical therapist is advised to pay closer attention to ways and means of designing resistive strengthening programmes for those patients suffering from the chronic form of rheumatoid arthritis