Objective: To identify factors causing diagnostic and therapeutic delay in patients with rheumatoid arthritis, and to evaluate relationship of diagnostic and therapeutic delay with disease outcome.
...Methods: This cross-sectional study was conducted in Rheumatology Department, Fatima Memorial Hospital, Lahore, Pakistan, from May 2018 to July 2018. In this study 102 patients fulfilling ACR/EULAR criteria 2010 were enrolled. Lag times were calculated in months: lag-1 (delay in initial medical consultation); lag-2 (delay in consulting rheumatologists); lag-3 (diagnostic delay); lag-4 (therapeutic delay). Disease activity and functional outcome were measured by DAS28, HAQ-DI respectively. Association of lag-3 and lag-4 with HAQ-DI and DAS28 was calculated by Pearson correlation.
Results: Median (IQR) disease duration of study group was 6(2-10) years. Initial consultations were with; orthopedic surgeon 40(39.2%), general practitioner 27(26.5%), rheumatologist 13(12.7%), medical specialists 14(13.7%). Median (IQR) lag times in months: lag-1 (delayed initial consultation): 2(0-5), lag-2 (delay in consulting rheumatologist): 30(7.7-72), lag-3 (diagnostic delay): 12(3-48), lag-4 (therapeutic delay):18(5.7-72). Factors attributed to lag-3 (diagnostic delay) and lag-4 (therapeutic delay) (p<0.05): older Age (r= 0.2), education level (r= - 0.2), initial consultation (non-rheumatologist) (r=0.2), lag-2(r=0.8), >three doctors visited before diagnosis(r=0.6). Positive anti-CCP antibodies(r=0.2) and lag-1 (delayed initial consultation) (r=1) were associated with lag-3 (diagnostic delay) only; no association was found with positive RA factor. Significant correlation (p=<0.05) of lag-3 (diagnostic delay) was found with both DAS28(r=0.2) & HAQ-DI(r=0.2). Similarly lag-4 (therapeutic delay) also correlated with both & DAS28(r=0.2) & HAQ-DI(r=0.3) (p=<0.05).
Conclusion: Diagnostic and therapeutic delay were associated with older age, lower education and delayed consultation with rheumatologist but not with positive RA factor. Positive anti-CCP antibodies were associated with diagnostic delay only. Diagnostic and therapeutic delay led to high disease activity and poor functional outcome in RA patients.
doi: https://doi.org/10.12669/pjms.37.4.3471
How to cite this:Naeem F, Khan SEA, Saeed MA, Farman S. Diagnostic and therapeutic delay in Rheumatoid Arthritis patients: Impact on disease outcome. Pak J Med Sci. 2021;37(4):1001-1007. doi: https://doi.org/10.12669/pjms.37.4.3471
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Objective
The aim is to determine the pattern of initial clinical presentations of systemic lupus erythematous (SLE) in patients in a Pakistani lupus cohort.
Methods
This is a multi-centric, ...retrospective, descriptive study that was done through the analysis of electronic records of patients registered with outdoor clinics of the Arthritis Care Foundation (ACF) from November 2021 to March 2023. Follow-up records of all patients diagnosed and labeled as SLE as per ACR/EULAR criteria 2019 were reviewed and only those patients whose initial presentation of SLE was documented at their incident visit (after verifying the signs and symptoms from record of their GP/referring physicians’ visits) were included in the study. A total of 388 patients diagnosed with SLE were included in the study. Their data was then entered and analyzed by using SPSS 23. The qualitative data was expressed as percentages and numbers while the quantitative variables were expressed as mean and standard deviation. Data correlation was calculated by Chi-Square test, and a p-value of less than 0.05 was considered statistically significant.
Results
Of our 388 patients, 360 (92.8%) were females and 28 (7.2%) were males giving a female-to-male ratio of 12:1. The mean age of our patients was 32.8 + 9.8 years. Mucocutaneous manifestations were most commonly reported in our patient group by 336 (86.7%) patients. Musculoskeletal complaints were the next most common presenting feature reported by 246 (61.9%) patients followed by constitutional symptoms in 78 (20.1%) patients, and renal involvement in 42 (10.8%) patients.
Conclusion
In our study, a majority of patients presented with mucocutaneous symptoms. It is therefore of paramount importance to suspect autoimmune diseases in patients with these system involvements.
Introduction
Pakistan has a population of over 200 million with only 75 trained rheumatologists. To address the needs of rheumatology care, it is of paramount importance to train the primary care ...physician as a first line of defense.
Methods
The project “Empowering Family Physicians; fighting disability” was the recipient of a 2018 ILAR grant. This project began with development of an evidence-based curriculum using ACR Rheum2learn modules along with guidelines from international societies. A blended learning approach was chosen with nine online learning modules sandwiched between two face-to-face sessions. Participants’ assessment entailed quizzes, clinical scenarios, and portfolio development all completed online, while face-to-face sessions relied upon power-point presentations and an objective structured clinical examination. Course impact was assessed with pre-course and post-course questionnaires. Overall perception of the training was evaluated through candidate feedback.
Results
Participants were enrolled from across the country totaling 48 health care providers (44 family physicians and 4 allied health professionals). The adherence to face-to-face sessions was 82.5% and 63.6% for the online component. The mean score for post-course assessment (mean = 2.369, SD = 0.3425) was significantly higher than for the pre-course assessment (mean = 1.792, SD = 0.4838) with statistically significant difference of,
t
(12) = − 7.756,
p
< 0.0001 (confidence interval: − 0.7390 to − 0.4149). The perception of the strategy was positive with 80% strongly satisfied with the workshops and presentations.
Conclusion
Empowering family physicians by training them in rheumatology care can be an effective tool to fight unmet needs in access to musculoskeletal health care. We plan to offer a shortened version of the course at regular intervals.
Key Points
• Pakistan has a huge shortage of rheumatology care with only 75 rheumatologists caring for a population of over 200 million.
• To improve access to rheumatology care,the “Empowering Family Physicians; Fighting disability” course was launched in 2018 with the help of anILAR grant.
• A blended learning approach comprising of 9 online modules sandwiched between two face-to-face sessions was chosen.
• A statistically significant difference between pre- and post-courseself-assessment of participantssuggests that the courseis an effective tool for teaching Family Physicians.
The present study aimed to determine the pattern and cause of noninfectious uveitis in rheumatology practice. The secondary objective was to identify the pattern of treatment and outcomes.
This ...retrospective cross-sectional study was conducted in the Department of Rheumatology, National Hospital and Medical Centre, Lahore, Pakistan. After receiving consent, electronic medical records (EMRs) of all patients with a diagnosis of noninfectious uveitis (NIU) from November 2019 to January 2023 were reviewed, and a total of 52 patients labeled as having noninfectious uveitis were identified. The collected data included age at diagnosis, anatomical location of uveitis, associated systemic disease, used medications, and outcomes. All cases had been diagnosed and assessed mutually by a rheumatologist and an ophthalmologist using the International Uveitis Study Group classification system to classify the pattern of uveitis by location, clinical course, and laterality and rule out the possibility of other ophthalmologic diseases. Disease activity was defined using the Standardization of Uveitis Nomenclature (SUN) guidelines. Data was analyzed on SPSS Statistics version 23 (IBM Corp, Armonk, NY, USA).
The mean age of the patients in this study was 36.02 ± 43.31 years, with 31 (59.6%) male patients. Anterior uveitis was the most common type observed among the patients at 55.8%, panuveitis was found in 25%, intermediate uveitis and posterior uveitis were seen in 9.6% each. Based on laterality, unilateral eye involvement was identified in 53.8% of patients. Spondyloarthritis (SpA) and idiopathic uveitis were observed in 34.6% and 28.8%, respectively. In this study, 28 (54.9%) patients were on conventional disease-modifying antirheumatic drugs (cDMARDDs), and 23 (45.1%) were on biological DMARDs. In the biologics group, 82% of patients were in remission in comparison to 60% in the cDMARDs group.
To the best of our knowledge, this is the first report on noninfectious uveitis in the Pakistani population. The study concluded that anterior uveitis is the most common type of uveitis and is more common in males. Spondyloarthropathy is one of the most common underlying systemic diseases. Human leukocyte antigen (HLA)-B27 is associated more with uveitis. Biologics are more effective than cDMARDs in controlling the disease. Collaborative work between different specialties resulted in early diagnosis of underlying systemic disease, better management plans, and disease outcomes. To obtain further details on noninfectious uveitis, a population-based study is needed in Pakistan.
ABSTRACT Objective: To determine the short-term efficacy and safety of Secukinumab in Pakistani patients with ankylosing spondylitis and psoriatic arthritis in regular clinical practice. Study ...Design: Case series. Place and Duration of Study: Department of Rheumatology, National Hospital and Medical Centre, Lahore Pakistan from Aug 2019 to Feb 2021. Methodology: Patients diagnosed with ankylosing spondylitis according to assessment of spondyloarthritis International Society criteria and psoriatic arthritis according to classification criteria for psoriatic arthritis (CASPAR), who were started on Secukinumab, were enrolled. Disease activity scores and adverse events were recorded in the 12th and 24th weeks. The primary outcomes were remission and low disease activity, and the secondary outcomes were the recording of Adverse events on each visit. Results: There were 42 patients registered. The mean duration of disease was 11.86±7.31 years for AS and 9.19±4.87 years for PsA patients. At 24 weeks of follow-up, 10% of patients discontinued treatment, 73.7% of AS patients, and 94.7% of PsA patients achieved complete remission or low disease activity. No significant AEs were noted at 24 weeks, except for upper respiratory tract infections. One patient developed a lower respiratory tract infection after 24 weeks of treatment, and one died during treatment (possible myocardial infarction). Conclusion: Secukinumab was effective and safe in patients with Ankylosing Spondylitis and Psoriatic Arthritis in this study, despite advanced disease with long disease duration.
Objective: To determine the real-world efficacy and safety of subcutaneous Tocilizumab in patients with rheumatoid arthritis.
Study Design: Case series.
Place and Duration of Study: Department of ...Rheumatology, National Hospital and Medical Centre, Lahore Pakistan, from Aug 2019 to Dec 2020.
Methodology: In this study, 33 patients receiving subcutaneous Tocilizumab 162 mg every two weeks as monotherapy or with conventional synthetic disease modifying anti-rheumatic drugs were followed per standard study protocol. Increasing or decreasing the dosing interval was allowed according to disease activity at the discretion of the treating rheumatologist. The primary outcome was patients achieving Low Disease Activity as per Clinical Disease Activity Index (>2.8-10.0) and Disease Activity Score-28(>2.6-3.2). The secondary outcome was a clinically meaningful improvement in Disease Activity Score -28 (reduction of ≥1.2 units in Disease Activity Score-28 score). Adverse events were recorded at each follow-up visit.
Results: Of the 33 patients, 25(75.8%) were biologics-naive, 9(27.2%) patients achieved the target of Low Disease Activity as per Clinical Disease Activity Index (2.9-10.0) and 8(24.2%) patients achieved Low Disease Activity as per Disease Activity Score-28(2.7-3.2). At six months, the proportion of patients achieving clinically meaningful improvement (decrease ≥1.2) in Disease Activity Score -28 was 13(54.2%). Overall, 14(42.4%) patients developed adverse events and 3(9.1%) patients discontinued Tocilizumab owing to adverse events.
Conclusion: Tocilizumab has been seen to be an effective biologic in only one-third of patients, and it was tolerated in twothirds of the patients.Keywords: Conventional synthetic disease modifying anti-rheumatic drugs, Efficacy, Rheumatoid arthritis, Safety, Subcutaneous tocilizumab.
Objective: To determine the short-term efficacy and safety of Secukinumab in Pakistani patients with ankylosing spondylitis and psoriatic arthritis in regular clinical practice.
Study Design: Case ...series.
Place and Duration of Study: Department of Rheumatology, National Hospital and Medical Centre, Lahore Pakistan from Aug 2019 to Feb 2021.
Methodology: Patients diagnosed with ankylosing spondylitis according to assessment of spondyloarthritis International Society criteria and psoriatic arthritis according to classification criteria for psoriatic arthritis (CASPAR), who were started on Secukinumab, were enrolled. Disease activity scores and adverse events were recorded in the 12th and 24th weeks. The primary outcomes were remission and low disease activity, and the secondary outcomes were the recording of Adverse events on each visit.
Results: There were 42 patients registered. The mean duration of disease was 11.86±7.31 years for AS and 9.19±4.87 years for PsA patients. At 24 weeks of follow-up, 10% of patients discontinued treatment, 73.7% of AS patients, and 94.7% of PsA patients achieved complete remission or low disease activity. No significant AEs were noted at 24 weeks, except for upper respiratory tract infections. One patient developed a lower respiratory tract infection after 24 weeks of treatment, and one died during treatment (possible myocardial infarction).
Conclusion: Secukinumab was effective and safe in patients with Ankylosing Spondylitis and Psoriatic Arthritis in this study,despite advanced disease with long disease duration.Keywords: Ankylosing spondylitis, Efficacy, Psoriatic arthritis, Safety, Secukinumab.
To determine the level of depression in Rheumatoid Arthritis and its relationship with severity of Rheumatoid Arthritis.
This cross sectional analytical study was conducted from March 2014 to May ...2014. Total 102 cases of Rheumatoid Arthritis (RA) diagnosed as per ACR (American College of Rheumatology) 1987 criteria were enrolled from Rheumatology Department, Fatima Memorial Hospital. Severity of Rheumatoid Arthritis was assessed by Health Assessment Questionnaire (HAQ) and disease activity score (DAS - 28) while severity of depression was measured by Beck Depression Inventory (BDI) scale II questionnaire. The relationship between depression and disease activity (severity) of Rheumatoid Arthritis was assessed by calculating correlation coefficient between depression, disease activity score (DAS 28) of Rheumatoid Arthritis and health assessment questionnaire (HAQ).
Out of 102 patients, 77(75.5%) were females and 25(24.5%) males. The mean age of patients was 43.5± 11.9 years and the mean duration of disease was 7.8 ± 5.5 years.71.5% of Rheumatoid Arthritis patients were found to have some degree of depression and this was directly related to the severity of disease. Moderate and severe depression were present in 23 (22.5%) and 19(18.6%) patients respectively.
In this study, almost three-fourths of Rheumatoid Arthritis patients were found to have depression. There was a strong association between Rheumatoid Arthritis disease activity and the level of depression. So it is imperative for clinicians treating Rheumatoid Arthritis patients to screen them for co morbid depression and manage it accordingly.
Freedom of Expression guaranteed as fundamental right with reasonable restrictions replicates in every responsible media practice comprised for constant affairs of keeping abreast the public while ...situation in the province of Balochistan is multi-layered. In spite of the fact that there are many grey areas, media is still considered powerful in exercising its freedom and which is needed to be controlled in one sided perspective while another view depicts that unnecessary imposed restrictions curtail the true freedom. It is necessary to know that up to what extent freedom is given to exercise one's right and how and on what grounds, exercising the right may cause imposition of restrictions. Balance between Freedom and restrictions are reciprocal relationship of right and duty where understanding by different stakeholders in variant manner causes its true interpretation. Due to divergence of views, consensus on the proper code of conduct had not been built by authorities and media practitioners therefore practicing in exact accurate manner seems challenging in region of Balochistan particularly. Examining ethical standards practiced by Journalists and restrictions in order to determine future perspectives of Balochistan would be primarily focused through this research work. This study aims to explore the connection in the middle of practicing ethical standards and imposed reasonable restrictions in the guaranteed right under the provisions of Article 19 of the Constitution of Pakistan in the light of factual circumstances in Balochistan to recognize expected state for future viewpoint.
To determine the pattern of initial clinical manifestations of Systemic Lupus Erythematosus (SLE) and to compare these features with those recorded elsewhere in Pakistan.
This cross-sectional, ...descriptive study was performed in the Department of Rheumatology, Fatima Memorial Hospital, Lahore, Pakistan, from November 2015 to January 2016. Sixty one patients of SLE diagnosed as per ACR (American College of Rheumatology) 1982 revised criteria, were enrolled. The patients were evaluated for the initial clinical manifestations of SLE. The information was collected on a specially designed proforma and analyzed by using SPSS version 17.
Out of 61 patients, 49 (80.3%) were females and 12 (19.7%) males, showing a female to male ratio of 4:1. The mean age of patients was 26.2 ± 7.9 years. Fatigue was the most common presenting feature in 56 (91.8%) patients, followed by joint pains in 55 (90.2%) and fever in 54 (88.5%). Renal involvement was found in 46 (75.4%). Comparison of these presenting features was made with other studies carried out in Northern Pakistan (Islamabad) and in central Punjab (Pakistan). There were statistically significant differences in fever, fatigue and arthritis between our patients and the other two above mentioned study groups. However, comparison of renal manifestations showed significant difference only with Islamabad study, and not with previous study from central Punjab.
In this study, majority of patients presented with combination of fatigue, fever, rash and arthritis. Almost three-fourth of patients had renal manifestations at initial presentation. Therefore, it is important for clinicians to have high index of suspicion for SLE, when patients present with above symptoms.
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