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Menopause is an age-dependent physiological condition associated with a natural decline in estrogen levels, which causes a progressive decrease in muscle mass and strength, and bone density. Estrogen deficiency occurring during menopause will affect both the gynecological area and the whole body which will directly act on skeletal muscle through estrogen receptors. Although various factors are associated with falls in menopausal women, impaired balance and mobility have been consistently identified as the main risk factors. Identification of the factors associated with balance and fall risk may enable therapists to design treatments to help reduce the risk of falls and the consequences. Since the impact of impaired balance and fall risk among postmenopausal women is undefined. The purpose of this study was to assess the relationship between ankle range of motion and muscle strength with balance and fall risk in post-menopausal women. The ankle ROM and muscle strength were examined by using a universal goniometer and push-pull hand-held dynamometer respectively; the balance was assessed by Y balance test (YBT) and fall risk was measured by Fall Efficacy Scale International (FES-I). Karl Pearson correlation coefficient was used to find the relationship between ankle ROM, ankle strength, balance, and fall risk among postmenopausal women which showed a low positive correlation between the ankle ROM and YBT whereas a moderate positive correlation between the ankle strength and YBT which was statistically significant. The correlation between FES-I and ankle ROM and ankle strength were high and moderate respectively which was also statistically significant. Keywords: Postmenopausal women, ankle range of motion, ankle strength, balance, fall risk, YBT

Within rheumatoid arthritis (RA) patients treated with intravenous tocilizumab (IV-TCZ), it is unclear if power Doppler ultrasonography (PDUS) can predict future clinical response. This study sought to determine if baseline PDUS or its early changes can predict 12-week and 24-week disease activity outcomes, and quantify the need for dose escalation (4 to 8 mg/kg). Fifty-four RA patients starting IV-TCZ were evaluated at baseline, 4, 6, 12, 16, and 24 weeks using 34-joint PDUS (US34-PDUS), clinical disease activity index (CDAI), 28-joint disease activity score using erythrocyte sedimentation rate (DAS28-ESR), ACR 20/50/70, health assessment questionnaire-disability index (HAQ-DI), and PDUS 20/50/70, a novel measure. Logistic regression models evaluated the predictive utility of US34-PDUS of DAS28-ESR response after adjusting for covariates. Ninety-four percent of patients required dose escalation to 8 mg/kg. US34-PDUS, CDAI, and DAS28-ESR improved significantly over 24 weeks (p

Introduction: Phyllodes tumor constitutes an uncommon group of mammary fibroepithelial neoplasm, having incidence of about 0.3% to 1% of breast tumors. The median age of occurrence of disease is 40 to 50 years. These tumors were first recognized by Muller, who used the term “cystosarcoma phyllodes” (phyllos = leaf, Greek). The differential diagnosis between phyllodes tumor & fibroadenoma and histological grading of phyllodes tumor is challenging. Material and Methods: Retrospective data from cytology and histopathology record in pathology Department, Muzaffarnagar Medical College, Muzaffarnagar showed seven cases of phyllodes tumor. In all cases, Fine Needle Aspiration Cytology (FNAC) was initially performed and was further confirmed on histopathology. Results: The age range of these patients was from 18 to 61 years. The size of the breast lesion ranged from 6x5 cms to 40x30 cms. Tumors were classified according to WHO grading system based on the degree of stromal cellularity and atypia, presence or absence of stromal overgrowth, mitotic count and nature of tumor margin. Out of seven cases, two cases of were reported as benign phyllodes tumor, four as borderline and one as malignant. Two cases recurred within one year, one was benign and other one was diagnosed as borderline. Conclusion: Preoperative diagnosis and proper management is important in phyllodes tumor to minimize the recurrence and malignant potential. So, accurate diagnosis of phyllodes tumor is crucial so that they are effectively treated. Treatment include wide surgical excision with negative margins. Keywords: Breast, Phyllodes, Fibroadenoma, Classification, Fibroepithelial neoplasm.

Plantar fasciitis is a disorder that results in pain in the heel and plantar surface. Chronic inflammation of posterior bony attachment of the plantar aponeurosis is known as plantar fasciitis. As per statistics, 1 in 10 people develop heel pain at some point in their life. Out of heel pain from all causes, 80% is due to plantar fasciitis. People are advised to take rest, physiotherapy, orthotics, splinting or steroid injections. Despite proper management in modern medicine, reoccurrence rate is more. Hence it is relevant to find out a meth-od of management of this condition using Ayurveda. The causative and risk factors create a cumulative micro trauma to plantar fascia and it may be considered as Vraṇa and the inflammatory changes in plantar fascia may be considered as Vraṇa Śōpha. For inflammations with recent origin bloodletting should be car-ried out to reduce pain and obviate suppuration. So Jalaukāvacaraṇa was done as it is a non-invasive, pa-tient compliant and time saving procedure. A total number of 20 participants with the symptoms of plantar fasciitis were selected and evaluated, by taking detailed history and clinical examination. The study was conducted at Shalyatantra OPD of VPSV AVC, Kottakkal. Jalaukāvacaraṇa was done on 1st, 8th and 15th days. Clinical assessments were done on 1st, 8th, 15th 22nd and 43rd days. On statistical analysis, it was found that the Jalaukāvacaraṇa shows 67.85 % of effect in the management of plantar fasciitis. Ja-laukāvacaraṇa is having more efficacy in acute cases (duration within 6 months), as Raktaviśrāvaṇa is indicated for recent inflammations.

Musculoskeletal ultrasound quantifies the total synovial inflammatory burden in rheumatoid arthritis (RA) but is time consuming when scanning numerous joints. This study evaluated a novel patient-centered method for constructing a longitudinal ultrasound score in RA patients. Fifty-four RA patients starting intravenous tocilizumab were evaluated with power Doppler ultrasound (PDUS) of 34 joints and DAS28-ESR was assessed at baseline and weeks 4, 12, 16, and 24. The sentinel joint score (SJS) was derived from the reduced subset of joints with PDUS ≥ 1 at baseline. Total PDUS (tPDUS) score and US7 were also calculated. Changes in tPDUS and SJS were correlated. Effect sizes were calculated for tPDUS, SJS, and US7. The proportion of “flipped” joints without baseline PDUS signal that later developed PDUS signal was estimated. At baseline, 1236/1829 joints scanned (67.5%) did not have PDUS signal. The proportion of “flipped” joints at 24 weeks was 5.6% for ≥ 1, 2.9% for ≥ 2, and 1.0% for = 3 PD. tPDUS and SJS scores were highly correlated (r = 0.91 to 0.97). Overall the effect sizes for tPDUS, SJS, and US7 increased over 24 weeks, where SJS was the highest (SJS 1.00 4-week, 1.07 12-week, 1.26 24-week) and tPDUS and US7 were comparable (tPDUS 0.32 4-week, 0.52 12-week, 0.84 24-week; US7 0.23 4-week, 0.52 12-week, 0.74 24-week). In RA patients starting a biologic, scanning only joints with baseline PDUS signal can substantially reduce the number of joints requiring follow-up scanning by 67.5% and improves feasibility. “Flipped” joints are infrequently seen after starting therapy. ClinicalTrials.gov NCT01717859

Introduction: Breast cancer is the most frequently diagnosed cancer among females worldwide. p53 tumor suppressor gene regulates the cell cycle and DNA repair and its over-expression in breast cancer is associated with a worse prognosis. Objective: This study was done to correlate p53 over-expression with histopathological parameters such as tumor size, tumor grade and lymph node metastasis in breast carcinoma. Materials and Methods: This retroprospective study was conducted in a tertiary care centre, western U.P. retroprospectively from July 2014 to June 2019. Immuno-histochemical evaluation of 50 histologically confirmed cases of breast carcinoma was done. Results: A total of 50 patients of breast carcinoma were analysed. Most common was Invasive carcinoma of no special type (NST). Most common age group involved was 40-49 years and majority were of age more than >45 years of age. Majority of breast carcinoma cases were of left breast and involving upper outer quadrant. In majority of cases, the tumor size was of more than 2 to 5cms. Majority of cases of breast carcinoma were of grade II according to Nottingham Modified Bloom Richardson System. More than half of patients with lymph nodes showed metastatic deposits. Majority of cases were in moderate prognostic index group. Out of 50 cases, 24(48%) cases showed p53 [removed]5%). High p53 [removed]>50%) was seen in 8(16%) cases of breast carcinoma. Conclusion: A statistically significant association was found between p53 expression, tumor size and lymph node metastasis. No statistically significant association was found between p53 overexpression and tumor grade. Overall, p53 overexpression was found to be poor prognostic factor and its detection may help in risk catergorization and designing future target therapies. Keywords: Breast cancer, Invasive carcinoma, Lymph node, p53 overexpression, Immuno-histochemistry.

Background: Splenic fine needle aspiration cytology (FNAC) has been used as a diagnostic method since the turn of last century, with the first report being in 1916. It has the reputation of being dangerous & difficult to assess, but these prejudicial ideas are fundamentally wrong. FNAC remains the easy, cheap, safe and first mainstay diagnostic investigation. Objective: The objective of the present study was to evaluate and determining the diagnostic role of aspiration cytology in splenic lesions. Methods: Fine needle aspiration cytology (FNAC) of the spleen was performed in 34 cases in our retrospective analysis, with 28 cases aspirated under ultrasonological guidance and 6 cases aspirated blindly. There were 23 male and 11 female patients, ranging in age from 2 to 69 years, with 8 paediatric patients. All essential precautions and tests, including a coagulation profile, were carried out prior to the procedure. Results: Five of the 34 FNAC cases had bloody aspirates, while the other two had normal splenic aspirates. In 27 of the cases, a definitive diagnosis was possible. The most patients (8 cases) in the non-neoplastic group had extramedullary hematopoiesis, followed by 4 cases of tuberculosis, 3 cases each of kala azar and storage disease, and 2 cases with granulomas. We had two cases of non-Hodgkins lymphoma, one case of Hodgkin lymphoma, two cases of hairy cell leukaemia, and one case of histiocytosis in the neoplastic group. When aspiration was performed blindly or with ultrasound guidance, no significant differences in cellularity were observed. In our research, no procedural problems were discovered. Conclusion: As a result, when carried out with extreme caution, as a primary inquiry, FNAC spleen is a safe, low-cost, quick, and highly diagnostic treatment.

Salivary duct carcinoma is an aggressive malignancy which phenotypically resembles high-grade breast ductal carcinoma, it has a high mortality rate and parotid gland is the most common location. Here, we report a case of an extensive salivary gland malignancy involving the left middle third of face in a 65-year-old male patient. Computed tomography confirmed a large and extensive heterogenous radiopacity in the left maxillary sinus region which revealed calcification causing destruction of the posterolateral and medial wall of the left maxillary sinus and also causing severe destruction of the left lateral wall of the nose and the pterygoid plates. Keywords: Ductal carcinoma, Malignancy, Recurrence.

Objective To provide updated American College of Rheumatology (ACR) recommendations on rheumatoid arthritis (RA) disease activity measurements to facilitate a treat-to-target approach in routine clinical care. Methods A working group conducted a systematic literature review from the time of the prior ACR recommendations literature search. Properties of disease activity measures were abstracted, and study quality was assessed using the Consensus-Based Standards for the selection of Health Measurement Instruments 4-point scoring method, allowing for overall level of evidence assessment. Measures that fulfilled a minimum standard were identified, and through a modified Delphi process preferred measures were selected for regular use in most clinic settings. Results The search identified 5,199 articles, of which 110 were included in the review. This search identified 46 RA disease activity measures that contained patient, provider, laboratory, and/or imaging data. Descriptions of the measures, properties, study quality, level of evidence, and feasibility were abstracted and scored. Following a modified Delphi process, 11 measures fulfilled a minimum standard for regular use in most clinic settings, and 5 measures were recommended: the Disease Activity Score in 28 Joints with Erythrocyte Sedimentation Rate or C-Reactive Protein Level, Clinical Disease Activity Index, Simplified Disease Activity Index, Routine Assessment of Patient Index Data 3, and Patient Activity Scale-II. Conclusion We have updated prior ACR recommendations for preferred RA disease activity measures, identifying 11 measures that met a minimum standard for regular use and 5 measures that were preferred for regular use in most clinic settings.

Breast cancer is the most commonly diagnosed cancer in female worldwide. BRCA 1 is located predominantly in nucleus. BRCA 1 is associated with breast cancer. Materials and Methods: This was retroprospective study, 50 known cases of breast carcinoma were analysed in Muzaffarnagar Medical College, Muzaffarnagar. Observation and Results: The age range of patients was from 28-70 years and mean age of patients was 50.24 years. Majority of breast carcinoma were above 45 years of age (64%) and of upper outer quadrant (52%) and of grade II (48%). Invasive carcinoma of no special type (NST) formed the majority of cases (82%) followed by Invasive lobular carcinoma (6%). Altered BRCA 1 expression was seen in ER, PR and HER 2 negative cases. Conclusions: Invasive Carcinoma of no special type was the commonest morphological type. Majority of cases of breast carcinoma were of grade II. Keywords: BRCA 1, Invasive Carcinoma NST, ER, PR, Her 2 neu, IHC.

Foot pain is common in rheumatoid arthritis (RA), from forefoot involvement in early RA to later involvement of the hind foot. Foot and ankle involvement can lead to reduced walking distance and affect quality of life1. The prevalence of hind foot pain was estimated at 17% in early RA and up to 52% in patients with established RA2. Left untreated, inflammation of the subtalar joint can lead to progressive eversion of the joint, posterior tibial tendon tendinopathy, and collapse of the medial arch3. Clinically, pain from the joint is often reported in the lateral hind foot. Anatomically, the talus forms the mechanical gateway from the leg to the foot4. Its superior surface articulates with the fibula and tibia. A complex articulation is formed between the talus, calcaneus, and navicular bone inferiorly and anteriorly4,5. The subtalar joint is functionally a single joint that, anatomically, is divided into an anterior part, the talocalcaneonavicular joint or anterior subtalar joint (ASTJ) and a posterior part, the talocalcaneal joint or posterior subtalar joint (PSTJ)4,5. The ASTJ is formed by the navicular bone and the head of the talus anteriorly and the anterior and middle facets of the talus and the calcaneus (sustentaculum tali) inferiorly (Figure 1a and 1b). The spring ligament supports the joint inferiorly. The talonavicular joint and anterior talocalcaneal joint therefore form a continuity and together will be referred to as the ASTJ4,5. The ASTJ is separated from the PSTJ by the sinus tarsi and tarsal canal with several strong ligaments within the sinus tarsi. The PSTJ consists of the posterior facets of the talus and the calcaneus4,5. It is … Address correspondence to Dr. G.S. Kaeley, 653-1 West Eighth St., LRC 2nd Floor L-14, Jacksonville, Florida 32209-6561, USA. E-mail: drgurj{at}gmail.com

Background: Gall bladder is very common organ to be affected by many pathological diseases which include wide spectrum of the lesions from congenital ones to inflammatory or premalignant and malignant lesions.Aim: Study the spectrum of histopathological lesions in gallbladder in Cholecystectomy specimens.Material and Methods: The study was conducted in the Department of Pathology, Muzaffarnagar Medical College, Muzaffarnagar. Total of 434 cholecystectomy specimen were studied.Result: Maximum cases (231/434 cases) were of chronic cholecystitis followed by acute cholecystitis (28 cases), eosinophilic cholecystitis (3 cases), cholesterolosis (31 cases), follicular cholecystitis (11 cases), xanthogranulomatous cholecystitis (9 cases) and one case each of mucocele and porcelain gall bladder. Metaplasia was seen in 83 cases (19.12%), dysplasia in 16 cases (3.68%) and malignancy in 5 cases (1.15%).Conclusion: Gall bladder with stones of prolonged duration associated with risk of premalignant and malignant conditions making histopathological examination necessary for timely recognization of lesion.

Deployment of wireless sensor networks are usually found in military applications for intrusion detection, forest fire detection, environmental monitoring, civil applications etc. Deployment of sensors are application specific and poses many concerns and limitations like data redundancy, node clustering, discovery of useful information, localization and others. One of the critical issues that needs attention is the deployment of optimal number of sensor nodes in a given environment (phenomenon) based on the dynamics and redundancy in measured data to conserve energy and avoiding redundant nodes in wireless sensor network (WSNs) for cost effectiveness.To address such challenges, machine learning plays a vital role. In order to provide a solution to WSNto grasp the dynamics of the environment, we propose a novel machine learning technique i.e. Hebbian learning model that learns effectively theenvironmental changes and provides a better decision-making for optimal number of sensors deployment and energy saving in a given location.Theproposed model is implemented by considering environmental parameter values with hebbian machine learning technique and is verified for its performance. We found that hebbian learning has provided a better solution by learning and adapting to the dynamics of the environment with optimal number of sensor nodes by considering redundant data flow between the nodes and intern eliminating the redundant nodes that saves energy and node cost, and also prolong the lifetime of the network without suspending the monitoring activity.

Magnetic resonance imaging (MRI) and musculoskeletal ultrasound (MSUS) are sensitive imaging modalities used by clinicians to assist in decision-making in the management of rheumatoid arthritis (RA). This review will examine the utility of MRI and MSUS in diagnosing RA, predicting RA flares, tapering therapy, assessing remission, and examining difficult periarticular features. We will also outline the strengths and weaknesses of utilizing MRI and MSUS as outcome measures in the management of RA.

To provide guidance on the implementation of recommended American College of Rheumatology (ACR) rheumatoid arthritis (RA) disease activity and functional status assessment measures in telehealth settings.An expert panel was assembled from the recently convened ACR RA disease activity and functional status measures working groups to summarize strategies for implementation of ACR-recommended RA disease activity (the Clinical Disease Activity Index [CDAI], Disease Activity Score in 28 joints using the erythrocyte sedimentation rate or the C-reactive protein level [DAS28-ESR/CRP], Patient Activity Scale II [PAS-II], Simplified Disease Activity Index [SDAI], and Routine Assessment of Patient Index Data 3 [RAPID3]) and functional status (the Health Assessment Questionnaire II [HAQ-II], Multidimensional Health Assessment Questionnaire [MDHAQ], and PROMIS physical function 10-item short form [PROMIS PF-10]) measures in telehealth settings.Measures composed of patient-reported items (disease activity: PAS-II, RAPID3; functional status: HAQ-II, MDHAQ, PROMIS PF-10) require minimal modification for use in telehealth settings. Measures requiring formal joint counts (the CDAI, DAS28-ESR/CRP, and SDAI) can be calculated using patient-reported swollen and tender joint counts. When the feasibility of laboratory testing is limited, the CDAI can be used in place of the SDAI, and scoring modifications of the DAS28-ESR/CRP without the acute-phase reactant are available. Assessment of the validity of these modifications is limited. Implementation of these measures can be facilitated by electronic health record collection, mobile applications, and provider/staff administration during telehealth visits.The ACR-recommended RA disease activity and functional status measures can be adapted for use in telehealth settings to support high-quality clinical care. Research is needed to better understand how telehealth settings may impact the validity of these measures.

Background Musculoskeletal ultrasound (MSUS) and the multi-biomarker disease activity (MBDA) score are outcome measures that may aid in the management of rheumatoid arthritis (RA) patients. This study evaluated tofacitinib response by MSUS/MBDA scores and assessed whether baseline MSUS/MBDA scores or their early changes predict later clinical response. Methods Twenty-five RA patients treated with tofacitinib were assessed at baseline, 2, 6 and 12-weeks. Power doppler (PDUS) and gray scale (GSUS) ultrasound scores, MBDA score, clinical disease activity index (CDAI), and disease activity score (DAS28) were obtained. Pearson correlations and multiple linear regression models were used to evaluate associations and identify predictors of response to therapy. Results MSUS, MBDA scores, CDAI, and DAS28 improved significantly over 12 weeks (p p p p p = 0.03). Conclusions RA patients treated with tofacitinib for 12 weeks demonstrated improvement by clinical, imaging, and biomarker end-points. Baseline PDUS and MBDA score were predictive of CDAI and DAS28 responses. This is the first study to evaluate early measurements of MSUS and MBDA score as predictors of clinical response in RA patients treated with tofacitinib. Trial registration ClinicalTrials.gov NCT02321930 (registered 12/22/2014).

Background Joint replacements continue to occur during a rheumatoid arthritis (RA) patient’s lifetime despite significant advances in available treatment options. The purpose of this study was to examine and quantify synovitis in surgically operated joints by ultrasound (US) in RA patients starting a new therapeutic agent. Methods RA subjects were enrolled in either tocilizumab or tofacitinib open-label, investigator-initiated trials and were assessed by ultrasound. In a subset of RA patients with joint replacements and/or operations of joint areas (OJA; e.g. joint arthroscopies, fusions, and synovectomies), joint-level scores of synovitis were compared between replaced joints, OJAs, and native joints. Joint-level synovitis was measured by grayscale (GSUS (0–3)) and power Doppler (PDUS (0–3)) at baseline and follow-up (3–6 months). McNemar’s test or Wilcoxon signed rank test utilized the mixed effects ordinal logistic regression models. Results Twenty RA patients had a total of 25 replaced joints and 24 OJA. All replaced joints had GSUS> 1 and 92% had PDUS> 1 at baseline, while OJA and native joints had lower evidence of GSUS> 1 (37.5, 38% respectively) and PDUS> 1 (45.8, 62% respectively). GSUS and PDUS semiquantitative scores improved significantly with treatment in replaced joints (p = 0.01, p = 0.007), and native joints (p Conclusions In RA, joint replacement does not eliminate or prevent ultrasound measured synovitis, where all replaced joints have some evidence of US synovitis. US can also act as a potential marker of response to therapy in replaced joints. Scoring US synovitis in replaced joints should be considered in ultrasound RA clinical trials. Trial registration ClinicalTrials.gov NCT01717859 (registered 10/31/2012); ClinicalTrials.gov NCT02321930 (registered 12/22/2014).

Objective.Obese patients with rheumatoid arthritis (RA) report more joint swelling and tenderness and often have poorer responses to therapy than nonobese patients. The aim of this posthoc analysis of the MUSICA trial was to compare imaging and clinical disease activity measures in obese and nonobese patients with RA.Methods.MUSICA evaluated methotrexate (MTX) 20 mg/week versus 7.5 mg/week in combination with adalimumab (ADA) in RA patients with an inadequate response to MTX. Patients were categorized by baseline body mass index as normal (< 25), overweight (≥ 25 to < 30), or obese (≥ 30). Synovial vascularity and hypertrophy, swollen and tender joint counts (SJC and TJC), American College of Rheumatology (ACR) responses, and low disease activity (LDA), defined as Clinical Disease Activity Index < 10 and 28-joint count Disease Activity Score using C-reactive protein (DAS28-CRP) < 3.2, were assessed at weeks 12 and 24.Results.Patient characteristics were similar among groups at baseline. Obese patients had numerically smaller changes from baseline to weeks 12/24 in SJC, TJC, DAS28-CRP, and synovial hypertrophy and vascularity versus nonobese patients. Significantly fewer obese patients reached ACR20/50 at weeks 12 and 24, and LDA at Week 12; this difference was especially apparent in patients receiving 7.5 mg/week MTX but was no longer significant at Week 24.Conclusion.Obese patients with RA had worse clinical and ultrasonographic responses than nonobese patients, which were partly overcome with time. Obese patients may experience better and faster clinical improvements if ADA is initiated with high-dose (20 mg/week) rather than low-dose MTX. [ClinicalTrials.gov: NCT01185288]

Skin ulcers in scleroderma (SSc) patients are considered a major challenge, both in clinical assessment and treatment decisions. The objective of our study is to assess ultrasonographic (US) morphology of skin ulcers in SSc patients and evaluate if US will be of value in enhancing our clinical information and influence our management plans. We examined a convenience sample of 21 skin ulcers reported in 10 SSc patients by US. We used a previously published US definition of normal skin and developed a preliminary US definition of skin ulcer. Skin ulcers were evaluated by gray scale (GS) and power Doppler (PD) and separated into ulcer and non-ulcer lesions; pain and ulcer measures were obtained using visual analogue scales (VAS). Lesions were characterized and ulcers were clinically and sonographically measured. Ten patients presenting with 21 skin lesions were examined by US. Applying our US definition of skin ulcer, all ulcers were available to measure by ultrasound. Eight lesions were sonographically defined as ulcers, and 13 lesions as non-ulcer lesions. Three ulcers had high PD signals suggestive of infection requiring antibiotic treatment and were monitored for 2 weeks showing a decrease of the pain, VAS, and PD signals. Five lesions showed subclinical calcinosis. This is the first study to show the promising role of US in defining skin ulcers of SSc patients. US may support the assessment of morphology and extent of skin ulcers in SSc and can be a helpful tool for detecting underlying pathology.

ObjectiveIn rheumatoid arthritis (RA), MRI provides earlier detection of structural damage than radiography (X-ray) and more sensitive detection of intra-articular inflammation than clinical examination. This analysis was designed to evaluate the ability of early MRI findings to predict subsequent structural damage by X-ray.MethodsPooled data from four randomised controlled trials (RCTs) involving 1022 RA hands and wrists in early and established RA were analysed. X-rays were scored using van der Heijde-modified or Genant-modified Sharp methods. MRIs were scored using Outcome Measures in Rheumatology (OMERACT) RA MRI Score (RAMRIS). Data were analysed at the patient level using multivariable logistic regression and receiver operating characteristic curve analyses.ResultsProgression of MRI erosion scores at Weeks 12 and 24 predicted progression of X-ray erosions at Weeks 24 and 52, with areas under the curve (AUCs) of 0.64 and 0.74, respectively. 12-week and 24-week changes in MRI osteitis scores were similarly predictive of 24-week and 52-week X-ray erosion progressions; pooled AUCs were 0.78 and 0.77, respectively. MRI changes in synovitis at Weeks 12 and 24 also predicted progression of X-ray joint damage (erosion and joint-space narrowing) at Weeks 24 and 52 (AUCs=0.72 and 0.65, respectively).ConclusionsEarly changes in joint damage and inflammation detected with MRI predict changes in joint damage evident on subsequent X-rays. These findings support the use of MRI as a valid method for monitoring structural damage in short-duration RCTs.

Psoriatic arthritis (PsA) affects up to 30% of patients with psoriasis and may include musculoskeletal manifestations such as enthesitis. Enthesitis is associated with joint damage, and early detection and treatment are essential to management of the disease. Traditionally assessed by clinical examination and conventional radiography, entheseal inflammation can now be more accurately assessed earlier in the disease using techniques such as ultrasound, magnetic resonance imaging, computed tomography, and molecular imaging. However, there is little consensus on the optimum definition for diagnosing enthesitis in PsA or on the ideal scoring system for measuring response to treatment. This review aims to summarize the benefits and limitations of different imaging modalities in the assessment of enthesitis. It also proposes that adoption of standardized definitions and validation of scoring systems and imaging techniques in clinical trials will allow the efficacy of new treatment options to be assessed more accurately.

To evaluate use of a British English version of the validated French FLARE-RA questionnaire among American English speaking patients. In addition, to create a culturally adapted American English (AmE) FLARE-RA questionnaire and to examine its attributes of patient-reported RA flare status.Using standardized cultural adaptation guidelines, we cognitively debriefed 25 American English speaking rheumatoid arthritis (RA) outpatients and created AmE-FLARE-RA with their input. One hundred three additional RA patients were recruited. Patients completed the Routine Assessment of Patient Index Data 3 (RAPID3), patient global visual analogue scale (VAS), AmE-FLARE-RA, and self-reports of flare. Physician global VAS, physician-assessed flare, swollen and tender joint count (TJC), and clinical disease activity index (CDAI) were documented. AmE-FLARE-RA and disease activity measures were compared between patient-reported and physician-reported flare categories.Patients were female (89%), with mean (SD) age 51.1 (± 15.3) years and mean disease duration (SD) 11.9 (± 10.1) years, with 26% in remission/low disease activity. Total AmE-FLARE-RA scores, RAPID3, CDAI, and patient global VAS were significantly higher for both patient-reported flares and physician-reported flares compared with non-flaring patients by self- or physician report (p 0.05). Total AmE-FLARE-RA scores correlated significantly with RAPID3 (corr = 0.50, p 0.0001) and with CDAI (corr = 0.45, p 0.0001). Across "no flares," "one flare," and "several flare" groups, there was a non-significant increase in AmE-FLARE-RA scores (p = 0.07).The British English FLARE-RA was successfully adapted for AmE-speaking RA patients. AmE-FLARE-RA significantly correlated with RAPID3 and CDAI and distinguished between patient-reported and physician-reported flares, making it useful to detect flares in American RA patients.Key Points• The American English FLARE-RA (AmE-FLARE-RA) questionnaire is the result of cognitive debriefing with American RA patients using the British English version of the validated French FLARE-RA and incorporates patient-recommended language modifications..• Patients self-reporting flares had significantly higher AmE-FLARE-RA scores, compared with those without flares at the time of visit. AmE-FLARE-RA scores correlate with RAPID3 and CDAI.• There was a non-statistically significant trend using the AmE-FLARE-RA scores when examining patients with no flare, one flare, or several flares.• AmE-FLARE-RA total scores are uniformly elevated (~ 6.0 on a 0-10 scale), regardless of discordance between patient and MD assessment of flare at time of visit (~ 30%).

OBJECTIVE:The evaluation of disease activity in obese rheumatoid arthritis (RA) patients presents challenges particularly in the clinical assessment of swollen joints. This study examines the effect of obesity on the American College of Rheumatology (ACR) core set measures used in assessing RA disease activity with specific focus on the swollen joint count (SJC). METHODS:We examined a cross-sectional cohort of 323 early seropositive RA patients (symptom duration ≤15 months). Patients were biologic-naive with equal to or more than 6/44 SJC and equal to or more than 9/44 tender joint count. The ACR core set measures, components of Disease Activity Score (DAS) 44/erythrocyte sedimentation rate (ESR), DAS28/ESR4 item, Clinical Disease Activity Index (CDAI), and body mass index (BMI) were collected. Disease activity measures were compared between BMI categories. Multivariable linear regression models assessed the relationship between high BMI (≥30 kg/m) and lower-extremity (LE) SJC and SJC44 while accounting for other ACR measures. RESULTS:Disease Activity Score 44/ESR4 item, Health Assessment Questionnaire Disability Index, physician global, and SJC44 differed across BMI categories (p < 0.05). Of the SJC44, metacarpophalangeal joints and LE joints (knees, ankles, metatarsophalangeal joints) were associated with increased swelling in all BMI groups (P < 0.05). Obesity was significantly associated with LE SJC after adjusting for ACR core set measures. CONCLUSIONS:There is a direct association between increased BMI and increased swelling of LE joints in RA patients. Increases in DAS44-measured disease activity are higher in obese RA patients because of increased LE swollen joints. Disease Activity Score 28 and Clinical Disease Activity Index, which emphasize upper-extremity joint assessment, are not significantly influenced by obesity.

Problem considered Adolescence, being the transitional phase, is marked by physical and psychological changes. Considering the challenges of adolescent girls (10–19 years) and long-term potential of investment, adolescent health was given special emphasis in NHP 2015. Methods To assess the effect of social and behavior change communication by using infotainment in community perception of Adolescent reproductive and sexual health care in high priority districts of Assam. Interventional Study-Before-after cross-sectional study, conducted in six HPD of Assam, along with Focus Group Discussions. Adolescent girls (AGs) were interviewed using predesigned pretested format. FGDs were conducted, 2 per district in each group. Social and behavior change communication (SBCC) intervention was given using facts for life video show followed by discussion and feedback. Statistical analysis used rates, ratio, proportion, and chi square. Results From 1350 households, 528 adolescent girls were interviewed. Knowledge about anemia was poor – only 56.1% agreed that anemia can be prevented. Majority (65.3%) did not know about any contraceptive methods. Safe sexual practices and HIV were known to 25.2% AGs. Majority (74.8%) did not know about STI/RTI – many (36.2%) would not inform anybody while some (25.6%) will consult doctor for such symptoms. SBCC intervention showed significant improvement in knowledge and perception of AGs ( p Conclusions SBCC by using infotainment in community perception and practices for adolescent health, nutrition, awareness about HIV/AIDS, and other RTI/STI was found effective in improving awareness amongst adolescent girls in High Priority Districts of Assam.

Background: Splenic fine needle aspiration cytology (FNAC) as a diagnostic procedure has been used since beginning of last century and was first reported in 1916. The objective of the study was to evaluate the diagnostic role of aspiration cytology in splenic lesions. Methods: In our retrospective study Fine needle aspiration cytology (FNAC) of spleen was done in a total 34 cases, out of which 28 cases were aspirated under ultrasonological guidance and 6 cases were aspirated blindly. There were 23 male and 11 female patients and the age range of the patients was from 2 to 69 years with 8 patients from paediatric group. Before commencing the procedure all the necessary precautions and investigations including coagulation profile were done. Results : Out of 34 FNAC cases, 5 were bloody aspirate while 2 cases showed normal splenic aspirate. In 27 cases definite diagnostic opinion was possible. Amongst non-neoplastic group maximum patients (8 cases) were showing features of extra medullary hematopoeisis followed by 4 cases of tuberculosis, then 3 cases each of kala azar and storage disorder and 2 cases showed granulomas. In the neoplastic group, we had 2 cases of non-Hodgkins lymphoma, one case of Hodgkin lympoma with 2 cases of hairy cell leukemia and one case of histiocytosis. No major difference in the cellularity noticed when the aspiration done blindly or under ultrasound guidance No procedural complications were seen in our study. Conclusion: Hence when done with full precautions FNAC spleen is a safe, cheap, rapid and highly diagnostic procedure as a primary investigation.

Background: Gestational diabetes mellitus (GDM) affects 2-25% of pregnancies depending on population characteristics and criteria used. It is associated with an increased risk of fetal malformation and perinatal mortality. The aim of the study was to know the prevalence of GDM, the risk factors associated with women with GDM and the feto-maternal outcome.Methods: A prospective study conducted among 200 antenatal women attending Obstetrics and Gynaecology (OBG) Outpatient Department in A. J. Institute of Medical Sciences and Research Center from March 2019 to August 2019. GDM was diagnosed with 2-hour 75 gm oral glucose tolerance test according to diabetes in pregnancy study group of India (DIPSI) criteria. Basic demographic details and maternal and fetal outcomes were analysed.Results: The prevalence of GDM was high (24.5%) compared to other studies. Normoglycemia was achieved with diet alone in 71.5%, diet and metformin in 16.3% and 12.2% with insulin. Risk factors included higher body mass index (BMI) and history of GDM. Emergency caesarean rate was higher among GDM women (p

Background and aimsTo evaluate changes in the high-density lipoprotein (HDL) proteome and HDL function in active rheumatoid arthritis (RA) patients initiating therapy with abatacept or adalimumab in the Abatacept Versus Adalimumab Comparison in Biologic-Naïve RA Subjects with Background Methotrexate (AMPLE) study.MethodsUltra high-pressure liquid chromatography (UHPLC) coupled with ion mobility mass spectrometry (LC-IM-MS) was used to analyze proteins associated with immunoaffinity-captured HDL from plasma of 30 patients with RA randomized to either abatacept (n = 15) or adalimumab (n = 15) therapy. Paraoxonase 1 (PON1) activity, HDL anti-oxidant capacity, cholesterol profiles, and homocysteine levels were also measured at baseline and following treatment. Repeated-measures analyses were performed using mixed-effect linear models to model the within-subject covariance over time.ResultsIn models controlling for age, sex and treatment group, improvement in inflammation measured by decreases in CRP was associated with improvement in HDL function and changes in several HDL-associated proteins including significant decreases in lipopolysaccharide-binding protein, serum amyloid A-I (SAA-I) and inter-alpha-trypsin inhibitor heavy chain H4 (p values

The role of musculoskeletal ultrasound (MSK-US) in rheumatoid arthritis (RA) is evolving, albeit with twists and turns. Early RA randomized clinical studies have demonstrated little added value of MSK-US when used prospectively in a treat-to-target strategy1,2. Recent editorials have discussed the issues of clinical trial design and standardization US measures raised by these studies3,4. Ostensibly the goal of therapy in RA is to achieve remission and hence halt progression of erosions, as well as to maintain function. However, sustained remission is not obtained in the majority of patients with established RA5. Further, despite more stringent composite and Boolean remission criteria, progression of erosions still occurs regardless of applied clinical remission criteria6,7,8. Progression of erosions in subjects in remission is considered a result of subclinical synovitis. MSK-US can be used at the bedside to gauge residual synovitis in many joint areas. In metaanalyses of heterogeneous RA populations in clinical remission, the prevalence of greyscale and Doppler-positive subjects was estimated at 43%9. Residual synovitis prevalence was comparable even when using alternate definitions of remission. Power Doppler seems to be the key component of imaging synovitis linked to progression of erosions9,10. Of note in the 4 studies included for structural progression, definition of progression ranged from change of total Sharp score of greater than zero to greater than the smallest detectable difference9,10. In addition, prevalence of residual synovitis was higher in patients … Address correspondence to Dr. G.S. Kaeley, University of Florida College of Medicine, Division of Rheumatology, PO Box 162, Ponte Vedra, Florida 32004, USA. E-mail: drgurj{at}gmail.com

Objective To evaluate the effect of sustained American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) Boolean remission on residual joint inflammation assessed by magnetic resonance imaging (MRI) and to secondarily evaluate other clinical definitions of remission, within an early seropositive rheumatoid arthritis (RA) cohort. Methods A subcohort of 118 RA patients was enrolled from patients who completed the 2-year, double-blind randomized Treatment of Early Aggressive Rheumatoid Arthritis (TEAR) trial. Patients received a single contrast-enhanced 1.5T MRI of their most involved wrist. Two readers scored MRIs for synovitis, osteitis, tenosynovitis, and erosions. Clinical assessments were performed every 3 months during the trial and at time of MRI. Results The subcohort was 92% seropositive with mean age 51 years, duration 4.1 months, and Disease Activity Score in 28 joints using the erythrocyte sedimentation rate 5.8 at TEAR entry. Total MRI inflammatory scores (tenosynovitis + synovitis + osteitis) were lower among patients in clinical remission. Lower MRI scores were correlated with longer duration of Clinical Disease Activity Index (CDAI) remission (ρ = 0.22, P = 0.03). At the time of MRI, 89 patients had no wrist pain/tenderness/swelling; however, all 118 patients had MRI evidence of residual joint inflammation after 2 years. No statistically significant differences in damage or MRI inflammatory scores were observed across treatment groups. Conclusion This is the first detailed appraisal describing the relationship between clinical remission cut points and MRI inflammatory scores within an RA randomized controlled trial. The most stringent remission criteria (2011 ACR/EULAR and CDAI) best differentiate the total MRI inflammatory scores. These results document that 2 years of triple therapy or tumor necrosis factor plus methotrexate treatment in early RA does not eliminate MRI evidence of joint inflammation.

Background Despite advances in rheumatoid arthritis (RA) therapeutic agents, difficulty in managing RA flares persists, and remission or the persistent absence of inflammation remains challenging to achieve. The French FLARE (F-FLARE) was developed to facilitate and standardize detection and measurement of RA flares between clinic visits.1,2 We have previously reported the cognitive debrief for the published British English version, which determined that revision of wording and presentation of items was required. Here we report validation of the American English version of FLARE (Am-E FLARE-RA).3 Objectives To assess whether the Am-E FLARE questionnaire performs comparably to the French version of FLARE in detecting RA flare in an American English-speaking clinic population. Methods We enrolled patients attending UCLA rheumatology clinics. After informed consent, patients completed a questionnaire to collect demographics, Am-E FLARE, RAPID3, patient global visual analog scale (VAS), and self-reported flare at time of visit or between visits (yes/no). Questionnaires were provided to patients without specific instruction. From the electronic medical records, we extracted MD global VAS, MD-reported flare, seropositivity, disease duration, swollen/tender joint counts (SJC/TJC), and calculated the clinical disease activity index (CDAI). Analyses included Wilcoxon rank sum tests and Spearman correlations to assess criterion and concurrent construct validity. Results Eighty-five RA patients diagnosed by the1987 American College of Rheumatology (ACR) criteria enrolled in our study. For the study population as a whole, mean age was about 50 years and most were female. Mean disease duration was about 10 years and about 65% were seropositive. (see Table). Am-E FLARE scores were significantly higher in patients9 self-reporting flare compared to patients who reported no flare (p=0.005), and also for patients with MD-reported flare compared to those without flare (p=0.008) (see Table). Interestingly, there were no significant differences in SJC (p=0.82) and physician global (p=0.19) between patients who self-reported flare versus those who reported no flare. In addition, the Am-E FLARE scores correlated moderately with both CDAI (corr=0.46) and RAPID3 (corr=0.57). Conclusions The Am-E FLARE is feasible for use in clinic, and shows good criterion validity, with scores significantly higher in patients who self-report flare. In addition, Am-E FLARE shows good discriminant validity, distinguishing patients who are flaring according to MD or patient self-report from those who are not. Finally, Am-E FLARE demonstrates construct validity comparable to that of the original French version of FLARE. References Jean-Marie Berthelot, Michel De Bandt, Jacques Morel, et al. A tool to identify recent or present rheumatoid arthritis flare from both patient and physician perspectives: The “FLARE” instrument. Ann Rheum Dis 2012;71:1110–1116. Fautrel B, Morel J, Berthelot JM, et al. Validation of FLARE-RA, a self-administered tool to detect recent or current rheumatoid arthritis flare. Arthritis Rheumatol. 2016 Sep. 16. EULAR14-SCIE-4820. Disclosure of Interest None declared

Background Clinical swollen joint examination of the obese rheumatoid arthritis (RA) patient can be difficult. Musculoskeletal Ultrasound (MSUS) has higher sensitivity than physical examination for swollen joints (SJ). The purpose of this study was to determine the joint-specific association between power Doppler (PDUS) and clinical SJ in RA across body mass index (BMI) categories. Methods Cross-sectional clinical and laboratory data were collected on 43 RA patients. PDUS was performed on 9 joints (wrist, metacarpalphalangeal 2–5, proximal interphalgeal 2/3 and metatarsalphalangeal 2/5). DAS28 and clinical disease activity index (CDAI) were calculated. Patients were categorized by BMI: 30. Demographic and clinical characteristics were compared across BMI groups with Kruskal-Wallis test and chi-square tests. Joint-level associations between PDUS and clinically SJ were evaluated with mixed effects logistic regression models. Results While demographics and clinically-determined disease activity were similar among BMI groups, PDUS scores significantly differed (p = 0.02). Using PDUS activity as the reference standard for synovitis and clinically SJ as the test, the positive predictive value of SJ was significantly lower in higher BMI groups (0.71 in BMI

Scrotal carcinoma is a rare tumor. We report two cases of this rare tumor. First case, a 40 year male, presented with a non-healing ulcer at the upper part of scrotum on right side, which did not respond to routine therapy. Patient had this ulcer for last five months. He had been a worker at automobile work-shop for last fifteen years and a chronic smoker for two decades. Scrotal skin was excised and sent for histopathology. It was reported to be as squamous cell carcinoma. This was likely due to a repeated occupational exposure outcome. Second case was of a 38 year male presented with a cauliflower like growth at the upper part of scrotum on right side, which did not respond to therapy. Patient had this growth for last eight months. He is a chronic smoker for last 25 years. He had no significant occupational history. The patient underwent fine needle aspiration cytology and was reported to be squamous cell carcinoma with marked tumor diathesis. After literature review, we conclude that scrotal carcinoma is currently a rare tumor, and even more in cases with occupational exposure to carcinogens. These case reports highlight the importance of proper history taking regarding occupation, smoking etc.

Objective To investigate the relationship of genetic and biochemical determinants of paraoxonase 1 activity to carotid plaque as a surrogate marker of cardiovascular (CV) risk in patients with rheumatoid arthritis (RA). Methods The relationships between paraoxonase 1 activity, PON1 genotype (for the functional polymorphism at position 192), and carotid plaque presence were determined in 168 RA patients. After an overnight fast, blood was collected for lipoprotein analysis, and paraoxonase 1 activity was measured using paraoxon as the substrate. The PON1 Q192R genotype was determined for all patients. Lipoprotein cholesterol levels, traditional CV risk factors, medication use, and RA disease characteristics were assessed for all patients. Results Paraoxonase 1 activity values in the RA patients were highest for the RR genotype, intermediate for the QR genotype, and lowest for the QQ genotype (P < 0.0001). Compared to patients with either the QQ genotype or the QR genotype, patients with the RR genotype demonstrated decreased risk of carotid plaque on multivariate analysis, controlling for traditional CV risk factors, high-sensitivity C-reactive protein levels, prednisone use, and cholesterol-lowering medication use (P < 0.05). Additional multivariate logistic regression analysis controlling for the above factors also revealed a significant association of plasma paraoxonase 1 activity with carotid plaque in RA patients. Lower plasma paraoxonase 1 activity was associated with increased risk of carotid plaque (P < 0.05). Conclusion The current findings suggest a relationship of the genetic determinants and activity of paraoxonase 1 to CV risk in RA patients, as assessed by the presence or absence of carotid plaque. Further CV outcome studies are warranted to validate the utility of paraoxonase 1 as a biomarker of CV risk in patients with RA.

Objective Methotrexate (MTX) taken as monotherapy is recommended as the initial disease-modifying antirheumatic drug for rheumatoid arthritis (RA). The purpose of this study was to examine outcomes of a blinded trial of initial MTX monotherapy with the option to step-up to combination therapy as compared to immediate combination therapy in patients with early, poor-prognosis RA. Methods In the Treatment of Early Rheumatoid Arthritis (TEAR) trial, 755 participants with early, poor-prognosis RA were randomized to receive MTX monotherapy or combination therapy (MTX plus etanercept or MTX plus sulfasalazine plus hydroxychloroquine). Participants randomized to receive MTX monotherapy stepped-up to combination therapy at 24 weeks if the Disease Activity Score in 28 joints using the erythrocyte sedimentation rate (DAS28-ESR) was ≥3.2. Results Attrition at 24 weeks was similar in the MTX monotherapy and combination groups. Of the 370 evaluable participants in the initial MTX group, 28% achieved low levels of disease activity and did not step-up to combination therapy (MTX monotherapy group). The mean ± SD DAS28-ESR in participants continuing to take MTX monotherapy at week 102 was 2.7 ± 1.2, which is similar to that in participants who were randomized to immediate combination therapy (2.9 ± 1.2). Participants who received MTX monotherapy had less radiographic progression at week 102 as compared to those who received immediate combination therapy (mean ± SD change in modified Sharp score 0.2 ± 1.1 versus 1.1 ± 6.4). Participants assigned to initial MTX who required step-up to combination therapy at 24 weeks (72%) demonstrated similar DAS28-ESR values (3.5 ± 1.3 versus 3.2 ± 1.3 at week 48) and radiographic progression (change in modified Sharp score 1.2 ± 4.1 versus 1.1 ± 6.4 at week 102) as those assigned to immediate combination therapy. The results for either of the immediate combination approaches, whether triple therapy or MTX plus etanercept, were similar. Conclusion These results in patients with early, poor prognosis RA validate the strategy of starting with MTX monotherapy. This study is the first to demonstrate in a blinded trial that initial MTX monotherapy with the option to step-up to combination therapy results in similar outcomes to immediate combination therapy. Approximately 30% of patients will not need combination therapy, and the 70% who will need it are clinically and radiographically indistinguishable from those who were randomized to receive immediate combination therapy.

Objective.Rapidly predicting future outcomes based on short-term clinical response would be helpful to optimize rheumatoid arthritis (RA) management in early disease. Our aim was to derive and validate a clinical prediction rule to predict low disease activity (LDA) at 1 year among patients participating in the Treatment of Early Aggressive Rheumatoid Arthritis (TEAR) trial escalating RA therapy by adding either etanercept or sulfasalazine + hydroxychloroquine [triple therapy (TT)] after 6 months of methotrexate (MTX) therapy.Methods.Eligible subjects included in the derivation cohort (used for model building, n = 186) were participants with moderate or higher disease activity [Disease Activity Score 28-erythrocyte sedimentation rate (DAS-ESR) > 3.2] despite 24 weeks of MTX monotherapy who added either etanercept or sulfasalazine + hydroxychloroquine. Clinical characteristics measured within the next 12 weeks were used to predict LDA 1 year later using multivariable logistic regression. Validation was performed in the cohort of TEAR patients randomized to initially receive either MTX + etanercept or TT.Results.The derivation cohort yielded 3 prediction models of varying complexity that included age, DAS28 at various timepoints, body mass index, and ESR (area under the receiver-operator characteristic curve up to 0.83). Accuracy of the prediction models ranged between 80% and 95% in both derivation and validation cohorts, depending on the complexity of the model and the cutpoints chosen for response and nonresponse. About 80% of patients could be predicted to be responders or nonresponders at Week 12.Conclusion.Clinical data collected early after starting or escalating disease-modifying antirheumatic drug/biologic treatment could accurately predict LDA at 1 year in patients with early RA. For patients predicted to be nonresponders, treatment could be changed at 12 weeks to optimize outcomes.

Rheumatoid arthritis (RA) increases in incidence and prevalence with age, with a peak in the sixth decade of life. Elderly onset RA (EORA) may be genetically different from younger onset RA, and with immune dysfunction associated with aging, environmental factors may also influence EORA onset. Smoking, periodontitis and viral infections are examples of environmental factors that have been shown to be associated with development of EORA, and even hormonal changes with menopause may be a source of RA activation in older patients. EORA can be distinguished from polymyalgia rheumatica, inflammatory hand osteoarthritis or psoriatic arthritis by rheumatoid factor or anticitrullinated protein antibodies. Comorbidities influence treatment risk–benefit and require proactive management; these include arteriosclerotic cardiovascular disease, obesity, diabetes, GI tract conditions, lung disease, renal disease or malignancies, as well as susceptibility to infection. As inclusion of older RA patients is lower in clinical trials, safety data in this group are limited and this influences treatment choice, especially for biologics. Despite the efficacy of biologics, they are less likely to be used in older RA patients. This is problematic as glucocorticoids, when used in the elderly, are associated with serious infections, cardiovascular and fracture risk, among other side effects. Similarly, analgesics and NSAIDs should be used cautiously. Taking into account comorbidities, treat-to-target strategies with nonbiologic disease-modifying antirheumatic drugs and biologics can be applied with an expectation of acceptable risk–benefit in these patients.

Introduction: Cervical intraepithelial neoplasia and cervical cancer remain important health problems. Cervical cytology by Papanicolaou (Pap) smears is an effective means of screening for cervical premalignant and malignant conditions. Aim: The aim of this study was to assess the prevalence of cervical dysplasia in pre- and postmenopausal women in western Uttar Pradesh and to find out risk factors as far as possible. Materials and Methods: A total of 4,703 cases were enrolled, cervical scrape smears were collected and stained using Papanicolaou′s method and hematoxylin and eosin stain. The emphasis was put on epithelial abnormalities and smears were classified according to The Bethesda System 2001. Results: 81.06% (3812) smears were satisfactory according to The Bethesda System. Maximum numbers of cases (40.37%) were in age group 30-39 years. The epithelial abnormalities constituted 3.23% of all cases. Low-grade squamous intraepithelial lesion (LSIL) formed the largest number (1.36%), while high-grade squamous intraepithelial lesion (HSIL) formed 0.91%. Eleven cases of squamous cell carcinoma (SCC) were detected. The study has shown a relatively high prevalence of epithelial abnormalities in cervical smears with increasing age, parity, early age at first coitus (

Patient reported outcomes (PROs) are essential to the judicious care of patients with rheumatoid arthritis (RA). Rheumatologists were pioneers in this field with the first papers using PROs published in the 1940s.1 Exploring the link between PROs, which are potentially subjective, and the more objective radiographic or MRI measures of structural damage and joint inflammation is important. The former describe the patient experience, which is after all the point of clinical medicine, while the latter provide information about the disease process itself, which can be influenced by clinicians using modern therapeutic approaches. The recent paper published by Baker et al 2 highlights a critical demonstration that inhibition of inflammation and progression of structural damage directly impacts reported pain of patients with RA and physical function, and positively influences their assessment of disease activity. This publication is one of several thought-provoking post hoc analyses performed within the MRI substudies of the Golimumab Before Employing Methotrexate as the First-Line Option in the Treatment of Rheumatoid Arthritis of Early Onset (GO-BEFORE) and Golimumab in Active Rheumatoid Arthritis Despite Methotrexate Therapy trials.3–6 The first meta-analyses to examine the link between physical function and radiographic damage were published in 2000 and 2003.7 ,8 These studies were performed in the prebiologic era, where even small cross-sectional cohort studies demonstrated an association between total radiographic damage and the health assessment questionnaire-disability index (HAQ-DI). A subsequent comprehensive literature review of publications between 1990 and 2008 (including some postbiologic disease modifying antirheumatic drugs (DMARD) trials) eliminated cross-sectional studies9 and provided a synopsis of four key concepts regarding the relationship between structural damage and HAQ: (A) 9/19 randomised controlled trials (RCTs) demonstrated a significant relationship between baseline radiographic damage and end of study HAQ, (B) 10/19 showed significant correlations cross-sectionally across the entire trial duration; …

Reverse cholesterol transport (RCT) is a major antiatherogenic function of high density lipoprotein (HDL). In the current work, the authors evaluated whether the RCT capacity of HDL from rheumatoid arthritis (RA) patients is impaired when compared to healthy controls.HDL was isolated from 40 patients with RA and 40 age and sex matched healthy controls. Assays of cholesterol efflux, HDL's antioxidant function and paraoxanase-1 (PON-1) activity were performed as described previously. Plasma myeloperoxidase (MPO) activity was assessed by a commercially available assay.Mean cholesterol efflux capacity of HDL was not significantly different between RA patients (40.2% ± 11.1%) and controls (39.5% ± 8.9%); p=0.75. However, HDL from RA patients with high disease activity measured by a disease activity score using 28 joint count (DAS285.1), had significantly decreased ability to promote cholesterol efflux compared to HDL from patients with very low disease activity/clinical remission (DAS282.6). Significant correlations were noted between cholesterol efflux and the DAS28 (r=-0.39, p=0.01) and erythrocyte sedimentation rate, (r=-0.41, p=0.0009). Higher plasma MPO activity was associated with worse HDL function (r=0.41/p=0.009 (antioxidant capacity); r=0.35, p=0.03 (efflux)). HDL's ability to promote cholesterol efflux was modestly but significantly correlated with its antioxidant function (r=-0.34, p=0.03).The cholesterol efflux capacity of HDL is impaired in RA patients with high disease activity and is correlated with systemic inflammation and HDL's antioxidant capacity. Attenuation of HDL function, independent of HDL cholesterol levels, may suggest a mechanism by which active RA contributes to increased cardiovascular (CV) risk.

The aim of the study was to carry out water quality assessment and to identify sources responsible for deterioration of quality in the Malad creek, Mumbai, India. Creek receives sewage and wastewater from various drains and partially treated effluent from Malad and Versova treatment facilities. To assess the water quality, sampling locations were identified in the creek based on discharges of wastewater and sewage. Identified locations were traced in physical space by a global positioning system. Samples were collected during low and high tides and analyzed for physical, chemical and bacteriological parameters such as pH, Turbidity, DO, BOD, NH3-N, PO4 and FC and compared with SW-II Standards. Parameters were also analyzed statistically and correlated to determine the relationship amongst the parameters using SPSS software. The idea was to determine the probable causes contributing to the pollution in the creek. Various options were suggested for improvement in the creek quality based on water quality assessment.

Differences in clinical characteristics of older and younger rheumatoid arthritis (RA) patients have led some researchers to believe that RA in older patients is a distinct clinical entity and requires specialized therapeutic management. Whether or not there are any differences in clinical features and prognosis between older and younger RA patients, there is general consensus that RA should be treated aggressively early in the course of the disease to achieve the best clinical outcome. For this reason, all patients, irrespective of age, are treated with commonly used disease-modifying antirheumatic drugs/biologic agents. Although the data are limited, published safety and efficacy papers on older RA patients suggest that most disease-modifying antirheumatic drugs/biologic agents have similar efficacy and safety outcomes to younger RA patients. However, due to multiple comorbidities, older RA patients may be at a higher risk for adverse drug reactions.

Guidelines and recommendations developed and/or endorsed by the American College of Rheumatology (ACR) are intended to provide guidance for particular patterns of practice and not to dictate the care of a particular patient. The ACR considers adherence to these guidelines and recommendations to be voluntary, with the ultimate determination regarding their application to be made by the physician in light of each patient’s individual circumstances. Guidelines and recommendations are intended to promote beneficial or desirable outcomes but cannot guarantee any specific outcome. Guidelines and recommendations developed or endorsed by the ACR are subject to periodic revision as warranted by the evolution of medical knowledge, technology, and practice.

Objective.To evaluate responses by time to initiation of nonbiologic disease-modifying antirheumatic drugs (DMARD) in a DMARD-naive cohort of patients with early seropositive rheumatoid arthritis (RA).Methods.Subjects were categorized by the time from symptom onset to the first DMARD use (median 5.7 months, range 0.6–15.9). Subjects who started their first DMARD within 5 months of symptom onset were compared to subjects who started after 5 months. Disease Activity Scores (DAS-44) and total Sharp Score (TSS) progression rates were analyzed using Wilcoxon rank-sum and chi-square tests; multiple linear regression analysis adjusted for potential covariates. The slope of the least-squares regression line was calculated to estimate the annualized TSS progression rates.Results.Of 233 RA patients, 76% were female and mean age was 50 (SD 13) years. At DMARD start, DAS-44 was similar in all subsets within the 0.6 to 15 months’ duration between symptom onset and DMARD initiation. Erosion scores tended to be higher in those who started DMARD later, but Health Assessment Questionnaire-Disability Index (HAQ-DI) scores were higher in those who started DMARD earlier. During the 2 years after DMARD initiation, improvements in HAQ-DI and DAS-44 were similar in the various duration subsets, with about 25% ever achieving DAS remission (DAS < 1.6). Radiographic progression tended to be numerically but not statistically more rapid in the earlier subsets.Conclusion.Following initiation of nonbiologic DMARD therapy at various times within 15 months of symptom onset, improvements of DAS-44, HAQ-DI, remission rate, and radiographic progression rate were similar, although higher baseline erosion scores were present in those with later initiation of DMARD.