2021 Asia-Pacific League of Associations for Rheumatology clinical practice guideline for treatment of gout.

BACKGROUND: Gout is the most prevalent inflammatory arthritis in the Asia-Pacific region and worldwide. This clinical practice guideline (CPG) aims to provide recommendations based on systematically obtained evidence and values and preferences tailored to the unique needs of patients with gout and hyperuricemia in Asia, Australasia, and the Middle East. The target users of these guidelines are general practitioners and specialists, including rheumatologists, in these regions. METHODS: Relevant clinical questions were formulated by the Steering Committee. Systematic reviews of evidence were done, and certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation methodology. A multi-sectoral consensus panel formulated the final recommendations. RESULTS: The Asia-Pacific League of Associations for Rheumatology Task Force developed this CPG for treatment of gout with 3 overarching principles and 22 recommendation statements that covered the treatment of asymptomatic hyperuricemia (2 statements), treatment of acute gout (4 statements), prophylaxis against gout flare when initiating urate-lowering therapy (3 statements), urate-lowering therapy (3 statements), treatment of chronic tophaceous gout (2 statements), treatment of complicated gout and non-responders (2 statements), treatment of gout with moderate to severe renal impairment (1 statement), and non-pharmacologic interventions (5 statements). CONCLUSION: Recommendations for clinically relevant scenarios in the management of gout were formulated to guide physicians in administering individualized care.

Büchi's model based analysis of local anesthetic action in procaine hydrochloride: Vibrational spectroscopic approach.

The drug action of ester type local anesthetic (LA) procaine hydrochloride (PRC HCl) is activated by blocking Na+ ion flow when it binds to the ion channel in the ligand gated sodium ion channel protein. Büchi's model, explains binding action of ester type LA drug with receptor in terms of charge transfer, dipole-dipole, hydrogen bonding and van der Waals interactions through lipophilic, ester and hydrophilic moieties. The present work investigates molecular structural and vibrational spectral features of para amino benzoate group, ester part and tertiary amino group respectively belonging to lipophilic, ester and hydrophilic moieties, accountable for the binding of drug to sodium channel. The electron transport mechanism through the ring responsible for structural deviation from benzenoid to quinonoid form and consequent dipolar nature of carbonyl group have been investigated, based on the analysis of XRD, DFT computed molecular structure, 8a ring mode and NBO charges. The characteristic UV absorption peaks and vibrational marker bands of LA drugs have been identified and the charge transfer interaction responsible for lipophilic binding has been investigated. The blocking of Na+ in the ion channel has been probed using attractive and repulsive energy profile. The molecular polarizability has been computed to substantiate the correlation between the structure activity relationship of LA drug molecule and molecular polarizability. The low toxicity of PRC HCl was evaluated using in vitro cytotoxicity study, confirming it as a potential short acting local anesthetic.

Chikungunya Infection: A Re-emerging Epidemic.

Chikungunya (CHIK) is an arboviral infection caused by the chikungunya virus. An unusual feature of CHIK is its long periods of quiescence followed by an epidemic of devastating severity that can involve millions of people. Manifestations of CHIK range from a mild self-limiting febrile illness with arthralgia and rash to crippling acute and lingering debilitating arthritis. In about 10-60% of patients, musculoskeletal symptoms may persist for up to 3-5 years. Management is mainly symptomatic, with analgesics, antipyretics and non-steroidal anti-inflammatory agents. Ecological changes together with alterations in the viral genome facilitate the development of newer variants with greater pathogenicity, a matter of great concern. The social and economic burdens to a society as a result of CHIK epidemics have generated a considerable interest in the scientific community to decipher the reasons underlying myriad manifestations and to develop management strategies for tackling the menace of CHIK across the globe.

An Adolescent with Progressive Enlargement of Digits: Case report and proposed diagnostic criteria for macrodystrophia lipomatosa.

Macrodystrophia lipomatosa (ML) is a rare congenital non-hereditary condition caused by an increase in all mesenchymal elements. We report a 14-year-old girl who presented to the Medical Outpatient Department, Kunhitharuvai Memorial Charitable Trust Medical College, Kozhikode, India, in 2017 with progressive enlargement of digits. An X-ray and T1-weighted magnetic resonance imaging scan showed enlargement of the phalanges of the middle and index finger of the left hand with an overgrowth of soft tissues. The patient was subsequently diagnosed with ML. As the condition is benign and usually asymptomatic, no medical treatment was deemed necessary. This report describes a case of ML and proposes a set of diagnostic criteria to aid clinicians in the differential diagnosis of the condition.

Asymptomatic hyperuricemia: is it time to intervene?

Whether to treat hyperuricemia uncomplicated by articular gout, urolithiasis, or uric acid nephropathy is an exercise in clinical judgment and universal agreement is lacking. Patients with coronary artery disease, chronic kidney disease, and early onset hypertension with persistent hyperuricemia are likely to be benefited with urate-lowering therapy. The paradigm of the causative association of hyperuricemia with cardiovascular and chronic kidney diseases seems to have progressed from skepticism to increasing evidence of a true relationship. Although such evidences are mounting, they are not enough to support pharmacotherapy for all patients with asymptomatic hyperuricemia. Further studies are needed to determine which patients are likely to get beneficial effects from pharmacotherapy and the minimum threshold of uric acid level required to experience clinical benefits.

Gout: an Asia-Pacific update.

Even though, Hippocrates recognized gout as an affection of older men and a product of high living long back in 5th century BC, this painful condition promises to accompany humanity to the 21st century. The incidence is progressively rising and females are also affected in the modern era. There are also regional and ethnic variations in the incidence, the genetics of which is being studied. The recommended best therapy for the acute attacks and long term prophylaxis has improved remarkably in the recent years. However, patients are often treated inadequately and risk factors for their disease are not well explored in daily practice. Although well designed long term studies of current and newer treatment are welcomed, educating doctors especially the primary care physicians who manage majority of gout cases, in optimizing the currently available management options would improve the present care.

Pre-rheumatoid arthritis and its prevention.

Pre-rheumatoid arthritis (pre-RA) is the preclinical period of the disease that precedes the onset of clinically apparent RA. It includes the interaction between genetic and environmental risk factors and development of disease-related autoantibodies and joint symptoms and signs, which may be considered nonspecific or unclassified for RA. A better understanding of the pre-RA stage will be useful in developing screening programs for early detection of RA. Identifying and modifying risk factors such as smoking, periodontitis, obesity, viral infections, and hormonal or dietary factors will be useful in preventing RA in susceptible population.

Investigations of vibrational spectra and bioactivity of novel anticancer drug N-(6-ferrocenyl-2-naphthoyl)-gamma-amino butyric acid ethyl ester.

The bioactivity of compounds is mainly dependent on molecular structure and the present work aims to explore the bonding features responsible for biological activity of novel anticancer drug N-(6-ferrocenyl-2-naphthoyl)-gamma-amino butyric acid ethyl ester (FNGABEE). In the present study, we investigate the molecular structural properties of newly synthesized title compound through experimental and quantum chemical studies. The detailed vibrational analysis has been performed using FT IR and FT Raman spectrum, aided by DFT computed geometry, vibrational spectrum, Eigen vector distribution and PED, at B3LYP/6-311++G(d,p) level. The resonance structure of naphthalene, different from that of benzene, revealed by molecular structure has been investigated using CC and CC stretching modes. The proton transfer in amide has been analyzed to obtain spectral distinction between different carbonyl and CN groups which point to the reactive sites responsible for binding with DNA and bovine serum albumin (BSA). The spectral distinction between eclipsed and staggered form of ferrocene has been analyzed. The molecular docking of FNGABEE with BSA and DNA has been performed to find the strength of binding and the moieties responsible for the interactions. The experimental binding studies of FNGABEE with BSA and DNA has been performed using UV absorption spectroscopy and fluorometric assay, to find the nature and strength of binding.

Dyslipidemia and its relationship with antiphospholipid antibodies in APS patients in North Kerala.

OBJECTIVE: Antiphospholipid antibody syndrome (APS) is one of the most common acquired thrombophilic disorders resulting in arterial and venous thromboses. APS is a major cause for cerebrovascular accidents or stokes, myocardial infarction, venous thromboembolism and recurrent abortions/pregnancy losses especially in young patients. APS patients have an increased risk of atherosclerotic cardiovascular events. There are only two studies on lipid abnormalities in APS patients. None of them have studied the relationship between individual laboratory tests for APS and lipid profile abnormalities. Here we describe the significance of the relationship between various APS tests and lipid profile abnormalities in a subset of APS patients who presented with arterial thrombosis in a tertiary care hospital. MATERIAL AND METHODS: The study was conducted at Government Medical College, which is a tertiary care referral hospital. All patients who presented to the medicine department with APS during a two-year period were studied. A patient was considered to be positive for anticardiolipin (aCL) antibody or anti-ß2 glycoprotein (anti-ß2G) if the titer was more than 15 IU/mL, and a high titer was considered to be more than 40 IU/mL for Immunoglobulin (lg) IgG and IgM isotypes. The fasting lipid profile was measured in all patients, and lipid profile abnormalities were defined with cutoffs of low-density lipoprotein (LDL) levels of >150 mg/dL, triglyceride (TG) levels of >150 mg/dL, and high-density lipoprotein (HDL) levels of <40 mg/dL. The relationship between lipid abnormalities and individual tests for APS, aCL IgG and IgM and anti-ß2G IgG and IgM, were determined by statistical analysis. RESULTS: The study population included 77 APS patients, with 53% of patients between 20 and 40 years. The commonest abnormality in the lipid profile test was elevated TG levels of >150 mg/dL in 51.9% of the patients, followed by low HDL levels (<40 mg/dL) in 38.9% of the patients and high LDL levels (>150 mg/dL) in 40.2% of the patients. There was a statistically significant relationship between anti-ß2G IgG levels and HDL and LDL levels, but not TG levels. Only LDL levels had a statistically significant relationship with aCL IgM levels. None of the lipid abnormalities had any statistically significant relationship with aCL IgG levels. CONCLUSION: This study highlights the importance of testing lipid profile abnormalities in APS patients and the existence of a statistically significant relationship between antiphospholipid antibody tests and lipid profile abnormalities.

Disability with Persistent Pain Following an Epidemic of Chikungunya in Rural South India.

OBJECTIVE: We investigated the effects of chronic rheumatic and musculoskeletal symptoms on the functional status of people affected by the chikungunya (CKG) epidemic in the Calicut District, Kerala, South India in 2009. METHODS: A cross-sectional house-to-house survey was conducted 18 months after the CKG epidemic to assess functional status of individuals with post-epidemic persistent pain. All respondents over age 15 years with persistent pain fitting the epidemiological case definition were included. Participants' functional status was assessed using the Health Assessment Questionnaire-Disability Index (HAQ-DI). Factors affecting severity of HAQ-DI were analyzed by ordinal regression. RESULTS: Of 3869 subjects interviewed, 1195 (34.3%) had a positive history of CHIKV virus infection (epidemiological or confirmed); 36.28% (624/1720) of CKG-affected individuals had persistent pain 18 months post epidemic. Mean age of those affected was 48.22 ± 15.6 years; 23.2% had no disability, while 16.2% had moderate to severe disability on the HAQ-DI. Significant factors affecting severity of disability on HAQ-DI included previous rheumatic musculoskeletal disease (OR 2.27), joint and soft-tissue involvement (OR 3.74), only joint involvement (OR 2.14), female sex (OR 1.44), diet (OR 4.73), and history of joint swelling (OR 1.72). CONCLUSION: Persistence of pain noted in post-CKG disease resulted in significantly deteriorated functional status of those affected.

Evans hole and non linear optical activity in Bis(melaminium) sulphate dihydrate: A vibrational spectral study.

Bis(melaminium) sulphate dihydrate (BMSD), an interesting melaminium derivative for nonlinear optical activity, has been subjected to vibrational spectral analysis using FT IR and FT Raman spectra. The analysis has been aided by the Potential Energy Distribution (PED) of vibrational spectral bands, derived using density functional theory (DFT) at B3LYP/6-31G(d) level. The geometry is found to correlate well with the XRD structure and the band profiles for certain vibrations in the finger print region have been theoretically explained using Evans hole. The detailed Natural Bond Orbital (NBO) analysis of the hydrogen bonding in BMSD has also been carried out to understand the correlation between the stabilization energy of hyperconjugation of the lone pair of donor with the σ(∗) orbital of hydrogen-acceptor bond and the strength of hydrogen bond. The theoretical calculation shows that BMSD has NLO efficiency, 2.66 times that of urea. The frontier molecular orbital analysis points to a charge transfer, which contributes to NLO activity, through N-H…O intermolecular hydrogen bonding between the melaminium ring and the sulphate. The molecular electrostatic potential (MEP) mapping has also been performed for the detailed analysis of the mutual interactions between melaminium ring and sulphate ion.

Multicenter study comparing case definitions used to identify patients with chronic obstructive pulmonary disease.

RATIONALE: Clinical trials in chronic obstructive pulmonary disease (COPD) usually require evidence of airflow obstruction and clinical risk factors. International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes or patient-reported physician diagnoses are often used for epidemiologic studies and performance improvement programs. OBJECTIVES: To evaluate agreement between these case definitions for COPD and to assess the comparability of study populations identified as having COPD not using the clinical trial reference standard. METHODS: We recruited patients from the COPD Outcomes-based Network for Clinical Effectiveness and Research Translation multicenter clinical registry in a cross-sectional study. Demographics, clinical, and post-bronchodilator spirometry data were collected at an in-person study visit. The kappa statistic (κ) was used to evaluate agreement. A multivariable logistic regression model was used to identify patient characteristics associated with meeting the trial reference standard. MEASUREMENTS AND MAIN RESULTS: A total of 998 (82.8%) of 1,206 study participants met at least one case definition for COPD (of the 998: 91% using ICD-9 codes, 73% using patient-reported physician diagnosis, 56% using trial reference standard); agreement between case definitions was poor (κ = 0.20-0.26). Lack of airflow obstruction was the principal (89%) reason patients identified as having COPD did not meet the trial reference standard. Patients who were black (vs. white), obese (vs. normal weight), or had depression (vs. not) were less likely to meet the trial reference standard (odds ratio [95% CI], 0.37 [0.26-0.53], 0.51 [0.34-0.75], 0.53 [0.40-0.71], respectively). CONCLUSIONS: Findings highlight concerns about the applicability of findings in clinical trials to patients meeting other case definitions for COPD.

Prevalence and factors related to rheumatic musculoskeletal disorders in rural south India: WHO-ILAR-COPCORD-BJD India Calicut study.

AIMS: To assess the prevalence and factors related to rheumatic musculoskeletal disorders (RMSD) in a rural population of south India. METHODS: The cross-sectional study included all individuals, 15 years and above, in a rural unit of Calicut District in North Kerala. Data were collected using the validated World Health Organization - International League of Associations for Rheumatology - Community Oriented Program for the Control of Rheumatic Diseases - Bhigwan model questionnaire by trained volunteers. In Phase 1 details of demographic characteristics, major co-morbidities and perceived musculoskeletal aches and pains were elicited. Phases 2 and 3 further evaluated and diagnosed the subjects. Predictors for RMSD were assessed using binary logistic regression analysis. RESULTS: There were 4999 individuals in the study. The prevalence of RMSD was 24.9% (95% CI 23.73; 26.12%). Females constituted 50.7% of the population; 5.1% of the respondents were illiterate; 80.9% belonged to low-income groups. Diabetes mellitus and hypertension affected 4.1% and 5.4% of the subjects respectively. The predictors for RMSD in the population were female sex, age, illiteracy, married status, low-income group, vegetarian diet, current alcohol consumption, current tobacco use, history of injury or accidents, diabetes and hypertension. Symptom-related ill-defined rheumatism (10.39%) followed by osteoarthritis (3.85%) were the most prevalent in the Phase 3 rheumatological evaluation. CONCLUSION: There is an urgent need to introduce lifestyle modifications in high-risk groups and start rehabilitation for those affected. Community rheumatology in primary health care settings in rural areas needs to be strengthened by introducing national programs addressing RMSD at the grassroots level.

The 'partial resonance' of the ring in the NLO crystal melaminium formate: study using vibrational spectra, DFT, HOMO-LUMO and MESP mapping.

The molecular geometry and vibrational spectral investigations of melaminium formate, a potential material known for toxicity and NLO activity, has been performed. The FT IR and FT Raman spectral investigations of melaminium formate is performed aided by the computed spectra of melaminium formate, triazine, melamine, melaminium and formate ion, along with bond orders and PED, computed using the density functional method (B3LYP) with 6-31G(d) basis set and XRD data, to reveal intermolecular interactions of amino groups with neighbor formula units in the crystal, intramolecular H⋯H repulsion of amino group hydrogen with protonating hydrogen, consequent loss of resonance in the melaminium ring, restriction of resonance to N(3)C(1)N(1) moiety leading to special type resonance of the ring and the resonance structure of CO(2) group of formate ion. The 3D matrix of hyperpolarizability tensor components has been computed to quantify NLO activity of melamine, melaminium and melaminium formate and the hyperpolarizability enhancement is analyzed using computed plots of HOMO and LUMO orbitals. A new mechanism of proton transfer responsible for NLO activity has been suggested, based on anomalous IR spectral bands in the high wavenumber region. The computed MEP contour maps have been used to analyze the interaction of melaminium and formate ions in the crystal.

Association between chronic periodontitis and rheumatoid arthritis: a hospital-based case-control study.

Rheumatoid arthritis (RA) and chronic periodontitis are the most common chronic inflammatory diseases with remarkable pathological and clinical similarities. A lot of similarities exist between RA and periodontitis at cellular and molecular levels. The relationship between these two chronic inflammatory diseases is still unclear. This case-control study was undertaken to determine the possible association between chronic inflammatory diseases like RA and periodontitis. The case group consisted of 100 patients attending the Rheumatology clinic who have rheumatoid arthritis (RA group). Age- and gender-matched 112 patients without RA attending the Outpatient wing of Department of General Medicine formed the control group (NRA group). The number of missing teeth, gingival index (GI), oral hygiene index-simplified (OHI-S), probing pocket depth (PPD) and clinical attachment levels (CAL) were evaluated in both the groups. Rheumatoid disease activity was assessed by DAS-28 score system. Systemic markers of inflammation like erythrocytic sedimentation rate (ESR) and serum levels of C-reactive protein (CRP) were assessed. There was a statistically significant difference in GI, OHI-S, PPD, CAL, ESR and CRP levels between cases (RA group) and controls (NRA group) (P < 0.05). Among subjects with RA, there was no association between the rheumatoid disease activity and the severity of periodontal disease. The occurrence and severity of periodontitis was found to be higher in RA subjects as compared to subjects without RA, suggesting a positive relation between these two chronic inflammatory diseases.

Striatal GABA receptor alterations in hypoxic neonatal rats: role of glucose, oxygen and epinephrine treatment.

Hypoxia in neonates disrupts the oxygen flow to the brain, essentially starving the brain and preventing it from performing vital biochemical processes important for central nervous system development. Hypoxia results in a permanent brain damage by gene and receptor level alterations mediated through neurotransmitters. The present study evaluated GABA, GABAA, GABAB receptor functions and gene expression changes in glutamate decarboxylase in the corpus striatum of hypoxic neonatal rats and the treatment groups with glucose, oxygen and epinephrine. Since GABA is the principal neurotransmitter involved in hypoxic ventilatory decline, the alterations in its level under hypoxic stress points to an important aspect of respiratory control. Following hypoxic stress, a significant decrease in total GABA, GABAA and GABAB receptors function and GAD expression was observed in the striatum, which accounts for the ventilator decline. Hypoxic rats treated with glucose alone and with oxygen showed a reversal of the receptor alterations and changes in GAD to near control. Being a source of immediate energy, glucose can reduce the ATP-depletion-induced changes in GABA and oxygenation helps in overcoming reduction in oxygen supply. Treatment with oxygen alone and epinephrine was not effective in reversing the altered receptor functions. Thus, our study point to the functional role of GABA receptors in mediating ventilatory response to hypoxia and the neuroprotective role of glucose treatment. This has immense significance in the proper management of neonatal hypoxia for a better intellect in the later stages of life.

NIR-FT Raman and infrared spectra and ab initio computations of glycinium oxalate.

The single crystals of glycinium oxalate are grown by slow evaporation technique and vibrational spectral analysis is carried out using NIR-FT Raman and FT-IR spectra. The ab initio quantum computations are also performed at HF/6-31 G(d) level to derive the optimized geometry, atomic charges and vibrational frequencies of the glycinium oxalate molecule. Vibrational analysis indicates the presence of peculiar intermolecular C-H...O hydrogen bonding interaction producing "blue shift" of C-H stretching frequency. The vibrational spectra confirm the existence of NH3(+) in glycinium oxalate. Hydroxyl vibrations with different inter and intra molecular H-bonding are analysed, supported by computed results.