OBJECTIVE: The aim of the study is to determine the prevalence of metabolic syndrome (MS) in Filipino patients with gout and know the specific component that is predominant in this population.
METHODS: Patients who are diagnosed with gout based on the American College of Rheumatology (ACR) criteria, at least 20 years old, attending the outpatient rheumatology clinic of a tertiary hospital from March 2012 to December 2012 and  willing  to sign written informed consent were included in  the study. The following information was collected: demographic and disease characteristics, blood pressure, body mass index, waist circumference, triglycerides, HDL, and fasting blood sugar. MS was defined according to the revised NCEP/ATP III criteria using the WHO Asia-Pacific obesity criteria. Results were reported in means and proportion.
RESULTS: Sixty-three patients were included in the study. The mean age of onset and at time of diagnosis of gout were 47.3 years and 52.9 years, respectively. At the time of the study, the average duration of gout was five to 10 years. The male to female ratio was 6:1. The prevalence of MS was 47.6% (30/63) with male to female ratio of 5:1.The prevalence of abdominal obesity was 39.7%, hypertension 36.5%, low HDL 31.7%, high triglycerides 30.2%, and diabetes mellitus 14.3%.
CONCLUSION:The prevalence of MS in this subset of Filipino patients with gout was 47.6%. Its most common component was abdominal obesity found in 39.7% of cases. This is an area of intervention that needs to be addressed in the care of these patients.

Human ; Male ; Female ; Middle Aged ; Adult ; Metabolic Syndrome X ; Obesity, Abdominal ; Obesity ; Hdl-triglyceride ; Triglycerides ; Diabetes Mellitus ; Lipoproteins, Hdl ; Hypertension ; Adenosine Triphosphate

BACKGROUND: Valid and reliable assessment of pain is essential in the management of rheumatologic conditions. Standardized pain assessment scales have been developed and used in clinical trials, but remain underutilized in clinical practice.

OBJECTIVE: To evaluate the use of the different pain assessment scales: Numeric Rating Scale (NRS), Verbal Descriptive Scale (VDS),Visual Analog Scale (VAS) and Wong Baker Face Scale (FACES) among adult patients with musculoskeletal pain seen in the Rheumatology Out-Patient Clinic in a tertiary government hospital in Manila, Philippines.

METHODS: This is a cross sectional study of adult patients with symptoms of musculoskeletal pain seen in a rheumatology out-patient clinic. The patients answered the different pain assessment scales and ranked them according to ease of use and preference. We checked for correlation of results of the different pain assessment scales using Spearman correlation.     

RESULTS: Ninety-four patients are included in this study. Eighty-one percent are females, with mean age of 52 (±SD 14.12) years old. Majority (73%) have low level of education. Forty-one percent have rheumatoid arthritis, 21% have osteoarthritis and 12% have gout. NRS is preferred and ranked easiest to use by 41.5% of patients. FACES is a close second; preferred by 39.4% and considered easy to use by 36.2% VAS ranks last on over-all preference and ease of use. On subgroup analysis, VDS was preferred by male patients while FACES was preferred by those with low educational status. The pain score obtained using NRS was significantly correlated with VDS, VAS, and FACES (p=<0.005).     

CONCLUSION: The NRS is a validated tool that is easy to use and preferred by patients. The FACES is a good alternative if the patient has difficulty with the NRS. We recommend the use of these pain scales in clinical practice in the Philippines to standardize the assessment and monitoring of pain among patients with rheumatic conditions

Human ; Male ; Female ; Aged ; Middle Aged ; Adult ; Pain Measurement ; Musculoskeletal Pain ; Rheumatology ; Osteoarthritis ; Arthritis, Rheumatoid ; Rheumatic Diseases ; Gout

SYNOPSIS: Cardiac tamponade among systemic lupus erythematosus (SLE) patients is an unusual event. The pericardial effusion may be a consequence of uremia, infections in the pericardium, or the lupus pericarditis itself. We present four atypical cases of cardiac tamponade from pericarditis of connective tissue disease (CTD), all of which were treated with drainage and immunosuppressants. Due to the rarity of this combination, management was a challenge.
CLINICAL PRESENTATION: Four females each sought consult for dyspnea associated with typical manifestations of connective tissue disease such as arthritis, characteristic rashes, serositis, typical laboratory features, and a positive ANA and/or anti-dsDNA. The first three cases fulfilled the criteria for SLE, while the fourth fulfilled the criteria for SLE-dermatomyositis overlap syndrome. Echocardiography was done due to suspicion of pericardial involvement and revealed massive pericardial effusion in tamponade physiology in all cases.
DIAGNOSIS: Cardiac tamponade from serositis due to connective tissue disease [SLE (case 1 to 3) or SLE-dermatomyositis overlap (case 4). Other common etiologies of tamponade such as bacterial, tuberculous, malignant, and uremic pericardial effusion were ruled out by clinical and laboratory tools, including Gram stain and culture, cytology, PCR, and biochemical testing. The pericardial fluid of the first case tested positive for lupus erythematosus (LE) cells, indicative of lupus serositis.
TREATMENT AND OUTCOME: All patients underwent pericardial drainage via tube pericardiostomy. They received high dose glucocorticoids after infectious etiologies for the pericardial effusion were ruled out. The fourth case with the overlap syndrome, however, required more immunosuppressants using azathioprine and methotrexate. Resolution of pericardial effusion was noted with this approach. Three of four were discharged improved, however, the third case suffered from worsening nephritis and pulmonary hemorrhage leading to her demise.
SIGNIFICANCE AND RECOMMENDATIONS: Four cases of cardiac tamponade as a manifestation of connective tissue disease were presented. Literature underlines the rarity of this condition anytime during the course of SLE. Despite this, SLE should be considered as one of the differential diagnosis of cardiac tamponade, especially in patients who manifest with multi-systemic findings. Likewise, massive pericardial effusion should be considered in patients with a connective tissue disease presenting with subtle evidence of pericardial involvement. It requires timely identification and treatment with high dose steroids, after other causes such as infections have been excluded. Immediate drainage through pericardiocentesis or pericardiostomy in combination with immunosuppressants may be life-saving.

Human ; Female ; Adult ; Adolescent ; Pericardiocentesis ; Pericardial Effusion ; Azathioprine ; Cardiac Tamponade ; Methotrexate ; Glucocorticoids ; Serositis ; Dermatomyositis ; Immunosuppressive Agents ; Pericardial Fluid ; Neutrophils ; Lupus Erythematosus, Systemic ;

Objective: To assess the association between D-dimer and clinical outcomes in adults with COVID-19. Methods: We reviewed published articles and preprints from MEDLINE, Cochrane Library, Cornell Open Access Publication (COAP), MedRxiv, and BioRxiv databases. We included cohort studies on the association between D-dimer and the outcomes of thromboembolism, mortality, and worsening severity among hospitalized adults with COVID-19. Results: We found 25 observational studies on the association between D-dimer and the outcomes of thromboembolism, mortality, or worsening severity. There was an increased risk of thromboembolism (OR 5.61 [95% CI 3.97, 7.94]) with higher D-dimer levels across different COVID-19 severities. D-dimer levels are associated with higher in-hospital mortality (OR 5.57 [95% CI 2.74, 11.31]) and worsening severity manifesting as critical illness (OR 1.91 [95% CI 1.05, 3.48] to 2.58 [95% CI 1.57, 4.24]), disease progression (HR 2.846 [95% CI 2.10, 3.85]), or need for mechanical ventilation (HR 3.28 [95% CI 1.07, 10.10]). However, some methodological flaws, such as incomplete laboratory or follow-up data and concern on varied D-dimer cut-offs and definitions of worsening disease, raise some uncertainty in the widespread use of D-dimer as a prognostic marker. Conclusion A higher D-dimer value is associated with worse clinical outcomes among hospitalized adults with COVID-19 and may be a useful prognostic indicator.
COVID-19

Among pregnant women, 1-2% are anti-Ro positive and while half of them have symptoms of connective tissue disease, the rest are asymptomatic. The presence of anti-Ro is of concern because of the risk of congenital heart block in the child. We report the case of an asymptomatic 27-year-old G2P1(1001) woman, who presented with persistent fetal bradycardia in her 21st week of gestation (AOG) and was found to have elevated titers for anti-Ro (>320 U/ml). Hydroxychloroquine 200 mg/day and prednisone 10 mg/day were given from the 33rd week of gestation up until the delivery. At 37 weeks AOG, she delivered a live male neonate with a complete heart block. On the 6th day of life, the infant remained bradycardic, hence a pacemaker was inserted and heart rate maintained at 100-120 bpm. On subsequent follow-ups, the mother and child did not develop any systemic manifestations and the infant was thriving well. While a diseased condition may not be apparent in a pregnant anti-Ro positive woman, the risk of neonatal lupus (NL) is demonstrated in this patient’s case. This report illustrates how prenatal care of an asymptomatic woman led to the discovery of a fetal abnormality and served to prepare the family and the medical team to ably handle the birth and subsequent care of a neonate with NL.

INTRODUCTION: There is no documentation of the causes of hospitalization among lupus patients in the Philippines in recent times and this study hopes to fill in this knowledge gap. Thus, this study reports the outcomes of hospitalizations among patients with systemic lupus erythematosus (SLE) admitted at the charity wards of the University of the Philippines-Philippine General Hospital (UP-PGH). METHODS: A retrospective chart review was done on all admitted patients with SLE from January 2015 to December 2015 admitted at UP-PGH, the national referral center and tertiary training government hospital in Manila, Philippines. RESULTS: There were a total of 81 SLE patients meeting the inclusion criteria. SLE admission comprised 3.1% (138/4408) of admitted charity cases in our department. The most common reasons for hospitalizations are infection (64.1%), lupus activity (60.3%), and lupus activity with infection (47.4%). The mean duration of hospitalization was 12.4 (SD 8) days. Patients with organ damage from lupus were mostly able to fully recover (20%) while those admitted due to more than one reason mostly had partial recovery (95.2%). Infection is the top leading cause of death (6%). Serositis [OR 0.11, 95% confidence interval (CI) 0.02- 0.63] and number of ACR SLE criteria fulfilled on diagnosis (OR 0.47, 95% CI 0.22- 0.997) were likely to have poor outcome of hospitalization. The over-all cohort’s survival on admission was 100.0%, 98.8%, 97.4%, and 92.5% for one, two, six, and more than 15 days of admission, respectively. CONCLUSION: Our cohort confirms the results of previous studies suggesting that infection and disease activity were the top reasons for hospitalization among lupus patients whether living from emerging and developed nations. Indeed, the morbidity and mortality of our patients remains a great challenge not just among physicians but with the government and various stakeholders.
Lupus Erythematosus, Systemic ; Hospitalization

Introduction: Systemic lupus erythematosus (SLE) is a chronic inflammatory systemic disease that can affect any organ including the central nervous system (CNS). Subarachnoid hemorrhage (SAH) is one of its rare CNS manifestations. Posterior reversible encephalopathy syndrome (PRES), with features of headache, seizures, altered mental status, visual loss, and typical imaging findings, has recently been associated with SLE and immunosuppression, including use of high dose steroids. The patient was seen in University of the Philippines-Philippine General Hospital (UP-PGH), a tertiary training hospital in Manila, Philippines Case: A 33-year-old female with lupus had PRES and SAH after methylprednisolone pulse therapy (MPPT) for nephritis. She presented with headache, hypertension and seizure. Initial cranial imaging showed hypodense areas in both parietotemprooccipital regions and small acute infarcts. She was intubated and treated with anti-convulsants for seizure; hydrocortisone and mycophenolate mofetil for SLE. She regained awareness on the seventh hospital day and was extubated. On the eleventh hospital day, she had fever, cough and was noted to be drowsy. She had increasing serum creatinine and decrease in urine output. Repeat cranial CT scan showed subarachnoid hemorrhage at the right sylvian fissure and better delineation of the previously described hypodensities (consistent with PRES). She was treated for hospital acquired pneumonia and underwent hemodialysis. Pneumonia was resolved and patient became conscious with no recurrence of neurologic symptoms. Consecutive outpatient visits showed a conscious and less edematous patient. Hemodialysis was eventually discontinued until she had normal creatinine with adequate urine output. Anti-seizure medications were also discontinued. Cranial CT scan a year later revealed normal brain parenchyma indicating resolution of previously noted hypodensities and subarachnoid hemorrhage. Conclusion There is a need to recognize PRES and differentiate it from irreversible neurologic conditions. With early identification and prompt intervention, permanent neurologic deficits may be prevented.
Lupus Erythematosus, Systemic ; Lupus Nephritis ; Subarachnoid Hemorrhage

Objective: The coronavirus disease 2019 (COVID-19) pandemic has limited healthcare delivery for patients with chronic diseases, including Systemic Lupus Erythematosus (SLE). This study aims to describe the outcomes of patients with SLE in a national COVID-19 referral center in the Philippines. Methods: A review of records of all adult patients with SLE seen in the University of the Philippines-Philippine General Hospital (UP-PGH) from March 2020 to December 2021 was done. Data about patient characteristics, health encounters, and outcomes before and after the first visit during the study period were extracted. Descriptive statistics were employed. Results: Our population of 403 patients was predominantly young (mean age 34.53 ± 11.14 years), female, and unemployed. This consisted of 370 known cases of SLE, 92 were diagnosed in institutions outside UP-PGH, and 33 new patients. Over the 22-month study period, there were 2,093 medical encounters, most of which were teleconsultations (81.70%). During an average gap of 53.6 ± 26.7 weeks between the last consultation and the first visit within the pandemic study period, 84 patients (22.70%) discontinued at least one of their SLE control medications, 68 (18.38%) patients developed a lupus flare, and 79 (21.35%) were hospitalized for various reasons. On their return to the rheumatology clinic during the pandemic, 37.47% were in lupus flare, 28.29% needed to be hospitalized, and 20 died. However, 86.75% of flares were controlled. During subsequent health encounters, 48 patients had a new flare (43 of these were controlled) and 20 died. The most common reason for hospitalization (n=160) was lupus disease flare and the most common cause of death (n=40) was pneumonia. Sixty patients acquired COVID-19 infection from which most recovered and four died. Conclusion Audio teleconsultation was the most common method used by our lupus cohort to interact with their doctors during the pandemic. There was an average of a year-long interruption in medical care for 62.70%. More than a third developed a disease flare and 15% acquired COVID-19 but outcomes were good in more than 85%. Despite the challenges posed by the pandemic, the majority of our lupus cohort who were able to continue their treatment had favorable outcomes.
COVID-19 ; Philippines

Key Findings Several laboratory tests are found to be associated with disease severity and mortality in COVID-19, and may be used to prognosticate patients and guide management. • Around 20% of COVID-19 patients develop severe illness that may require intensive care and lead to fatal complications. This necessitates prioritization of patients requiring urgent medical care before disease progression. • Certain laboratory markers (biomarkers) may reflect the processes involved in the clinical deterioration of infected patients. Hence, their use in the identification of patients at high risk of progression to severe disease or death has been investigated. • Current available evidence shows that the following laboratory abnormalities in a person with COVID-19, especially when found early during hospitalization, are associated with severe or critical disease or mortality: 1. Markers of organ dysfunction a. Reduced oxygen saturation b. Elevated lactic dehydrogenase (LDH) c. Elevated blood urea nitrogen (BUN) or serum creatinine d. Elevated cardiac troponin (cTnI) e. Elevated direct bilirubin, reduced albumin f. High radiographic score or CT severity score, or consolidation on CT scan 2. Marker of abnormal coagulation – D-dimer 3. Markers of immune dysfunction a. Elevated IL-6 b. Elevated C-reactive protein (CRP) c. Elevated neutrophils d. Reduced lymphocyte percentage e. Reduced CD4+ T lymphocytes 4. Secondary bacterial infection – Elevated procalcitonin • Proposed prediction models utilizing these markers, however, need further validation before they can be recommended for routine clinical use.
Coronavirus ; Covid-19

Introduction: Statins have been shown to have antiinflammatory and immunomodulatory effects. In vitro studies show that these drugs inhibit inflammatory cells, decrease the expression of major histocompatibility complex (MHC), decrease adhesion molecules and inflammatory cytokines (IL6 and IL10), that are also implicated in SLE pathogenesis. In terms of immunomodulary effects, animal studies demonstrate that statins exacerbate/trigger cellular apoptosis and induce a shift in the Th1/Th2 balance leading to B-cell reactivity and production of pathogenic autoantibodies. Whether statins have clinical effects in SLE have not been widely studied. In terms of disease activity, studies show contradicting results. The researchers aim to determine the effect of statins on the disease activity of SLE based on the best available evidence Methods: A systematic literature search of PubMed, Scopus, and Cochrane databases was done with no date and language restrictions. Included studies were on adult SLE patients and randomized controlled trials that used statins as intervention and reported SLE disease activity as an outcome measure. Two reviewers did quality appraisal, risk bias assessment, and data extraction. Results: Three studies met the eligibility criteria and were included in this review. Quantitative synthesis was done. The pooled analysis of these studies suggests that atorvastatin has no significant effect on disease activity using random effects model with an overall effect of 0.12 (P=0.90, 95% CI -1.65, 1.88). Conclusion Atorvastatin neither increased nor decreased SLE disease activity. Therefore possibly it can be safely given to SLE patients without the risk of triggering or exacerbating a flare.
Hydroxymethylglutaryl-CoA Reductase Inhibitors ; Systematic Review