Assessment of Growing Pain and its Risk Factors in School Children.

Mujammel Haque, Kamrul Laila, Md. Mahbubul Islam, Mohammad Imnul Islam, Manik Kumar

Department of Paediatrics, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh

Background: In majority of cases of children limb pain are due to growing pain (GP), which is the most common form of episodic childhood musculoskeletal pain. Method: This cross sectional study was conducted  among school children aged 6-12 years in four schools at Bhairab, Kishoreganj. Standard criteria set by Peterson (1986) were used for diagnosis of GP. Pretested questionnaires in Bangla were distributed among the children by purposive sampling. After completions, children with limb pain were selected for further history and clinical examination. Age and sex matched healthy children were selected as controls. Result: Among 540 distributed questionnaires 404 (74.8%) responded. Among responders 23.5% had limb pain of which 19.3 % were diagnosed as GP. Highest number of cases was found in 8+ year age group. Site of pain was calf muscle (69.2 %) in the majority. Timing of pain was at night in 82.05 % cases. In 66.6 % of cases pain was improved with massage. GP hampered activities like sleep, sports and schooling  in 26.9 %, 21.7 % and 8.9 % respectively. GP was associated with headache in 12.8% and abdominal pain in 6.4% cases. Obesity, overweight, over activity and family history of GP were significantly higher among GP cases. Conclusion: Growing pain was found to be the most common cause of limb pain. Multiple risk factors like obesity, over activity and family history were identified in this study.

Impact of Juvenile Idiopathic Arthritis on School Attendance and Performance

KamrulLaila, Mujammel Haque, Md. Mahbubul Islam, Mohammad Imnul Islam, Manik Kumar Talukder, ShahanaAkhter Rahman

Department of Paediatrics, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh

Background: Juvenile idiopathic arthritis (JIA)  is the most common chronic rheumatic illness n and is a significant cause of morbidity and disability. Therefore, the potential for school attendance and academic performance become compromised. Objective: To assess the impact of JIA on academic performance, potential causes of absenteeism, school failure and relationship between schooling. Material and Method: School going JIA patients  having at least 2 years of schooling  were included. Two hundred JIA patients were selected  purposively. A questionnaire was completed for each participant including data related to schooling, academic difficulties and their causes, absenteeism and school failure. Fifty four controls were taken who were the healthy sibs of those JIA patients. Result: Academic difficulties were observed for reading, writing and both due to disease process and deformity. Number of absent days and poor attendance in examination was significantly higher in JIA patients. Only 18% had improved result than the academic year prior to disease onset, 57% deteriorated and 22% stopped schooling. There were 44 cases of school failure among JIA patients, 30 had school re-entry. No children had school failure or re-entry among the control group. Multiple causes of absenteeism like flare, hospitalization, side effects of drugs, movement difficulties, Children who did not participate in sports activities were 9.3% in control group and 48.5% in case group (p value < 0.001). Conclusion: It is evident from this study that JIA has negative impact on schooling characterized by poor attendance and academic performance


Lipid Profile in Juvenile Idiopathic Arthritis  Patients in Active and Inactive State of Disease.

Mydul Islam Khan, Shahana A Rahman.

Department of Paediatrics, Bangabandhu Sheikh Mujib Medical University, Dhaka , Bangladesh

Background: Dyslipidemia is a feature of JIA and may act as a fertile soil for future cardiovascular morbidity due to pro-atherogenic pattern of lipid that may run in parallel with inflammation. Objective: To assess and compare the lipid profile in active and inactive state of disease and to determine the relationship of lipid profile with disease duration and inflammatory activity at baseline. Material and Method: In this prospective observational study, 55 newly diagnosed cases of JIA fulfilling the ILAR criteria were included. History, clinical examination and laboratory parameters including fasting lipid profile, ESR, CRP and other base line investigations were recorded in a questionnaire. Result: Low level of HDL and abnormal high level of TG was present in most of the patients (70.9% and 45.5% respectively) when the levels were adjusted with age range. Positive correlation of TC, LDL; and negative correlation of HDL with CRP was found (p- value 0.047, 0.004 and 0.004 respectively). While lipid profile was compared between active and inactive disease state, HDL cholesterol and TG levels were significantly improved. Conclusion: Dyslipidemia was present in JIA patients that included low HDL cholesterol levels and high TG levels. This pro-atherogenic lipid profile became normal when the disease became inactive.

Serum Lipid Profiles in Pediatric Systemic Lupus Erythematosus Patients: A Study from Bangladesh

Mohammad Mofizul Islam, Shahana Akhter Rahman, Mohammad Imnul Islam, Satya Narayan Chaudhary, Mohammad Aminul Islam, Mohammed Mahbubul Islam, Manik Kumar Talukder

Department of Paediatrics, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh

Objective: To assess the lipid profile in pediatric SLE (pSLE) patients in active disease state and compare it with inactive state. Methodology: It was an observational study carried out in the Department of Pediatrics, Bangabandhu Sheikh Mujib Medical University, Shahbagh, Dhaka-1000, Bangladesh from January 2013 to June 2014. A total 30 patients fulfilling the ACR 1997 criteria were enrolled in this study. Age and sex matched 15 controls were also included. Lipid profiles were measured at diagnosis, at 3 months and at 9 months follow up. Results: At the time of diagnosis, pSLE patients’ mean triglyceride level and HDL cholesterol levels were significantly abnormal. At 3 three months follow up, when disease activity was high and patients were on high dose steroid therapy, there was increased total cholesterol, LDL and HDL cholesterol level. At 9 months follow up when most of the patients had inactive disease and were on low dose steroid, all the lipids were within normal range. Comparison of active disease group with inactive disease group at 9 months found significant improvement of total cholesterol, triglycerides and HDL cholesterol levels. Conclusion: Control of SLE seems to be the most important factor in normalizing the lipids.

Comparison of Serum Immunoglobulin Concentrations During Active and Inactive Disease States in Juvenile Idiopathic Arthritis Patients.

Sajib Mohammad Raiyhan, Mohammad Imnul Islam, ShahanaARahman.

Department of Paediatrics, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh

Background: It is expected that most of the JIA patients have abnormal immunoglobulins  during active diseases state which would become normal after treatment during inactive disease state. Objective: Comparison of serum Immunoglobulin (IgG, IgM and IgA) concentrations during active and inactive disease states in patients with Juvenile Idiopathic Arthritis (JIA). Method: This was a prospective observational study. Diagnosed oligoarticular and polyarticular JIA patients attending paediatric rheumatology clinic and in patient department of Bangabandhu Sheikh Mujib Medical University  were included in the study. Quantitative measurements of serum IgG, IgA and IgM were measured at the time of diagnosis  during active diseases state and again repeated when disease state became inactive during follow up. Result: Out of 33 JIA patients, 13 were male and 20 were female. Mean age was 7.97±3.72 years. Among them 22 were Oligo JIA and 11 were poly JIA patients. Mean IgG, IgM, IgA was 13.04±4.41 and 9.88±2.31 g/L, 3.25±1.80 (High normal range) and 1.82±0.88 g/L, 3.29±1.18 and 1.34±0.47 g/L (low normal range)  in active and inactive state of disease, respectively.  Mean differences of immunoglobulin between active and inactive disease state were significant. Conclusion: High concentration of IgG, IgA, and IgM were found during active disease state of JIA patients which became low in inactive state of disease. 

Thyroid Functions and Thyroid Auto-Antibodies in Paediatric Systemic Lupus Erythematosus Patients: A Study from Bangladesh

Satya Narayan Chaudhary, Shahana Akther Rahman, Mohammad Imnul Islam,  Suraiya Begum, Manik Kumar Talukdar, Md Israque Hossain Ansari, Mizanul Hasan

Department of Paediatrics, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh

Background: Thyroid dysfunction may be associated in pediatric SLE cases and may present as euthyroid, subclinical hypothyroid, hypothyroid or hyperthyroid states. Objective: Aim of this study was to assess thyroid functions (serum T3, T4,TSH) and thyroid antibodies in pediatric SLE patients. Method:  It was a cross sectional study. Pediatric SLE patients who fulfilled the ACR 1997 revised classification criteria for SLE were enrolled in this study. Sixteen apparently healthy children were enrolled as reference group.Disease activity was measured by systemic lupus erythematosus disease activity index (SLEDAI). Serum T3, T4, TSH and auto-antibodies including, anti-thyroid peroxidase (anti-TPO) and anti- thyroglobulin (anti-TG) were measured by radio-immuno assay method in the National Institute of Nuclear Medicine and Allied Sciences, Bangabandhu Sheikh Mujib Medical University,Dhaka. Result: Among a total number of 50 pSLE cases, 41 (82%) cases were in euthyroid state, 4 had subclinical hypothyroidism, 3 had hypothyroidism and 2 patients had euthyroid sick syndrome. All the cases of reference group were in euthyroid state. Anti-thyroid peroxidase (TPO) antibody was positive in 24 pSLE cases and anti-thyroglobulin (TG) antibody was positive in 16 patients. Thyroid disorder was present in 9 cases and 7 of them had positive anti-TPO antibody. Conclusion: Thyroid disorders and presence of thyroid auto antibodies were common in pSLE patients. Anti-TPO positivity was more common than Anti-TG positivity.


Assessment of Serum Concentrations of Vitamin D, Calcium, Inorganic Phosphate, Alkaline Phosphatase and Parathormone in Juvenile Idiopathic Arthritis Patients in Bangladesh

Sufia Khatun Sumi, Shahana A Rahman, Mohammed Mahbubul Islam, Mohammad Imnul Islam, Manik Kumar Talukder

Department of Paediatrics, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh

Background: There are multifactorial causes of decrease in bone mass in JIA patients which correlate with the duration of active disease. By measuring the vitamin D level we can assess the deficiency or insufficiency earlier and can predict the risk of osteoporotic bone fracture and can give appropriate supplementation of vitamin D and calcium. Objective: This study was done to determine the status of serum 25(OH) D, calcium, inorganic  phosphate, alkaline phosphatase and parathormone (PTH) in patients with JIA. Method: It was a cross sectional study. Thirty newly diagnosed cases of   JIA attending the pediatric rheumatology clinic of Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from July 2014 to December 2015 were included. Fifteen age and sex matched control were selected. Serum 25(OH) D, calcium, inorganic phosphate, alkaline phosphatase and parathormone were measured in cases and controls. Result: Among JIA patients, 60 % and among controls 33% had hypovitaminosis D. In JIA group the mean level of all biochemical parameters were significantly lower than control group except serum 25 (OH) D levels. Level of 25(OH) D was decreased as disease duration increased and level of calcium, inorganic phosphate and alkaline phosphatase decreased with the decrease of 25 (OH) D levels and there was no change of parathyroid hormone level. Conclusion: More than half of JIA patients had hypovitaminosis D. There was positive relationship between 25(OH) D level and other biochemical parameters except PTH and negative relationship between 25(OH) D level and disease duration


Hla-Dr Typing and Different Clinical Manifestations of Paediatric Systemic Lupus Erythematosus Patients in A Tertiary Hospital, Bangladesh

Susmita Das, Md Imnul Islam, Manik Kumar Talukder, Shahana A Rahman

Department of Paediatrics, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh

Introduction: Association of Major histocompatibility complex (MHC) with SLE is widely studied and found that HLA class II genes are strongly associated with SLE. Among HLA-DR types, some alleles are considered as risk factors for clinical manifestations and some alleles may predict early diagnosis of different organ involvement. Objective: To determine the association between HLA-DR typing with different clinical manifestations in paediatric SLE patients. Methodology: It was a cross-sectional study. Thirty two newly diagnosed cases of pSLE were included in this study. Age and sex matched 10 apparently healthy children were selected as control. Result: Most predominantly found HLA-DR types among pSLE cases were DR15 (63%), DR07 (41%) and DR04 (31%). HLA-DR07 was found in 80% of control group which was significantly different (p<0.05). In this study, pSLE patients presented with skin rash (84%) followed by constitutional symptoms (78%), renal features (75%), musculoskeletal (68%) and gastrointestinal (60%) manifestations. HLA-DR15, DR07 and DR04 were most frequent in above mentioned manifestations, but HLA-DR13 was not present in patients with renal manifestations (p<0.05). HLA-DR11 and DR13 showed significant association with arthritis and hematologic manifestations were associated with DR11. Conclusion: Among HLA-DR types, most frequently associated alleles were DR15 followed by DR07 and DR04.This study found significant association of HLA-DR types with different clinical manifestations of pSLE patients

Patterns and Consequences of  Post-Chikungunya Arthritis - A Longitudinal Study in a Tertiary Care Hospital in Bangladesh

Sigma Hossain, Minhaj Rahim Choudhury, Md. Ariful Islam, Md. Masudul Hassan, Surayea Yeasmin

                       Bangabandhu Sheikh Mujib Medical University, Dhaka Bangladesh     

Introduction: Chikungunya (CHIK) fever, is a viral illness, characterized by 3-7 days of high fever, headache, rash, myalgia, and severe arthralgias/arthritis, the hallmark of the disease. The aim of the study was to identify the clinical patterns and consequences of post-chikungunya arthritis. Methodology: This longitudinal study was carried out during a major out-break of CHIK infection in Dhaka, Bangladesh in 2017. One hundred and forty-two IgM and/or IgG positive patients were included in the study who were followed up for the next one year. A semi-structured questionnaire along with validated Bengali version of Health Assessment Questionnaire (HAQ) was used for face to face interview. Result: The mean age of the patients was 43.12±10.94 years where 72 patients (50.7%) were male and 116 patients (81.7%) were urban resident. Ninety-six patients (69.7%) had polyarthritis whereas 36 patients (25.4%) had Oligoarthritis in the acute and subacute stage. Symmetrical joint involvement was present in 120 patients (84.5%). MSUS findings of 32 patients showed that tenosynovitis, tendinitis and synovial hypertrophy were found in 24 (75.0%), 6 (18.7%) and 4 (12.5%) patients respectively. The mean HAQ score was 1.34 ±0.72 at baseline. After 3months (D90), Chronic CHIK arthritis developed in 59 (41.5%) patients. Among them, 35(59.3%) patients were undifferentiated arthritis (UA) whereas 8(13.5%) had RA and 16(27.1%) had SpA. At the end of 1year, among 27 patients with persistent disease,10 (21.7%) had monoarthritis, 14 (30.4%) had oligoarthritis and 3 (6.5%) had polyarthritis. Mild, moderate and severe functional disability was present in 42 (89.4%), 3 (6.4%) and 2 (4.3%) patients respectively. Twelve patients were dropped out at the end of one year. Conclusion:  Chronic arthritis is frequent in CHIK infection. A significant number of patients did not follow any particular pattern however RA and SpA also frequent.

Assessment of Vitamin D, Calcium and Bone Mineral Density in Juvenile Idiopathic Arthritis Patients

Md. Shahin Akter, Shahana A Rahman

Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh

Objective: To assess the serum concentrations of vitamin D, calcium and bone mineral density (BMD) in with juvenile idiopathic arthritis (JIA) patients and to compare them with those of healthy children. Method: In this  cross sectional study, 75 JIA cases were compared with age, sex matched healthy controls. Laboratory evaluations included serum calcium and 25-hydroxy vitamin D.  BMD was assessed by Dual energy X ray absorptiometry of the lumbar spine and both femur neck. In children, low bone mass was defined as a Z-score of BMD equal to or less than -2. Result: Mean vitamin D level in both cases and controls was low. But in cases it was much lower. Vitamin D deficiency and insufficiency in JIA patients was 69.3% and 21.3% respectively. Mean concentration of serum calcium of cases was 9.46±0.46 mg/dl. Low bone mass in JIA patients at lumbar, right femur and left femur was found as 97.3%, 69.3% and 70.7% respectively. All types of JIA had low bone mass in lumbar vertebrae. BMD Z-score in right and left femoral neck showed a significant correlation with types of JIA (p=0.007 and 0.035 respectively). There was no significant association between disease duration and vitamin D or BMD. Conclusion: Hypovitaminosis D was frequent in JIA patients and healthy controls and low BMD was common among JIA cases.

Assessment of Disease Activity in Systemic Lupus Erythematosus- Validation of Four Common Clinical Indices

  Abul Khair Ahmedullah, Md. Nazrul Islam, Md. Ariful Islam, Alamgir Mushtak Ahammad,           Syed Atiqul Haq

Department of  Rheumatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh           

Background: Disease activity tools are important for the clinical evaluation of SLE patients. Objective: This study was aimed to assess the reliability and validity of SLEDAI, SLEDAI-2K, MEX-SLEDAI and SLAM indices to SLE response outcome.  Method: This observational study was conducted in the SLE clinic of BSMMU Dhaka, Bangladesh. The 4 tools SLEDAI, SLEDAI-2K, MEX-SLEDAI and SLAM indices were tested in 43 consecutive SLE patients fulfilling ACR criteria after having ethical clearance from IRB of Bangabandhu Sheikh Mujib Medical University. The evaluations were done by 2 qualified physicians on 3 occasions, in an interval of 3 to 5 weeks. Result:  Out of 75 enrolled subjects all indices were served on 3 occasions by two physicians in 43 cases. Convergent validity among instruments was R2= 0.486 to 0.952. Reliability of instruments were SLEDAI (R2= 0.94, 0.98, 0.90 at 1st, 2nd and 3rd visit), SLEDAI-2K (R2= 0.92, 0.98, 0.87 at 1st, 2nd and 3rd visit), MEX-SLEDAI (R2= 0.92, 0.94, 0.85 at 1st, 2nd and 3rd visit) and SLAM (R2= 0.96, 0.93, 0.93 at 1st, 2nd and 3rd visit). The coefficient of responses ranged from 1.1 to 2.3 for improvement and 0.7 to 1.5 for worsening. The SLEDAI had the best mathematical properties with sensitivity 86%, specificity 99% and overall accuracy of 94%. The MEX-SLEDAI had 63% sensitivity and 96% specificity with an overall accuracy of 78%. The convergent validity was shown by the strong correlation of scores among the different instruments (R2= 0.488 to 0.964). Conclusion: The SLEDAI, SLEDAI-2K, MEX-SLEDAI and SLAM indices instruments are reliable and valid. In resource constrain situations MEX-SLEDAI can be considered as a clinical evaluation tool. 

Translation, Adaptation as well as Validation of  Osteoporosis Questionnaire and Assessment of Knowledge on Osteoporosis in College Students

Rezaul Karim, Md. Nazrul Islam, Abul Khair Ahmedullah

Department of Rheumatology, Bangabandhu Sheikh Mujib Medical University,Dhaka, Bangladesh

Objective: To test reliability of translated and culturally adapted Bangla version of the Osteoporosis Knowledge Assessment Tool (OKAT) and assessment of knowledge on osteoporosis in college students. Method: This observational study was of two parts. The part one consisted of two phases; phase 1 and phase 2. At phase 1, the original English OKAT questionnaire was translated into Bangla and adapted in the local socio-cultural context following the standard recommendation by Beaton et. al. published in 2000. At phase 2 of the study, test-retest reliability was assessed on 126 rheumatic patients and healthy attendants. Content validity was assessed using item level and scale level content validity index. Construct validity was assessed using factor analysis. Cronbach’s Alpha value was considered for internal consistency assessment of questionnaire. Test-retest reliability was assessed using intraclass correlation coefficient. In second part of study, adapted Bangla version of OKAT questionnaire were served in 406 college students. Students who answer >60% of question were considered knowledgeable about osteoporosis. Chi-square test was used to assess gender based knowledge. Result: In part one, understandability was done on 20, twelve years old (class VI) school going children of both genders. All items were understood. Mean age of pretest subject was 36.52+9.49 years, response rate was 100% and two English words were adapted. Mean age of test-retest subjects was 31.60+10.22 years. Both I-CVI and S-CVI score was 1, indicating high content validity, Intraclass correlation was (0.55 to 0.94) showed strong test-retest reliability. Cronbach’s Alpha was 0.636 and acceptable. Second part of study, mean age of college students was 20.49+1.27 years. Only 7.9% of students was answer >60% of question. Conclusion: The psychometric properties of translated and culturally adapted Bangla version of OKAT were acceptable. The college students had poor knowledge on osteoporosis.

Osteoporosis Screening Recommendations in Contrast to Clinical Practice; Review of FRAX-Based Treatment Thresholds and Use of Forearm Bone Mineral Density

Asif Hasan Khan1, Md. Nazrul Islam1and2, Fahid Bin Nazrul2 , Nira Ferdous2and3                                  Abul Khair Ahmedullah1

1Department of Rheumatology, Bangabandhu Sheikh Mujib Medical University , Dhaka, Bangladesh;                2Modern One Stop Arthritis Care and Research Center®, Dhaka, Bangladesh;                       3Department of Medicine, MH Samorita Medical College, Dhaka, Bangladesh

Aim:To evaluate fracture risk assessment tool (FRAX)-based treatment thresholds and utilization of forearm bone mineral density. Method: In this cross sectional observational study, 275 clinically suspected cases of osteoporosis aged more than 50 years with self reported height loss, clinically unexplained low back pain, early menopause (<45 years of age), lean and thin, short stature and spinal deformity (Kyphosis) were enrolled. Bone mineral density was measured at lumbar spine, neck of femur on both sides and distal radius on non-dominant side. FRAX score was calculated by FRAX calculator (India model). Result: FRAX-based treatment thresholds were found higher in  years of age group. Osteoporosis was found in distal radius (65.1%), followed by lumbar spine (38.5%) and neck of femur (17.1%). Spine levels as L1-L2 detected most cases of osteoporosis. Sensitivity, specificity, positive predictive value and negative predictive value were 8.51%, 97.37%, 40% and 83.77% respectively when 10-year probability of major osteoporotic fracture without bone mineral density was compared with osteoporosis level of femoral neck. Sensitivity, specificity, positive predictive value and negative predictive value were 84.91%, 47.38%, 50.28% and 83.33% respectively when bone mineral density at distal radius was compared with osteoporosis level of lumbar spine. Sensitivity, specificity, positive predictive value and negative predictive value were 87.23%, 39.47%, 22.91% and 93.75% respectively when bone mineral density at distal radius was compared with osteoporosis level of femoral neck. Conclusion: Forearm bone mineral density showed good sensitivity and negative predictive value in relation with bone mineral density of lumbar spine and femoral neck. So, as a screening test in suspected osteoporosis cases with normal lumbar spine and femoral neck bone mineral density values, forearm bone mineral density measurement can give more treatable cases.

Urinary Tract Infection in Patients of Systemic Lupus Erythematosus-Report from A Developing Country

Mohammad Abul Kalam Azad , Md. Nazrul Islam

Department of Rheumatology, Bangabandhu Sheikh Mujib Medical University,Dhaka, Bangladesh

Background: Urinary tract infection (UTI) is one of the important causes of morbidity and mortality in Systemic Lupus Erythematosus (SLE). Objective: To observe the frequency, causative organisms and risk factors for UTI in SLE. Method :This observational study was conducted in the department of Rheumatology, BSMMU, Dhaka, Bangladesh from September 2012 to January 2014. A total 169 diagnosed SLE patients were enrolled consecutively. Patients with features of urinary tract infection were considered as case and symptoms negative considered as controlled. The patients having DM, recurrent UTI and having communication problem were excluded. Urinary symptoms including demographic variables, disease activity index (SLEDAI), organ damage index (SLICC/ACR) were evaluated. Dose, duration and cumulative dose of steroid, HCQ, MMF, azathioprine and cyclophosphamide were evaluated for risk factors of UTI. Serum C3, C4, CRP, ANA, anti-ds DNA, CBC, urine R/E with C/S were done. Result :Out of 169 patients 19 patients were excluded. In forty patients UTI was diagnosed and observed high.  Most common organism detected was E. coli.   High disease activity, organ damage in frequency 28.57%. The most common organism was E. coli (52.5%). High SLEDAI and SLICC/ACR score, lupus nephritis, and use of cyclophosphamide were found as risk factors for UTI by Bi-variate analyses. The use of cyclophosphamide in SLE patients were found as significant risk factor in multivariate analyses. Conclusion: Frequency of UTI in SLE was quiet the past, suffering from lupus nephritis, and use of cyclophosphamide were notable risk factors for UTI. 

An Assessment and Predictors of Response to Steroid Monotherapy in Patients of Takayasu Arteritis in Bangladeshi Population: A Longitudinal Study

Farzana Shumya1,  Ahmad Mursel Anamb2and3, Minhaj Rahim Choudhurya1, Abu Shahina1,            Syed Atiqul Haque1, Md Nazrul Islam1

1Department of Rheumatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh, 2International Fellowship Trainee,  3Department of Acute and General Internal Medicine, Western General Hospital, Edinburgh

Introduction: Efficacy of steroid in Takayasu arteritis (TA) varies in different studies. Some recent studies show that the efficacy of steroid is < 20%, which is lower than the previous studies. In addition, different groups have different opinion regarding induction therapy, whether it is monotherapy only with prednisolone (Pred) or combined with immunosuppressive medication in TA. The aim is to assess the remission rate with prednisolone in TA in Bangladeshi population and to determine the characteristics in patients which will guide physician to choose initial induction therapy. Methodology: Twelve consecutive active TA patients were enrolled and received 1 mg/kg prednisolone (pred). Disease activity assessed using the Indian Takayasu Activity Score- CRP (ITAS-CRP). The patients were followed after 1 month of starting pred and disease activity reassessed. The patients who were not in remission or relapse during tapering of pred put on methotrexate and followed. Follow- up continued up to 12 months. Result:  After 1 month 45.5% (CI: 17.28-73.62) patients went into remission. Relapsed during tapering of pred was 80% and 9.1% patients were in sustained remission only with pred. The relapsed rate on methotrexate during tapering of pred was 20% (CI: 44.6-19.75). Those patients had onset of symptoms less than 15 months prior to onset of therapy and did not have syncope, stroke, TIA and aortic regurgitation and hypertension responded to prednisolone. In 3 out of 11 patients’ pulses reappeared. Presence of carotidynia (P value 0.03) found as significant predictor for reappearance of pulse. Disease duration, baseline ITAS-CRP found lower in pulse reappearance group than the patients whose pulse did not reappear. Conclusion: The response to prednisolone is variable in different population of TA. Proper identification of baseline factors in Takayasu arteritis might help physician to decide induction regimen: with prednisolone alone or combined with immunosuppressive.

Lag Time Between Onset of Symptoms and Initiation of Dmards Therapy in Patients with Rheumatoid Arthritis and Factors Influencing The Lag Time in Bangladesh

Md. Zahid Amin, Shamim Ahmed, Syed Atiqul Haq, Minhaj Rahim Choudhury

Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh

Introduction:  Rheumatoid arthritis (RA) is a chronic disease leading to progressive joint damage, disability and increased morbidity. The initial three months after symptom onset represent an important therapeutic window. No effort was made so far in Bangladesh to know the extent of treatment delay and possible causes of this delay. Method: This cross sectional study was conducted in outpatient department of rheumatology, BSMMU from January 2017 to June 2018.  For generating possible factors that may be responsible for the delay focused group discussion were done including seven members (three rheumatologists and four residents) in the group. Preliminary questionnaire were served among ten patients to refine questionnaire and to add factors. A total 154 patient aged ≥ 18 years who met 2010 ACR/ EULAR criteria for RA were enrolled after having written informed consent. Associations between the lag time and the factors affecting the lag time were analyzed by multiple linear regression analysis. Result: The mean lag time between onset of symptoms and starting of Disease Modifying Anti Rheumatic Drugs (DMARDs) in our patients were 28.6±36.1 months. Mean distance from nearest rheumatology services for our patients were 48.7±59.7 kilometers whereas mean distance from nearest healthcare facility was 4.4±3.8 kilometers. Several factors were found to be significant in the regression model like year of RA symptom onset, predominant pattern of initial joint involvement, improper referral by primary care physician, lack of correct information on availability of physicians having expertise in RA treatment (p < 0.05). Conclusion: Based on our findings it would be prudent to take several steps to decrease treatment delays in our country like adopting policies to increase the number of rheumatologists, establishing proper referral pathways and  building mass awareness regarding benefits of early management of this chronic debilitating disease.

Daily Administration of Different Dosages of Indomethacin and Etoricoxib in Axial Spondyloarthritis

Khandker Mahbub-Uz-Zaman1, Pallab Chakraborty3, M Masudul Hasan1, AbulKhair Ahmedullah1, Md. Ariful Islam 1, Nira Ferdous2and4, Md. Nazrul Islam1and2

1Department of Rheumatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh;  2Modern One Stop Arthritis Care and Research Center®, Dhaka, Bangladesh;                    3Immunization and Vaccine Development Programme, World Health Organization;              4Department of Medicine, MH Samorita Medical College, Dhaka, Bangladesh.

Aim: To determine serum creatinine change with different dosages of indomethacin and etoricoxib in AxSpA. Method: This two-phased randomized clinical trial was conducted in the Rheumatology department, BSMMU. In phase 1, group A (n=32) and group B (n=29) patients received indomethacin 75 mg bid and 50 mg bid respectively with omeprazole. At 3rd week, serum creatinine and response (BASDAI<4) was evaluated. In phase 2, non-responders and drug intolerants (of phase 1) of group A (n=14) and group B (n=27) received daily etoricoxib 90 mg and 60 mg respectively with omeprazole. At 3rd week visit of both phases, non-responders were excluded and responders followed up till 24 weeks. Result: The results of 3rd weeks were shown. Mean age (n=61) was 31.2 ± 7.8 years, 67.2% male. Lower dosages of both drugs were minimally effective. With indomethacin 150 mg (n=32), 3 patients had raised s.creatinine (> 25% from baseline), out of them 1 (3.1%) had s.creatinine >1.3 mg/dl (1.69 mg/dl). With etoricoxib 90 mg/day and 60 mg/day none had raised s.creatinine. No significant rise of blood pressure with either drug. BASDAI score <4 was in 23 (71.9%), and 3 (21.4%) with indomethacin 150 mg and etoricoxib 90 mg respectively. Improvement of ASQoL score with; indomethacin 150 mg (4.0±2.5) and etoricoxib 90 mg {-0.6±2.5 (deteriorated after improvement with indomethacin)}. With indomethacin 150 mg/day, 40.6% reported dizziness, of them 3 dropped. Conclusion: Indomethacin 150 mg/day was effective without significant creatinine rise, but with frequent dizziness. Etoricoxib was minimally effective in indomethacin refractory cases.


Study on Low Back Pain and Disability in Auto Rickshaw Drivers

Kazi Rakibul Islam, Sarder Mahmud Hossain, Bilkis Banu, Ulfat Ara

Department of Public Health, Northern University, Dhaka, Bangladesh

Background: Work-related musculoskeletal disorders, especially low back pain, cause substantial economic losses to individuals as well as to the community. Professional drivers have been found to be at high risk for developing LBP due to prolonged sitting and vehicle vibration. Objective: This study was carried out to determine the level of low back pain and disability among 220 auto rickshaw drivers in Dhaka city. Method: This descriptive cross sectional stud was done on 220 auto rickshaw drivers in Dhaka city.  Samples were taken by purposive sampling technique and data were collected by face to face interview among the auto rickshaw drivers from four CNG stands and two garages around Dhaka city with a pretested, modified and semi-structured questionnaire. The level of disability was determined by Oswestry Disability Index. Data processing and analyses were done using SPSS version 19. Result: It was found that the age range of the respondents was 25 to 60 years. Among them 45.5% respondents were in 31-40 years of age group with a mean of 34.95 ± 7.732 years. About 36.4% of the respondents’ working period was more than 10 years. The study demonstrated that maximum (62.7%) auto rickshaw drivers reported low back pain and 75.4% had minimal disability and remaining 24.6% had moderate disability. The study found significant association of low back pain with age and working days in a week (p<0.05). Another association between sitting posture and low back pain was found highly significant (p<0.001). Conclusion: Low back pain is a frequent phenomenon in Bangladesh as well as all over the world. So, occupational health and safety management programs should be implemented to prevent adverse health effect among auto rickshaw drivers.

Efficacy and Safety of Tofacitinib in the Treatment of NSAIDs-Refractory Axial Spondyloarthritis: A Clinical Trial

Md. Asadul Islam, Md. Nahiduzzaman Shazzad, Shamim Ahmed, Syed Atiqul Haq, Sigma Hossain

Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh

Introduction: Tofacitinib is a targeted synthetic disease modifying anti-rheumatic drug (tsDMARD), which affects cytokine pathway thereby modulate immune response and reduce inflammation. This study was carried out to assess the efficacy and safety of Tofacitinib in the treatment of NSAIDs refractory axial spondyloarthritis (SpA). Method: In this open label clinical trial, Tofacitinib 5 mg twice daily was given to the 52 NASIDs refractory axial SpA patients. At the end of 3rd month, the patients were assessed for the efficacy of the drug. Primary efficacy end point was ASAS 20 response. At the end of 3rd month the patients who had ASDAS CRP improvement more than or equal to 1.1, they continued with the same 5 mg twice daily dose of Tofacitinib. The patients who did not have ASDAS CRP improvement more than or equal to 1.1, the dose of Tofacitinib was increased to 10 mg twice daily. All the patients were assessed at the end of 6th month. Secondary efficacy endpoints were ASAS 40, ASAS 70 response, ASDAS CRP <1.3, ASDAS ESR <1.3, BASDAI<2. Result: ASAS 20 responses were achieved by 73.01% patients at the end of 3rd month and 82.7% patients achieved it at the end of 6th month. ASAS 40 and 70 response was achieved by 65.4% and 30.8% at the end of 3rd month and 76.9% and 44.2% at the end of 6th month. ASDAS CRP improvement more than or equal to 1.1 was by 80.8 % patients. ASDAS ESR <1.3, ASDAS CRP <1.3 and BASDAI <2 was achieved by 21.4%, 50% and 71.4% patients at the end of 6th month. Conclusion: Tofacitinib 5mg twice daily is effective and safe for the treatment of NASIDs refractory axial Sp A. Tofacitinib 10 mg twice daily has more efficacies and less safety than 5 mg twice daily dose.


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