Kemal Erol

The Turkish Version of Multidimensional Assessment of Fatigue and Fatigue Severity Scale is Reproducible and Correlated With Other Outcome Measures in Patients With Systemic Sclerosis

Objectives This study aims to evaluate the reproducibility of Turkish versions of multidimensional assessment of fatigue (MAF) and fatigue severity scales (FSS) and the relationship between health related quality of life, disability, and psychological status in patients with systemic sclerosis (SSc). Patients and methods A total of 21 female patients (mean age 47.14±10.39 years; range 18 to 75 years) who met 2013 American College of Rheumatology/European League Against Rheumatism criteria for SSc were evaluated for severity of organ involvement and symptoms. Turkish version of MAF, FSS, and visual analog scale of fatigue were assessed at baseline and after two to three weeks. Level of dyspnea was noted and disability, functional limitation, and quality of life were assessed by health assessment questionnaire, 6-minute walking distance, and short-form 36, respectively. Results Ten patients had diffuse and 11 had limited SSc. MAF subscales and FSS had significant correlations with short-form 36-vitality subscale and 6-minute walking distance. Intraclass correlation coefficients for FSS and visual analog scale of fatigue were 0.824 (95% confidence interval, 0.566- 0.929) and 0.932 (95% confidence interval, 0.832-0.972), respectively. The intraclass correlation coefficients for MAF subscales changed between 0.916 and 0.968, except for MAF-timing (intraclass correlation coefficient, 0.404). Conclusion Our results revealed that FSS and MAF subscales had high reproducibility and correlated well with quality of life and disability scales which, to some extent, may suggest convergent validity of MAF subscales and FSS in SSc. The incompatible nature and four-choice answering in two items of MAF-timing may be the underlying reason for trivial relationship with other parameters. The Turkish version of MAF and FSS may be used to assess fatigue in patients with SSc.

An important cause of pes planus: the posterior tibial tendon dysfunction

Posterior tibial tendon dysfunction (PTTD) is an important cause of acquired pes planus that frequently observed in adults. Factors that play a role in the development of PTTD such as age-related tendon degeneration, inflammatory arthritis, hypertension, diabetes mellitus, obesity, peritendinous injections and more rarely acute traumatic rupture of the tendon. PTT is the primary dynamic stabilizer of medial arch of the foot. Plantar flexion and inversion of the foot occurs with contraction of tibialis posterior tendon, and arch of the foot becomes elaveted while midtarsal joints are locked and midfoot-hindfoot sets as rigid. Thus, during the walk gastrocnemius muscle works more efficiently. If the PTT does not work in the order, other foot ligaments and joint capsule would be increasingly weak and than pes planus occurs. We present a 10-year-old female patient diagnosed as PTTD and conservative treatment with review of the current literature.

Fluoroscopy-guided intra-articular steroid injection for sternoclavicular joint arthritis secondary to limited cutaneous systemic sclerosis: a case report

We report a case of fluoroscopy-guided intraarticular steroid injection for sternoclavicular joint (SCJ) arthritis caused by limited cutaneous systemic sclerosis (SSc). A 50-year-old woman diagnosed with limited cutaneous SSc presented with swelling and pain in the right SCJ. MRI revealed signs of inflammation consistent with right-sided sternoclavicular joint arthritis. After the failure of oral medications, we performed fluoroscopy-guided injection in this region. She reported complete resolution of her symptoms at 4 and 12-week follow-ups. This outcome suggests that a fluoroscopy-guided SCJ injection might be a safe and successful treatment option for sternoclavicular joint arthritis.

Common Mistakes in the Dual-Energy X-ray Absorptiometry (DXA) in Turkey. A Retrospective Descriptive Multicenter Study

BACKGROUND Osteoporosis is a widespread metabolic bone disease representing a global public health problem currently affecting more than two hundred million people worldwide. The World Health Organization states that dual-energy X-ray absorptiometry (DXA) is the best densitometric technique for assessing bone mineral density (BMD). DXA provides an accurate diagnosis of osteoporosis, a good estimation of fracture risk, and is a useful tool for monitoring patients undergoing treatment. Common mistakes in BMD testing can be divided into four principal categories: 1) indication errors, 2) lack of quality control and calibration, 3) analysis and interpretation errors, and 4) inappropriate acquisition techniques. The aim of this retrospective multicenter descriptive study is to identify the common errors in the application of the DXA technique in Turkey. METHODS All DXA scans performed during the observation period were included in the study if the measurements of both, the lumbar spine and proximal femur were recorded. Forearm measurement, total body measurements, and measurements performed on children were excluded. Each examination was surveyed by 30 consultants from 20 different centers each informed and trained in the principles of and the standards for DXA scanning before the study. RESULTS A total of 3,212 DXA scan results from 20 different centers in 15 different Turkish cities were collected. The percentage of the discovered erroneous measurements varied from 10.5% to 65.5% in the lumbar spine and from 21.3% to 74.2% in the proximal femur. The overall error rate was found to be 31.8% (n = 1021) for the lumbar spine and 49.0% (n = 1576) for the proximal femur. CONCLUSION In Turkey, DXA measurements of BMD have been in use for over 20 years, and examination processes continue to improve. There is no educational standard for operator training, and a lack of knowledge can lead to significant errors in the acquisition, analysis, and interpretation.

Comparison of Pain Characteristics in Patients with Rheumatoid Arthritis and Systemic Sclerosis with Particular Reference to Neuropathic Pain Component: Cross-Sectional Study

Objective: The aim of the study was to compare characteristics of pain in terms of neuropathic pain (NeP) and to assess the association between the neuropathic component and quality of life (QoL) in patients with systemic sclerosis (SSc) and rheumatoid arthritis (RA). Subjects and Methods: Fifty-four patients (47 females, 7 males) with SSc and 53 patients (46 females, 7 males) with RA were assessed for outcome measures including disease activity, physical functions, mental condition and health-related QoL (HRQoL) measures (Short Form-36; Hospital Anxiety and Depression Scale), and pain. NeP was assessed by the Douleur Neuropathique 4 (DN4) and PainDetect questionnaires in this cross-sectional study. Results: The patients had similar education, smoking status, functioning, and HRQoL. However, the patients with RA declared a more severe visual analogue scale of pain and a higher BMI than those with SSc. The NeP component was detected in 42.6% (n = 23) of the SSc patients and in 45.3% (n = 24) of the RA patients (p > 0.05) according to DN4. On PainDetect, possible NeP was detected in 13.0% (n = 7) versus 15.1% (n = 8), whereas 16.7% (n = 9) versus 17.0% (n = 9) were likely to have NeP in SSc and RA, respectively (p > 0.05). Most of the NeP characteristics were similar in SSc and RA, except for numbness and painful cold, which were notably more common in patients with SSc. Having the NeP component (according to DN4) had no influence on functioning and HRQoL in SSc; however, the NeP component revealed a heavier burden of disease regarding functional status, HRQoL, and psychometric components in RA. Conclusion: The NeP component was similar between patients with SSc and RA. However, NeP was associated with a heavier burden of disease in patients with RA.

Comparison of Level of Fatigue and Disease Correlates in Patients With Rheumatoid Arthritis and Systemic Sclerosis

Objectives This study aims to compare the levels of fatigue in patients with rheumatoid arthritis (RA) and systemic sclerosis (SSc) and to assess the potential influence of fatigue on clinical variables. Patients and methods Age- and sex-matched adult patients with SSc (n=50; 6 males, 44 females; mean age 47.7 years; range 23 to 72 years) and RA (n=51; 6 males, 45 females; mean age 50.8 years; range 23 to 71 years) were consecutively recruited. Patients were examined and evaluated for disease specific and generic outcome measures including disease activity parameters, physical functions, psychological status, and health related quality of life measures. Level of fatigue was assessed by Fatigue Severity Scale and Multidimensional Assessment of Fatigue scale. These were interviewed by the same experienced physician who was blind to clinical data. Results Patients had similar educational and smoking status, as well as functioning and health related quality of life. However, patients with RA declared higher levels on visual analog scale-pain (p=0.012) and higher body mass index than patients with SSc (p<0.0001) and lower distances in six-minute walking test (p=0.002). Levels of fatigue were quite similar between patients with RA and SSc. Levels of fatigue, measured by different scales, were significantly correlated with physical functions and health related quality of life measures and psychometric variables in both groups; however, the correlation coefficients were relatively higher in patients with RA. Conclusion Fatigue is a major problem in patients with RA and SSc. Our findings revealed that level of fatigue was quite similar between patients with RA and SSc and significantly correlated with physical functions and health related quality of life. Patients with RA and SSc should be carefully evaluated for fatigue by using valid scales and the impact of fatigue on clinical measures should not be overlooked.

SAT0245 Comparison of Pain Characteristics in Patients with Rheumatoid Arthritis and Systemic Sclerosis: A Cross-Sectional Study

Background Rheumatoid arthritis (RA) is a systemic inflammatory disease characterized by progressive destruction of inflamed joints leading to severe disability and functional loss. Systemic sclerosis is a multisystem autoimmune disease characterized by vasculopathy, diffuse fibrosis of skin and various internal organs. Pain is usually an overlooked entity in patients with SSc compared to RA. Objectives To compare pain characteristics particularly in terms of neuropathic pain (NeP) and to assess the possible impact of neuropathic component on functioning, physical and mental components of health related quality of life (HRQoL) in patients with RA and SSc. Methods Patients who met ACR/EULAR criteria for SSc and RA were recruited. Patients with prior diagnosis or taking medications for NeP, mood disorders, uncontrolled diabetes or neurological disorders or taking any biologic agents for their treatments were excluded. Patients were examined and evaluated for disease specific and generic outcome measures including disease activity parameters, physical functions, psychological status and health related quality of life measures (SF-36; HAQ; Hospital Anxiety and Depresson Scale, HADS). The DN4 interview and PainDetect questionnaire were applied by the same experienced physician who was blind to patients clinical and outcome data. Patients with a score ≥4 in DN4 were considered as “probable NeP”; between 13–18 or ≥19 in PainDetect were considered as “possible” or “likely NeP”, respectively. Results Fifty patients (44 F, 6 M) with SSc and fifty-one (45 F, 6 M) with RA were included. Patients had similar age and similar gender, educational and smoking status, as well as functioning and HRQoL. However, patients with RA declared more severe pain on VAS-pain (p=0.012), and higher body mass index than patients with SSc (p<0.0001). NeP component was similar in patients with SSc vs RA. NeP component was detected 42.0% in SSc, and 47.1% in RA (p>0.05) according to DN4 scores. According to PainDetect questionnaire, possible NeP was detected in 12.0% vs 15.7%, whereas 16.0% vs 17.6% had likely NeP in SSc and RA, respectively (p>0.05). Neuropathic characteristics of pain were similar in SSc and RA defined as burning, electric shock, tingling, pins and needles, and itching except for numbness and painful cold which were significantly more prevalent in patients with SSc (%50.0 vs %25.5, p=0.011 and %50.0 vs %19.6, p=0.001; respectively). In SSc patients with or without NeP component had similar functioning and HRQoL measures. However, having NeP component revealed a heavier burden of disease regarding functioning, HRQoL and psychometric components patients with RA. NeP +ve NeP −ve P SSc (n=21) (n=29)  Age 53.43±9.58 43.55±13.82 0.004  HAQ 0.55±0.62 0.53±0.60 0.758  SF-36 – PCS 53.90±21.62 48.58±20.41 0.350  SF-36 – MCS 64.33±21.36 53.87±20.85 0.087  HADS – depression 7.76±3.45 7.10±3.63 0.636  HADS – anxiety 7.38±3.75 6.10±4.17 0.252  6-min walk, m 408.95±67.16 433.21±82.46 0.336 RA (n=24) (n=27)  Age 50.21±9.17 51.30±11.02 0.850  HAQ 0.48±0.62 0.57±0.64 0.727  SF-36 – PCS 40.55±17.63 59.77±20.37 0.0001  SF-36 – MCS 42.83±15.06 68.99±21.14 0.0001  HAD – depression 9.29±4.30 5.56±4.33 0.004  HAD – anxiety 10.08±3.78 5.67±4.37 0.0001  6-min walk, m 378.33±77.27 368.15±69.74 0.690 Conclusions The NeP component was similar in patients with RA and SSc. However NeP was associated a heavier burden of disease in patients with RA. Disclosure of Interest None declared

SAT0246 Comparison of Level of Fatigue and Disease Correlates in Patients with Rheumatoid Arthritis and Systemic Sclerosis

Background Rheumatoid arthritis (RA) and systemic sclerosis (SScl) are two different forms of connective tissue diseases associated with significant morbidity. While fatigue is not required for a diagnosis of RA or SScl persistent fatigue is an important clinical problem which may interfere with loss of functioning and health related quality of life (HRQoL) and contribute to the increased disease burden. Several studies compared these two diseases in terms of clinical, laboratory and imaging aspects, however level of fatigue has not been evaluated comparatively. Objectives The aim of this study was to compare levels of fatigue in RA and SSc and to assess potential influence of fatigue on clinical variables. Methods Patients meeting the ACR/EULAR criteria for SSc and RA with an age more than 18 were consecutively recruited. Patients with a prior diagnosis of psychiatric disorders or fibromyalgia or taking medications for these disorders, or with uncontrolled diabetes, neurological disorders or taking any kind of biologic agents were excluded. Patients were examined and evaluated for disease specific and generic outcome measures including disease activity parameters, physical functions, psychological status and health related quality of life (HRQoL) measures. Level of fatigue was assessed by Fatigue Severity Scale (FSS) and Multidimensional Assessment of Fatigue (MAF) scale. These were interviewed by the same experienced physician who was blind to clinical data. Results Fifty patients (44 F, 6 M) with SSc and fifty-one (45 F, 6 M) with RA were included. Patients had similar age and similar gender, educational and smoking status, as well as functioning and HRQoL. However, patients with RA declared higher levels on VAS-pain (p=0.012), and higher body mass index than patients with SSc (p<0.0001) and lower distances in 6-minute walking test (p=0.002). Levels of fatigue which were assessed by VAS, FSS and MAF were quite similar between patients with RA and SSc. Levels of fatigue, measured by different scales, were significantly correlated with physical functions and HRQoL measures and psychometric variables in both groups, however the correlation coefficients were relatively higher in patients with RA. SSc, n=50 RA, n=51 P Age 47.70±13.07 50.78±10.11 0.189 BMI, kg/m2 26.26±5.95 30.96±6.17 0.0001 Symptom duration, years 10.10±7.04 11.06±8.01 0.525 VAS – pain 3.95±2.94 5.25±2.08 0.012 HAQ 0.54±0.60 0.53±0.63 0.946 SF-36 – vitality 48.40±20.26 51.76±21.54 0.421 SF-36 – PCS 50.81±20.88 50.72±21.27 0.983 SF-36 – MCS 58.27±21.49 56.68±22.60 0.719 FSS 4.67±1.77 4.39±1.94 0.439 MAF – severity 6.37±2.07 5.50±2.37 0.064 MAF – distress 5.80±2.74 5.56±2.56 0.656 MAF – interference ADL 4.78±2.25 5.07±2.17 0.534 MAF – timing 6.39±2.05 6.56±2.08 0.696 MAF – global fatigue index 27.77±12.22 25.27±12.77 0.317 6-min walk, m 423.40±76.82 372.94±83.43 0.002 VAS – F 5.96±2.67 5.14±2.84 0.148 Conclusions Fatigue is a major problem in patients with RA and SSc. This is the first report comparing these two diseases in terms of fatigue and its correlates. Patients with RA and SSc should be carefully evaluated for fatigue by using valid scales and the impact of fatigue on clinical measures should not be overlooked. Disclosure of Interest None declared

Rheumatoid pannus compressing the medulla oblongata.

A 47-year-old woman with a 33-year history of rheumatoid arthritis (RA) visited our outpatient clinic complaining of numbness in her hands and progressive weakness in all four extremities. She had urinary incontinence for 1 month. On physical examination, she had joint deformities due to RA in all four extremities. The deep tendon reflexes were hyperactive and she was quadriparetic. Cervical spine magnetic resonance imaging revealed periodontoid pannus formation that had destroyed the C1 and C2 vertebrae bodies and compressed the medulla oblongata (Fig. 1). Figure 1 A T2-weighted magnetic resonance imaging of the sagittal cervical spine shows compression of the medulla oblongata by periodontoid pannus (shown by the arrow). We administered three infusions of 1,000 mg of methylprednisolone intravenously to relieve her symptoms. However, the response to the steroid pulses was poor. A neurosurgeon recommended surgery, but the patient refused. Antitumor necrosis factor (anti-TNF) therapy was contraindicated because the patient had active pulmonary and urinary infections. At follow-up, her neurological symptoms were unchanged. Typically, RA affects synovial joints. Spinal involvement generally presents in the cervical spine. Myelomalacia can develop with compression of the cervical spinal cord by periodontoid pannus. Recently, the treatment of RA has become more effective and the development of periodontoid pannus has become very rare. When patients with RA present with difficulty walking, progressive weakness of all four extremities, spasticity, and neurogenic bladder symptoms, the clinician should consider periodontoid pannus compression. The literature includes cases of periodontoid pannus treated successfully with surgery. In addition, two cases were treated successfully with infliximab. Therefore, anti-TNF therapy in the early stages of rheumatoid myelopathy might obviate the need for surgery.