Femoral head avascular necrosis of in a young cushingoid opium addicted patient in the context of new combined opioid substance with corticosteroids.

AVN should be considered in addicted to oral opium patient without history of glucocorticoid consumption who present with pelvic pain, due to recent reports of the illegal and secret addition of glucocorticoid in new combination substance with opium.

Paget's disease of bone in the patient presented with a bowed leg.

Key Clinical Message: In dealing with bowed limbs along with increased alkaline phosphatase (ALP), even if the typical changes to the face are not very noticeable at first glance, Paget's disease of the bone (PDB) should be suspected, and the necessary investigations should be carried out to confirm the diagnosis. Abstract: Paget's disease of the bone (PDB) is the second most prevalent metabolic bone disorder worldwide with disorganized bone remodeling. Here, a patient is presented with pain and bending of the right leg, whose skull and forehead changes are not noticeable at first glance, but with clinical suspicion and additional diagnostic evaluations, PDB diagnosis is confirmed for the patient.

The Association between the Expression of MicroRNA-4270 and MicroRNA-4441 with some Metabolic Factors in Iranian Rheumatoid Arthritis Patients.

MicroRNAs (miRs) play a role in several diseases, such as rheumatoid arthritis (RA). The purpose of this study was to discover new microRNAs and investigate their involvement in RA, examining their connections with inflammation and metabolic markers. New microRNAs related to RA were predicted using Mirbase and TargetScan databases based on RA target genes. The relationships between miRNAs and targets were visualized with Cytoscape software. Real-time polymerase chain reaction confirmed detectable miRNAs and metabolic factors were assessed using immunoassay and spectrometry methods in RA patients and healthy subjects. Four microRNAs (hsa-miR-153-5p, hsa-miR-4270, hsa-miR-4441, and hsa-miR-6754-5p) showed the highest correlation with RA target genes among millions of microRNAs. The expression of miR-146b (fold change=1.8) and miR-4441 (fold change=1.7) was notably reduced, while miR-4270 showed upregulation (fold change=1.8) in plasma from RA patients compared to healthy individuals. MiR-6754 exhibited a decrease (fold change=1.3) but was statistically insignificant. MiR-153-5p expression was undetectable in plasma. Receiver operating characteristic (ROC) curve analysis indicated that miR-4441, with an area under the ROC curve (AUC) of 0.7728, and miR-4270 (AUC=0.7353) were promising biomarkers for RA. The expression of these studied miRNAs significantly correlated with essential clinical characteristics, including liver enzymes, cholesterol, phosphorus, and vitamin D3. Our findings suggest that miR-4270 and miR-4441, present in the circulation, exhibit distinct expression patterns in RA. These microRNAs may serve as links between inflammation and metabolism and represent promising new biomarkers for this disease.

Immunological and oxidative stress biomarkers in Ankylosing Spondylitis patients with or without metabolic syndrome.

Ankylosing Spondylitis (AS) is a chronic inflammatory disorder of the spine and sacroiliac joints with unidentified etiology closely associated with metabolic syndrome (MetS). Recent studies have reported that immunological and oxidative stress factors are implicated in AS pathogenesis. The aim of this study was to investigate the oxidative and immunological factors in AS patients with or without MetS compare to control group. Real-Time PCR measured expression level of cytokines, transcription factors and related miRNAs. In addition, Th17 and Treg frequencies and cytokines secretion were evaluated by flowcytometry and ELISA methods, respectively. The oxidative stress biomarkers were also assessed with biochemical methods. In AS patients with MetS, higher Th17 and lower Treg frequency were observed. Increased levels of NF-kB and AP-1 mRNA expression were seen in AS patients with MetS (p = 0.0263 and p = 0.0104, respectively). MiR-146a and miR-223 were significantly decreased (p = 0.0005, p = 0.0161, respectively) and increase in miR-21 (p = 0.0002) was observed in AS patients with MetS compared to AS patients without MetS. Additionally, the secretion of TNF-α (p = 0.0167), IL-1ß (p = 0.303), CCL2 (p = 0.0254), CCL3 (p = 0.0119), CXCL8 (p = 0.0364), adiponectin (p = 0.0183) and the levels of SOD (p = 0.0421), NO (p = 0.0451) and CAT (p = 0.0128) were increased in AS patients with MetS. We were not observed significant differences in TOS and GPX levels between studied groups. The higher levels of oxidative stress and immunological inflammatory markers in AS patients with MetS provide further evidences on the oxidative stress and immunological relationship in these patients.

Demographic and clinical features of Behcet's disease in Azerbaijan.

AIM: Behcet's disease (BD) is a multisystem inflammatory disease characterized by recurrent aphthous ulcers, genital ulcers and uveitis. Demographic and clinical features of BD are different in various countries. Due to these ethnic discrepancies, we decided to consider the clinical picture of BD in the Azeri population of Iran and compare it with other ethnic groups. METHODS: This cross-sectional cohort study was carried out at the Connective Tissue Diseases Research Center of Tabriz University of Medical Sciences, Tabriz, Iran from 2006 to 2013. We considered the demographic and clinical findings in 166 patients with BD. Disease activity was measured by the Iranian Behcet's Disease Dynamic Activity Measure (IBDDAM) and Total Inflammatory Activity Index (TIAI). RESULTS: The male-to-female ratio was 1.7 : 1.0; the age of disease onset was 25.8 ± 8.9 years. Recurrent oral aphthous ulcers were the initial manifestations of BD in 83.1% of patients. Panophthalmitis and panuveitis were the most common ophthalmic manifestations of disease. Blindness occurred in 7.1% of patients. This study showed no difference between the two genders in mean age of disease onset and clinical manifestations. However, IBDDAM in men was higher than women. Retinal vasculitis in men was more common than women. CONCLUSIONS: BD in the Azeri population of Iran starts in the third decade and has a male predominance. The activity of the disease and retinal vasculitis in men is more predominant than women in Azerbaijan.

Adherence to treatment in patients with Behçet's disease.

AIM: Behçet's disease (BD) is a chronic, inflammatory disease with multisystem involvement. Adherence to treatment is low in chronic diseases as well as inflammatory and autoimmune diseases. This study assessed factors associated with non-adherence to treatment in patients with BD. METHODS: All the patients with BD who visited in the outpatient clinic of Connective Tissue Diseases Research Center in Tabriz University of Medical Sciences were included in the study. Adherence to treatment was evaluated by the consideration of medication compliance and appointment-keeping behavior. The relationships between adherence rate and six groups of variables were examined. A regression analysis was performed. RESULTS: A total of 137 patients (84 male and 53 female) were included. Totally, 50.7% of the patients were non-adherent to treatment. Side effects of medications and the high cost of treatment were the most frequent causes of non-adherence. Non-adherence was significantly more common in men, patients with low income, patients who were unaware of the disease complications, employed persons, and in patients who were on treatment with non-steroidal anti-inflammatory drugs (NSAIDs). CONCLUSIONS: Non-adherence is common in patients with BD. Male sex, low income, low knowledge about the disease, being employed and being on treatment with NSAIDs are the main risk factors for non-adherence.

Extra Corporeal Shock Wave Therapy Versus Local Corticosteroid Injection in the Treatment of Chronic Plantar Fasciitis, a Single Blinded Randomized Clinical Trial.

OBJECTIVES: Plantar fasciitis is a self-limiting condition, but can be painful and disabling. Among the different treatments which exist, corticosteroid injections are effective and popular. Extracorporeal shock wave therapy (ESWT) is another treatment modality used for resistant conditions. In this study, the authors evaluated the efficacy of radial ESWT versus corticosteroid injections in the treatment of chronic plantar fasciitis. DESIGN: Randomized clinical trial. SETTING: Physical medicine and rehabilitation research center in a university hospital. SUBJECTS: Forty patients with plantar fasciitis who did not respond to conservative treatment. METHODS: Patients were allocated to radial ESWT with 2000 shock waves/session of 0.2 mJ/mm(2) (n = 20) or local methylprednisolone injections (n = 20). Pain in the morning and during the day based on a visual analog scale (VAS), functional abilities using the foot function index (FFI), and satisfaction were evaluated before treatment and at 4 and 8 weeks after treatment. RESULTS: Patients (average age: 42.1± 8.20) received five sessions of ESWT or single steroid injection. Changes in the VAS in morning and during the day and the FFI throughout the study period were significant in both groups (P < 0.001). ESWT group had a higher reduction in VAS in morning and better function in FFI, but these changes were insignificant statistically [FFI decreased to 19.65 ± 21.26 points (67.4% improvement) in ESWT vs 31.50 ± 20.53 points (47.7%) in injection group at week 8, P = 0.072)]. Good or excellent results in the opinions of patients were achieved in 55% of ESWT and 30% of corticosteroid injection groups (P = 0.11). CONCLUSION: Both interventions caused improvement in pain and functional ability 2 months after treatment. Although inter-group differences were not significant, the FFI was improved more with ESWT and patients were more satisfied with ESWT, thus shockwave therapy seems a safe alternative for management of chronic plantar fasciitis.

Alendronate Effect on the Prevention of Bone loss in Early Stages of Ankylosing Spondylitis: A Randomized, Double-Blind, Placebo-Controlled Pilot Study.

BACKGROUND: Ankylosing spondylitis (AS) is an inflammatory rheumatic disease that leads to a progressive ankylosis of vertebras and ossification of paravertebral ligaments. Bone loss and osteoporosis are amongst the important complications of AS, treatment of which is a challenging issue. OBJECTIVES: This study aimed to clarify the effect of alendronate on the prevention of bone loss in patients with early AS. PATIENTS AND METHODS: In a randomized, double-blind, placebo-controlled study, 24 patients with early stages of AS were recruited in Emam Reza Hospital, Tabriz University of Medical Sciences. The diagnostic criteria of early AS were Schober's index ≥ 5, normal hip joint in pelvic radiography, and absence or rarity of syndesmophytes in spine radiography (Taylor index ≤ 1). The participants were randomly allocated to the treatment and control groups and received 70 mg/week of alendronate and the same dose of placebo, respectively, for 12 months. Before and 12 months after the intervention, bone densitometry was performed from lumbar and pelvic region using the dual-energy X-ray absorptiometry (DEXA) method with Hologic QDR model instrument. Patients, physicians who prescribed the medications and those who interpreted the outcomes, and densitometry technicians were unaware of the assigned medication to each patient. Both groups received supplemental calcium (1000 mg/day) and vitamin D (400 mg/day). RESULTS: After 12 months of treatment, hip and lumbar bone mineral density differences were not statistically significant between study groups (P = 0.061 and P = 0.112, respectively). No case of clinically apparent vertebral and nonvertebral fracture were observed in the treatment and control groups. CONCLUSIONS: Our results suggested that applying alendronate was ineffective in preventing bone loss in patients with early stages of AS.

Safety of less frequent monitoring of liver transaminases levels in rheumatic patients treated with low-dose methotrexate.

AIM: Consideration of the safety of liver transaminases monitoring every 12 weeks in patients with inflammatory connective tissue disorders who are treated with methotrexate (MTX). METHODS: In a retrospective study, the data from rheumatic patients receiving MTX were analyzed. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were measured every 12 weeks. Based on the physician's final decision about the continuation of MTX, the patients were classified into one of the following groups: continuation of MTX without MTX dose reduction, MTX dose reduction, MTX discontinuation due to liver complication and MTX discontinuation due to other reasons. RESULTS: A total of 809 patients who were on MTX were included in the study. The mean follow-up duration and the mean duration of treatment with MTX were 31.22 and 19.76 months, respectively. The mean accumulation dose of MTX was 865.85 mg. Due to the increase in the level of transaminases in 3.2% of the patients, MTX dose was reduced; and in 1.1% of the cases it was temporarily discontinued. In the follow-up of the patients with elevated transaminases, they returned to normal limits in 99.5% of patients; and only in four cases (0.5%) they remained elevated and MTX was discontinued. The probability of the patients remaining on MTX for 5 years without discontinuation for liver complications was 98.5% CONCLUSION: Liver transaminase monitoring every 12 weeks for MTX-treated patients is safe.

Randomized double-blind study of the effect of dexamethasone and methylprednisolone pulse in the control of rheumatoid arthritis flare-up: a preliminary study.

AIM: The objective of this study was to compare the efficacy and safety of dexamethasone and methylprednisolone for pulse therapy of rheumatoid arthritis flare-up. METHODS: This randomized double-blind controlled study was performed in the Emam Reza Educational Hospital of Tabriz University of Medical Sciences, Tabriz, Iran. Thirty rheumatoid arthritis patients who had severely active disease were recruited to the dexamethasone and methylprednisolone pulse groups. Disease activity of all the patients was measured by the Disease Activity Score in 28 joints (DAS28) at baseline, and days 4 and 30. RESULTS: The differences in the DAS28 at days 4 and 30, and the number of patients whose DAS28 obtained less than 3.2 and 2.6 in the dexamethasone and methylprednisolone groups were non-significant. There was not any significant difference between the adverse effects of the treatments in the two groups. CONCLUSIONS: The results of the study suggest that dexamethasone pulse therapy is a safe and effective treatment for severe rheumatoid arthritis flare-up.

The status of serum vitamin D in patients with active Behcet's disease compared with controls.

OBJECTIVE: The aim of this study was to characterize the status of vitamin D in patients with active and recently diagnosed Behcet's disease (BD) and the relationship between vitamin D levels and BD activity. METHODS AND MATERIALS: In this cross sectional study 48 patients with BD and 47 age- and sex-matched healthy controls were included. BD was diagnosed by the International Criteria for BD. Behcet's patients were new cases who were not on any treatment. BD activity was measured by the Iranian Behcet's Disease Dynamic Activity Measure (IBDDAM) and Behcet's Disease Current Activity Form (BDCAF). 25(OH)D measured by enzyme-linked immunosorbent assay method as an indicator of vitamin D status. RESULTS: The mean 25-hydroxyvitamin D (25(OH)D level in the BD group was lower than the control group. Insufficiency and deficiency of 25(OH)D in the BD group was more common than the control group. No correlation was observed between the total IBDDAM, ophthalmic IBDDAM, and BDCAF with 25(OH)D levels. No correlation was found between the major symptoms of BD and 25(OH)D value. CONCLUSIONS: Our study suggests that deficiency of 25(OH)D may be a trigger factor for BD.

A multicenter study of clinical and laboratory findings of palindromic rheumatism in Iran.

OBJECTIVE: Considering demographic, clinical and laboratory characteristics of palindromic rheumatism and finding out the difference between rheumatoid factor and anti-cyclic citrullinated peptide positive and negative cases of palindromic rheumatism in Iran. METHODS: In this cross-sectional and multicenter study, patients with intermittent arthritis were evaluated by a rheumatologist for palindromic rheumatism. Diagnosis of palindromic rheumatism was made after ruling out other causes of recurrent arthritis, and the fulfillment of the Pasero and Barbieri criteria. Then the demographic and clinical characteristics were recorded and compared in rheumatoid factor and anti-cyclic citrullinated peptide positive and negative patients. RESULTS: Of the 69 patients with palindromic rheumatism, 35 were men and 34 were women. The mean ages of the patients at the time of diagnosis were 38.5 ± 14.6 years. The mean attack intervals and duration of the attacks were 66.3 ± 38.4 days and 3.9 ± 3.3 days, respectively. The most commonly involved joints were knees, metacarpophalangeals and proximal interphalangeals. Rheumatoid factor in 46.4% and anti-cyclic citrullinated peptide in 42% of the cases were positive. Palindromic patients with positive anti-cyclic citrullinated peptide had higher age, shorter duration of disease, shorter duration of attacks, more frequent attacks and more metacarpophalangeal joints involvement. CONCLUSIONS: Rheumatoid factor and anti-cyclic citrullinated peptides were found in a high proportion of patients with palindromic rheumatism. The clinical features of the disease in our study were different in rheumatoid factor and anti-cyclic citrullinated peptide positive and negative patients.

Effect of ethnic origin (Caucasians versus Turks) on the prevalence of rheumatic diseases: a WHO-ILAR COPCORD urban study in Iran.

The objective of this study was to compare the prevalence of musculoskeletal complaints and rheumatic disorders in Caucasians and Turks in an identical environment. Subjects were selected randomly for an interview from Tehran's 22 districts. The Community Oriented Program for Control of Rheumatic Diseases questionnaire was filled in, positive cases were examined, and if needed, laboratory or X-ray tests were performed. A total of 4,096 houses were visited, and 10,291 persons were interviewed. They were 71.4% Caucasians and 23.1% Turks with similar distribution of age and gender. Musculoskeletal complaints of the past 7 days were detected in 40.8% of Caucasians and 45.5% of Turks (p < 0.001). In Caucasians, the total of musculoskeletal complaints in men was 33.8% (95% CI, 31.4-36.2%) versus 48.3% in women (95% CI, 45.7-50.8%). In Turks, the total of musculoskeletal complaints in men was 36.6% (95% CI, 32.2-41.1%) versus 55.8% in women (95% CI, 55.8-60.6%). The data of Caucasians versus Turks were as follows: knee pain 20.2% (95% CI, 18.2-22.1) versus 24.1% (95% CI, 20.5-27.6), with p < 0.001; dorso-lumbar spine pain 15.1% (95% CI, 13.6-16.6) versus 18.4% (95% CI, 15.1-21.8), with p < 0.001; shoulder pain 10.7% (95% CI, 9.4-11.9) versus 12.3% (95% CI, 9.7-14.8), with p = 0.025; osteoarthritis 14.1% (95% CI, 12.8-15.2) versus 16.4% (95% CI, 14.3-18.6), p = 0.04; and knee osteoarthritis 12.3% (95% CI, 11.8-14.1) versus 15.3% (95% CI, 13.3-17.4), with p < 0.001). There were no significant differences regarding the prevalence of soft tissue rheumatism, rheumatoid arthritis, ankylosing spondylitis, Behcet's disease, fibromyalgia, and gout. Although musculoskeletal complaints were more frequent in Turks than in Caucasians, the prevalence of rheumatic disorders was rather similar except for knee osteoarthritis.

WHO-ILAR COPCORD Study (Stage 1, Urban Study) in Iran.

OBJECTIVE: To find the prevalence of musculoskeletal complaints and rheumatic disorders in Iran. METHODS: Tehran, with one-ninth of the population of Iran and of mixed ethnic origins, was selected as the field. Subjects were randomly selected from the 22 districts. Interviews were conducted once a week, on the weekend. The 3 phases of stage 1 were done on the same day, in parallel, like the fast-track Community Oriented Program for Control of Rheumatic Diseases (COPCORD). RESULTS: Four thousand ninety-six houses were visited and 10,291 persons were interviewed. Musculoskeletal complaints during the past 7 days were detected in 41.9% of the interviewed subjects. The distribution was: shoulder 14.5%, wrist 10%, hands and fingers 9.4%, hip 7.1%, knee 25.5%, ankle 9.8%, toes 6.1%, cervical spine 13.4%, and dorsal and lumbar spine 21.7%. Degenerative joint diseases were detected in 16.6% of subjects: cervical spondylosis 1.8%, knee osteoarthritis (OA) 15.3%, hand OA 2.9%, and hip OA 0.32%. Low back pain was detected in 15.4% and soft tissue rheumatism in 4.6%. Inflammatory disorders were rheumatoid arthritis 0.33%, seronegative spondyloarthropathies 0.23%, ankylosing spondylitis 0.12%, systemic lupus erythematosus 0.04%, and Behçet's disease 0.08%. Fibromyalgia was detected in 0.69% and gout in 0.13% of the studied population. CONCLUSION: The large urban COPCORD study in Iran showed a high prevalence of rheumatic complaints in the population over the age of 15 years, 41.9%. Knee OA and low back pain were the most frequent complaints.