Inoshi Atukorala

Is There a Dose-Response Relationship Between Weight Loss and Symptom Improvement in Persons With Knee Osteoarthritis?

We examined the dose‐response relationship between weight reduction and pain/functional improvement in persons with symptomatic knee osteoarthritis (KOA) participating in a community‐based weight loss program.

Valdecoxib: the rise and fall of a COX-2 inhibitor

Introduction: Valdecoxib is a cyclooxygenase-2 (COX-2) selective anti-inflammatory drug. It is associated with a reduced incidence of gastrointestinal complications and is potentially useful for patients with rheumatological diseases requiring longer term anti-inflammatory treatment. Areas covered: Due to a perceived increased risk of thrombotic events, particularly cardiovascular hazards and reports of unpredictable, potentially life threatening skin reactions, valdecoxib has been voluntarily withdrawn from the market since 2005. This review manuscript examines the therapeutic potential and the adverse events of valdecoxib utilising a pubmed and web of sciences search to select literature on this subject. Expert opinion: While valdecoxib did have reduced incidence of gastrointestinal complications due to a perceived increased risk of thrombotic events it was withdrawn. The limitations of the research supporting the withdrawal of this potential are discussed.

SAT0452 Do Traditional Risk Factors for Knee Osteoarthritis Predict Pain Flares in Knee Osteoarthritis?: Table 1.

Background Knee pain is the main cause of disability and reduced function in knee osteoarthritis (KOA). Though knee pain in osteoarthritis was previously perceived as a chronic condition it is now established that KOA pain fluctuates.There is emerging evidence that time variant risk factors-such as knee injury, buckling and mood- are associated with knee pain flares. But, it is not known whether conventional risk factors associated with KOA – age, gender, body mass index-are associated with pain flares in KOA. Objectives This study examines whether conventional time invariant risk factors for KOA and baseline pain felt by the patient are associated with KOA pain flares. Methods Study participants were selected from a 3-month web-based longitudinal follow up study developed to identify risk factors for KOA pain flares. Participants were requested to complete online questionnaire at days 0, 30, 60 and 90 (control period assessment points) and at time points whenever they experienced knee pain flare (case period assessment points) during the follow up period. A KOA pain flare was defined as current pain with a greater than 2 point increase (on a 0–10 point numeric rating scale) from the mildest KOA pain intensity reported at day 0. The association of pain flares with traditional risk factors for knee osteoarthritis -gender, weight, height, body mass index- was assessed by negative binomial regression. The duration of knee osteoarthritis, baseline pain intensity (lowest pain and highest pain scores at baseline) were similarly evaluated. The best explanatory variable was decided by forward selection. Results 345 persons (61.2% females) with multiple KOA pain flares were selected. Their mean age was 62.1years (SD ±8.2). The mean body mass index was 29.8kg/m2 (SD ±6.5). The participants rated their baseline pain (on a numeric rating scale) as being 4.41 (SD± 2.02) and their worst pain as being 7.91 (SD ±1.74). An average of 1.92 (SD 2.59) flares were documented during the 3-month period. The levels of baseline pain – usual and worst pain felt at baseline- were the only parameters significantly associated with KOA pain flares (Table 1).Table 1. Association between time invariant risk factors of KOA and KOA pain flares Incidence rate ratio (95% CI) P value Age 0.99 (0.98–1.01) 0.99 Female gender 0.87 (0.65–1.16) 0.35 Height 0.99 (0.98–1.01) 0.76 Weight 1.00 (0.99–1.01) 0.16 Body mass index 1.02 (0.99–1.04) 0.08 Duration of knee osteoarthritis 0.99 (0.98–1.00) 0.49 Baseline pain score – lowest level of pain intensity 1.25 (1.17–1.34) <0.001 Baseline pain intensity – highest pain intensity felt at baseline 1.29 (1.18–1.40) <0.001 CI: Confidence Interval. Conclusions The baseline pain scores were the strongest predictors of pain flares of knee osteoarthritis. The traditional risk factors associated with knee osteoarthritis did not usefully predict pain flares. The traditional time invariant risk factors may not be associated with short term variability in pain though they are associated with long term outcomes of knee osteoarthritis. It is postulated that as knee pain is already present, time invariant risk factors that contributed to the original symptom causation are not associated with pain flare. Acknowledgement Joanna Makovey, Ben Metcalf, Lyn March and Kim Bennell Disclosure of Interest None declared

Response to: ‘Synovitis in knee osteoarthritis: a precursor or concomitant feature?’ by Zeng et al

We thank Zeng et al 1 for their interest in our paper ‘Synovitis in knee osteoarthritis: a precursor of disease?’.2 We would like to clarify the reason we chose radiographs over MRI to identify early radiographic knee osteoarthritis (OA). We agree with the authors statement that MRI is more sensitive than knee radiographs for identification of early knee OA.3 However, at the moment the MRI definition of knee OA has not been …

Multiple ring-enhancing cerebral lesions in systemic lupus erythematosis: a case report.

IntroductionInfectious disease in an immunosuppressed patient is a diagnostic challenge. The clinical presentation and the body’s immune response may be quite different from those seen in an immunocompetent patient with the same infection. It is also a race against time to diagnose, as many of these infections can be fatal without timely intervention.Case presentationWe present the case of a 39-year-old Sri Lankan woman who was on immunosuppressive treatment for systemic lupus erythematosis and who presented with multiple ring-enhancing lesions of the brain. The most likely diagnosis, given the clinical picture, available investigation results, and characteristics of magnetic resonance imaging, was central nervous system tuberculosis. Owing to the small size of the lesions, a tissue biopsy could not be performed. Our patient responded well to a trial of anti-tuberculosis therapy, and there was clinical and radiological evidence of recovery. A paradoxical reaction with the initiation of anti-tuberculosis therapy was observed and this had to be countered with a prolonged course of steroids.ConclusionsOur experience and previous evidence from case reports suggest that high-dose steroids for a prolonged period (up to eight weeks) should be administered to counter the initial deterioration after starting anti-tuberculous chemotherapy for central nervous system tuberculomas.

Delay in diagnosis of generalized miliary tuberculosis with osseo-articular involvement: a case report

IntroductionDiagnosis of atypical tuberculosis is difficult. Therefore, it is important that physicians are aware of rare presentations of tuberculosis to avoid diagnostic delays.Case presentationWe present the case of a 17-year-old Sri Lankan man who presented to our facility with an ill-defined large induration over the skin of his left buttock and thigh. A cause could not be found despite extensive investigations. He also complained of chronic knee pain, but this was not investigated further at the time due to spontaneous resolution. Three years later his knee disease flared up again, with pain, swelling and restriction of movement. A synovial biopsy was suggestive of tuberculosis. He was started on antituberculosis therapy, to which he responded well. Our patient was asymptomatic two months after completion of therapy without any subsequent flare-ups. A chest roentgenogram taken on his second presentation showed evidence of tuberculosis sequelae in his lungs. The most likely diagnosis for the buttock and thigh swelling, when considering the entire clinical picture, is a tuberculous abscess. The constellation of skin and skeletal symptoms and pulmonary tuberculosis is a rare occurrence in an immunocompetent individual, but cases have been reported.ConclusionsThis case demonstrates the different presentations and the diagnostic difficulties posed by atypical manifestations of tuberculosis. It also demonstrates the value of maintaining a high degree of suspicion in endemic areas, even in the absence of microbiological evidence.

AB1041 Household Ergonomics: Development and Validation of A Novel Tool To Assess Physical Exposures Contributing To Household Work Related Low Back Pain

Background Household ergonomic risks-especially physical exposures straining the low back during manual household work can contribute to low back pain in housewives. To date, there are no screening tools to identify physical exposures that cause household work related low back pain. Objectives To develop and validate “Physical Exposure Check-Household work related low back pain (PEC-HLBP)”, a tool to assess physical exposures contributing to household work related low back pain. Methods Items for PEC-HLBP were generated based on a theoretical framework developed through review of literature, qualitative observations and expert opinion. Item reduction was by a panel of 10 experts based on a scoring system. The draft PEC-HLBP was developed into an interviewer-administered questionnaire with responses in a Likert scale to facilitate responses on the gradient of the physical exposure and the scoring system adopted reflected the gradient of exposure. PEC-HLBP was designed to be answered based on household work activities routinely being performed by the respondent. Exploratory factor analysis using principal component analysis was performed on a sample of 250, 20–50 year old eligible housewives to further reduce items and to assess construct validity. Internal consistency and test retest assessed the reliability. Results The initial PEC-HLBP contained 36 items. Ten items which scored an average score less than 2 by the panel of experts (score based on the importance as a physical exposure on a 1–5 scale) were eliminated. Exploratory factor analysis of draft PEC-HLBP with 26 items showed 9 factors (Eigen values 1.008–5.163) explaining 64.18% of total variance. All 26 items in draft tool showed factor loadings above 0.4 not requiring further reduction of items. Two factors with items of similar loadings were amalgamated based on the theoretical framework. Finalized PEC-HLBP contained 26 items in eight domains which were assigned names to depict the items they contained (figure 1). Experiencing the physical exposures or not were determined based on a predetermined cut off score for each domain. The mean duration to complete the questionnaire was 16 (±4) minutes. Cronbachs Alpha was 0.789 (95% CI 0.725–0.825).The test-retest reliability was good (Spearman`s coefficient above 0.77) for all domains. Response rate among housewives was 83.3% and the response rate for each question was 100% with no missing data. Conclusions PEC-HLBP is a valid, reliable and acceptable tool to assess physical exposures contributing to household work related low back pain among housewives Acknowledgement Medical Research Institute, Sri Lanka Disclosure of Interest None declared

THU0331 Do EEG Changes in SLE Correlate with SLE Disease Activity

Background Subclinical electroencephalographic (EEG) changes are seen in patients with systemic lupus erythematosus (SLE), including those without central nervous system (CNS) involvement [1]. Baseline and paroxysmal EEG changes are seen in the majority, but temporo-limbic changes occur more commonly in those with seizures [2]. It is yet unknown if SLE disease activity correlates with EEG changes seen in SLE. Moreover, no particular EEG patterns have been described in in SLE patients with and without CNS involvement. An EEG marker of disease activity or CNS involvement will be critical in selecting patients with CNS lupus for aggressive immune suppression. Objectives Describe the association of EEG changes with (1) SLE disease activity (2)CNS and non-CNS disease flares Methods 70 subjects fulfilling the American College of Rheumatologists criteria for SLE were evaluated over one year. Patients with previous seizures not due to SLE including CNS infections, head injury & previous neurosurgical procedures were excluded. Socio demographic data, disease characteristics, British Isles Lupus Activity Group (BILAG) disease activity assessment, neuropsychiatric lupus screening questionnaire (NPSLEQ) and 30 minute awake EEGs were collected. Subjects were categorized to two groups depending on current disease activity: Group A-high disease activity (BILAG scores of A and B), Group B-low disease activity. 30min EEGs were read by an investigator blinded to patient information and group allocation. Results Group A comprised of 20 (Mean age 32 (SD = 7.7)) and Group B comprised of 50 patients (Mean Age 33 (SD = 8.1). The majority were female (95% in Group A; 96% in Group B). In Group A, 50 % had CNS flares at assessment with the remainder having renal flares: 85% & 15% of group A had BILAG scores of A & B respectively. In Group B, 30% & 70% had previous CNS & renal involvement respectively. Of them 2%, 80% and 8% had BILAG scores of C, D, E respectively. The mean NPSLEQ score was 22 in active CNS SLE and 10 in renal flares. Abnormal EEG findings were more common in Group A (70%) compared to Group B (12%) (p =0.002). In group A, those with CNS (90%) and renal flares (50%) had abnormal EEGs (p=0.58). But, temporal lobe changes were more common in active CNS flares (44%) compared to renal flares (0%) (p=0.032). Higher scores on NPSLQ screening were significantly associated with CNS flares (p=0.021) and focal temporal activity (p= 0.038). Temporal changes were also seen in 50% of patients with previous CNS lupus. Lateralisation was not detected in those with focal changes. Conclusions Abnormal EEGs in SLE were associated with high disease activity and high NPSLQ score. Subjects with active and chronic CNS involvement were more likely to have temporal changes on EEG than those with renal involvement. Temporal EEG changes may be useful in differentiating patients with CNS involvement from those with other system flares. References Gora MK et al. Wiad Lek. 2003; 56(5-6):220-226. Glanz BI et al. Clin Electroencephalogr. 1998 Jul; 29(3):128-131. Disclosure of Interest None Declared