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 ;

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.

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

Neuropsychiatric SLE (NPSLE) comprises the neurologic and psychiatric syndromes observed in patients with SLE after exclusion of other causes. The diagnosis of NPSLE is challenging due to diverse clinical manifestations and absence of laboratory or radiologic biomarkers.

We present the case of a patient with SLE with a chronic isolated seizure and was successfully managed with antiepileptic medication and high-dose corticosteroids.

Seizures may occur as an isolated manifestation of an SLE flare. Ischemic and inflammatory causes of seizure may coexist in active lupus and both should be considered in managing patients. A prompt and holistic workup to rule out metabolic, infectious, and structural neural causes and lupus disease activity of seizures is prudent for patients with SLE.

Human ; Female ; Young Adult: 19-24 Yrs Old ; Antiphospholipid Syndrome ; Seizures

BACKGROUND

Rheumatoid arthritis (RA) is a systemic autoimmune disease characterized by inflammatory arthritis and extra-articular involvement. Comorbidities are highly prevalent in patients with RA, in particular cardiovascular disease (CVD), which is responsible for over 50% of premature deaths. This study aimed to describe cardiovascular diseases and their risk factors among patients with rheumatoid arthritis in the Philippine General Hospital (PGH).

OBJECTIVE

To describe cardiovascular (CV) diseases and their risk factors among patients with rheumatoid arthritis.

METHODS

A retrospective descriptive cross-sectional study was done in the University of the Philippines – Philippine General Hospital (UP-PGH) inpatient and outpatient services. The study included patients 18 years old and above diagnosed with RA and fulfills the 1987 American College of Rheumatology or 2010 American College of Rheumatology-European League Against Rheumatism (ACR/EULAR) classification criteria with no overlap features with other autoimmune connective tissue diseases and with complete records of the information required for the study from January 2019-December 2022. The primary outcomes of interest were the prevalence of CV diseases and CV risk factors. Descriptive statistics were used to summarize the data.

RESULTS

There were 123 patients in the study, 93.4% outpatients, and 95.1% females, with a mean age and disease duration of 51.3 and 9.8 years, respectively. Disease activity was moderate in 35% and high in 9.7%, based on disease activity score (DAS 28) or clinical disease activity index (CDAI) scores. Methotrexate (54%) was the most commonly used conventional synthetic disease-modifying antirheumatic drug (csDMARD). Glucocorticoid use was observed in 51.2%. None of the patients were receiving a biologic DMARD. There were 24 (19.5%) patients with CV diseases, namely myocardial infarction, heart failure, and stroke. There were 87 (70%) patients with at least one CV risk factor and 62 (50.4%) with multiple risk factors. The risk factors identified were: dyslipidemia (43.1%), hypertension (40.7%), elevated body mass index (35.7%), and diabetes mellitus (15.4%). There were f ive deaths in the hospitalized patients (4%), one due to a myocardial infarction.

CONCLUSION

The majority (70%) in our cohort had at least one CV risk factor, 19.5% had an identified CV disease, and one died from a myocardial infarction. Dyslipidemia was the most common CV risk factor. The high proportion of patients with CV disease and CV risk factors highlights the need to add the screening and management of CV diseases and risk factors as a priority among patients with rheumatoid arthritis.

Human ; Female ; Cardiovascular Diseases ; Arthritis, Rheumatoid ; Asian

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

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

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