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Persistent hypertension in lupus nephritis and the associated risk factors

Shaharir SS, Mustafar R, Mohd R, Mohd Said MS, Gafor HA

Clin Rheumatol, 2015 Jan;34(1):93-7.
PMID: 25373448 DOI: 10.1007/s10067-014-2802-0

Arterial hypertension (HPT) burden up to two third of systemic lupus erythematosus (SLE) patients and contributes to accelerated atherosclerosis and cardiovascular (CV) risk. We aim to determine the prevalence of HPT among lupus nephritis (LN) patients who were in complete remission (CR) for a minimum of 6 months, with estimated glomerular filtration rate (eGFR) of >60 mL/min/1.73 m(2). This is a cross-sectional study of 64 LN patients who attended Nephrology/SLE Clinic at The National University of Malaysia Medical Centre (UKMMC). Persistent hypertension (blood pressure (BP) ≥140/90 mmHg for at least two occasions), CR for a minimum of 6 months and eGFR of >60 mL/min/1.73 m(2) were identified. Univariate and multivariate analyses were performed to determine the demographic and disease characteristics associated with HPT. Thirty-four of them (53.1 %) were hypertensive. Persistent HPT was associated with disease duration, acute kidney injury and high BP at the onset of LN, longer duration interval to achieve CR, number of relapses and cyclosporine A (CyA) use. There were no associations between histological classes, nephrotic range proteinuria, body mass index and waist circumference with HPT. Factors independently associated with HPT were disease duration OR 1.06 [95 %CI (0.91-1.24)], longer duration interval to achieve CR OR 1.104 [95 %CI (1.02-1.19)], number of relapses OR 2.53 [95 % CI (1.01-6.3)] and CyA use OR 5.3 [95 % CI (1.14-23.9)]. The prevalence of HPT among LN is high despite in remission. Aggressive treatment is important to achieve early CR and to prevent relapses.
Study site: Nephrology/SLE clinics, Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM), Kuala Lumpur, Malaysia
Rituximab for refractory digital infarcts and ulcers in systemic sclerosis

Khor CG, Chen XL, Lin TS, Lu CH, Hsieh SC

Clin Rheumatol, 2014 Jul;33(7):1019-20.
PMID: 24722688 DOI: 10.1007/s10067-014-2579-1

Systemic sclerosis is an uncommon connective tissue disease characterised by excessive deposition of collagen and vasculopathy which affects the skin and multiple internal organs. It is associated with autoimmunity, inflammation, vasculopathy and fibrosis. Managing Raynaud's phenonemon, digital infarcts and ulcers in systemic sclerosis patients is often a challenge particularly among rheumatologists. We report a case of systemic sclerosis patient with refractory digital infarcts and ulcers responded successfully with rituximab.
Antiphospholipid syndrome in Sarawak: real world experience in a developing country

Teh CL, Leong TS

Clin Rheumatol, 2015 Jan;34(1):175-8.
PMID: 24831689 DOI: 10.1007/s10067-014-2671-6

We performed a cross-sectional study of all antiphospholipid syndrome (APS) patients during an 8-year period (2006-2013) to describe the clinical features, serology profiles, treatment regimes, and outcomes in our center. There were a total of 59 patients in our study with the female to male ratio of 9:1. They have a mean age of 41.6 ± 12.1 years and a mean duration of illness of 38.4 ± 68.5 months. The majority of patients presented with vascular thrombosis (69.5 %) with equal arterial and venous involvements. Twenty-six patients (44.1 %) presented with obstetric complications with recurrent abortions (32.2 %) as the main manifestation. Most patients were on daily warfarin doses of 2-6 mg (91.0 %) with target INR of 2-3. There was neither recurrent thrombosis nor bleeding complications documented. There were 80 % live births following treatment in our patients.
Impact of tight control strategy on rheumatoid arthritis in Sarawak

Teh CL, Wong JS

Clin Rheumatol, 2011 May;30(5):615-21.
PMID: 20886247 DOI: 10.1007/s10067-010-1583-3

The aim of our study is to describe the impact of tight control strategy on the care of RA patients in Sarawak General Hospital. We performed a prospective study of all patients with a diagnosis of RA who received treatment at the Rheumatology Clinic in Sarawak General Hospital over a 1-year period. Systematic DAS-driven treatment adjustments aimed to achieve low disease activity (DAS 28-ESR <2.6) were carried out in the clinic over the 1-year period. Disease activity and treatment regimes of all 142 patients were collected for at baseline and 1 year later for statistical analysis. Our patients have a significantly lower DAS 28 with a mean of 2.99 ± 0.95 compared with baseline of 4.31 ± 1.34 (p < 0.000). More patients were in remission 1 year later compared to baseline (36.6% vs 11.3%). Tight control strategy has a positive impact on the care of RA patients in our centre. By optimising the care of RA through tight control strategy, RA can be better controlled in our centre.

Study site: Rheumatology clinic, Sarawak general hospital
The pattern and clinical manifestations of rheumatoid arthritis in Sarawak General Hospital

Teh CL, Wong JS

Clin Rheumatol, 2008 Nov;27(11):1437-40.
PMID: 18773254 DOI: 10.1007/s10067-008-0945-6

The aim of our study is to describe the pattern, clinical features, treatment regimes, and disease activity among the patients treated for rheumatoid arthritis (RA) in the Sarawak General Hospital. We performed a cross-sectional study of all patients with a diagnosis of RA who received treatment at the General Medical Clinic and the Rheumatology Clinic in Sarawak General Hospital over a 1-year period from 1st June 2006 to 31st May 2007. Demographic data, clinical features, and disease activity of all 154 patients were collected for statistical analysis. Rheumatoid arthritis afflicts all the major racial groups in Sarawak including the native population. Our patients have a mean disease duration of 5.4 years (SD 5.69) and a mean duration of delay in diagnosis RA and initiation of disease-modifying antirheumatic drug (DMARD) treatment of 42.9 months (SD 60.1). They have a low rate of interstitial lung disease (6.5%) and rheumatoid nodules (4.5%). Rheumatoid factor was positive in 65.5% of our patients. They have a mean Disease Activity Score (DAS) 28 score of 4.28 (SD 1.33). Only 12.5% of our patients are in remission with DAS 28 < 2.6 and 30.9% of our patients are having high disease activity with DAS 28 > 5.1. Despite the high usage of DMARDs in Sarawak (>80%), our patients have severe disease with high disease activity indices. This is most likely due to delay in diagnosis and initiating DMARDs in RA patients in Sarawak.

Study site: General Medical Clinic and the Rheumatology Clinic in Sarawak General Hospital
Fulltext Dietary calcium and bone mineral density in premenopausal women with systemic lupus erythematosus

Chong HC, Chee SS, Goh EM, Chow SK, Yeap SS

Clin Rheumatol, 2007 Feb;26(2):182-5.
PMID: 16565892 DOI: 10.1007/s10067-006-0258-6

The primary objective of this study was to determine the relationship between dietary calcium intake and bone mineral density (BMD) in premenopausal women with systemic lupus erythematosus (SLE) on corticosteroids (CS). The secondary aim was to identify other risk factors for osteoporosis in these patients. A cross-sectional sample of patients attending the SLE Clinic at a teaching hospital was recruited. BMD was measured using dual-energy X-ray absorptiometry. Daily dietary calcium intake was assessed using a structured validated food frequency questionnaire, in which patients were asked to estimate their food intake based on their recent 2-month dietary habits. Sixty subjects were recruited with a mean age of 33.70+/-8.46 years. The median duration of CS use was 5.5 years (range 0.08-24). The median cumulative dose of steroids was 17.21 g (range 0.16-91.37). The median daily dietary calcium intake was 483 mg (range 78-2101). There was no significant correlation between calcium intake and BMD, even after correcting for CS use. There were also no correlations between BMD and the duration of SLE, cumulative CS use, duration of CS use, smoking, alcohol intake, and SLE disease activity index score. Twenty-eight (46.7%) patients had normal BMD, 28 (46.7%) had osteopenia, and four (6.6%) had osteoporosis. Duration of SLE significantly correlated with cumulative CS dosage. In conclusion, 6.7% of these Asian premenopausal SLE women had osteoporosis and only 46.7% had normal BMD. Daily dietary calcium intake did not correlate with BMD.
Study site: SLE clinic, University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia
Amyopathic dermatomyositis and pulmonary fibrosis

Chow SK, Yeap SS

Clin Rheumatol, 2000;19(6):484-5.
PMID: 11147762

'Amyotrophic dermatomyositis' (ADM) is used to describe a small subgroup of patients with the typical skin rash associated with dermatomyositis but without muscle involvement. Lung involvement in ADM is rare. We report on the management of a patient with ADM associated with pulmonary fibrosis at presentation, and her response to corticosteroid treatment.
IgG anti-beta(2) glycoprotein I antibodies in Malaysian patients with antiphospholipid syndrome and systemic lupus erythematosus: prevalence and clinical correlations

Ong SG, Cheng HM, Soon SC, Goh E, Chow SK, Yeap SS

Clin Rheumatol, 2002 Sep;21(5):382-5.
PMID: 12223986 DOI: 10.1007/s100670200102

The aim of this study was to investigate the incidence of IgG anticardiolipin antibody (ACL) and IgG anti-beta(2) glycoprotein I antibody (anti-beta2GPI) positivity in patients with primary or secondary antiphospholipid syndrome (APS) and systemic lupus erythematosus (SLE), to assess the association between IgG ACL and anti-beta2GPI, and the relationship between the presence of ACL and anti-beta2GPI with the clinical manifestations of APS. IgG ACL and IgG anti-beta2GPI levels were measured in 51 SLE patients, 20 patients with SLE and APS (secondary APS) and 11 primary APS patients using commercially available ELISA kits. Relationships between laboratory data and clinical manifestations of the patients were examined. The incidence of IgG ACL positivity was significantly higher in primary (36.4%) and secondary (40%) APS than in SLE (13.7%) patients (P = 0.02). The incidence of IgG anti-beta2GPI positivity was significantly higher in primary (54.5%) and secondary (35%) APS than in SLE (7.8%) patients (P = 0.0006). Mean levels of IgG ACL and anti-beta2GPI were significantly higher in the primary and secondary APS than in the SLE patients (P = 0.002 for both). A significant relationship was found between IgG ACL and IgG anti-beta2GPI (P = 0.01, R(2) = 0.56). There was a significant correlation between the presence of IgG ACL and a history of thrombosis in the combined primary and secondary APS group, but not in SLE patients. In conclusion, in this study IgG ACL and IgG anti-beta2GPI are closely related and mean levels of IgG ACL and IgG anti-beta2GPI are higher in patients with either primary or secondary APS than in SLE patients.
Study site: Rheumatology Clinic, University Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia
Rheumatological publications from Malaysia: a bibliometric study

Teng CL, Chew WZ, Das Gupta E, Yeap SS

Clin Rheumatol, 2020 Feb;39(2):547-552.
PMID: 31784864 DOI: 10.1007/s10067-019-04839-0

OBJECTIVES: To assess the content, authorship and study design of rheumatological publications written by Malaysian authors or about rheumatological conditions in Malaysia.
METHODS: The Malaysian Medical Repository (MyMedR), a web-based database of Malaysian health and medical publications, and Scopus were searched to retrieve rheumatological publications from Malaysia, for the period 1950 until 30 June 2019. The type and number of publications in each rheumatological subject area and the overall trend of publication numbers and citations were analysed.
RESULTS: 547 publications were found for the time period studied. There was a 27-fold increase in the number of publications from the period up to 1980 compared to 2010-2019. The median number of citations per paper was 5, but unlike the number of publications, there was only a slight increase in the number of citations with time. 84.5% of the papers were cited at least once. The top 3 conditions generating the most publications were systemic lupus erythematosus, 36.7%, followed by rheumatoid arthritis, 17.0%, and osteoporosis, 13.9%.
CONCLUSIONS: The number of rheumatological publications in Malaysia have increased over time, especially in the last decade. However, the average number of citations per publications remains low and the majority of publications are in journals with low impact factors. Thus, the quality of rheumatological publications from Malaysia can be further improved.Key Points• There have been only a limited number of bibliometric analysis of rheumatology publications from Asia.• In Malaysia, the number of rheumatology publications has increased over time.• However, there is still room for improvement in terms of the quality of the publications.
Socioeconomic inequality in patients with rheumatoid arthritis: a systematic review and meta-analysis

Salari N, Kazeminia M, Shohaimi S, Mohammadi M

Clin Rheumatol, 2021 Jun 22.
PMID: 34159490 DOI: 10.1007/s10067-021-05829-x

BACKGROUND: Rheumatoid arthritis is a chronic inflammatory and systemic autoimmune disease associated with synovial fluid inflammatory lesions and articular changes. The aim of the present study was to determine socioeconomic inequality in RA patients using a meta-analysis approach.
METHODS: A systematic search of national and international databases of SID, MagIran, Google Scholar, Cochrane, Embase, ScienceDirect, Scopus, PubMed, and Web of Science (WoS) was conducted to find articles published from 1988 to March 2020. Random effects model was used for analysis and heterogeneity of studies was investigated using I2 index. Data analysis was then carried out using Comprehensive Meta-Analysis (Ver. 2).
RESULTS: A total of 51 articles with a total sample size of 48,195 individuals were included in the meta-analysis in all the components. The results showed that 18.9% (95% CI: 4.9-13.25%) of patients were single patients, 70.6% (95% CI: 63.5-76.8%) were married, 31.6% (95% CI: 24.5-39.7%) had low economic status, 52.1% (95% CI: 5.8-44.53%) had moderate economic status, level of education was below diploma in 33% (95% CI: 27.1-39.5%) of cases, 36.2% (95% CI: 27.3-46.1%) were smokers, and 8.8% (95% CI: 2.8-24.1%) of patients were unemployed.
CONCLUSION: The results of the present study indicate high socioeconomic inequality in RA patients in the main components of the study. Hence, to improve the aforementioned status and find causes and do the monitoring at all levels, appropriate solutions must be adopted by providing feedback to policy-makers.
KEY POINTS: • The results showed that 18.9% (95% CI: 4.9-13.25%) of patients were single patients. • 70.6% (95% CI: 63.5-76.8%) were married and 31.6% (95% CI: 24.5-39.7%) had low economic status. • 52.1% (95% CI: 5.8-44.53%) had moderate economic status; 36.2% (95% CI: 27.3-46.1%) were smokers.
Effect of ethnicity on disease activity and physical function in psoriatic arthritis in a multiethnic Asian population

Leung YY, Fong W, Lui NL, Thumboo J

Clin Rheumatol, 2017 Jan;36(1):125-131.
PMID: 27796663 DOI: 10.1007/s10067-016-3460-1

Geographic differences in manifestation of psoriatic arthritis (PsA) could be related to differences in genetic or environmental factors. We aimed to compare the disease activity and functional status using validated outcome measures among patients with PsA of different ethnicities living in the same environment. We performed a cross-sectional study on consecutive patients with PsA classified by the Classification Criteria for Psoriatic Arthritis (CASPAR) criteria from a single center. Sociodemographic data, clinical variables, and patient-reported outcomes were collected using a standardized protocol. Disease activities were assessed by validated composite scores: clinical Disease Activity Index for Psoriatic Arthritis (cDAPSA), Composite Psoriatic Disease Activity Index (CPDAI), and minimal disease activity (MDA). Physical function was assessed with Health Assessment Questionnaire (HAQ) and the Medical Outcome Study Short-Form 36 (SF36) physical function subscales. Linear regression analyses were performed to identify variables associated with disease activities and physical function. Ninety-eight patients (51.5%, men) with mean (±SD) age and duration of PsA of 51.5 ± 13.8 and 5.5 ± 8.4 years were recruited. Indian was overrepresented compared with the national distribution of ethnicities. Compared to Chinese, Indian patients were more likely to be using biological therapies, have higher tender joint count, and worse enthesitis. Higher proportion of Indians had higher disease activity categories measured by cDAPSA, CPDAI, and MDA and had poorer physical function. In the multivariable analysis, ethnicity was significantly associated with HAQ and SF36-PF. Compared to Chinese, Indians with PsA living in the same environment had worse disease activity and physical function measured by validated outcomes.
Study site: Psoriatic arthritis clinic in a tertiary referral center, Singapore
Severe infections in systemic lupus erythematosus: disease pattern and predictors of infection-related mortality

Teh CL, Wan SA, Ling GR

Clin Rheumatol, 2018 Aug;37(8):2081-2086.
PMID: 29667100 DOI: 10.1007/s10067-018-4102-6

Infection is a major cause of morbidity and mortality among patients with systemic lupus erythematosus (SLE). To describe the pattern of serious infections in patients with SLE and to identify the predictors of infection-related mortality among SLE patients with serious infections, we prospectively studied all SLE patients who were hospitalized with infections in Sarawak General Hospital during 2011-2015. Demographic data, clinical features, and outcomes were collected. Cox regression analysis was carried out to determine the independent predictors of infection-related mortality. There were a total of 125 patients with 187 episodes of serious infections. Our patients were of multiethnic origins with female predominance (89.6%). Their mean age was 33.4 ± 14.2 years. The patients had a mean disease duration of 66.8 ± 74.0 months. The most common site of infection was pulmonary (37.9%), followed by septicemia (22.5%). Gram-negative organisms (38.2%) were the predominant isolates within the cohort. There were 21 deaths (11.2%) during the study period. Independent predictors of infection-related mortality among our cohort of SLE patients were flare of SLE (HR 3.98, CI 1.30-12.21) and the presence of bacteremia (HR 2.54, CI 0.98-6.59). Hydroxychloroquine was protective of mortality from serious infections (HR 9.26, CI 3.40-25.64). Pneumonia and Gram-negative organisms were the predominant pattern of infection in our SLE cohort. The presence of flare of SLE and bacteremia were independent prognostic predictors of infection-related mortality, whereas hydroxychloroquine was protective of infection-related mortality among SLE patients with serious infections.
A global perspective on the challenges and opportunities in learning about rheumatic and musculoskeletal diseases in undergraduate medical education : White paper by the World Forum on Rheumatic and Musculoskeletal Diseases (WFRMD)

Al Maini M, Al Weshahi Y, Foster HE, Chehade MJ, Gabriel SE, Saleh JA, et al.

Clin Rheumatol, 2020 Mar;39(3):627-642.
PMID: 31127461 DOI: 10.1007/s10067-019-04544-y

Rheumatic and musculoskeletal diseases (RMDs) encompass a spectrum of degenerative, inflammatory conditions predominantly affecting the joints. They are a leading cause of disability worldwide and an enormous socioeconomic burden. However, worldwide deficiencies in adult and paediatric RMD knowledge among medical school graduates and primary care physicians (PCPs) persist. In October 2017, the World Forum on Rheumatic and Musculoskeletal Diseases (WFRMD), an international think tank of RMD and related experts, met to discuss key challenges and opportunities in undergraduate RMD education. Topics included needs analysis, curriculum content, interprofessional education, teaching and learning methods, implementation, assessment and course evaluation and professional formation/career development, which formed a framework for this white paper. We highlight a need for all medical graduates to attain a basic level of RMD knowledge and competency to enable them to confidently diagnose, treat/manage or refer patients. The importance of attracting more medical students to a career in rheumatology, and the indisputable value of integrated, multidisciplinary and multiprofessional care are also discussed. We conclude that RMD teaching for the future will need to address what is being taught, but also where, why and to whom, to ensure that healthcare providers deliver the best patient care possible in their local setting.
Fulltext Impact of COVID-19 on hospitalization of patients with systemic lupus erythematosus (SLE)

Lee WWH, Cheong YK, Teh CL, Wan SA, Chuah SL, Singh BSM

Clin Rheumatol, 2021 11;40(11):4775-4777.
PMID: 34510293 DOI: 10.1007/s10067-021-05920-3
Cartilage oligomeric matrix protein (COMP) in rheumatoid arthritis and its correlation with sonographic knee cartilage thickness and disease activity

Sakthiswary R, Rajalingam S, Hussein H, Sridharan R, Asrul AW

Clin Rheumatol, 2017 Dec;36(12):2683-2688.
PMID: 28889184 DOI: 10.1007/s10067-017-3817-0

The aim of the study is to investigate the correlation of serum cartilage oligomeric matrix protein (COMP) levels with articular cartilage damage based on sonographic knee cartilage thickness (KCT) and disease activity in rheumatoid arthritis (RA). A total of 61 RA patients and 27 healthy controls were recruited in this study. Serum samples were obtained from all subjects to determine the serum COMP levels. All subjects had bilateral ultrasound scan of their knees. The KCT was based on the mean of measurements at three sites: the medial condyle, lateral condyle and intercondylar notch. Besides, the RA patients were assessed for their disease activity based on 28-joint-based Disease Activity Score (DAS 28). Serum COMP concentrations were significantly elevated in the RA patients compared to the controls (p = 0.001). The serum COMP levels had an inverse relationship with bilateral KCT in RA subjects and the healthy controls. COMP correlated significantly with disease activity based on DAS 28 (r = 0.299, p = 0.010), disease duration (r = 0.439, p =
Non-tuberculous mycobacterium bacteraemia in a pregnant systemic lupus erythematosus (SLE) patient: a case review and pooled case analysis

Shaharir SS, Sulaiman Sahari N, Mohamed Fuad Z, Zukiman WZHW, Mohd Yusof NH, Sulong A, et al.

Clin Rheumatol, 2018 Mar;37(3):837-847.
PMID: 28971307 DOI: 10.1007/s10067-017-3855-7

Non-tuberculous mycobacteria (NTM) are recognized as an important cause of human diseases and infections. It is commonly known to cause infections of the skin, soft tissue infections, and pulmonary infection as well as bacteraemia. We report a challenging case of severe mycobacterium abscessus bacteraemia in a pregnant lady with active systemic lupus erythematous (SLE). A comprehensive literature review of NTM infection among SLE patients was also performed, and pooled analysis of the reported cases, including our case, was done to determine the clinical characteristics and factors associated with poor outcome of NTM infection.

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