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13th Annual PSR Conference



Message of President CPSP

Professor Chaudhry, Zafarullah
President CPSP

 

I congratulate the Pakistan Society of Rheumatology for holding the 13th annual conference of Rheumatology in the historical city of Lahore. The Pakistan Society of Rheumatology has been a pioneer in making inroads to create awareness about arthritis and related diseases amongst physicians, as the morbidity and mortality of arthritis related illnesses is significant. We are all aware of the fact that there is an acute shortage of trained Rheumatologists in Pakistan and coping with an ever-increasing burden of arthritic patients is a great challenge. Hence, on this auspicious occasion, I announce with great pleasure that the College of Physicians and Surgeons Pakistan has recently included the specialty of Rheumatology in its Fellowship programmes. The objective is to train and create a faculty of rheumatology so that the burden of Rheumatic diseases can be shared and translated into greater patient benefit. It is a befitting tribute in this Bone and Joint Decade to join hands with the rest of the world, to help patients with arthritis.

I wish the Pakistan Society of Rheumatology success in its praiseworthy effort of holding various conferences and promoting awareness amongst physicians, as well as the general public.

Conference Key Abstracts

 

1. THE PAINFUL FOOT

2. EMERGENCY RHEUMATOLOGY

3. FIBROMYALGIA

4. CRITICAL DIGITAL ISCHAEMIA

5. CHILDHOOD ARTHRITIS

6. INJECTION TECHNIQUES

7. RHEUMATOLOGY: PITFALLS AND MYTHS

8. MEASURING BONE MINERAL DENSITY: METHODS & INTERPRETATION

9. ROLE OF MUSCULOSKELETAL ULTRASOUND IN RHEUMATOLOGY

10. THE ABNORMAL LOWER LIMB BIOMECHANICS

11. BONE DENSITY AMONGST VARIOUS AGE GROUPS IN PAKISTAN

12. SHORT TERM EFFICACY AND SAFETY OF LEFLUNOMIDE IN PAKISTANI PATIENTS WITH RHEUMATOID ARTHRITIS: A PROSPECTIVE STUDY

13. COMPARISON OF EFFICACY & TOLERABILITY OF PHLOGENZYM IN RHEUMATIC DISORDERS

14. ANKYLOSING SPONDYLITIS

15. EXERCISE THERAPY IN TOTAL KNEE REPLACEMENT OF A RHEUMATOID ARTHRITIS PATIENT

16. PREVALENCE OF VITAMIN D DEFICIENCY IN POSTMENOPAUSAL WOMEN

17. DEPRESSION IN AMPUTEES: A STUDY OF 40 AMPUTEES AT FAUJI FOUNDATION HOSPITAL, RAWALPINDI

18. GOUT

19. POSTURAL BACK PAIN-PREVENTION IS BETTER THAN CURE

20. PATTERN OF JUVENILE RHEUMATOID ARTHRITIS SEEN IN 91 PATIENTS PRESENTING TO AN URBAN RHEUMATOLOGY CLINIC

21. PATTERN OF DISEASE MODIFYING ANTI-RHEUMATIC DRUGS (DMARDs) USED IN 100 NEWLY REFFERED PATIENTS OF RHEUMATOID ARHTRITIS



1. THE PAINFUL FOOT

Prof. Farooqi, Abid, FRCPI
Pakistan Institute of Medical Sciences, Islamabad

Foot pain is a common symptom across all types of populations. The causes may emanate from the various sources including the spine, pelvis, leg-length discrepancy, neurological disturbances, local soft-tissue problems e.g bunions, metatarsalgia or indeed diseases of the foot joints themselves. This presentation aims to highlight the major causes of foot pain in our population, ways to examine the foot having such a problem and the range of treatment options available.


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2. EMERGENCY RHEUMATOLOGY

Gibson, Terence
Consultant Rheumatologist
Guys and St Thomas Hosptials, London, UK

A miscellany of rheumatological problems present to the emergency services which are usually poorly trained to identify and manage rheumatic diseases.  A majority of acute admission notes make no reference to the musculoskeletal system neither in the history nor the examination.

Two broad categories of patients present as emergencies:

  1. Acute complications of recognised, established diseases.
  2. Acute presentation of previously unrecognised rheumatic disease.

Conditions which fall into the former group include sepsis in patients on corticosteroids or immunosuppressives, CNS involvement in lupus, ruptured tendons/Bakers cysts of inflammatory peripheral arthritis, cord compression due to RA cervical spine disease, and  falls in the elderly with RA/OA.

In the latter category is the common hot swollen joint due to gout and pseudogout, haemarthrosis, sepsis and reactive arthritis.  Joint aspiration and synovianalysis for crystals can establish a rapid diagnosis and treatment without admission. Every rheumatology department should be equipped with a polarising microscope and be able to respond to urgent examination of synovial fluid. Absence of crystals from very turbid fluid suggests sepsis and admission.  Septic arthritis can be treated by a rheumatologist and there is no advantage to washouts or insertion of a drain. 

Acute peripheral arthritis with rashes form a subgroup in which psoriasis, lupus, erythema nodosum, neisseria infection and vasculitis are prominent.

Severe spinal pain in middle and later life may be caused by malignant disease or spinal osteomyelitis due to pyogenic organisms or T.B. The diagnosis may be established by needle aspiration of spinal swelling or C.T. guided aspiration/biopsy of imaged abnormalities.

A department should have in place a protocol that allows rapid access to urgent rheumatology opinions, access to hot clinics and guidelines for managing acute rheumatological presentations in the emergency room.

Conclusions:

Many complications of chronic rheumatic diseases result in emergency attendances. Acute arthritis requires the urgent examination of synovial fluid where possible. Rapid access to rheumatology opinions and provision of acute arthritis protocols should be a feature of all rheumatology departments.


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3. FIBROMYALGIA

Dr. Alam, Mahfooz
Consultant Rheumatologist
Liaquat National Hospital, Karachi

Fibromyalgia is a chronic Musculoskeletal pain Syndrome with a prevalence of up to 15% in Rheumatology outpatient clinics. The condition is referred to with various synonyms in the literature, Fibrositis and Chronic Fatigue Syndrome being the more common ones. It is a diagnosis of exclusion but has specific diagnostic criteria. Many connective tissue disorders and inflammatory arthropathies may mimic the clinical presentation of Fibromyalgia. There is no specific lab test to confirm the diagnosis but good clinical acumen is the key. It is one of the most difficult rheumatological ailments to treat and most of the patients are never satisfied. These are the patients that most Rheumatologists hate to deal with, but of course they need help.

The presentation will discuss peculiar aspects of the disease pertinent to our socioeconomic milieu.

Established diagnostic criteria and patho physiology of the disease will be discussed briefly with more time spent on recent advances in the management.  


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4. CRITICAL DIGITAL ISCHAEMIA

Gibson, Terence
Consultant Rheumatologist
Guys and St Thomas Hosptials, London, UK

Most patients with ischaemic fingers or toes have an established disease that offers a likely explanation. This talk dwells on those cases whose ischaemic or gangrenous digits have no known cause.

Overall, the most common association is diabetes but in the absence of this illness a differential diagnosis can be predicated on age, gender, smoking history, involvement of either fingers, toes or both, bilateral or unilateral features.  Emboli usually affect one side, vasospastic disease the fingers, vasculitis the fingers, toes or both, prothrombotic and malignant conditions the toes more than fingers.

Investigation may include ultrasound angiology, echocardiography, thrombophilia screen, connective tissue disease serology.

Immediate management should include heparin, aspirin and vasodilatation with intravenous Iloprost.  Subsequent management for the vasospastic disease of scleroderma might include digital sympathectomy, vasodilatation with calcium channel blockers, endothelin receptor blockade (e.g. bosentin) or a phospho-diesterase inhibitor (e.g. sildenafil) and repeated Iloprost infusions.  Prothrombotic disease e.g. antiphospholipid syndrome requires long term anticoagulation.  Thrombus formation is an element of vasospastic disease and warfarin is an added option beyond initial heparin. Vasculitis as an uncomplicated cause of digital ischaemia is uncommon but if it is a suspected associate of vasospastic or prothrombotic disease immunosuppression with corticosteroids, cyclophosphoamide or other cytotoxic drugs is warranted.  Surgical amputation plays no part in the management.  In older subjects where no embolic, atheromatous, thrombotic or vasospastic disease can be identified C.T. scanning of chest, abdomen and pelvis is required in a search for malignancy.

Conclusions:

  1. Embolus, atheroma, thrombus, vasospasm or vessel inflammation may contribute in isolation or in combination to digital ischaemia.
  2. Recognition of an embolic source, associated diseases and likely mechanism of ischaemia should be pursued by careful clinical, imaging and laboratory assessment.
  3. Management is designed to rescue viable tissue and restore near normal blood flow by vasodilatation, anticoagulation and anti inflammatory measures.  Apart from digital sympathectomy, surgery should be avoided.


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5. CHILDHOOD ARTHRITIS

Raja, Sumaira Farman
MRCP (London), CCD (USA)
Graduate Certificate Paediatric Rheumatology (Australia)
Assistant Professor Rheumatology
FMH College of Medicine & Dentistry, Lahore

The unfortunate delay in diagnosing, and hence treating children with Juvenile idiopathic arthritis impacts the lives of these children who are then, unfortunately, disabled for life by this potentially controllable condition.

The reasons for this delay may be the many mimics of arthritis in children: infections, malignancies, musculoskeletal abnormalities, orthopaedic and some other miscellaneous conditions.

Additionally there are differences between adult Rheumatoid arthritis and Juvenile idiopathic arthritis, both in presentation and results of diagnostic tests. However, there is a general lack of awareness of these differences, which additionally contributes to this delay in diagnosis, and treatment.

These points are highlighted by this presentation.


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6. INJECTION TECHNIQUES

Dr. Aziz, Wajahat
MBBS, FCPS, MRCP, MACP
Associate Professor of Rheumatology
Pakistan Institute of Medical Sciences, Islamabad

Intra-articular steroid injection is a useful technique to acquire for doctors in the field of rheumatology and orthopaedic surgery as well as family medicine. When proper precautions are exercised and appropriate indications are adhered to, intra-articular injections of steroids can yield gratifying results in the management of many conditions of soft tissue structures and joints. 


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7. RHEUMATOLOGY: PITFALLS AND MYTHS

Dr. Jafry, Raza
Consultant Rheumatologist
Liaquat National Hospital, Karachi

This is a brain storming, interactive session which consists of brief case presentations from our daily clinical practice followed by a question and list of possible options. The commentary will guide participants to choose options which are most appropriate, evidence based and follow good clinical practice. The questions and their explanation will help to improve cognitive ability of the practicing doctors whenever they will manage patients suffering from various rheumatic disorders .The speaker will provide rationale for the correct approach and answer any questions in this regard.


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8. MEASURING BONE MINERAL DENSITY: METHODS & INTERPRETATION

Dr. Akhtar, Waheed
Osteoporosis Specialist
Ashford & St.Peter's Hospitals, United Kingdom

The only sure way to determine bone density and fracture risk for osteoporosis is to have a bone mass measurement (also called bone mineral density or BMD test).

There are a number of methods / tests available in the market to measure BMD but among them Dual energy X-ray Absorptiometry (DXA) of spine & hip (axial DXA), is still considered to be the ‘Gold Standard’. According to WHO, the diagnostic criteria for osteoporosis depends on T-score and is as follows:

  • T-score ≥ -1                               Normal
  • T-score between -1 and -2.5>      Osteopenia
  • T-score ≤ -2.5 or less                  Osteoporosis

This classification of osteoporosis is only to be used with axial DXA. WHO criteria do not apply to peripheral testing as it is machine-specific. For diagnostic classification of osteoporosis, T-scores are to be used and not Z-scores and NHANES III standardised reference database should be used. BMD values from different manufacturers are not comparable.

Serial BMD can be performed to:

  • Monitor response to treatment.
  • Evaluate loss of bone density in treated / non-treated patients – suggesting the need for re-evaluation / initiation of treatment.
  • Monitor patients not being treated who are at risk of bone loss, in order to determine if treatment is needed

Intervals between BMD testing should be determined according to each patient’s clinical status

Osteoporotic patients

  •  Consider 1 year after initiation or change of therapy

Osteopenic patients

  •  Repeat after 2 years or sooner if rapid bone loss is expected.

Patients with normal BMD

  •  Repeat after 3-5 years or sooner if rapid bone loss is expected.

This information is in accordance with the guidelines of National Osteoporosis Society (NOS) –UK and the National Institute of Health and Clinical Excellence (NIHCE) – UK.


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9. ROLE OF MUSCULOSKELETAL ULTRASOUND IN RHEUMATOLOGY

Prof Dr. Gilani, Syed Amir
MBBS (Pb) M.Sc( Canada) PhD(Switzerland) PhD(Sudan)
Fellowship in MUSK Ultrasound (USA)
Associate Professor of Radiology
L.UdES University Lugano, Switzerland
President International Society of Musculoskeletal Ultrasound (Austria)

Introduction: The advent of musculoskeletal ultrasound in 1985 has revolutionized the diagnostic capacities of the medical diagnostic ultrasound which can save time, money and unwanted exposure of the human body to X-Rays and Magnetic Waves.

Objectives: In this state of art lecture we are going to demonstrate the sonographic pictures on grey scale and color doppler ultrasound in patients of Rheumatoid Arthritis discussing the accuracy and predictive values of the modality used for the Musculoskeletal system as a whole and rheumatology as a goal.

Method and material: Toshiba Xerio with color Doppler and Panoramic view is used to scan the patients, who are referred from some of the renowned hospitals in the city of Lahore including CMH, FMH, Services Hospital, Rehabilitaion centre etc.

Results: We shall be discussing the sonographic appearance and accuracy of the modality in scanning the normal anatomy of joints and diagnosis and differential diagnosis of multiple pathologies of the extremities.

We shall also discuss few cases of RA with their differential diagnosis done of ultrasound and color Doppler.

Discussions: A part of the presentation shall include the real time demonstration of the sonographic appearance of most of the structures in normal volunteers and in patients.

CONCLUSION: We shall discuss the cases of Synovitis, tenosynovitis, tendinosis,bone erisions and many other pathologies concluding that Ultrasound must be one of the main finger of Rheumatologists hand while he/she is going to touch his/her patient as a physician.


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10. THE ABNORMAL LOWER LIMB BIOMECHANICS

Dr. Ahmed, Riaz
Resident Sports Physician NCA,
National Cricket Academy, Pakistan Cricket Board, Lahore

Athletes, children and sedentary people among population may suffer from the overuse injury of the lower limb if not assessed for biomechanical deformities (excessive pronation, excessive supination and abnormal pelvic movements)  early on i.e. Hallux abducto valgus ( Bonion ) Plantar faciites, Achilies tendinities, Peroneal tenidinites, Medial shin pain, Patellar tendonitis, Patello-femoral syndrome, iliotibial band friction syndrome, Hamstring strain, Metatarsal / navicular or  fibular stress fracture, Osgood –Schlatter disease or Sinding Larsen –Johansson disease and sever’s diseases.

Abnormal biomechanics may result from static (anatomical) or functional (secondary) abnormalities. Static abnormalities such as leg length discrepancies or genu valgum cannot be altered. However, the secondary effects caused by these abnormalities may be prevented or reduced by compensatory devices and by incorporation of an appropriate exercise therapy program for the purpose of regaining strength, stability in the muscles & pain free range of motion in the joints.

The aim of the workshop will be to give Practitioners a better understanding of lower limb biomechanics and offer treatment modalities which target the cause of these conditions, not just the symptoms.


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11. BONE DENSITY AMONGST VARIOUS AGE GROUPS IN PAKISTAN

Dr. Malik, Javaid Mehmood
Dept. of Rheumatology and Rehabilitation
Fauji Foundation Hospital, Rawalpindi

Introduction: Bone strength is assessed by determining bone mineral density and bone quality turnover of bone size and geometry, micro architecture damage accumulation, mineralization etc. Reduced bone strength leads to increased risk of fractures.

Bone mineral density (BMD) testing is done by dual energy X-ray absorptiometry (DXA). It is a very reliable clinical tool. Peak bone mass is usually achieved by age 25 years. On average it deteriorates by 1% per annum till menopause and then it declines more rapidly. 

There is a strong correlation between mechanical strength and BMD measured by DXA. Similarly there is a strong correlation with fracture risk. Randomized clinical trials have shown a reduction in absolute number of fractures as well as fracture risk with drug therapy based on BMD measured by DXA. However, the magnitude of fracture risk reduction that is attributable to an increase in BMD is variable.

The mean BMD and standard deviation of the reference population is a critical variable in determining T-scores and Z-scores. T-score is a comparison of patients’ DMD to a young adult whereas Z-score is a comparison of patient’s BMD to a person of the same age and sex. 

Objective:  An observational, pilot study, to assess average bone mineral density in various age groups and compare it with NHANES III data.

Methods: Total bone mineral content bone area at lumbar spine and hips were measured. Patients were stratified into age wise groups i.e. 20-29, 30-39, 40-49, 50-59, 60-69 and greater than 70 years. Both T-scores and z-scores were calculated. 

Results: Preliminary finding of this study will be presented at the meeting. 


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12. SHORT TERM EFFICACY AND SAFETY OF LEFLUNOMIDE IN PAKISTANI PATIENTS WITH RHEUMATOID ARTHRITIS: A PROSPECTIVE STUDY

Dr Saeed, Muhammad Ahmed; Dr Mir, Nighat; Dr Raja, Sumaira Farman; Hameed, Raffaqat; Umair, Muhammad; Ghafoor, Irum
Division of Rheumatology,
FMH College of Medicine and Dentistry, Lahore, Pakistan

Background: Leflunomide is a disease modifying anti-rheumatic drug for active Rheumatoid arthritis (RA). This drug has been widely studied in west but to our knowledge there has been no available local data.

Purpose: To evaluate the efficacy and safety profile of Leflunomide in patients with active RA either alone or in combination with other disease modifying anti-rheumatic drugs.

Methods: It is a prospective, non-comparator, open label study in a setting of care as usual. Total 63 consecutive patients with active RA started on Leflunomide between 15-08-06 and 15-12-06 were enrolled. Data regarding patient and disease characteristics, dose of Leflunomide, adverse events and lab tests was collected from outpatient medical records. Leflunomide was started with full loading dose in 5 (8%), half loading dose in 39 (62%) and without loading dose in 19 (30%) patients. Methotraxate was used as a concomitant DMARD in 20 (32%) patients. Efficacy was accessed by improvement in American College of Rheumatology (ACR) criteria for disease activity. Primary end-point was 20% improvement in ACR criteria (ACR-20) after 6months. Secondary end-points were ACR-50 and ACR-70 response. Safety was assessed by adverse events and any adverse change in lab parameters including complete blood counts, liver and kidney function tests. Follow up visits were scheduled every 4-6 weeks as our usual clinical practice.

 

Results: out of 63 patients 54 (85.7%) were females. Mean age was 46±12.6 yrs. Mean disease duration was 5.1±4.5 yrs. 52 (86.6%) patients achieved ACR 20 response at 6months. ACR 50 and ACR 70 response were met in 32 (53%) and 5 (8.3%) of cases. 20% of patients experienced at least one adverse event related to Leflunomide.  Alanine transaminases were raised in 7(11%) patients only. Three (4.7%) patients had diarrhoea. Two patients developed mild rash. All adverse events were managed by reduction in maintenance dose and there were no patient withdrawals because of above adverse events.

Conclusion: This 6 months prospective study conducted in a setting of daily rheumatology practice shows that Leflunomide is an effective DMARD and it has manageable safety profile by avoiding the full loading dose and by adjusting the maintenance dose.

Keywords:    Rheumatoid Arthritis, Leflunamide.


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13. COMPARISON OF EFFICACY & TOLERABILITY OF PHLOGENZYM IN RHEUMATIC DISORDERS

Dr. Stauder, Gerhard
Chief Scientific Advisor Pharmascript Munich, Germany

Introduction: Phlogenzym is a Biological Response Modifier capable of normalizing our normal immune functions. It lowers down the pro-inflammatory cytokines levels like TNF α and Interlukin- 1, thus helps to reduce the inflammation of Synovial tissue and synovial fluid and ultimately provides protection from cartilage and bone damage. Phlogenzym also increases the activity of macrophages and natural killer cells and thus enhancing the removal of circulating immune complexes and cellular debris at tissue level.

Rheumatoid Arthritis is an auto immune disorder and hyperactivity of immune system results in devastating outcomes. Current treatment of rheumatoid arthritis affects the main pathogenic mechanisms of its development. However side effects of some of the therapies, and also insufficient effectiveness of the others, motivates search for new therapeutic agents in the treatment of this disease.

In an open, randomized trial conducted under supervision of Postgraduate Education, Military Medical Academy, City Rheumatology Centre, St.Petersburg, Russia.

Objective: To assess the efficacy of systemic enzyme therapy in the treatment of Rheumatoid Arthritis.

Subject: 156 patients were enrolled and divided in two groups. One group received Methotrexate and NSAID therapy (65 patients) while other group received Phlogenzym in combination with Methotrexate and NSAID (91 patients). 

Method: All patients were assessed on the basis of routine clinical and laboratory studies

Results: The group taking Phlogenzym as adjuvant therapy showed superior efficacy in therapy as compared to conventional therapies with regard to Ritchie Index (Improved 10.7 points Vs 14.4 points), Morning stiffness (improved 49.6 minutes Vs 92.0 minutes) and lee index (improvement 4.2 points Vs 5.7 points). P value was highly significant in all cases.

Conclusion: Phlogenzym therapy presents a highly effective method of RA treatment, which directly influences the pathogenic mechanisms of the disease so provides synergistic effects as adjuvant therapy with conventional therapies.


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14. ANKYLOSING SPONDYLITIS

Dr. Tassadaq, Naureen
Classified Rehabilitation Specialist
Rheumatology and Rehabilitation Dept
Fauji Foundation Hospital
Rawalpindi.

A chronic inflammatory arthritis of unknown etiology predominantly involving sacro-iliac and spinal joints, leading to progressive fusion of the spine. Twenty first century physicians who care for these patients must be aware of current pharmacological and rehabilitation strategies to control disease, limit impairment, preserve or enhance function and reduce disability. Rehab medicine aims to maintain and restore function and prevent dysfunction. Rehabilitation in Ankylosing Spondylosis is based on formulation of individualized treatment plans by utilizing education, physical modalities and techniques, exercise, assistive and adaptive devices, energy conservation, joint protection, psychosocial management and vocational planning. The care of patients with Ankylosing Spondylosis is a multidisciplinary team effort. Rehabilitation treatment plans must be individualized for the patient’s needs; they should be practical, economical, and valued by the patient to enhance compliance. Treatment should begin early in the disease process to help prevent impairment and functional decline and so that the patient identifies this as part of the overall management plan. Rehabilitative rheumatology treatments and techniques must be monitored carefully, and periodic reevaluation of the patient with adjustments in treatment should be made.


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15. EXERCISE THERAPY IN TOTAL KNEE REPLACEMENT OF A RHEUMATOID ARTHRITIS PATIENT

Ikram, Salman
Senior Physiotherapist
Dept. of Rheumatology & Rehabilitation
Fauji Foundation Hospital Rawalpindi

Total knee arthoplasty procedures are successfully in use around the world to restore joint mobility, correct deformity, improve aerobic conditioning, improve the disability status of the patient, decrease or diminish pain, promote better muscle control with increase strength and also to improve patients functional capabilities with resultant boost in patient’s lifestyle and overall psychosocial status.

I will be discussing all that and much more in my presentation especially the factors essential for a successful total knee arthoplasty. What are the indications and contraindications, best post operative rehabilitation protocols and manoeuvres, what are good exercises techniques especially in rheumatic patient’s, what are different phases of the rehabilitation, what are the activities best suited after arthoplasty.

I will be presenting useful information on prosthetic designs, method of fixation, types of material, surgical techniques, post operative complications and rehabilitation problems. I hope that you will find my presentation helpful in highlighting information on all aspects of total knee arthoplasty.


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16. PREVALENCE OF VITAMIN D DEFICIENCY IN POSTMENOPAUSAL WOMEN

Dr. Nasim, Amjad
Dept. of Rheumatology & Rehabilitation
Fauji Foundation Hospital Rawalpindi

Introduction:

There is a resurgence of intrest in vitamin D amogst endocrionologists, public health scientists, rheumatologists, chemical pathologists etc. The reason for this interest is that according to current definitions  a significant percentage of general population suffers from vitamin D deficiency. This is true for postmenopausal women as well. Hence this pilot study was designed to determine the vitamin D status of postmenopausal women at a university hospital.

Objective:

To determine the 25 hydroxy vitamin D3 levels of postmenopausal women at a rheumatology clinic.

Methods:

The first 10 patients presenting every morning in OPD were selected. DXA scan of lumbar spine and hip was done. 25 hydroxy vitamin D3 levels were tested at by Roche Elycces analyzer. Other parameters tested were CBC, TFT, LFT, urea, creatinine and blood glucose.

Results:

The final results of this study will be presented at the meeting.


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17. DEPRESSION IN AMPUTEES: A STUDY OF 40 AMPUTEES AT FAUJI FOUNDATION HOSPITAL, RAWALPINDI

Khan, Rafique Rehana
Rehab Psychologist
Dept. of Rheumatology and Rehabilitation
Fauji Foundation Hospital, Rawalpindi

Amputation, at present, is mostly traumatic but it may be elective as in cases of diabetic foot, Buerger’s disease, gangrene, malignancy etc. With the loss of a limb, the individual’s body image is distorted and he thinks that he is no longer a complete human being. He loses all the practical and expressive functions, which were formerly carried out by means of the limbs. For some time he feels helpless. Many of them imagine in the early weeks of lower limb amputation that they will never be able to walk again. Apart from loss of physical functions, the amputee loses hopes and aspirations for the future; his plans and ambitions get shattered. Thus, he hasn’t just lost his limb, but has lost a slice of his world and a large part of his future. It was strongly felt that even today there might be many amputees who continue to remain sad, depressed and mourn over their loss and feel dejected and despondent. There may be a considerable number who remain tense, worried and anxious over their future interpersonal relationship in their social, vocational, familial and marital sphere. Some will have an overt mental breakdown and need active psychiatric treatment. In others, where the mental symptoms are not so obvious, a careful psychiatric interview will help in bringing to the fore the inner turmoil that can only be resolved by a psychiatrist.

Keeping in view the psychological needs of the amputees, present work was planned to study the frequency of depression in amputees. The objectives of the study were to identify amputees requiring psychiatric treatment.


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18. GOUT

Dr. Parveen, Tahira
Registrar Rheumatology
Liaquat National Hospital, Karachi

Gout is a common disorder of uric acid metabolism that can lead to deposition of MonoSodium Urate crystals in soft tissues, recurrent episodes of debilitating arthritis, and if untreated, joint destruction and renal damage. Gout is definitely diagnosed by demonstration of negatively birefringent urate crystals in aspirated synovial fluids. About 1% of Americans have gout and it is more common in Blacks.

As a rule, uric acid levels are elevated for 20 yrs before the onset of gout. Only less than 5% of the patients with gout are over-producer, most of them are under-excreters. Acute monoarthritis is the usual initial presentation, typically involving smaller, lower extremity joints. Renal stones may precede the onset of gout in 40% of patients.

NSAIDS, steroids and colchicines are used in the management of acute gout. Long term management of gout is focused on lowering uric acid levels and target level of uric acid is less than 6mg/dl. Diet modification along with therapeutic agents are used to lower uric acid levels.

Gout that is treated early and properly carries an excellent prognosis, if patient’s compliance is good. 


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19. POSTURAL BACK PAIN-PREVENTION IS BETTER THAN CURE

Mr. Ahmad, Ashfaq
B.S.P.T (Pb), P.G.C. (Khi), M.P.P.S, Certified by F.S.B.P.T (USA),
Consultant Physiotherapist
FMH Institute of Allied Health Sciences, Lahore

Outline:       

  • Posture, Causes & Types Common Faulty Postures
  • Workstation Disorders
  • Haphazard of high heel
  • Ill fitted bras and their effects
  • Preventive Measures
  • Ideal Sitting, Sleeping & Standing Postures
  • Patient advice & Patient Re-education
  • Plan of care & Physical Therapy Interventions


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20. PATTERN OF JUVENILE RHEUMATOID ARTHRITIS SEEN IN 91 PATIENTS PRESENTING TO AN URBAN RHEUMATOLOGY CLINIC

Dr Saeed, Muhammad Ahmed; Dr Mir, Nighat; Dr Raja, Sumaira Farman
Division of Rheumatology
FMH College of Medicine & Dentistry
Lahore Pakistan

Objective: To determine various types of juvenile rheumatoid arthritis (JRA) seen in patients visiting our rheumatology clinic.

Materials and methods: A retrospective review of case records of 91 patients ages <= 16 yrs, who satisfied American College of Rheumatology (ACR) criteria for juvenile rheumatoid arthritis was done. These patients visited our rheumatology clinic from April 2002 to Jun 2004.

Results: Total patients were 91. Females were 49(54%) and males were 42(46%). There was an overall female predominance except for pauciarticular type where males were more than females 24(60%) vs. 16(40%) p value <0.05. Mean age of onset was 10.7 yrs + 4 yrs. Polyarticular sub-type was the commonest pattern seen in 51.6% of cases while 44% of the patients had pauciarticular disease. Systemic JRA was seen in 4.4%. Rheumatoid factor was positive in 48.4% cases with Polyarticular disease and in this sub-group of seropositive polyarticular patients 88% were females.

Conclusion: Pattern of JRA in this case series was quite different in comparison to data generated from western countries. Mean age of onset was much higher than quoted in literature. Polyarticular sub-type was the commonest pattern seen in our patients, where as pauciarticular is more prevalent in the west. Rheumatoid factor was positive in 48.4% of the patients with polyarticular disease in contrast to 5-10 % seen in western data. As sero positive polyarticular JRA is associated with more aggressive disease and disability so these patients have to be identified earlier and need aggressive treatment with disease modifying agents.

 Keywords: -   Arthritis.    Juvenile.    Pakistan.


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21. PATTERN OF DISEASE MODIFYING ANTI-RHEUMATIC DRUGS (DMARDs) USED IN 100 NEWLY REFFERED PATIENTS OF RHEUMATOID ARHTRITIS

Dr Saeed, Muhammad Ahmed; Dr Mir, Nighat; Dr Raja, Sumaira Farman
Division of Rheumatology
Fatima Memorial Hospital College of Medicine & Dentistry, Lahore Pakistan

Objective: To determine the pattern of different disease modifying anti-rheumatic drugs (DMARD’s) prescribed to patients with Rheumatoid Arthritis prior to their first visit in our rheumatology clinics.

Study Design: Observational descriptive, case series.

Study Place & Duration: This study was conducted in Division of Rheumatology at Fatima Memorial College of Medicine & Dentistry, Lahore, Pakistan 

Materials and Method: We enrolled 100 patients with Rheumatoid Arthritis (RA) fulfilling American College of Rheumatology (ACR) criteria. After interviewing each patient at his/her first visit by trainee fellow a questionnaire was filled  having information about demographic variables, disease duration and treatment history.

Results: Out of 100 patients 83% were females. Mean age at presentation to a rheumatologist was 41.7 + 11.7 years. Mean disease duration at their first visit in our clinic was 4.78 + 4.75 years. 54% of the patients had consulted Orthopedic Surgeon for their joint pains. 38 % of RA patients had been to Medical specialist for treatment during their course of disease. 24% had at some point in time were treated by GP’s. 33% had been on Hakeem or Homeopathic medications. Only 7% had ever consulted a rheumatologist. 64% patients had been on Methotraxate. Mean dose of Methotraxate used in patients treated by Orthopedic Surgeons was 7.5 + 2.5 mg. Patients going to GP’s were being treated with a mean dose of 5.5 + 2mg. Mean dose of Methotraxate used by Medical Specialist was 10.+2.5mg. 23% of the patients had never been on any DMARD. Only 16% of the patients had been counselled about disease course and prognosis. Periodic monitoring of side effects of DMARD’S in terms of labs was done in only 10%.

Conclusion: This pilot study highlights many pitfalls in the treatment of patients with RA. The standard of care is to start DMARD’s earlier and in optimal dosages. Lab tests should be done periodically for monitoring the toxicity of DMARD’s. Patients should be counselled about the disease course and prognosis.

KEY WORDS:  Rheumatoid Arthritis, Methotrexate


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