Turkish Journal of Rheumatology - 2013; 28(1) - Current Issue

Telemedicine in Rheumatology

Haydar G�K — 2013-01-01

Multiple Imputation of Missing Values Using the Response Function Method Based on a Data Set of the Health Assessment Questionnaire Disability Index

2013-01-01

Objectives: This study aims to investigate how imputing missing values in data obtained from the Health Assessment Questionnaire Disability Index (HAQ-DI) influences the bias and precision of patient disability measurements. Patients and methods: Hypothetical missing data sets were created by deleting item responses completely at random from the original data set with three missingness proportions (0.10, 0.30 and 0.50). Multiple imputation was carried out using the response function method for each hypothetical data set containing the missing values. The Rasch model was used to estimate the patients' latent trait levels for the original data, the hypothetical incomplete data sets, and the multiple imputed data sets. Then the estimates from the hypothetical missing data sets and the multiple imputed data sets were compared with those of the original data set. Results: A bias in disability estimates was observed, particularly as the missingness proportion increased for both the incomplete and imputed data; however, this bias was indiscernible even for the 0.50 proportion of missingness. In terms of the uncertainty of the disability estimates, the imputed data had a higher precision of estimates than the incomplete data. Conclusion: When researchers encounter missingness in data collected with the HAQ-DI, the response function imputation could be a convenient approach to impute missing values in order to improve the precision of the patient disability level estimates.

Is There a Balance Problem in Hypermobile Patients with Fibromyalgia?

Yasemin ULUS, Ye�im AKYOL, Berna TANDER, Dilek DURMU�, Ayhan B�LG�C�, �mer KURU — 2013-01-01

Objectives: This study aims to investigate the relationship between hypermobility and balance problem and the possible effect of this relationship on fall frequency in patients with fibromyalgia syndrome (FMS). Patients and methods: Sixty female patients with FMS and 30 healthy female controls were included in the study. The mean age of all participants was 41.8�9.9 years with a range of 22 to 62 years. The patients were divided into three groups: group 1 included FMS patients with hypermobility, group 2 included FMS patients without hypermobility, and group 3 included controls. Outcome measures for the FMS patients included disease duration, pain as assessed by the Visual Analog Scale (VAS), disease activity as assessed by the Fibromyalgia Impact Questionnaire (FIQ). The number of falls, functional performance as assessed by six-minute walk distance (6MWD) test, balance as assessed by the one-legged balance test with open eyes in conjunction with the Berg Balance Scale (BBS), and hypermobility as assessed by the Beighton criteria were evaluated in all participants. Results: There was no statistically significant difference between groups 1 and 2 in terms of duration of disease, VAS pain, FIQ, or number of falls (p>0.05). The number of falls was significantly different in group 1 than group 3 (p<0.05). There was no significant difference among the groups in the 6MWD test (p>0.05). The mean one-leg balance testing time and the mean BBS score were significantly different in the three groups (p<0.05). No significant correlation was found among the pain and balance tests and the number of falls (p>0.05). Hypermobility had a significant effect on the balance tests (p<0.001). Conclusion: The balance problem was found to be significantly higher in FMS patients with hypermobility than in those without hypermobility and in the healthy controls. This situation needs to be considered when clinically assessing FMS patients, as well as the patients should be informed, and appropriate measurements should be performed.

Comparison of Mini-squats and Straight Leg Raises in Patients with Knee Osteoarthritis: A Randomized Controlled Clinical Trial

2013-01-01

Objectives: In this study, we aimed to compare the effects of the straight leg raise exercise (SLRE) and mini squat exercise (MSE) on pain intensity, performance, muscle strength, physical function and balance in patients with knee osteoarthritis (OA). Patients and methods: Forty female patients (mean age 59.93�10.61 years; range 30-65 years) who were admitted to Ba�kent University Hospital between February 2009 and February 2010 with bilateral knee OA were included in this randomized controlled double-blind clinical trial. The patients were assigned into two groups, including SLRE and MSE. Both exercise groups were scheduled for a threeweek program of five sessions per week. Both groups also received an electrotherapy program in each session. Knee pain using the visual analog scale (VAS), physical performance using Timed Up and Go (TUG) Test, isokinetic quadriceps and hamstring muscle strengths using Cybex II, static balance using SportKAT 3000, physical function using Knee Injury and Osteoarhtritis Outcome Score-Physical Function Short Form (KOOS-PS) were assessed at baseline, at treatment end, and one month after treatment end. Results: No significant difference was found in static balance testing parameters after exercise program (EP) (p=0.659) and during follow-up period (p=0.327) between the groups. There was no significant difference in KOOS-PS scores after EP (p=0.398) and during follow-up (p=0.201) between SLRE and MSE groups. There was no significant difference in VAS scores af ter EP (p=0.149), however significant difference was found during follow-up (p=0.030) between SLRE and MSE groups. Mini squat exercise group had significantly higher TUG scores and higher right knee extensor torque at 60�/sec (p=0.024), 90�/sec (p=0.003), 120�/sec (p=0.005) and 180�/sec (p=0.017) compared to the SLRE group at the end of EP. Conclusion: Further studies are required including long-term follow-up and the evaluation criteria of the effectiveness of SLRE and MSE after this period.

An Analysis of Laboratory Characteristics of Patients with Suspected Rheumatoid Arthritis

2013-01-01

Objectives: The aim of this study was to characterize a population of patients with rheumatological signs and symptoms according to laboratory tests. Patients and methods: Data of a total of 386 patients (90 males, 296 females; mean age 45.9 years; range 14 to 91) with rheumatological signs and symptoms for a three-year period were retrospectively analyzed. Inflammatory activity using erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) tests were evaluated at the microbiology laboratory of Afyon Kocatepe University, Faculty of Medicine, Afyonkarahisar. The presence of rheumatoid factor (RF) and cyclic citrullinated peptide (CCP) antibodies were also analyzed. The ESR (mm/h) was determined by standard methods, while the RF and CRP were measured by immunonephelometry. The anti-CCP was studied by using a test kit according to the manufacturer's instructions. Results: A total of 270 patients were examined in a physical medicine and rehabilitation clinic. The results for anti-CCP, RF, CRP, and ESR were positive in 58 (21.5%), 77 (28.9%), 120 (44.4%) and 107 patients (39.6%) respectively. Among these patients, a total of 67 were diagnosed with rheumatoid arthritis (RA). When we considered the association of ESR, CRP, RF, and anti-CCP positivity with RA diagnosis, both anti-CCP (F=0.920) and RF (F=0.782) had a high positive correlation with RA. There was a close association between CRP (F=0.289) and ESR (F=0.236). Each of them had a moderate correlation with RA. Conclusion: Our study results showed that anti-CCP, followed by RF was the most closely associated autoantibody in suspected RA patients. The anti-CCP and RF combination provided the best test sensitivity.

The Frequency and Major Determinants of Depression in Patients with Rheumatoid Arthritis

Behnaz BEHNAM, Jamileh MOGHIMI, Raheb GHORBANI, Farahnaz GHAHREMANFARD — 2013-01-01

Objectives: This study aims to investigate the relationship between the prevalence of depression and its severity in Iranian patients with rheumatoid arthritis (RA) and to identify useful clinical correlations of the depressive symptoms. Patients and methods: One hundred and forty patients (28 males, 112 females; mean age 46.4�13.5; range 19-80 years) who met the American College of Rheumatology (ACR) criteria for RA in the outpatient rheumatology clinic of the Fatemieh and Amir hospitals in Semnan were included. The patients were divided into two groups including patients with active RA (n=56) and with inactive RA (n=84). One hundred and forty age and gender-matched healthy volunteers who work at the hospital without a history of rheumatological disorder were also included as controls. Depressive symptoms were assessed using the Iranian version of the Beck Depression Inventory II (BDI-II). Results: The overall prevalence of mild-to-moderate depression was 30.4% in the active RA group, 22.6% in the inactive RA group, and 12.1% in the control group. Severe depression was only observed in two of the subjects. One of those was in the active RA group, and the other was in the control group. Multivariate analysis showed that female gender as well as levels of erythrocyte sedimentation rate and C-reactive protein were associated with the development of depression in RA patients. Conclusion: The overall prevalence of mild-to-moderate depression in patients with active RA is notably higher. Thiscan be strongly associated with the gender and serum inflammatory markers.

A Comparison of the Efficacy of Dry Needling, Lidocaine Injection, and Oral Flurbiprofen Treatments in Patients with Myofascial Pain Syndrome: A Double-Blind (For Injection, Groups Only), Randomized Clinical Trial

P�nar K��k ERO�LU, �zlem YILMAZ, Hatice BODUR, Can ATE� — 2013-01-01

Objectives: The aim of this study was to assess and compare the efficiency of dry needling, lidocaine injection and oral flurbiprofen treatments in patients with myofascial pain syndrome (MPS) involving the neck and back region. Patients and methods: A total of 60 patients (7 males, 53 females; mean age 33.7 years; range 18 to 50 years) were included in this prospective study. The patients were divided into three groups by block randomization. Each group was assigned to dry needling for trigger points, lidocaine injection (double blind) or oral flurbiprofen 200 mg/day over seven days. All patients were also prescribed a standardized home exercise program based on stretching of the affected muscles. Before treatment and on the third and 14 days after treatment, pain severity was assessed by visual analog scale (VAS), degree of tenderness at the trigger points by algometry, active joint range of motion of the neck and shoulders by goniometry, and the quality of life by Nottingham Health Profile. Results: There was a significant improvement in pain severity, trigger point tenderness, joint range of motion, and quality of life in all three groups on the third and 14^th days of treatment. No significant difference was found in treatment efficiency among the groups. Conclusion: Treatments with dry needling, lidocain injection and oral flurbiprofen along with home exercises are all effective in the management of MPS.

Left Main Coronary Dissection in a Patient with Takayasu's Arteritis

2013-01-01

Takayasu's arteritis is a type of vasculitis which is characterized by chronic inflammation involving the aorta and its major proximal branches. The inflammatory process in the vessel wall due to intimal thickening and fibrosis may result in catastrophic events such as vascular stenosis and spontaneous dissection. However, spontaneous coronary dissection is a relatively rare outcome. The use of transthoracic echocardiography in the evaluation of thoracic aortic involvement has been shown to be advantageous since this method is relatively cheap and non-invasive. In this article, we report a 48-year-old female case who was previously diagnosed with Takayasu's arteritis with a spontaneous left main coronary artery dissection which was detected by coronary angiography following the sudden onset of severe chest pain.

Osteoid Osteoma of the Sacrum Mimicking Sacroiliitis: A Case Report

G�rkan �ZKO� — 2013-01-01

A 23-year-old female patient admitted with continuous pain localized in her right sacroiliac joint for four months. She had been diagnosed with sacroiliitis in another clinic. Her plain radiographs, bone scintigraphy and laboratory tests were normal. Magnetic resonance imaging showed a nonspecific edema of the bone marrow at the posterior corner of the sacrum which had been misdiagnosed as sacroiliitis. Computed tomography (CT) showed a nidus located posteriorly at the S2 vertebra of the neighboring sacroiliac joint. A removal of the nidus and pathological examination revealed a diagnosis of osteoid osteoma. Although osteoid osteoma is a very rare entity in the differential diagnosis of sacroiliac pain, it should be kept in mind in the presence of aching pain which is refractory to conservative treatment and responsive to nonsteroidal anti-inflammatory drugs. Magnetic resonance imaging is not always diagnostic, whereas CT is more helpful for diagnosing osteoid osteoma.

Intracardiac Thrombosis and Coronary-to-Pulmonary Artery Fistula with Pulmonary Embolism and Budd-Chiari Syndrome in Beh�et's Disease: A Case Report

Tolga AKSU, Ay�eg�l �Z — 2013-01-01

Beh�et's disease (BD) is a multisystemic, chronic and inflammatory vasculitis presentation. A 29-year-old male patient with BD was admitted to our clinic with dyspnea and chest pain. On his physical examination, a left parasternal murmur resembling the sound of a machine was detected along with abdominal ascites. The patient's electrocardiography and chest X-ray were normal. Thoracic computed tomography (CT) revealed a chronic pulmonary embolism. On abdominal CT, a thrombus was detected in the hepatic vein and inferior vena cava, which was consistent with Budd-Chiari syndrome (BCS). Twodimensional transthoracic echocardiography demonstrated a mass on the right atrium protruding into the right ventricle. On the suprasternal view, abnormal flow surrounding the arcus aorta and pulmonary artery was detected. Coronary angiography showed a fistula formation between the left main branch and pulmonary artery. A treatment with anti-inflammatory drugs and heparin was initiated. Complete recovery of the pulmonary embolism and intracardiac thrombosis were observed at six months. In this article, we present a BD patient with intracardiac thrombosis and coronary-to-pulmonary fistula associated with a pulmonary embolism and BCS.

Primary Sjogren's Syndrome Presenting with Renal Tubular Acidosis and Central Pontine Myelinolysis: A Case Report

Sui RUBO, Lei ZHANG — 2013-01-01

In this case report, we present a-75-year-old female case of primary Sjogren's syndrome (pSS) with distal renal tubular acidosis (RTA) as revealed by severe hypokalemia along with normal anion gap metabolic acidosis and abnormally acidified urine. The patient had a brain stem lesion as confirmed by quadriplegia, hypersomnia, and dysphagia. Laboratory tests revealed that the anti-Ro/SSA and anti-La/SSB antibodies were positive. Magnetic resonance imaging of the brain showed a hyperintense signal at T₁ and T₂ in the mid-pons, a typical characteristic of central pontine myelinolysis.

Avascular Necrosis of the Femoral Head in a Patient with Beh�et's Disease

Murat ERS�Z, G�l�in URAL, Elif Esen �ZDEM�R, Selami AKKU� — 2013-01-01

Ultrasound in the Diagnosis, Monitoring, and Treatment of Retrocalcaneal Bursitis

Levent TEK�N, Alparslan Bayram �ARLI, Selim AKARSU — 2013-01-01