S Shankar

Prevalence of peripheral neuropathy in patients with newly diagnosed rheumatoid arthritis

Abstract Objective To look for the frequency and pattern of neuropathy in Indian patients with rheumatoid arthritis (RA). Patients and Methods One hundred newly diagnosed patients with RA (ACR 1987 revised criteria) visiting our hospital, over a period of 3 years were screened. Diabetics, outstation patients, chronic alcoholics, those with any known cause for peripheral neuropathy and patients having an overlap with the other rheumatological illness were excluded. Clinical assessment included detailed history and examination with special reference to extra-articular features and neuropathy with relevant clinical parameters like tender joint count, swollen joint count, etc. Routine laboratory investigations and autoantibodies (RF, ANA, anti-CCP) were obtained on all patients. All the patients with or without clinical manifestations of neuropathy underwent nerve conduction studies. Autonomic function studies were performed in selected patients. Results Subjects included 66 patients (M 13:F 53) with mean age of 42 (±13.42) years and median disease duration of 36 months (IQR-13.5, 60). Sensory symptoms were present in 9 patients (13.6%). None had motor symptoms. On neurological examination, 16 patients had sensory (24.2%) and 6 (9.09%) had motor abnormalities. Nerve conduction studies showed abnormality in 25 patients (37.87%). Evidence of entrapment neuropathy was found in 6 patients (9.09%; 5 patients with median nerve involvement [unilateral, 3 and bilateral, 2] and 1 patient with unilateral ulnar nerve involvement), 3 patients had only sensory neuropathy, 5 had mixed sensory motor and 3 had only motor neuropathy. Eight patients (12.12%) had only small fibre neuropathy as detected by sympathetic skin response and quantitative sensory testing. Conclusion This study shows high prevalence of subclinical neuropathy in Indian patients with RA. This may be an important contributor to disability.

DAS 28 for defining remission in rheumatoid arthritis in Indian patients

Abstract Objective To establish DAS 28 and DAS 28-3 scores that best define remission in Indian patients with rheumatoid arthritis (RA). Patients and Methods All patients diagnosed with RA visiting AIIMS, New Delhi over a period of 3 months were recruited. Clinical assessment included 28 joint counts for swelling and tenderness, duration of early morning stiffness, patient global assessment of disease activity, fatigue, joint pains and ESR. DAS 28 and DAS 28-3 scores were calculated and receiver operating characteristics curve analysis was performed to define cutoff values utilizing ‘ACR 5/6’ and ‘ACR 4/5’ remission criteria. Results Subjects included 207 patients (M: 44; F: 163) with mean age of 47.4 ± 12.6 years, median disease duration of 8 [4.12–14] years.‘ACR 5/6’ and ‘ACR 4/5’ criteria for remission were satisfied by 34 (16.42%) and 44 patients (21.25%) patients, respectively. DAS 28 score of 2.94 (sensitivity 84.4%, specificity 85.3%) and DAS 28-3 score of 3.02 (sensitivity 82.1%, specificity 82.4) best defined the ‘ACR 5/6’ remission. Corresponding values using ‘ACR 4/5’ remission were 3.04 (sensitivity 85.9%, specificity 84.1%) for DAS 28 and 3.05 (sensitivity 82.2%, specificity 81.8%) for DAS 28-3. Conclusions A cutoff value

Complex regional pain syndrome—management options

Abstract The natural history of Complex Regional Pain Syndrome (CRPS) is not well understood and the progression varies between different patients. The pathogenesis of this disorder is not well understood and a single mechanism can barely account for all the changes that are seen. In the absence of any pathognomonic sign or investigation, the diagnosis is suggested by the presence of constellation of symptoms, signs and laboratory findings. It is often under-diagnosed and undertreated resulting in significant morbidity and impaired quality of life. The crux of management lies in formulating a multidisciplinary planned approach based on the principles of chronic pain management, rehabilitation and psychotherapy with physiotherapy playing a very important role. Corticosteroids might be useful in a select group of patients in the early stages. Long-term use is not recommended as it has a questionable risk-benefit ratio. A number of new drugs are being tried that include thalidomide, calcium channel blockers, free radical scavengers, oral sympatholytic drugs, and clonidine. Encouraging results have been seen with bisphosphonates. Lenalinomide and neurotropin are other newer agents undergoing evaluation for efficacy in CRPS. Owing to lack of proper understanding of the pathogenesis and lack of animal models, current treatment for CRPS is essentially symptomatic and suboptimal. This paper attempts to review the role of various therapeutic modalities in the management of CRPS with emphasis on the emerging therapies.