Aseptic pyomyositis in rheumatoid arthritis treated with corticosteroid and DMARDs.

Pyomyositis is a purulent infection of skeletal muscle that is mostly observed in tropical countries. Aseptic pyomyositis is a rare, potentially life-threatening disorder characterized by the formation of sterile pus in muscle. We present a case of 53-years old female, diagnosed case of seropositive rheumatoid arthritis, presented with pain and swelling of the right calf muscle for 2 weeks. There was no history of fever, cough, skin erythema, no history of prolonged standing or immobility, or fetal loss. The diagnosis was made as rheumatoid arthritis with autoimmune pyomyositis, and the patient was treated with oral prednisolone 1mg/kg body weight in tapering dose, cs DMARDS, (methotrexate 25 mg once a week, and leflunomide 20mg daily hydroxychloroquine 200 mg daily orally) and another supportive treatment along with surgical drainage of pus was done. There was complete resolution of the initial lesion and remission of the primary disease in 3 months.

Late Onset Dipeptidyl Peptidase -4 Inhibitor Associated Seronegative Rheumatoid Arthritis.

Drug-induced arthritis is not an uncommon scenario. DPP-4 inhibitors could potentially cause adverse-events mediated by cytokine-induced inflammation leading to arthritis. The activity of the DPP-4 enzyme could be inversely related to the development of rheumatoid arthritis, explaining the increased inflammatory activity with its inhibition by a drug. We discuss a 72-year-old gentleman with twenty-three years of history of type 2 diabetes mellitus, who after 6 years of treatment with a DPP-4 inhibitor, developed features of inflammatory arthritis and fulfilled the criteria for seronegative rheumatoid; which eventually subsided after stopping the drug. Keywords: DDP-4 inhibitor; diabetes mellitus; Nepal; rheumatoid arthritis; seronegative.

A Study of Metabolic Parameters in Patients with Gout: A Single Center Study from Nepal.

BACKGROUND AND AIMS: To study the prevalence of deranged metabolic parameters in patients with gout. METHODS: This was a prospective, cross-sectional observational study conducted at a tertiary level rheumatology center in Nepal. Patients over 18 years and diagnosed as gout using the ACR/EULAR 2015 classification criteria were included in the study. Known cases of chronic kidney disease, liver disease and heart diseases were excluded. Baseline demographic data along with records of weight, waist circumference, lipid profile, glucose profile, blood pressure measurement, serum uric acid level and inflammatory markers were taken. Diagnosis of metabolic syndrome (MS) was made according to the National Cholesterol Education Program criteria. Approval was obtained from the ethical review board of the National Center for Rheumatic Diseases. RESULTS: A total of 523 patients with gout were enrolled in the study, out of which 97.0% were male. The mean age at diagnosis was 49.1±12.8 years. Most of the patients were overweight with a mean BMI of 27.0±3.6 kg/m2. About 8.1% had preexisting diabetes mellitus, 24.6% had hypertension, 5.1% had hypothyroidism and 45.1% had dyslipidemia. Patients fulfilling 2 out of 5 criteria of MS were 60.6% whereas 30.6% fulfilled 3 out of 5 criteria. CONCLUSION: Gout was commonly observed in middle-aged men. The prevalence of metabolic syndrome and its components was high in patients with gout. Management of gout should also include screening and management of the metabolic syndrome.

Clinico-demographic Profile of Undifferentiated Inflammatory Arthritis Patients.

BACKGROUND: Undifferentiated inflammatory arthritis is a group of inflammatory joint diseases that do not fulfil the classification criteria for any other rheumatic or connective tissue disorders. This study aims to describe the clinical, demographic and serological features of undifferentiated inflammatory arthritis cases presenting at a tertiary level rheumatology centre from Nepal. METHODS: A descriptive cross-sectional study conducted at National Centre for Rheumatic Diseases, Kathmandu, Nepal which represents a midterm analysis of the undifferentiated inflammatory arthritis registry maintained at the centre. Patients more than 18 years of age, who consented for the study having least one swollen or tender joint were enrolled. Ethical approval was obtained from Nepal Health Research Council. RESULTS: A total of 1120 patients were enrolled in the study out of which 941 (84%) were females. The mean age at diagnosis was 46.0±12.8 years and most of them were in overweight range (mean BMI: 27.0±5.8) with 818 (73%) patients having BMI more than 24.0. Patients mostly had low disease activity at presentation (DAS 28 score of 2.5±0.8). Other markers of inflammation and patient reported outcome measures (health assessment questionnaire, patient global assessment and visual analogue scale) were also in the moderate range. Seropositivity for anti-citrullinated peptides and anti-nuclear antibodies was seen in 5 (0.45%) and 43 (3.8%) patients respectively. Majority of patients were non-smokers (77%). Inflammatory arthritis on musculoskeletal ultrasonography was seen in 638 (57%). CONCLUSIONS: Undifferentiated inflammatory arthritis was more common in overweight females. Serological markers and smoking status are not common features in these patients.

Knowledge, Attitudes, and Practice Regarding COVID-19 among Patients with Musculoskeletal and Rheumatic Diseases in Nepal: A Web-Based Cross-Sectional Study.

PURPOSE: The global health crisis created by coronavirus disease in 2019, ie, COVID-19, is of serious concern to rheumatologists. The relationship of rheumatic diseases, their therapies, and COVID-19 with multiple genuine and malicious information available online can influence the knowledge and attitudes of rheumatic patients. This Google Forms study was conducted to understand the knowledge, attitudes, and practices of rheumatology patients with regard to COVID-19 in Nepal. METHODS: A web-based cross-sectional study was conducted among patients with rheumatic diseases. A modified version of a questionnaire was used after consent had been obtained. It was then translated into Nepali for comprehensibility. The final questionnaire contained a total of 29 questions: six on demographic parameters and twelve, five, and six on knowledge, attitudes and practice, respectively. Simple descriptive statistics were used to describe the positive responses in each domain. Logistic regression analysis was done to observe demographic variables associated with knowledge, attitudes, and practice. RESULTS: Among 380 participants, 63.2% were female, the majority (42.1%) aged 18-29 years, and all were literate. Most were aware of the clinical features of COVID-19 (91.6%), 71.5% had positive attitudes toward its control, some (31.5%) thought that they had a greater chance of contracting COVID-19 than others, and 18.9% believed that antirheumatic medications could increase their susceptibility to infection. A majority (>94.7%) of them practiced preventive measures. CONCLUSION: Patients with rheumatic diseases were aware of the general clinical features, routes of transmission, and general preventive measures regarding COVID-19 and did not significantly change their treatment practices.

Translation, validation and cross-cultural adaptation of the Revised Fibromyalgia Impact Questionnaire (FIQR) in Nepali language.

OBJECTIVE: To translate, cross-culturally adapt and test the psychometric properties of the Revised Fibromyalgia Impact Questionnaire (FIQR) in Nepali language (Nepali FIQR). METHODS: The translation was performed following the methodological standards described by Beaton. Comprehensibility testing of the preliminary version was done in 40 fibromyalgia patients, and a pre-final version was prepared after making changes in the original version to maintain the equivalence with the target version. Psychometric testing was done in another group of 130 fibromyalgia patients to test for content validity and reliability. Construct validity was tested with visual analog score (VAS) for pain and Short Form (SF)-36. RESULTS: Nepali FIQR was comprehensible to 92.5% patients. The internal consistency was also acceptable with Cronbach's alpha of 0.900, 0.714 and 0.863 for function, overall and symptoms domain, respectively. Construct validity was also acceptable with a moderate correlation between Nepali FIQR and VAS and SF-36. Test-retest reliability of the total Nepali FIQR and of each item were acceptable with intraclass correlation coefficient (ICC) of >0.7 in all items except for question 1 of function domain (ICC: 0.65). CONCLUSIONS: Nepali FIQR is a comprehensible, reliable and valid tool for evaluation of the functional status of Nepalese patients with fibromyalgia and should be implemented in routine clinical care and research settings.

Efficacy of Vitamin E in Methotrexate-Induced Hepatotoxicity in Rheumatoid Arthritis: An Open-Label Case-Control Study.

OBJECTIVE: To examine the efficacy of vitamin E in methotrexate- (MTX-) induced transaminitis in patients with rheumatoid arthritis (RA). METHODS: A case-control study was conducted at a tertiary rheumatology center for 12 months. Patients with RA on MTX and deranged aminotransferases were included. Patients with previous liver diseases, baseline transaminitis before methotrexate initiation, alcohol intake, muscle diseases, under hepatotoxic drugs, and aminotransferases > 3 times the upper normal limit were excluded. The patients were divided into treatment (vitamin E 400 mg bid for 3 months) and control groups (no vitamin E) using a random number table. The dose of MTX was unaltered. Follow-up was done after 3 and 6 months. Independent t-test was done to compare means of two groups. Paired t-test was done to compare differences in mean. RESULTS: Among 230 patients, 86.5% were female with a mean BMI of 25.9 ± 4.5 kg/m2. In the treatment group, SGPT and SGOT at baseline were 73.1 ± 20.4 and 60.2 ± 24.5 IU/L, respectively; at 3-month follow-up 44.6 ± 34.2 and 38.3 ± 20.8 IU/L, respectively; and at 6-month follow-up 40.4 ± 35.7 and 34.2 ± 21.9 IU/L, respectively. In the control group, SGPT and SGOT at baseline were 63.4 ± 15.1 and 46.8 ± 13.7 IU/L, respectively, and at 3-month follow-up 55.8 ± 45.9 and 45.5 ± 30.9 IU/L, respectively. Significant decrease in the level of aminotransferases was seen in the treatment group (p value < 0.001) and not in the control group (p values 0.161 and 0.728, respectively). The change in levels of SGPT and SGOT from baseline to 3 months of follow-up was statistically significant in between two study groups (p values 0.007 and <0.001, respectively). From the control group, 29 patients were crossed over to vitamin E for the next 3 months. SGPT and SGOT decreased from 97.6 ± 44.1 to 46.1 ± 40.9 and 69.3 ± 34.9 to 29.1 ± 11.6 IU/L, respectively (p values 0.031 and 0.017, respectively). CONCLUSION: Vitamin E significantly attenuates MTX-induced transaminitis.

Synovial fluid uric acid level aids diagnosis of gout.

Examination of urate crystal in synovial fluid (SF) remains the gold standard for diagnosis of gout, but is not universally available. SF uric acid (UA) level may be measured by the uricase method with an automated analyzer. The present study aimed to evaluate the utility of SF to serum UA ratio (SSR) for diagnosis of gout. A cross-sectional study was conducted at the National Center for Rheumatic Diseases, Nepal. Patients presenting with acute (<1 day) joint pain and/or swelling were included. Aspiration was performed in all patients and fluid was subjected to testing for urate level, pH and cell counts and microscopy. Serum samples were also assessed for urate levels, and the SSR was calculated for each patient. A receiver operating characteristic curve was plotted to determine the cutoff value for indicating diagnosis of gout. The difference in SSR between gout and non-gout effusion was evaluated by one-way analysis of variance. A total of 181 patients were included of which 77 had gout. The remaining cases included osteoarthritis, pseudogout, rheumatoid arthritis and ankylosing spondylitis. SSR was significantly higher in gout patients than in any other group (P<0.05). An SSR of ≥1.01 had the highest sensitivity and specificity at 89.6 and 66.3%, respectively, for identifying gout effusion. The present results indicated that SSR may be used as an aid for gout diagnosis when polarizing microscopy is not available.

Pattern of abortion care in a tertiary level maternity hospital in Nepal.

INTRODUCTION: Complications from unsafe abortion are believed to account for the largest proportion of hospital admissions for gynaecological services in developing countries and not to mention the cost it imparts to the health system of a country. Therefore, it is equally important to find out the prevalence and the pattern of abortion among the women who utilize the safe abortion care services and provide a framework to target various health promotion programs including safe-motherhood and reproductive health; such that the future interventions to avoid the unintended pregnancy and unsafe abortion can be implemented accordingly. METHODS: A cross-sectional study was conducted in a tertiary care hospital in Kathmandu, Nepal. Social and demographic information of all the women seeking induced abortions from January 2011 to December 2012 were included and the result was analyzed. RESULT: Abortion contributed to about 1.68% of the total patient served in the hospital that provides both obstetrical and gynecological services. Of the total 4830 patients who underwent induced abortion in this period, the mean age was 27, 92.3% were from the Kathmandu valley and more than one-third women (35.2%) were illiterate who couldn't read and write. Majorities were more than two parity and belonged to higher caste. CONCLUSION: The socio-demographic profile of the abortion clients in Nepal has remained similar over the years. We need to address the accessibility and availability to the safe abortion care services along with other safe motherhood programs guaranteeing access to safe abortion and post-abortion care to all group of women and also, women education regarding contraception to avoid repeated abortions or unwanted pregnancy in the future.