BACKGROUND: Non traumatic osteonecrosis also known as  avascular necrosis (AVN),and tuberculous arthritis (TB    arthritis)most commonly present as chronic monoarticular conditions. Corticosteroid intake is known to predispose individuals to the development of these two conditions.                      
In AVN, corticosteroid remains to be the most common cause that leads to a final  common pathway of disrupting    blood supply to segments of bone causing cell death. In TB arthritis, corticosteroid renders  a patient relatively immunocompromised predisposing to this extrapulmonary infection.                                                                                                                                                         
The incidence of tubercular osteonecrosis in a patient with systemic lupus erythematosus is rare. A review of literature only showed one case report of tubercular osteonecrosis diagnosed by aspiration cytology. Since tuberculosis (TB) is a destructive but curable disease, early diagnosis  and  treatment  are essential.
OBJECTIVE: To present a case of tubercular osteonecrosis in a patient with systemic lupus erythematosus treated with anti-Koch's regimen and iloprost infusion.
CASE: A 27-year old Filipino female who was diagnosed with lupus nephritis and underwent three days  methylprednisolone pulse therapy. Lupus nephritis improved  and  was clinically inactive for two years. She  developed insidious onset of intermittent pain on her left knee, associated with swelling for four months with  subsequent right hip pain of one week duration. MRI of the left knee showed osteonecrosis and arthritis. Radiograph of the right hip showed osteonecrosis. She underwent arthrocentesis of the left knee and the synovial  fluid tested positive for tuberculosis by PCR. We started the patient on quadruple anti-Koch's regimen together with iloprost infusion which afforded clinical improvement. 
CONCLUSION: To our knowledge, this is the first reported case of a lupus patient with concomitant polyarticular osteonecrosis complicated by monoarticular tuberculous arthritis. Medical treatment, while it may be complicated by adverse drug events, is effective in symptomatic treatment, but a multidisciplinary approach is suggested for optimal outcome.

Human ; Female ; Adult ; Adrenal Cortex Hormones ; Arthritis ; Arthrocentesis ; Cell Death ; Early Diagnosis ; Iloprost ; Incidence ; Lupus Erythematosus, Systemic ; Lupus Nephritis ; Methylprednisolone ; Osteonecrosis ; Pain ; Polymerase Chain Reaction ; Tuberculosis, Osteoarticular

INTRODUCTION: Clinicians rarely screen their patients for musculoskeletal disorders during routing physical examination. Reasons vary, but inadequate teaching of musculoskeletal medicine is cited as a major factor. To address the above issue, the Section of Rheumatology, Department of Medicine, College of Medicine, and Philippine General Hospital, University of the Philippines Manila recently adopted the Gait, Arms, Legs and Spine Locomotor Screen (GALS) as the central focus of instruction for musculoskeletal conditions.
OBJECTIVES: A total of 189 medical interns participated in this descriptive study to determine whether GALS is deemed useful and can be readily applied in the outpatient clinics.
METHODS: Data was gathered using a questionnaire, key informant interviews, and chart review. The data was analyzed using measures of central tendency, percentages and qualitative evaluation.
RESULTS: Only 26% claimed to routinely perform the musculoskeletal screening examination and only 21% claimed they used the GALS technique. The medical interns emphasized that they were adequately taught to perform the GALS technique but felt that the routine of GALS was time consuming. Emphasis on musculoskeletal screening was done only during clinical rotations in specialties like rheumatology, rehabilitation medicine or orthopedics, but not in other specialties. In addition, only the Section of Rheumatology used the GALS technique.
CONCLUSION: The findings of this study suggest that while medical interns feel competent in performing the GALS technique, its application in the clinics leaves much room for emphasis and that there is a need to standardize instruction on musculoskeletal screening.

Human ; Male ; Female ; Ambulatory Care Facilities ; Arm ; Gait ; Hospitals, General ; Humans ; Leg ; Musculoskeletal Diseases ; Orthopedics ; Philippines ; Rheumatology ; Spine ; Surveys And Questionnaires

INTRODUCTION: Clinicians rarely screen their patients for musculoskeletal disorders during routing physical examination. Reasons vary, but inadequate teaching of musculoskeletal medicine is cited as a major factor. To address the above issue, the Section of Rheumatology, Department of Medicine, College of Medicine, and Philippine General Hospital, University of the Philippines Manila recently adopted the Gait, Arms, Legs and Spine Locomotor Screen (GALS) as the central focus of instruction for musculoskeletal conditions.
OBJECTIVES: A total of 189 medical interns participated in this descriptive study to determine whether GALS is deemed useful and can be readily applied in the outpatient clinics.
METHODS: Data was gathered using a questionnaire, key informant interviews, and chart review. The data was analyzed using measures of central tendency, percentages and qualitative evaluation.
RESULTS: Only 26% claimed to routinely perform the musculoskeletal screening examination and only 21% claimed they used the GALS technique. The medical interns emphasized that they were adequately taught to perform the GALS technique but felt that the routine of GALS was time consuming. Emphasis on musculoskeletal screening was done only during clinical rotations in specialties like rheumatology, rehabilitation medicine or orthopedics, but not in other specialties. In addition, only the Section of Rheumatology used the GALS technique.
CONCLUSION: The findings of this study suggest that while medical interns feel competent in performing the GALS technique, its application in the clinics leaves much room for emphasis and that there is a need to standardize instruction on musculoskeletal screening.

Human ; Male ; Female ; Arm ; Gait ; Hospitals, General ; Musculoskeletal Diseases ; Orthopedics ; Philippines ; Rheumatology ; Spine

BACKGROUND: At present, there is no normative value that can be used in the definition of sarcopenia in the Philippines. OBJECTIVE: We identified the reference cut-off values for: 1) muscle mass using bioimpedance analysis; 2) grip strength; 3) usual gait speed; 4) timed get-up-and-go; and 5) short physical performance battery in the Philippines in order to adapt the European Working Group on Sarcopenia in Older People (EWGSOP) criteria for the definition of sarcopenia. METHODS: Two hundred seventy six (135 males and 141 females) healthy Filipino adults, between 20 and 40 years, were included in this cross sectional study. A Fresenius Body Composition Monitor was used to measure lean tissue mass (LTM) and lean tissue index (LTI). A dynamometer was used to measure grip strength. Usual gait speed, timed get-up-and-go, and short physical performance battery were also determined. RESULT: The normative references for males and females, respectively, for LTI were 17.10 + 2.337 kg/m² and 12.63 + 2.119 kg/m²; for usual gait speed were 1.06 + 0.251 m/sec and 0.930 + 0.144 m/sec; and for grip strength were 39.76 + 7.567 kg and 26.68 + 5.243 kg. The sarcopenia cut-points for the males and females, respectively, for LTI were <12.50 kg/m² and <8.33 kg/m²; for usual gait speed were <0.55 m/sec and <0.65 m/sec; and for grip strength were <24.54 kg and <16.10 kg. CONCLUSION: This study presents cut-points for the determination of sarcopenia at-risk population among Filipinos.
Adult ; Anthropometry ; Body Composition ; Electric Impedance ; Female ; Gait ; Hand Strength ; Humans ; Male ; Philippines ; Sarcopenia*

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Objective: To describe the clinical profile of Filipino pediatric SLE patients as determined using the 2012 Systemic Lupus International Collaborating Clinics (SLICC) classification criteria. Methods: We checked which among the SLICC criteria were fulfilled by Filipino pediatric SLE patients when we examined them and their case records, as part of a nationwide genetic study on SLE conducted from October 2015 to March 2017. Results: Ninety-seven (out of 321) who were diagnosed to have SLE before 19 years of age were evaluated.The mean age of the population at the time of evaluation was 19.8 ± 6.9 years. Females comprised 94% of our population. Mean age of onset was 14.4 ± 2.7 years, while the mean age of diagnosis was at 14.5 ± 2.6 years. Acute cutaneous rash was found in 87%; oral ulcers 65%; renal disorder 63%; non-scarring alopecia 61%; arthritis 58%; chronic cutaneous rash 36%; leukopenia 35%; hemolytic anemia 34%; serositis 25%; thrombocytopenia 23%, and neurologic disorder 8%. Anti-nuclear antibody was present in 85%; low complement 32%; anti-dsDNA 28%; direct Coombs’ 16%; antiphospholipid antibody 3%; and anti-Smith antibody 1%. Kidney biopsy was performed in only 14% (14/97) of patients, of whom 27% had class III histopathologic characteristic. Conclusions Filipino pediatric SLE patients typically present with mucocutaneous, renal, and musculoskeletal involvement. Cardiopulmonary and neurologic manifestations are found to be less common among them. Finally, renal biopsy is not commonly performed among these patients.
Child ; Philippines ; Lupus Erythematosus, Systemic

Objectives: Systemic consequence of Chronic Obstructive Pulmonary Disease (COPD) is associated with progressive loss of muscle mass and function. Preliminary studies showed presence of sarcopenia in COPD leads to reduced pulmonary function and quality of life; studies on whether this condition results in consequent loss of bone mineral density (BMD) is still inconsistent. This study aims to examine the association of sarcopenia in COPD with osteoporosis. Methods: This is a post-hoc analysis of a study on forty-one (n ¼ 41) participants with COPD seen in a tertiary public hospital in Manila, Philippines who underwent pulmonary function test and dual-energy x-ray absorptiometry. Sarcopenia was defined using a Philippine-based criteria of low fat free mass index (FFMI) and low muscle strength - hand grip strength, and osteoporosis using World Health Organization T-score diagnostic criteria. Results: The prevalence of osteoporosis among COPD is 44%, and 63% in COPD with sarcopenia. There was no statistical difference seen in pulmonary function variables between COPD with and without osteoporosis. Significant positive correlations were observed between Forced Expiratory Volume in 1 s, FFMI, and appendicular lean muscle with total body BMD. Sarcopenia in COPD was associated with significantly increased risk for osteoporosis. Conclusions High prevalence rate of osteoporosis, and even higher among sarcopenic Filipino COPD patients should be further studied. The findings also suggest that sarcopenia in COPD is associated with increased risk of osteoporosis, and osteoporosis alone does not seem to affect lung function.

OBJECTIVES: Studies on the association of obesity and sarcopenia are conflicting. Some studies showed that obesity is associated with muscle loss and frailty while others showed that lower body mass index (BMI) is associated with increased sarcopenia. To date, there is paucity of data on sarcopenia and obesity among Filipinos. This study aims to determine the association of obesity and sarcopenia among Filipinos. METHODS: This is a cross sectional analytic study comparing sarcopenic versus nonsarcopenic in terms of obesity as measured by BMI and waist circumference (WC). Filipinos older than 40 years old were included. Obesity was defined using the World Health Organization (WHO) cutoff for BMI and WC. Sarcopenia was defined as low muscle mass and low muscle strength or physical performance. Population-specific cutoff points were used to define low muscle mass, strength, and performance. RESULTS: A total of 164 participants were included. The mean age is 60.33 years. Ten (6.10%) were sarcopenic and 4 (40.00%) of them were obese. Regression analysis showed that obesity is not significantly associated with increased sarcopenia (Incidence risk ratio [IRR], 14.62; 95% confidence interval [CI], 0.96–221.92; P = 0.05). However, age (IRR, 1.15; 95% CI, 1.09–1.21; P ≤ 0.01),WC (IRR, 0.92; 95% CI, 0.85–0.99; P = 0.02), smoking (IRR, 3.17; 95% CI, 1.11–9.03; P = 0.03), and alcoholic beverage drinking (IRR, 3.71, 95% CI, 1.26–10.89; P = 0.02) were found to be significant predictors of sarcopenia. CONCLUSIONS: There is no statistically significant association between obesity and increased risk of sarcopenia among participants, however, older age, smaller WC, smoking, and alcoholic beverage drinking were significant predictors of sarcopenia.
Adult ; Alcoholic Beverages ; Body Mass Index ; Drinking ; Humans ; Muscle Strength ; Obesity ; Odds Ratio ; Sarcopenia ; Smoke ; Smoking ; Waist Circumference ; World Health Organization

Objectives: Recent studies show that patients with young-onset gout present with visible tophi or nephrolithiasis on diagnosis. In the Philippines, where gout is prevalent, there is no published work on this subset of patients. This study presents the clinical characteristics of a cohort of Filipino patients with gout whose symptoms started at 30 years of age or younger. Methods: The case records of all patients who fulfilled the 1977 American College of Rheumatology (ACR) criteria for gout seen in four adult rheumatology services were reviewed. We selected those whose age of onset of gout was at 30 years or younger. The demographic characteristics, medical history, laboratory parameters, and presenting manifestations were described. Results: Six hundred sixty-nine records of patients with gout were reviewed; 101 (15%) fulfilled the young-onset gout criteria. The mean age of onset was 25±4.40 years (range 14-30), and the mean disease duration before diagnosis was 12.64±11.91 years. All of the patients were male and most were married; 76% were alcoholic beverage drinkers and 38% were smokers. A family history of gout was noted in 47%. Most patients (66%) were already on nonsteroidal anti-inflammatory drugs (NSAIDs), 24% on colchicine, and 14% on urate-lowering therapy before consult at the rheumatology clinic. By history, at onset, the most common pattern of joint involvement was monoarthritis (95%), affecting the ankles (60%), knees (52%), and 1st metatarsophalangeal (MTP) joint (51%). However, on the first rheumatology clinic visit, 34% of arthritis was polyarticular, more than 68% had more than three arthritis attacks per year, and there were tophi in 35%. The mean duration before visible tophi formation was 2.81±6.75 years. Around 21% had nephrolithiasis or a history thereof. The mean serum uric acid (SUA) was 9.18 mg/dL and the mean serum creatinine was 1.5 mg/dL. Thirty-seven percent had estimated glomerular filtration rate (GFR) <60 mL/min. Conclusion Young-onset gout was present in 15% of our patients and gout was familial in 47%. There was a delay in diagnosis of as long as ten years in most of the patients. On presentation at the rheumatology clinic, more than 34% had polyarticular arthritis, 35% had tophi, and 37% had low estimated GFR. This emphasizes the importance of awareness and prompt diagnosis to ensure correct treatment and prevention of complications
Gout

Background: Rheumatoid arthritis (RA) patients benefit from aerobic and strengthening exercises. Objective: To compare the effectiveness of a home exercise program against center-based aerobic and strengthening exercises on the grip strength, endurance, function, and fatigue among patients with RA. Methodology In this assessor-blind, randomized trial, 50 RA patients were assigned to either center-based physical therapy (CPT) or home exercise program (HEP) that included aerobic and strengthening exercises performed for four weeks. The grip strength, 6-minute walk test (6MWT), health assessment questionnaire disability index (HAQ-DI), and the multidimensional assessment of fatigue (MAF) index were determined at weeks 0 (baseline), 2 and 4 weeks.
Therapeutics ; Arthritis, Rheumatoid ; Fatigue ; Hand Strength