- Email: [email protected]
P69 An 11-year clinical review of Septic arthritis from a tertiary care
Abstracts of papers presented in IRACON – 2011 Introduction: Although the acute manifestations of chikungunya virus (CHIKV) illness are well documented, few Indian studies exist about the risk factors for the chronic rheumatic outcomes of CHIKV-infected patients. This study aims to understand the factors involved in the postepidemic chickungunya disease in a rural setting. Patients: Five hundred and eighty-one presumptive or laboratory-confirmed cases of CHIKV illness, reported from 840 households (3869 total population), during the outbreak (July– December 2009). All patients > 15 years with chickungunya were included in the study group. Methods: Community-based, retrospective cohort study 15 months after the epidemic. Data collected included demographic characteristics, major comorbidities, acute manifestations and impact of disease using the Health Assessment Questionnaire Disability Index (HAQDI). Regression analysis assessed the risk factors for persistent pain. Results: During the epidemic 30.89% of the population was affected; 48.6% of the affected developed persistent pain. Significant factors associated with persistent pain included female gender (OR 1.446), marital status (OR 1.563), old root mean square deviation (RMSD) (OR 2.242), diabetes (OR 1.679), joint swelling (OR 1.435); presently smoking (OR 1.806); subjects returning to work < 1 week (OR 3.027) or > 4 weeks (OR 1.818) and perceived moderate job burden (OR 1.724); 16.2% of those with persistent pain scored moderate to severe in the health assessment questionnaire disability index (HAQDI). Conclusions: Persistent pain is a frequent underlying postepidemic condition in our setting. These findings should be considered in the development of preventive measures.
P65 Changing morbidity pattern among old RMSD patients post-chikungunya Binoy J Paul1, Asuma A Rahim2, Romy Jose Thekkekara2, Thomas Bina2 Consultant Rheumatologist, Kozhikode, India, 2Department of Community Medicine, Government Medical College, Kozhikode, India
1
Introduction: Chikungunya, known for its acute and chronic musculoskeletal morbidities, swept large parts of Kerala between 2006 and 2009. The Calicut cohort of the WHO-ILAR Community Oriented Program for Control of Rheumatic Diseases (COPCORD) was the subject to the epidemic subsequent to the COPCORD rheumatological evaluation. This study was designed to assess the effect of chikungunya on the rheumatological profile of RMSD patients diagnosed in COPCORD. Patients: RMSD patients of the COPCORD-Calicut study, affected by chikungunya, being followed up through a series of ongoing health camps 30 months after the COPCORD evaluation. Methods: The rheumatological profile of willing participants is recorded and compared with their profile in the COPCORD database using appropriate statistical tests. Results: Twenty-eight patients participated in the study. Mean age of the participants was 52.36 ± 12.69 years. There was a significant increase in the number of joints involved (P value = 0.001) and fibrositis points (P value = 0.006) in the participants before and after chikungunya. There was also a significant increase in the mean number of diagnosis after chikungunya affection (pre: 1.035 ± 0.19, post: 2.25 ± 0.065; P value = 0.000). There was a significant rise in the number of persons affected with OA (17.9% before and 42.9% after P value = 0.016). The diagnosis of OA rose from 17.24% to 22.22% and soft tissue rheumatism from 10.34% to 15.87% of all diagnosis. Moderate to severe disability on the Health Assessment Questionnaire Disability Index rose from 15% to 35% of the respondents. Conclusions: Chikungunya has precipitated a worsening of the rheumatological profile of the RMSD- affected individuals.
P66 Rheumatological manifestations of HIV infection in a tertiary centre I Ghosh, V Marwaha, N Bajaj, H Singh, R Bahl, ND Reddy, CS Narayanan, AD Mathur Command Hospital (Western Command), Chandimandir, India Background: Rheumatological manifestations have been reported in HIV infection. They can occur as part of the disease process or as adverse effects of drugs. Materials and methods: This prospective study was conducted from September 2010 to June 2011 in the Rheumatology Department of Command Hospital (Western Command) Chandimandir Cantt, which is a tertiary care hospital. All HIV positive patients attending our hospital’s Rheumatology OPD/admitted in hospital were screened for musculoskeletal symptoms. Their ART status was recorded. They were asked to report in case they developed any musculoskeletal symptoms. A questionnaire was handed over to them and explained in detail. Mobile number was given to the patients with directions to contact the study team on as required basis. X-rays of relevant joints were done if required. CT/MRI was done if indicated. Patients with < 2 months follow-up were not included in the study. Results: A total of 76 patients were included in the study; 74 were male and 2 were female. The follow-up varied from 2 to 10 months. Rheumatological manifestations were recorded in three patients. One patient had nonspecific polyarthritis which improved with nonsteroidal anti-inflammatory drugs (NSAIDs). One patient had gout following pyrazinamide and improved with stoppage of drug and NSAIDs. One patient had frozen shoulder (left) which improved with NSAIDs and physiotherapy. No patient developed spondyarthritis. Conclusion: Rheumatological manifestations can occur in HIV infection both due to the disease and as a result of treatment. They respond well to therapy generally.
S19 P67 Chronic hepatitis C: a close mimic of rheumatological diseases—a case series of eight patients S Nagaraj, Neena Chitnis, Vishnu Sharma, Piyush Joshi, Preeti Nagnur-Metha, Avinash Buche, Rohini Samant Department of Rheumatology, PD Hinduja National Hospital and MRC, Mumbai, Maharashtra, India Objective: To study the clinical features and laboratory parameters of eight patients who presented with various rheumatic manifestations but diagnosed to have Hepatitis C on subsequent evaluation. Methods: Relevant demographical, clinical, laboratory and management details were noted from medical case records retrospectively. Results: Total 8 patients (7 females and 1 male). Median age was 43 years (range: 34–57 years). All patients had a history of blood transfusion. The median duration between blood transfusion and rheumatic manifestations was 26 years. Arthralgias/arthritis was present in seven patients, sicca symptoms in three, palpable purpura in two, Erythema nodosum in one and cryoglobulinemic vasculitis (glomerulonephritis and mononeuritis multiplex) in one. Four of the eight patients had elevated liver enzymes, four had thrombocytopaenia and one had leukopaenia. Five patients had strongly positive rheumatoid factor, three had decreased C3 levels. ANA was positive in two patients and cryoglobulins in one patient. Five patients received anti-HCV treatment with interferon and ribavarin. One patient with cryoglobinaemic vasculitis underwent plasmapharesis in another hospital. One patient refused antiviral treatment and one patient was lost to follow-up. Three patients with arthritis additionally needed sulfasalazine and hydroxychloroquine. The rheumatic manifestations subsided with anti-HCV treatment alone in three patients without the need for additional immunosuppressants. Conclusions: Hepatitis C should be suspected in the setting of unexplained cytopaenias, raised liver enzymes, sicca syndrome, glomerulonephritis and vasculitis. History of blood transfusion should be elicited in such patients. Treatment of hepatitis C alone may significantly ameliorate the symptoms in majority of the patients.
P68 “Spectrum of myositis due to bacterial infections”—rheumatologist experience in a university hospital P Damodaram, Emil J Thachil, ARK Naidu, H Shabina, K Suresh, L Rajasekhar, G Narsimulu Department of Rheumatology, Nizam’s Institute of Medical Sciences, Hyderabad, Andhra Pradesh, India Aim: To analyse the spectrum of myositis secondary to bacterial infections in patients at a rheumatology centre at a University hospital. Materials and methods: Records of inpatients admitted with myositis from 2006 to 2011 were retrieved. Demographical data, comorbidities, organisms involved and outcome was assessed. Results: n = 12; mean age = 30.5 ± 16.8 years; 10 males and 2 were females who had SLE. Organisms implicated: Staphylococcus aureus in four patients, Stenotrophomonas maltophila in two, Enterobacter in two and Streptococcus pneumonia, Streptococcus suis, Salmonella enteritidis in one patient each. The organism could not be isolated in one patient. Comorbidities were present in five patients, lupus in two, dermatomyositis, juvenile idiopathic arthritis and diabetes mellitus in one patient each. Simultaneous joint infections were noted in four patients and contiguous joint involvement was observed with streptococcus infections. The infection was nosocomial in one patient (Stenotrophomonas maltophila), and zoonotic in one (Streptococcus suis). All the others were community-acquired. All patients except one recovered with specific antimicrobial therapy. Conclusion: Myositis due to bacterial infections is the potential cause of admission in rheumatology units. All age groups are susceptible. Staphylococcus aureus is most commonly implicated. However, infections due to uncommon organisms and zoonotic infections are not rare.
P69 An 11-year clinical review of Septic arthritis from a tertiary care Arun Kumar Gupta, Vikas Agarwal, Able Lawrence, Ramnath Misra, Shiva Prasad, Amita Aggrawal Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Science, Lucknow, India Background: Septic arthritis is defined as bacterial invasion of the synovial space. Bacterial septic arthritis is an important medical condition considered a rheumatological emergency that can lead to rapid joint destruction and irreversible loss of function. Septic arthritis can be difficult to diagnosis, especially when it is mistaken for flare of pre-existing inflammatory arthritis. In this study, we analysed the patients seen in our hospital in the last decade. Methods: A retrospective study of all patients seen with septic arthritis at our hospital from January 1999 to August 2010 was undertaken. Joint aspirates were taken for microbiologic investigation. Results: Thirty patients (24 males) with septic arthritis were seen with median age of 41 (13–61) years. The knee was the most commonly affected joint. The duration of symptoms before presentation ranged between 4 and 17 days with a mean range of 11.1–3.6 days.
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Thirteen of the patients were on inadequate antibiotics before presenting. Common presenting symptoms were fever in 29 patients. The most common joints involved was knees in 25, the elbow in 4, the shoulders in 14 and ankle in 3 patients and hip and sternoclavicular in 1 patient. Five patients had polyarticular involved. Diagnosis was confirmed by pus aspiration and culture reports (blood and pus) in 27 patients. Of the 30 patients Staphylococcus aureus was grown in 20, coagulase-negative Staphylococcus in 4, Psedomonous aeuroginosa in 2, E. coli in 2, Acinectobecter baunanii and Salmonella enteritids in 1 each patients and Acinectobecter, Enterococcus faccilum, Citerobactor freundii in each. Blood cultures were positive in three patients. Of these 30 patients, 3 had feature of septic shock and 1 died. Patient who died had comorbidities such as cerebrovascular accident, chronic renal failure (CRF), obstructive uropathy, benign prostatic hypertrophy (BPH), acute renal failure in 1 patient. Conclusion: The joints of the lower limbs were more involved. Septic arthritis due to bacterial infection as serious and potentially life-threatening disease that can lead to rapid destruction of the vulnerable articular hyaline cartilage and irreversible loss of joint function early recognition and prompt treatment results in complete recovery.
Poster Presentations P72 C-reactive protein normal level—a systematic meta-analysis S Chandrashekara, Neethu Daniel, D Puneetha Rani, Jitendra K Sahoo, KP Suresh Department of Immunology and Rheumatology, ChanRe Rheumatology and Immunology Centre, Bangalore, Karnataka, India Introduction: C-reactive protein (CRP) is an acute phase protein, whose level increases to multiple folds in case of inflammation, including rheumatoid arthritis (RA). One area which still remains as a gray zone is the interpretation of the value of CRP at a population level. Although we can prognosticate based on the intra-individual variation of CRP levels, a normal value for an individual itself (based on his age, sex, race, and ethnicity) is not reflected clearly in the literature. Different references are adopted in its interpretation of CRP value like in cardiac risk profiling > 0.3 mg/dL to be associated with significant risk, whereas in RA a normal target has ranged from 1 mg/dL to 6 mg/dL. Even the reporting normal range differs from laboratory to laboratory. In order to find a reasonable normal range, we proposed to run a systematic meta-analysis review of the available literature on the levels of CRP to provide some clarity on the normal (healthy) cutoff values of CRP.
Miscellaneous P70 Frequency and predictors of postoperative periprosthetic fracture after total knee replacement (TKR): an analysis of 21,723 TKRs
Methods: A total of 96 studies were retrieved from PUBMED data base search and reviewed, in which 65 were excluded (diseased population, unclear data) and 31 were considered with 68,823 subjects. After testing for the significance of heterogeneity of studies based on chisquare test and tau-square (heterogeneity coefficient), fixed effect model or random effect model was selected for integrating the results.
JA Singh1,2, DG Lewallen2
Results: We divided the population based on the available information, those who were not having any sickness, non-smokers and not taken alcohol in the previous day. The populations that include smokers, diabetes and hypertension were analysed separately, to exclude the possible influence of the co-existing medical condition. Levels of CRP in different groups after meta-analysis were found that CRP value in healthy subjects (study = 7, subjects = 4356, mean ± SD = 0.673 mg/dL ± 0.209), in smoking and diabetics (study = 5, subjects = 13,909, mean ± SD = 1.335 mg/dL 0.321), smoking alone (study = 5, subjects = 7172, mean ± SD = 0.364 mg/dL + 0.112), diabetics (study = 1 (4 sets), subjects = 225, mean ± SD = 0.7655 mg/dL ± 0.319), diabetics and hypertension (study = 1 (2 sets), subjects = 2106, mean ± SD = 0.2962 mg/dL 0.648), diabetics and smokers and hypertension (study = 9, subjects = 41,055, mean ± SD = 1.136 mg/dL ± 0.189).
University of Alabama, Birmingham, AL, USA, 2Mayo Clinic School of Medicine, Rochester, MN, USA
1
Objective: To examine the risk factors for postoperative periprosthetic fractures following total knee replacement (TKR). Methods: In a cohort of all patients who underwent primary or revision total knee arthroplasty at Mayo Clinic, Rochester from 1989 to 2008, we used prospectively collected data in the Mayo Clinic Total Joint Registry to assess the frequency and predictors of postoperative periprosthetic fractures. Both modifiable (comorbidity, body mass index) and unmodifiable factors (age, gender, operative diagnosis, ASA class, prior cardiac and prior thromboembolic disease) predictors were assessedusing multivariable-adjusted Cox regression analyses separately for primary and revision TKR. Results: 12,914 patients underwent 17,633 primary TKRs and 3,286 patients underwent 4090 revision TKRs from 1989–2008. The frequency of postoperative periprosthetic fracture on or after postoperative day 1 was 1.1% (188/17,633) after primary TKR and 2.5% (104/4090) after revision TKR. Using multivariable-adjusted analyses, older age was significantly associated with lower risk of periprosthetic fractures after primary TKR (P < 0.001), namely, compared to ≤ 60 years, risk was lower with ages 61–70 (Hazard ratio, 0.51; 95% confidence interval (CI):0.35, 0.74) and 71–80 (Hazard ratio, 0.55; 95% CI:0.38, 0.80). In patients undergoing revision TKR, a diagnosis of non-union (Hazard ratio, 4.82; 95% CI:1.17, 19.87) or previous surgery with components removed (Hazard ratio, 2.12; 95% CI:1.34, 3.37) increased the risk of postoperative periprosthetic fracture, compared to a diagnosis of loosening/wear/osteolysis. Conclusions: We identified important risk factors for periprosthetic fractures after primary and revision TKR. Patients with these risk factors can be better informed of the increased risk of this uncommon, but serious complication of TKR.
P71 Postoperative periprosthetic fractures following primary total hip replacement JA Singh1,2, DG Lewallen2 University of Alabama, Birmingham, AL, USA, 2Mayo Clinic School of Medicine, Rochester, MN, USA
1
Objective: Study frequency and risk factors for postoperative periprosthetic fractures after primary total hip replacement (THR). Methods: We used the data from the Mayo Clinic Total Joint Registry to identify a cohort of all patients who underwent primary THR from 1989 to 2008. Additional data were obtained from other institutional databases. We used univariate- and multivariable-adjusted Cox regression analyses to assess the association of potential risk factors and the occurrence of periprosthetic fractures. Age, gender, body mass index (BMI), Deyo–Charlson comorbidity index, underlying diagnosis, American Society of Anaesthesiologists (ASA) class, prior cardiac or thromboembolic events and implant fixation (cemented vs. non-cemented) were assessed. Hazard ratios (HR) with 95% confidence interval (CI) are presented. Results: With a mean follow-up of 6.3 years, 305 periprosthetic fractures occurred in 14,065 primary THRs; 67% occurred 1 year or later. After multivariable adjustment, female gender (OR, 1.48; 95% CI 1.17–1.88; P = 0.001), Deyo–Charlson score of 2 (OR, 1.48; 95% CI 1.17– 1.88; P = 0.001) or 3 or higher (OR, 1.48; 95% CI 1.17–1.88; P = 0.001), underlying diagnosis of rheumatoid arthritis (OR, 1.48; 95% CI 1.17–1.88; P = 0.001) or avascular necrosis (OR, 1.48; 95% CI 1.17–1.88; P = 0.001), higher ASA class of 3 (OR, 1.48; 95% CI 1.17–1.88; P = 0.001) or 4 or higher (OR, 1.48; 95% CI 1.17–1.88; P = 0.001) were significantly associated with higher risk of periprosthetic fractures after primary THR. Cemented implant was associated with decreased risk (OR, 1.48; 95% CI 1.17–1.88; P = 0.001). Conclusions: We report independently associations of patient and implant characteristics with the risk of periprosthetic fractures. Patients in the high-risk categories can be better informed of prior to primary THR.
Conclusion: The meta-analysis result suggests that the optimum cutoff values for CRP healthy population can be taken as ≤ 0.7 0.2 mg/dL. We had not considered the race and methodology of estimation of CRP, since the numbers were less and the influence of them was not significant.
P73 Pain catastrophizing, but not widespread pain, is associated with poor pain outcomes after knee replacement: an analysis from the multicentre osteoarthritis study (MOST) JA Singh1, C Lewis1, K Wang2, D Felson2, M Nevitt3, D Torner4, L Bradley1, T Neogi2 1 3
University of Alabama, Birmingham, AL, USA, 2Boston University, Boston, MA, USA, University of Iowa, Iowa City, IA, USA, 4UCSF, San Francisco, CA, USA
Background/objective: Recent studies have suggested that pre-surgery mental and emotional health impact pain outcomes after knee replacement (KR). Little is known about the associations among pain catastrophizing, widespread pain and pain outcomes post-KR. Methods: We used data from the Multicenter OSTeoarthritis (MOST) study, a longitudinal cohort study of persons with or at high risk of knee OA. Western Ontario McMaster Osteoarthritis index (WOMAC) was used to assess pain and function at baseline, 30 and 60 months in the entire cohort, including those who had a KR during follow-up. We used data from clinic visits immediately prior to and at least 3 months after KR to assess the proportion of patients with poor pain outcomes: (1) moderate-severe knee pain post-KR (maximal score of at least moderate pain on at least one of the five WOMAC pain questions); and (2) poor pain responder (failure to achieve clinically meaningful change in knee pain, i.e., decrease of ≥ 5.6/20 on WOMAC pain in replaced knee after KR). Primary predictor variables of interest were (1) pain catastrophizing assessed by the Coping Strategies Questionnaire and (2) widespread pain assessed by a homunculus, categorized as present if there is pain reported above and below the waist, on both sides of the body, and axial pain. Multivariableadjusted regression analyses adjusted for age, sex, body mass index (BMI), ethnicity, clinic, contralateral knee OA or KR, comorbidity, lower back pain and pre-KR WOMAC pain. Results: During follow-up, 297 subjects had 391 new KRs with ≥ 1 study visit post-KR to ≥ 3 months after KR. Mean age was 66 ± 8, BMI 33 ± 7, 71% female, median time after KR 20 months with 94 patients having bilateral KRs; 34% patients had moderate-severe knee pain post-KR and 31% patients were poor pain responders. In multivariable-adjusted analyses, pain catastrophizing was associated with significantly higher odds of poor pain outcome with an odds ratio of 2.3 (95% CI, 1.3, 3.9; P = 0.0025), but widespread pain was not significantly associated, odds ratio of 1.2 (0.7, 2.1; P = 0.49). Pain catastrophizing was significantly associated with poor pain responder status with odds ratio of 2.8 (95% CI, 1.5, 5.1; P = 0.0008), but widespread pain was not significantly associated, odds ratio of 1.1 (0.6, 2.0; P = 0.71). Conclusions: This is the first evidence in a well-characterized longitudinal osteoarthritis cohort that pain catastrophizing is associated with worse pain outcomes post-KR. It is important to determine the cognitive, behavioural and neurophysiologic pathways that may mediate this relationship as well as the efficacy of coping skills training prior to KR on catastrophizing and postsurgical outcomes.
P65 Changing morbidity pattern among old RMSD patients post-chikungunya Binoy J Paul1, Asuma A Rahim2, Romy Jose Thekkekara2, Thomas Bina2 Consultant Rheumatologist, Kozhikode, India, 2Department of Community Medicine, Government Medical College, Kozhikode, India
1
Introduction: Chikungunya, known for its acute and chronic musculoskeletal morbidities, swept large parts of Kerala between 2006 and 2009. The Calicut cohort of the WHO-ILAR Community Oriented Program for Control of Rheumatic Diseases (COPCORD) was the subject to the epidemic subsequent to the COPCORD rheumatological evaluation. This study was designed to assess the effect of chikungunya on the rheumatological profile of RMSD patients diagnosed in COPCORD. Patients: RMSD patients of the COPCORD-Calicut study, affected by chikungunya, being followed up through a series of ongoing health camps 30 months after the COPCORD evaluation. Methods: The rheumatological profile of willing participants is recorded and compared with their profile in the COPCORD database using appropriate statistical tests. Results: Twenty-eight patients participated in the study. Mean age of the participants was 52.36 ± 12.69 years. There was a significant increase in the number of joints involved (P value = 0.001) and fibrositis points (P value = 0.006) in the participants before and after chikungunya. There was also a significant increase in the mean number of diagnosis after chikungunya affection (pre: 1.035 ± 0.19, post: 2.25 ± 0.065; P value = 0.000). There was a significant rise in the number of persons affected with OA (17.9% before and 42.9% after P value = 0.016). The diagnosis of OA rose from 17.24% to 22.22% and soft tissue rheumatism from 10.34% to 15.87% of all diagnosis. Moderate to severe disability on the Health Assessment Questionnaire Disability Index rose from 15% to 35% of the respondents. Conclusions: Chikungunya has precipitated a worsening of the rheumatological profile of the RMSD- affected individuals.
P66 Rheumatological manifestations of HIV infection in a tertiary centre I Ghosh, V Marwaha, N Bajaj, H Singh, R Bahl, ND Reddy, CS Narayanan, AD Mathur Command Hospital (Western Command), Chandimandir, India Background: Rheumatological manifestations have been reported in HIV infection. They can occur as part of the disease process or as adverse effects of drugs. Materials and methods: This prospective study was conducted from September 2010 to June 2011 in the Rheumatology Department of Command Hospital (Western Command) Chandimandir Cantt, which is a tertiary care hospital. All HIV positive patients attending our hospital’s Rheumatology OPD/admitted in hospital were screened for musculoskeletal symptoms. Their ART status was recorded. They were asked to report in case they developed any musculoskeletal symptoms. A questionnaire was handed over to them and explained in detail. Mobile number was given to the patients with directions to contact the study team on as required basis. X-rays of relevant joints were done if required. CT/MRI was done if indicated. Patients with < 2 months follow-up were not included in the study. Results: A total of 76 patients were included in the study; 74 were male and 2 were female. The follow-up varied from 2 to 10 months. Rheumatological manifestations were recorded in three patients. One patient had nonspecific polyarthritis which improved with nonsteroidal anti-inflammatory drugs (NSAIDs). One patient had gout following pyrazinamide and improved with stoppage of drug and NSAIDs. One patient had frozen shoulder (left) which improved with NSAIDs and physiotherapy. No patient developed spondyarthritis. Conclusion: Rheumatological manifestations can occur in HIV infection both due to the disease and as a result of treatment. They respond well to therapy generally.
S19 P67 Chronic hepatitis C: a close mimic of rheumatological diseases—a case series of eight patients S Nagaraj, Neena Chitnis, Vishnu Sharma, Piyush Joshi, Preeti Nagnur-Metha, Avinash Buche, Rohini Samant Department of Rheumatology, PD Hinduja National Hospital and MRC, Mumbai, Maharashtra, India Objective: To study the clinical features and laboratory parameters of eight patients who presented with various rheumatic manifestations but diagnosed to have Hepatitis C on subsequent evaluation. Methods: Relevant demographical, clinical, laboratory and management details were noted from medical case records retrospectively. Results: Total 8 patients (7 females and 1 male). Median age was 43 years (range: 34–57 years). All patients had a history of blood transfusion. The median duration between blood transfusion and rheumatic manifestations was 26 years. Arthralgias/arthritis was present in seven patients, sicca symptoms in three, palpable purpura in two, Erythema nodosum in one and cryoglobulinemic vasculitis (glomerulonephritis and mononeuritis multiplex) in one. Four of the eight patients had elevated liver enzymes, four had thrombocytopaenia and one had leukopaenia. Five patients had strongly positive rheumatoid factor, three had decreased C3 levels. ANA was positive in two patients and cryoglobulins in one patient. Five patients received anti-HCV treatment with interferon and ribavarin. One patient with cryoglobinaemic vasculitis underwent plasmapharesis in another hospital. One patient refused antiviral treatment and one patient was lost to follow-up. Three patients with arthritis additionally needed sulfasalazine and hydroxychloroquine. The rheumatic manifestations subsided with anti-HCV treatment alone in three patients without the need for additional immunosuppressants. Conclusions: Hepatitis C should be suspected in the setting of unexplained cytopaenias, raised liver enzymes, sicca syndrome, glomerulonephritis and vasculitis. History of blood transfusion should be elicited in such patients. Treatment of hepatitis C alone may significantly ameliorate the symptoms in majority of the patients.
P68 “Spectrum of myositis due to bacterial infections”—rheumatologist experience in a university hospital P Damodaram, Emil J Thachil, ARK Naidu, H Shabina, K Suresh, L Rajasekhar, G Narsimulu Department of Rheumatology, Nizam’s Institute of Medical Sciences, Hyderabad, Andhra Pradesh, India Aim: To analyse the spectrum of myositis secondary to bacterial infections in patients at a rheumatology centre at a University hospital. Materials and methods: Records of inpatients admitted with myositis from 2006 to 2011 were retrieved. Demographical data, comorbidities, organisms involved and outcome was assessed. Results: n = 12; mean age = 30.5 ± 16.8 years; 10 males and 2 were females who had SLE. Organisms implicated: Staphylococcus aureus in four patients, Stenotrophomonas maltophila in two, Enterobacter in two and Streptococcus pneumonia, Streptococcus suis, Salmonella enteritidis in one patient each. The organism could not be isolated in one patient. Comorbidities were present in five patients, lupus in two, dermatomyositis, juvenile idiopathic arthritis and diabetes mellitus in one patient each. Simultaneous joint infections were noted in four patients and contiguous joint involvement was observed with streptococcus infections. The infection was nosocomial in one patient (Stenotrophomonas maltophila), and zoonotic in one (Streptococcus suis). All the others were community-acquired. All patients except one recovered with specific antimicrobial therapy. Conclusion: Myositis due to bacterial infections is the potential cause of admission in rheumatology units. All age groups are susceptible. Staphylococcus aureus is most commonly implicated. However, infections due to uncommon organisms and zoonotic infections are not rare.
P69 An 11-year clinical review of Septic arthritis from a tertiary care Arun Kumar Gupta, Vikas Agarwal, Able Lawrence, Ramnath Misra, Shiva Prasad, Amita Aggrawal Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Science, Lucknow, India Background: Septic arthritis is defined as bacterial invasion of the synovial space. Bacterial septic arthritis is an important medical condition considered a rheumatological emergency that can lead to rapid joint destruction and irreversible loss of function. Septic arthritis can be difficult to diagnosis, especially when it is mistaken for flare of pre-existing inflammatory arthritis. In this study, we analysed the patients seen in our hospital in the last decade. Methods: A retrospective study of all patients seen with septic arthritis at our hospital from January 1999 to August 2010 was undertaken. Joint aspirates were taken for microbiologic investigation. Results: Thirty patients (24 males) with septic arthritis were seen with median age of 41 (13–61) years. The knee was the most commonly affected joint. The duration of symptoms before presentation ranged between 4 and 17 days with a mean range of 11.1–3.6 days.
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Thirteen of the patients were on inadequate antibiotics before presenting. Common presenting symptoms were fever in 29 patients. The most common joints involved was knees in 25, the elbow in 4, the shoulders in 14 and ankle in 3 patients and hip and sternoclavicular in 1 patient. Five patients had polyarticular involved. Diagnosis was confirmed by pus aspiration and culture reports (blood and pus) in 27 patients. Of the 30 patients Staphylococcus aureus was grown in 20, coagulase-negative Staphylococcus in 4, Psedomonous aeuroginosa in 2, E. coli in 2, Acinectobecter baunanii and Salmonella enteritids in 1 each patients and Acinectobecter, Enterococcus faccilum, Citerobactor freundii in each. Blood cultures were positive in three patients. Of these 30 patients, 3 had feature of septic shock and 1 died. Patient who died had comorbidities such as cerebrovascular accident, chronic renal failure (CRF), obstructive uropathy, benign prostatic hypertrophy (BPH), acute renal failure in 1 patient. Conclusion: The joints of the lower limbs were more involved. Septic arthritis due to bacterial infection as serious and potentially life-threatening disease that can lead to rapid destruction of the vulnerable articular hyaline cartilage and irreversible loss of joint function early recognition and prompt treatment results in complete recovery.
Poster Presentations P72 C-reactive protein normal level—a systematic meta-analysis S Chandrashekara, Neethu Daniel, D Puneetha Rani, Jitendra K Sahoo, KP Suresh Department of Immunology and Rheumatology, ChanRe Rheumatology and Immunology Centre, Bangalore, Karnataka, India Introduction: C-reactive protein (CRP) is an acute phase protein, whose level increases to multiple folds in case of inflammation, including rheumatoid arthritis (RA). One area which still remains as a gray zone is the interpretation of the value of CRP at a population level. Although we can prognosticate based on the intra-individual variation of CRP levels, a normal value for an individual itself (based on his age, sex, race, and ethnicity) is not reflected clearly in the literature. Different references are adopted in its interpretation of CRP value like in cardiac risk profiling > 0.3 mg/dL to be associated with significant risk, whereas in RA a normal target has ranged from 1 mg/dL to 6 mg/dL. Even the reporting normal range differs from laboratory to laboratory. In order to find a reasonable normal range, we proposed to run a systematic meta-analysis review of the available literature on the levels of CRP to provide some clarity on the normal (healthy) cutoff values of CRP.
Miscellaneous P70 Frequency and predictors of postoperative periprosthetic fracture after total knee replacement (TKR): an analysis of 21,723 TKRs
Methods: A total of 96 studies were retrieved from PUBMED data base search and reviewed, in which 65 were excluded (diseased population, unclear data) and 31 were considered with 68,823 subjects. After testing for the significance of heterogeneity of studies based on chisquare test and tau-square (heterogeneity coefficient), fixed effect model or random effect model was selected for integrating the results.
JA Singh1,2, DG Lewallen2
Results: We divided the population based on the available information, those who were not having any sickness, non-smokers and not taken alcohol in the previous day. The populations that include smokers, diabetes and hypertension were analysed separately, to exclude the possible influence of the co-existing medical condition. Levels of CRP in different groups after meta-analysis were found that CRP value in healthy subjects (study = 7, subjects = 4356, mean ± SD = 0.673 mg/dL ± 0.209), in smoking and diabetics (study = 5, subjects = 13,909, mean ± SD = 1.335 mg/dL 0.321), smoking alone (study = 5, subjects = 7172, mean ± SD = 0.364 mg/dL + 0.112), diabetics (study = 1 (4 sets), subjects = 225, mean ± SD = 0.7655 mg/dL ± 0.319), diabetics and hypertension (study = 1 (2 sets), subjects = 2106, mean ± SD = 0.2962 mg/dL 0.648), diabetics and smokers and hypertension (study = 9, subjects = 41,055, mean ± SD = 1.136 mg/dL ± 0.189).
University of Alabama, Birmingham, AL, USA, 2Mayo Clinic School of Medicine, Rochester, MN, USA
1
Objective: To examine the risk factors for postoperative periprosthetic fractures following total knee replacement (TKR). Methods: In a cohort of all patients who underwent primary or revision total knee arthroplasty at Mayo Clinic, Rochester from 1989 to 2008, we used prospectively collected data in the Mayo Clinic Total Joint Registry to assess the frequency and predictors of postoperative periprosthetic fractures. Both modifiable (comorbidity, body mass index) and unmodifiable factors (age, gender, operative diagnosis, ASA class, prior cardiac and prior thromboembolic disease) predictors were assessedusing multivariable-adjusted Cox regression analyses separately for primary and revision TKR. Results: 12,914 patients underwent 17,633 primary TKRs and 3,286 patients underwent 4090 revision TKRs from 1989–2008. The frequency of postoperative periprosthetic fracture on or after postoperative day 1 was 1.1% (188/17,633) after primary TKR and 2.5% (104/4090) after revision TKR. Using multivariable-adjusted analyses, older age was significantly associated with lower risk of periprosthetic fractures after primary TKR (P < 0.001), namely, compared to ≤ 60 years, risk was lower with ages 61–70 (Hazard ratio, 0.51; 95% confidence interval (CI):0.35, 0.74) and 71–80 (Hazard ratio, 0.55; 95% CI:0.38, 0.80). In patients undergoing revision TKR, a diagnosis of non-union (Hazard ratio, 4.82; 95% CI:1.17, 19.87) or previous surgery with components removed (Hazard ratio, 2.12; 95% CI:1.34, 3.37) increased the risk of postoperative periprosthetic fracture, compared to a diagnosis of loosening/wear/osteolysis. Conclusions: We identified important risk factors for periprosthetic fractures after primary and revision TKR. Patients with these risk factors can be better informed of the increased risk of this uncommon, but serious complication of TKR.
P71 Postoperative periprosthetic fractures following primary total hip replacement JA Singh1,2, DG Lewallen2 University of Alabama, Birmingham, AL, USA, 2Mayo Clinic School of Medicine, Rochester, MN, USA
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Objective: Study frequency and risk factors for postoperative periprosthetic fractures after primary total hip replacement (THR). Methods: We used the data from the Mayo Clinic Total Joint Registry to identify a cohort of all patients who underwent primary THR from 1989 to 2008. Additional data were obtained from other institutional databases. We used univariate- and multivariable-adjusted Cox regression analyses to assess the association of potential risk factors and the occurrence of periprosthetic fractures. Age, gender, body mass index (BMI), Deyo–Charlson comorbidity index, underlying diagnosis, American Society of Anaesthesiologists (ASA) class, prior cardiac or thromboembolic events and implant fixation (cemented vs. non-cemented) were assessed. Hazard ratios (HR) with 95% confidence interval (CI) are presented. Results: With a mean follow-up of 6.3 years, 305 periprosthetic fractures occurred in 14,065 primary THRs; 67% occurred 1 year or later. After multivariable adjustment, female gender (OR, 1.48; 95% CI 1.17–1.88; P = 0.001), Deyo–Charlson score of 2 (OR, 1.48; 95% CI 1.17– 1.88; P = 0.001) or 3 or higher (OR, 1.48; 95% CI 1.17–1.88; P = 0.001), underlying diagnosis of rheumatoid arthritis (OR, 1.48; 95% CI 1.17–1.88; P = 0.001) or avascular necrosis (OR, 1.48; 95% CI 1.17–1.88; P = 0.001), higher ASA class of 3 (OR, 1.48; 95% CI 1.17–1.88; P = 0.001) or 4 or higher (OR, 1.48; 95% CI 1.17–1.88; P = 0.001) were significantly associated with higher risk of periprosthetic fractures after primary THR. Cemented implant was associated with decreased risk (OR, 1.48; 95% CI 1.17–1.88; P = 0.001). Conclusions: We report independently associations of patient and implant characteristics with the risk of periprosthetic fractures. Patients in the high-risk categories can be better informed of prior to primary THR.
Conclusion: The meta-analysis result suggests that the optimum cutoff values for CRP healthy population can be taken as ≤ 0.7 0.2 mg/dL. We had not considered the race and methodology of estimation of CRP, since the numbers were less and the influence of them was not significant.
P73 Pain catastrophizing, but not widespread pain, is associated with poor pain outcomes after knee replacement: an analysis from the multicentre osteoarthritis study (MOST) JA Singh1, C Lewis1, K Wang2, D Felson2, M Nevitt3, D Torner4, L Bradley1, T Neogi2 1 3
University of Alabama, Birmingham, AL, USA, 2Boston University, Boston, MA, USA, University of Iowa, Iowa City, IA, USA, 4UCSF, San Francisco, CA, USA
Background/objective: Recent studies have suggested that pre-surgery mental and emotional health impact pain outcomes after knee replacement (KR). Little is known about the associations among pain catastrophizing, widespread pain and pain outcomes post-KR. Methods: We used data from the Multicenter OSTeoarthritis (MOST) study, a longitudinal cohort study of persons with or at high risk of knee OA. Western Ontario McMaster Osteoarthritis index (WOMAC) was used to assess pain and function at baseline, 30 and 60 months in the entire cohort, including those who had a KR during follow-up. We used data from clinic visits immediately prior to and at least 3 months after KR to assess the proportion of patients with poor pain outcomes: (1) moderate-severe knee pain post-KR (maximal score of at least moderate pain on at least one of the five WOMAC pain questions); and (2) poor pain responder (failure to achieve clinically meaningful change in knee pain, i.e., decrease of ≥ 5.6/20 on WOMAC pain in replaced knee after KR). Primary predictor variables of interest were (1) pain catastrophizing assessed by the Coping Strategies Questionnaire and (2) widespread pain assessed by a homunculus, categorized as present if there is pain reported above and below the waist, on both sides of the body, and axial pain. Multivariableadjusted regression analyses adjusted for age, sex, body mass index (BMI), ethnicity, clinic, contralateral knee OA or KR, comorbidity, lower back pain and pre-KR WOMAC pain. Results: During follow-up, 297 subjects had 391 new KRs with ≥ 1 study visit post-KR to ≥ 3 months after KR. Mean age was 66 ± 8, BMI 33 ± 7, 71% female, median time after KR 20 months with 94 patients having bilateral KRs; 34% patients had moderate-severe knee pain post-KR and 31% patients were poor pain responders. In multivariable-adjusted analyses, pain catastrophizing was associated with significantly higher odds of poor pain outcome with an odds ratio of 2.3 (95% CI, 1.3, 3.9; P = 0.0025), but widespread pain was not significantly associated, odds ratio of 1.2 (0.7, 2.1; P = 0.49). Pain catastrophizing was significantly associated with poor pain responder status with odds ratio of 2.8 (95% CI, 1.5, 5.1; P = 0.0008), but widespread pain was not significantly associated, odds ratio of 1.1 (0.6, 2.0; P = 0.71). Conclusions: This is the first evidence in a well-characterized longitudinal osteoarthritis cohort that pain catastrophizing is associated with worse pain outcomes post-KR. It is important to determine the cognitive, behavioural and neurophysiologic pathways that may mediate this relationship as well as the efficacy of coping skills training prior to KR on catastrophizing and postsurgical outcomes.