Risk of Cardiovascular disease in patients of Rheumatoid Arthritis (RA) presenting in a tertiary care hospital of Pakistan

Objective: To assess the cardio vascular disease [CVD] risk using framingham risk score and frequency of other co-morbidities associated with rheumatoid arthritis [RA]

Study Design: Cross sectional descriptive study

Place and Duration of Study: Rheumatology department of Fauji foundation hospital [FFH], Rawalpindi. The duration of the study was six months, from Nov 2017 to Apr 2018

Material and Methods: RA Patients between 40 to 80 years of age were selected from rheumatology outpatient department [OPD] at Fauji Foundation Hospital [FFH] Rawalpindi. After 12 hours of fasting, venous blood was taken for total serum cholesterol [TC], triglycerides [TG], low density lipoproteins [LDL], high density lipoproteins [HDL] and ESR [mm/1st hour]. Framingham risk score was calculated using online calculator and it was multiplied by a factor 1.5 as per European League against Rheumatism [EULAR] recommendations to find the correct cardiovascular risk. This gave us 10 year cardiovascular risk in each RA patient

Results: The study included 205 RA patients with a mean age [in years] of 53.12 +/- 10.60. Mean duration of disease [years] was 9.71 +/- 7.1. The commonest comorbidity in RA patients was hypertension found in 82 [40 percent] patients. 100 [48.78 percent] patients were overweight with mean body mass index [BMI] of 25.35 +/- 4.96. Diabetes was found in 38 [18.5 percent] patients. 51 [24.87 percent] patients had high low density lipoprotein [LDL] with mean LDL of 116.75 +/- 29.50 [mg/dL] whereas 88 [42.92 percent] patients had either borderline high or high total cholesterol with mean of 194.64 +/- 30.62 [mg/dL]. 104 [50.73 percent] patients had borderline high triglyceride levels with a mean of 166.48 +/- 63.03 [mg/dL]. 25 [12.2 percent] patients were smokers. 24[11.7 percent] patients had dexa scan proven osteoporosis [ T score <-2.5]. Amongst all, 54 [26.3 percent] patients had low cardiovascular risk, 93 [45.4 percent] had moderate risk and 58 [28.3 percent] had high risk according to Framingham risk score

Conclusion: RA patients have high cardiovascular risk. Other co-morbidities like hypertension, high BMI, diabetes, dyslipidemia, smoking and osteoporosis add to the morbidity and mortality of these patients

Are we missing the diagnosis of depression in patients with rheumatoid arthritis at a tertiary care facility?

Objectives: To determine if we are missing clinical depression in patients with Rheumatoid Arthritis and its relationship with functional disability and level of formal education in such patients

Methods: The data for this cross-sectional, analytical study was gathered from May 2015 till December 2015 and comprised of 128 with Rheumatoid arthritis diagnosed according to ACR/EULAR 2010 criteria. The study was conducted at Fauji Foundation Hospital Rawalpindi. Functional status was assessed with Modified Health Assessment Questionnaire [mHAQ] and Beck's Depression Inventory [BDI] was used for evaluation of symptoms of depression. The relation between depression, functional disability and educational status was established using Pearson correlation coefficient

Results: The study included 128 patients with no previous diagnosis of depression. 122 [95.3%] were females and 6 [4.7%] were males. The mean age was 51.75 +/- 9.25 years. Mean duration of disease was 8.95 +/- 7.1 years. According to this study, the diagnosis of clinical depression was missed in 47.7% of patients with Rheumatoid Arthritis who had been under regular follow up at a tertiary care facility. About 18% were keen to seek professional help for depressive symptoms while 62.6% had functional disability [mild - severe]. There is a positive correlation with BDI [Pearson's correlation +1] and functional disability. No correlation could be established between level of education and depression as out of 79 [61.7%] patients with no basic education, 45.5% had depression. In remaining 49 [38.2%] patients, with some formal education, 51.3% had clinical depression

Conclusion: Almost half of the patients with Rheumatoid Arthritis coming to a tertiary care set up had clinical depression but were never diagnosed or referred to a Psychiatrist. There is a positive correlation between depression and functional disability; however no statistically significant correlation could be established with the level of formal education. The study further emphasizes the importance of early recognition and swift referral of such patients to a psychiatrist since it is known to improve both treatment outcomes and functional status

Effects of timing of prednisolone on the duration of early morning stiffness, pain and disease activity score [das-28] in patients with rheumatoid arthritis

Objective: To determine the effects of timing of prednisolone on duration of early morning stiffness, pain score, number of swollen and tender joints, erythrocyte sedimentation rate [ESR] and disease activity score 28 [DAS-28] in joints in patients with rheumatoid arthritis. Study Design: It was quasi experimental study. Place and Duration of Study: This study was conducted in the department of rheumatology Fauji Foundation Hospital Rawalpindi over a period of 3 months, from Dec 2015 to Feb 2016

Material and Methods: Total sample size of 85 was calculated by using non probability consecutive sampling technique. Patients with established rheumatoid arthritis diagnosed on the basis of ACR 1987 criteria were included in the study. All these patients had a disease duration of minimum 6 months and were on disease modifying anti rheumatic drugs and were taking

Results: A total of 85 patients of established rheumatoid arthritis were included in the study. All patients were female with a mean duration of disease of 7.87 +/- 6.41 years. The mean age of patients was 49.39 +/- 10.24 years. Mean of pain score, duration of morning stiffness, DAS-28, number of tender and swollen joint count, and ESR was decreased in patients who took prednisolone at 10:00 pm and had significant statistical difference [p-value <0.001]

Conclusions: Administration of low dose of prednisolone at night has good effects on duration of early morning stiffness, pain scores, number of swollen and tender joints, ESR and DAS-28

Safety of Methotrexate and Leflunomide as a combination therapy in patients of rheumatoid arthritis

Objective: To study the safety profile of MTX+LEF combination in patients with active RA at 03 and 06 months

Study Design: Quasi-experimental study

Place and Duration of Study: Rheumatology department, Fauji Foundation Hospital Rawalpindi, from Jun 2015 to Dec 2015

Material and Methods: This quasi-experimental study was conducted at Rheumatology department, Fauji Foundation Hospital, Rawalpindi. Seventy two patients who had an active RA despite optimal dose [20- 25mg/week] of MTX were enrolled and leflunomide 20mg/day was added. Patients underwent clinical and laboratory review at 0, 1, 3 and 6 months to note any adverse effects

Results: Seventy two patients were enrolled with a mean age [years] +/- SD of 51.5 +/- 9.1 and a mean duration of disease [years] of 8.25 +/- 6.1. Patients had active disease at baseline with a mean disease activity score [DAS28] of 6.2 +/- 0.7. At 6 months the most frequent side effects [mostly mild]; were abdominal pain and nausea. Fifty Seven patients [79.1%] continued with the combination therapy. Only 3 patients stopped the treatment temporarily [due to raised ALT and vomiting]. Twelve patients discontinued treatment due to diarrhea, severe oral ulcers, markedly raised ALT; [Each affecting 2 patients] and severe vomiting, abscess, MTX Induced pneumonitis, severe chest infection [each affecting 1 patient]

Conclusion: MTX + LEF combination is safe to use in RA patients if vigilant clinical and laboratory monitoring is ensured

Healthy lookig hospital nurses showing vitamin D deficiency: correlation of vitamin D levels with their levels of parathyroid hormone and bone turnover markers

To evaluate the correlation of low vitamin D levels with parathyroid hormone [PTH] levels and bone turn over markers among apparently healthy hospital nurses. Screening was done on 50 recruited healthy female nursing staff, aged between 18 to 35 years, for vitamin D levels. Among them 31 were found to be deficient in vitamin D. These 31 nurses were selected for further evaluation in trance. Their vitamin D levels were calculated by using the electrochemiluminescence immunoassay. Blood samples were drawn to estimate serum PTH levels accordingly. Samples were also collected from these recruited subjects to evaluate their bone turn over markers, including, osteocalcin, procollagen type 1 N propeptide and Beta-Crosslaps. Out of 50 subjects, 31 subjects were found to have Vitamin D levels below 50 nmol/l. Out of these 31 subjects, 13 subjects, 41.9%, showed vitamin D levels below 20 nmol/l. Among these 13 subjects, all had significantly raised PTH levels [p-value: <0.001, r-value: -0.781]. In rest of all the subjects, including those having Vitamin D levels above 20nmol/l, inordinately, PTH levels were normal. No reciprocity was found between low Vitamin D and raised M'H levels with bone turnover markers, except with PlNP [r-value 0.022]. PTH levels show a steep augmentation in serum, when vitamin D levels ht the trough below 20 nmol/l. These are the subjects who should be treated prior to the development of complications of bone resorption. Moreover we could not find any significant correlation of Vitamin D and PTH with any bone turnover marker except PlNP

Haemodialysis vascular access practice patterns in north Pakistan

Mortality and morbidity rates in patients on haemodialysis vary among different countries widely due to variation in vascular access practices. Documented evidence of patterns and practices of various vascular access modalities in our population is scarce to allow for development of local guidelines or formulating steps to encourage adoption of international guidelines in Pakistani healthcare setup. To assess Vascular Access practices for haemodialysis patients in five dialysis facilities of Northern Pakistan. Cross sectional study. This study was carried out at five dialysis facilities in three cities of Northern Pakistan over a period of one year from March 2011 to March 2012. This cross sectional survey was completed by interviewing 536 end stage renal disease patients between 18 to 70 years of age over a period of one year. Duration of dialysis, types of access, current state and past history of vascular access were recorded and compared with International guidelines. Commonest 'current vascular access' was found to be AV fistula in 317 out of 536 patients [almost 60%] and the most common mode of 'first Vascular Access' [i.e. vascular access first used for haemodialysis] was catheter [83%]. Amongst patients who had dialysis during last eight months, 76.27% were still being dialysed via percutaneous catheters while this figure is less than 34% in Europe. Although the initial mode of dialysis in most cases is a line yet, majority of patients are dialyzed through native fistula. Need for a pre-emptive fistula is required to have superior longevity and fewer complications in haemodialysis patients

Knowledge, attitude and practices of healthcare providers towards deep vein thrombosis prophylaxis in five teaching hospitals of Rawalpindi

Prophylaxis of deep vein thrombosis [DVT] is underutilised in Pakistan. This crosssectional survey was designed to evaluate knowledge, attitude and practices of healthcare providers towards DVT prophylaxis in teaching hospitals in and around Rawalpindi. Knowledge, attitude and practices was assessed by a 12-item questionnaire filled-in by healthcare providers in five teaching hospitals. Eleven out of 12 questions were multiple-choice type and one was open ended. One hundred-sixty-nine, out of 200 questionnaires were returned and were analysed. Total 43.2% of the respondents were house-officers. Although 98.8% agreed that DVT prophylaxis is clinically important, but 39.4% actually prescribed it themselves. Out of these, only 10.3% respondents did it routinely. Low molecular weight heparin [LMWH] was the preferred prophylaxis used [36.7%]. Most of the respondents underestimated the prevalence and consequences of DVT in hospitalised patients. Knowledge and practices of healthcare providers about DVT prophylaxis in hospitalised patients is less than ideal. Hospitals need to develop their own guidelines for DVT prophylaxis.