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REVIEW ARTICLES
Oral manifestations of autoimmune connective tissue diseases
Akshat Pandey, Mimansha Pandey, Ved Prakash Pandey, Vinod Ravindran
December 2018, 13(4):264-272
DOI:10.4103/injr.injr_51_18  
Autoimmune connective tissue diseases possess difficulty in diagnosis and treatment due to uncertainty in etiology, a wide array of clinical presentation, and unpredictable disease course. Many such diseases like Sjögren syndrome, Rheumatoid arthritis, Systemic Lupus Erythematosus, Systemic Sclerosis, have characteristic oral findings, the identification of which may allow for early diagnosis and treatment. For the purpose of this narrative review we searched the databases such as MEDLINE the Embase and Cochrane library using search terms including “rheumatic” “autoimmune,” “connective tissue diseases,” “dental,” “oral,” and “manifestations” and the names of individual known diseases and also a manual search of bibliographies of these articles and of previously published reviews and animal studies. In this review, we describe the oral manifestation and dental considerations associated with these diseases which will allow the practitioner in holistic management of these patients.
  16,924 1,126 2
IRACON 2018
Poster Presentations

December 2018, 13(6):93-241
DOI:10.4103/0973-3698.247336  
  16,913 826 -
ABSTRACTS
Poster Presentations

November 2017, 12(5):16-132
  12,678 766 -
Abstract

December 2019, 14(6):99-249
  11,350 1,021 -
LETTERS TO EDITOR
Splitting dose of methotrexate in the management of rheumatoid arthritis: Making a mountain out of a molehill?
Navaf Kozhippurath Mohamedali, Vinod Ravindran
June 2017, 12(2):114-115
DOI:10.4103/injr.injr_42_17  
  11,490 448 -
REVIEW ARTICLES
Neonatal lupus: An update
Sathish Kumar
November 2016, 11(6):139-144
DOI:10.4103/0973-3698.194548  
Neonatal lupus erythematosus (NLE) is a syndrome that usually presents in the fetus or neonates that is caused by transplacental passage of autoantibodies from the mother. It is a clinical spectrum of cutaneous, cardiac, and systemic abnormalities observed in the newborn or infants whose mothers have autoantibodies against Ro/SSA and/or La/SSB. Congenital complete heart block is the most serious manifestation of NLE that can develop in utero or after birth. Multidisciplinary team involvement is indicated. This article will provide an overview the presentation of NLE and will review the evidence for current therapies.
  10,725 1,152 1
ORIGINAL ARTICLES
Standardizing initial dilution titers of antinuclear antibodies for the screening of systemic lupus erythematosus
Joseph Sushil Rao, Vineeta Shobha, Tinku Thomas, Usha Kini
September 2019, 14(3):211-217
DOI:10.4103/injr.injr_172_18  
Background: Systemic Lupus Erythematosus (SLE), a systemic autoimmune disease, is diagnosed by correlating clinical features with a positive Antinuclear Antibody (ANA) test. Detection of ANA by Indirect Immunofluorescence (IIF) is used for screening SLE and is dependent on initial dilution titers which require population-specific standardization. With lack of exclusive commercial kits for the South Indian population, it is necessary to standardize initial screening dilution titers for ANA to distinguish SLE and other rheumatic diseases from the healthy. Methods: Newly diagnosed SLE patients between 18 and 60 years along with healthy controls from South India over 8 months (September 2015–April 2016) were selected for this prospective study. Serum samples were subjected to ANA-IIF in dilution titers of 1:40, 1:80, and 1:100 as per kit recommendations. IIF intensity and staining patterns were correlated clinically and statistically analyzed. Results: ANA positivity in dilutions of 1:40 and 1:80 was seen in 2.1% of healthy controls and negative at 1:100. About 97.9% of SLE patients were positive at 1:100 dilution; speckled pattern being the most common (52.1%), followed by homogeneous (37.4%). The patterns were best appreciated in 1:100 dilution with high significant measure of agreement of kappa between the two pathologists for both patterns and intensity at all three dilutions. Conclusion: 1:100 is the best screening dilution to distinguish SLE patterns from normal healthy individuals, and its main advantage is the delineation of various ANA patterns when positive, especially when mixed at this lower dilution.
  10,946 249 1
ABSTRACTS
IRACON 2016: Poster Presentations

October 2016, 11(5):20-108
  10,219 778 -
REVIEW ARTICLES
Mimics of scleroderma
Kaveri K Nalianda, Mithun M Rathen, Soumya Jagadeesan, D Padmanabha Shenoy
November 2017, 12(6):171-179
DOI:10.4103/0973-3698.219086  
Systemic sclerosis is a rare autoimmune connective tissue disorder characterised typically by tightening and tethering of skin. However, several other disorders are also characterised by hardening and thickening of skin. These mimics can be potentially confused with systemic sclerosis, leading to a misdiagnosis. This review describes the aetiopathogenesis, clinical features and treatment of Morphea (localised scleroderma), Scleredema, Scleromyxoedema, Eosinophilic fasciitis, Nephrogenic Systemic Fibrosis, Diabetic Cheiroarthropathy, chronic GVHD, POEMS syndrome and drug induced scleroderma like illness. A careful and thorough clinical assessment is essential in order to differentiate these mimics from each other and from systemic sclerosis, establish the diagnosis, and initiate appropriate treatment.
  10,075 823 -
REVIEW ARTICLE
Vitamin D and autoimmune diseases
Shir Azrielant, Yehuda Shoenfeld
December 2017, 12(4):219-222
DOI:10.4103/injr.injr_99_17  
Vitamin D and its deficiency are becoming a subject of great interest in recent years. In addition to the well-known role of vitamin D in maintaining bone health, evidence from recent years are accumulating in favor of its importance in the functioning of the immune system. The association between vitamin D deficiency and autoimmune diseases has been supported by epidemiological studies, demonstrating higher prevalence of vitamin D deficiency among autoimmune patients, in comparison to the general population. Vitamin D was also associated to various autoimmune diseases in both molecular and interventional studies; among the associated diseases are: systemic lupus erythematosus, type 1 diabetes mellitus, multiple sclerosis and others. In this review, relevant literature on the association between autoimmunity and vitamin D deficiency will be reviewed and discussed, as well as a summary of important recommendations for vitamin D supplementations in autoimmune patients.
  9,720 732 3
TOPICAL REVIEW
Current treatment of osteoporosis
Subramanian Nallasivan
March 2019, 14(1):57-60
DOI:10.4103/injr.injr_74_18  
Osteoporosis is ever increasing as life expectancy continues to increase across the world. Hypovitaminosis D has been found to be prevalent even in children and adults, and hence, it is imperative to educate the public on the nutrition for bone health. “Love your bones and joints” was the slogan by the World Health Organization to increase the awareness among the public. Bone density is assessed by Dual Energy X-ray Absorptiometry scan and the T score system. Although biomarkers have been studied in research, their clinical utility is still elusive. Regular exercise and adequate intake of Calcium and Vitamin D are important to maintain bone health. Bisphosphonates are the first line drugs in the management of osteoporosis both for primary and secondary prophylaxis. Second-line drugs include denosumab, teriparatide, and newer drugs such as abaloparatide, romosozumab, and calcitonin, which have found more real-life acceptance and efficacious in the long-term management of osteoporosis. Romosozumab, a monoclonal antibody may well become the ideal osteoporosis drug with effects on bone formation and resorption. Surgical treatment choices include – Vertebroplasty and kyphoplasty are being accepted in specific instances and selected centers with variable success.
  9,066 875 2
REVIEW ARTICLES
Ultrasound of the hip in rheumatology
Girish Gandikota, Moe Tun
August 2018, 13(5):29-35
DOI:10.4103/0973-3698.238199  
Recent advances in musculoskeletal (MSK) ultrasound and transducer technology have enabled increased utilization of high-quality ultrasound in rheumatology clinics and by the bedside as an adjuvant to the clinical examination of the hip. Ultrasound is also an integral part of image-guided joint aspirations, injections, biopsies, and bursa injections. In this article, we will focus on basic ultrasound scanning technique and findings related to common rheumatologic pathologies of the adult symptomatic hip. Transducer positioning and essential sonographic bony landmarks will be reviewed and scanning in two orthogonal planes (both long and short axes of the structure) will be emphasized. Common hip pathologies such as synovitis, joint effusion, bursitis, greater trochanter pain syndrome, and hamstring pathology will be discussed. The reader will also be made aware of limitations of ultrasound in the evaluation of hip and emphasize the complementary role of ultrasound with other imaging modalities (radiographs, computed tomography, and magnetic resonance imaging). The diagnostic ability of MSK ultrasound is based on an operator's training and experience, the patient's habitus, and aptly chosen clinical indications. A good grasp of anatomy, sound ultrasound technique, and knowledge of limitations of ultrasound modality are essential for a safe ultrasound practice. A long-standing commitment of time and resources is needed to become competent and comfortable in scanning. Where possible, the training should be inbuilt into the postgraduate training. It is best that a rheumatologist adopts a career plan of learning, inclusive of MSK ultrasound, relevant to rheumatology.
  8,617 900 -
TOPICAL REVIEW
New treatments for systemic lupus erythematosus
Robert George Lahita
March 2017, 12(1):48-51
DOI:10.4103/injr.injr_1_17  
New therapies for systemic lupus erythematosus are rare. This is because of the complexity of the disease and its varied presentations. There are many variables and a variety of measurement scales that must be satisfied before a new agent is approved for use in humans. Attempts are ongoing to develop biological treatments for the disease using three approaches: B cell modulation, T cell regulation and cytokine inhibition. This paper reviews the current state of these three critical areas.
  7,950 1,040 2
REVIEW ARTICLES
Why women or why not men? sex and autoimmune diseases
Gilberto Cincinelli, Elena Generali, Rajkiran Dudam, Vinod Ravindran, Carlo Selmi
March 2018, 13(1):44-50
DOI:10.4103/injr.injr_1_18  
The epidemiology of autoimmune diseases is characterized by a significant sex dimorphism, with the majority of disorders being more prevalent in women. In a parallel fashion, the immune system shows sex-dependent differences in number and functions of both its innate and its adaptive arms, with women capable to mount a more vigorous response compared to men. This enhanced reactivity may contribute to the stronger defense against infectious agents and to the reasons for which, on the other hand, women are more prone to develop autoimmune diseases. Several factors have been studied and implied to play a role for such an imbalance, most notably sex chromosomes, sex hormones, and gut microbiota differences between sexes. Experimental studies on rodents demonstrate that sex chromosome abnormalities, alterations of gut microbiota composition, and fluctuations of sex hormone concentrations decrease the susceptibility to autoimmunity in female probes or increase it in the male counterparts. Nevertheless, it would be reductive to consider sex only as a risk factor; based on clinical experience, autoimmune disease onset and course differ between men and women in terms of disease progression and severity. Eventually, research has focused on sex as a determinant of antirheumatic treatment response with promising evidence for a further personalized management of patients with autoimmune diseases.
  7,600 604 3
ORIGINAL ARTICLES
Test–retest reliability and correlates of 6-minute walk test in patients with primary osteoarthritis of knees
Mahamed Ateef, Sivachidambaram Kulandaivelan, Shaziya Tahseen
December 2016, 11(4):192-196
DOI:10.4103/0973-3698.192668  
Background: In the assessment of primary osteoarthritis (OA) of knees several clinical tool including 6 minutes walk test (6 MWT) are used. The objective of this study was to to analyze the test-retest reliability of 6 MWT and its correlation with various parameters. Methods: Eighty patients (age, 56-79 years) with OA of knees met the inclusion criteria. Demographic and clinical characteristics including radiological severity of OA (by X-ray K/L grading) were recorded. Patients filled in the knee injury and osteoarthritis outcome score (KOOS) questionnaire. All patients performed 6 MWT twice with at least 48 h gap in-between. Results: Test–retest reliability of 6 MWT in primary OA knee patients was excellent with ICC 0.991 (95% confidence interval was 0.986–0.994). 6 MWT had a weak correlation with KOOS-symptom and KOOS-activities of daily living (rho = 0.397 and 0.364 respectively), a strong correlation with KOOS-pain and KOOS-sports (rho = 0.605 and 0.521 respectively), and a very strong correlation with KOOS-quality of life (rho = 0.758). It had a weak correlation with age and height (r = 0.497 and 0.302), a strong correlation with VAS, weight, and BMI (rho = −0.655, r = −0.510, and − 0.691, respectively), and a very strong correlation with disease severity (rho = −0. 849). Conclusion: 6 MWT was a reliable test and positively correlated with all KOOS subscales and negatively correlated with other parameters except height in primary OA knee.
  7,409 715 5
CASE-BASED REVIEW
Alopecia as the first manifestation of azathioprine myelosuppression in a genetically predisposed patient
Debashish Mishra, Shefali Khanna Sharma, Aman Sharma, Sanjay Jain, Varun Dhir
March 2019, 14(1):61-64
DOI:10.4103/injr.injr_127_18  
Azathioprine, an analog of mercaptopurine, is used for various inflammatory/autoimmune diseases in diverse fields such as rheumatology, ophthalmology, gastroenterology, and neurology. One of the dreaded side effects of this drug is myelosuppression, which can be either dose related or “idiosyncratic.” The latter group often manifests with sudden cytopenias and is often secondary to a genetic predisposition. Mutations in the genes thiopurine S-methyltransferase (TPMT) and nucleoside diphosphate-linked moiety X-type motif 15 (NUDT15) have been identified to predispose to severe myelosuppression with azathioprine. An important clinical clue that can precede the onset of myelosuppression is alopecia. Here, we describe the case of a young lady treated with azathioprine, who developed alopecia (progressing to alopecia totalis), which was followed by severe cytopenia – both of which recovered on stopping the drug. On genetic analysis, she was found to be homozygous for mutation in NUDT15 (C415T) but was negative for mutation in TPMT. We review various other cases reporting alopecia as a marker of azathioprine-induced myelosuppression and the genetic mutations described.
  7,693 293 2
REVIEW ARTICLES
Drug-induced vasculitis
Durga Prasanna Misra, Pallavi Patro, Aman Sharma
December 2019, 14(5):3-9
DOI:10.4103/0973-3698.272156  
Vascular injury due to drugs is recognized as a distinct entity under the Chapel Hill Consensus Conference 2012 definitions for vasculitis. Drug-induced vasculitis (DIV) may affect various types of vessels. Isolated cutaneous leukocytoclastic vasculitis is most commonly seen in association with antibiotics and nonsteroidal anti-inflammatory drugs. Drug-induced antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis has been classically associated with cocaine (alone or contaminated with levamisole), antithyroid drugs (propylthiouracil, methimazole, carbimazole) and hydralazine; minocycline often mimics medium-vessel vasculitis, with ANCA positivity. Drug-induced large-vessel vasculitis remains rare; however, it has been reported with anticancer agents targeting immune pathways, including immune checkpoint inhibitors. Cerebral vasculitis has been associated with oral or topical sympathomimetic drug use. Operational pathogenetic mechanisms in DIV include immune complex deposition, abnormal generation of neutrophil extracellular traps, and bypassing of normal immune checkpoints like that between programmed cell death ligand 1 on dendritic cells and programmed cell death 1 on T-lymphocytes. DIV can have an unpredictable course, and a significant proportion of patients require immunosuppressive therapy in addition to drug withdrawal.
  7,040 634 -
Paradigm shift in clinical trial regulations in India
Sandeep Lahiry, Rajasree Sinha, Shouvik Choudhury, Ayan Mukherjee, Suparna Chatterjee
March 2018, 13(1):51-55
DOI:10.4103/injr.injr_110_17  
India has the potential to contribute meaningfully to global clinical drug development. A critical enabler to achieve this potential is a balanced, predictable, and scientifically robust regulation involving clinical studies. In the past few years, the country's regulatory milieu has witnessed a positive transformation to favour ethical conduct of clinical trials, while appropriately supporting patient safety. Numerous amendments to existing policies governing the conduct of clinical studies are predicted to bring a paradigm shift in the overall regulatory scenario. In such view, it is important for us as academicians, to be abreast of such changes. We, therefore, discuss major regulatory highlights involving clinical research in India.
  6,545 887 3
EDITORIALS
Checklist prior to biologics: Indian perspective
Rajkiran Dudam, Narsimulu Gumdal
September 2016, 11(3):126-128
DOI:10.4103/0973-3698.187419  
  6,209 908 1
REVIEW
Pulmonary hypertension associated with connective tissue disease
Srinivas Rajagopala, Molly Mary Thabah
March 2017, 12(1):38-47
DOI:10.4103/0973-3698.199124  
Pulmonary hypertension (PH) is an important cause of morbidity and mortality in connective tissue diseases (CTDs). CTDs may cause PH due to several mechanisms; pulmonary arterial hypertension, associated interstitial lung disease, neuromuscular disease, and/or sleep disordered breathing leading to hypoxia, associated thromboembolic PH, and pulmonary venous hypertension due to left ventricular dysfunction. PH can be measured on echocardiography, but the gold standard for diagnosis is right heart catheterization. PH-specific therapy in addition to immunosuppression is the most common treatment used though data are scant. In this narrative review, we discuss the epidemiologic burden, clinical presentation, evaluation, and management of PH in CTDs.
  6,112 771 1
REVIEW ARTICLES
Fertility and pregnancy in systemic lupus erythematosus
Alexis Jones, Ian Giles
November 2016, 11(6):128-134
DOI:10.4103/0973-3698.194546  
Systemic Lupus Erythematosus (SLE) is a chronic multisystem autoimmune disease with a heterogeneous pattern of clinical and serological manifestations. The predilection for women, particularly of childbearing age, combined with improved survival has led to increasing numbers of women with lupus considering pregnancy. Management of pregnancy in SLE however, requires careful planning and close medical and obstetric monitoring to ensure optimal outcomes. This review, discusses possible causes of subfertility, issues regarding contraception and family planning as well as management of lupus during pregnancy and outcomes in pregnant women with SLE.
  6,190 602 3
BRIEF REPORT
Use of art as therapeutic intervention for enhancement of hand function in patients with rheumatoid arthritis: A pilot study
Sayali Khedekar, Apurv P Shimpi, Ashok Shyam, Parag Sancheti
June 2017, 12(2):94-96
DOI:10.4103/0973-3698.199130  
Background: Conventional physiotherapy treatment for patients with rheumatoid hand emphasizes on single-plane movements and strengthening exercises directed toward improvement of function and prevention of deformities. This may be nondirective and lacks creativity and hence may predispose to a high attrition from therapy. The current study aimed to evaluate the efficacy of art as a creative therapeutic procedure for enhancement of hand functions, self-perception, and quality of life in patients with rheumatoid arthritis (RA). Methods: A single-blinded, randomized controlled pilot study was conducted on 17 participants suffering from RA. The control group received conventional physiotherapy while the experimental group received art-based intervention with bimanual projects (viz., origami, paper quelling, clay modeling, and oil painting). Both groups received intervention for 45 min daily for 4 weeks. Pre- and post-interventional assessment was done using grip and pinch strength, Grip Ability Test (GAT), Jebsen–Taylor Hand Function Test (JHFT), Australian-Canadian Osteoarthritis Hand Index (AUSCAN), Michigan Hand Outcome Questionnaire (MHQ), and Health Assessment Questionnaire (HAQ). Results: There was an improvement in hand functions (grip strength [P = 0.042], two-point pinch strength [P = 0.039], three-point pinch strength [P = 0.043], GAT [P = 0.043], JHFT [P = 0.043]), self-perception (AUSCAN [P = 0.043], MHQ [P = 0.043]), and quality of life (HAQ;P = 0.043) in art therapy patients which was similar to conventional therapy patients. Conclusion: Art is an equally effective therapeutic intervention to conventional therapy for the enhancement of hand functions, self-perception, and quality of life in patients with RA.
  6,211 544 1
ORIGINAL ARTICLES
A cross-sectional study of different rheumatic diseases and their respective comorbidities at a tertiary care hospital in India
Baikan Saiteja Yadav, Arindam Nandy Roy, Syeda Sana Fatima
March 2019, 14(1):42-48
DOI:10.4103/injr.injr_112_18  
Background: Rheumatic diseases have many outcomes, but less understood are many manifestations of additional health conditions that are associated with these diseases called co-morbidities. The more co-morbid illnesses one has, the greater the interference with medical management of rheumatic diseases. It is important to recognize such illnesses and to account for them in the care of the individual patient. There are few studies pertaining to different co-morbidities associated with rheumatic conditions. Therefore, this study was carried out to evaluate different rheumatic diseases and their frequency, associated co-morbid conditions and their variation based on age and body mass index (BMI). Methods: This cross sectional study was designed to survey 1000 consecutive patients who were diagnosed to have rheumatic diseases for co-morbidities at our institution. Patients of either gender with age ≥18 years were included. Data was collected regarding demographics detail, diagnosed disease and co-morbid condition. Analysis was done by IBM SPSS version 17.0 and R version 3.4, the association of rheumatic disease and co-morbidity with age and BMI was analyzed using Chi-square test. Results: We found that that rheumatic disease and co-morbidity increased significantly with age and body mass index (BMI) (P < 0.005). A substantial proportion of patients with rheumatic diseases (45%) were foud to have co-morbidities. The most common amongst them are hypertension, hypothyroidism and diabetes mellitus in descending order of frequency. Conclusion: C-morbidities which are amenable to therapeutic measures are common in individuals with rheumatic diseases. Early detection of such co-morbid condition is helpful should be an integral part of rheumatology patient care.
  6,142 452 2
REVIEW ARTICLES
Ultrasound of ankle and foot in rheumatology
Amit Kumar Sahu, Prasan Deep Rath, Bharat Aggarwal
August 2018, 13(5):43-47
DOI:10.4103/0973-3698.238201  
Ankle and foot are frequent joints to be involved in arthritis. These joints, being superficial in nature, can be easily accessed by ultrasound. Other advantages of ultrasound are its easy availability, portability, and repeatability. Tenosynovitis, synovitis, tendinosis, bursitis, and enthesopathy are common findings in inflammatory arthritis, which can be easily evaluated by ultrasound. Follow-up and treatment response can also be evaluated with less cost to the patient. High-frequency (7–15 MHz) linear probes with availability of color and power Doppler are ideal for scanning the ankle and foot. Systematic evaluation is the primary requirement for a proper assessment. Ankle is evaluated compartment wise with specific positing for anterior, posterior, medial, and lateral compartments. Foot is evaluated according to the midtarsal joints and metatarsophalangeal and interphalangeal joints. Structured base evaluation of the compartments and joints should be done and the pathologies were noted. Thus, ultrasound of the ankle and foot is a very useful and easily available modality for identifying and distinguishing different rheumatological pathologies such as tendinitis, tenosynovitis, synovitis, bursitis, and enthesopathy of the ankle and foot.
  6,144 437 -
IMAGES IN RHEUMATOLOGY
Bilateral L4 pedicle stress fracture: An unusual cause of low back pain in an adolescent
V Sivakumar, Venkatraman Indiran
December 2017, 12(4):226-227
DOI:10.4103/injr.injr_85_17  
  6,187 282 -