National Center Hospital Research Articles

Fifteen Years of Non-Hodgkin Lymphoma in an Indonesian National Referral Hospital: Epidemiologic Trends and Diagnostic Challenges.

The global burden of lymphoma is substantial because of the increase in its incidence in recent decades. However, disease characteristics vary across different geographical locations. Numerous immunohistochemistry markers and molecular studies are essential to determine lymphoma diagnosis and prognosis. This poses significant challenges in developing countries with limited health care resources. This large-scale study assesses the frequency of non-Hodgkin lymphoma (NHL) in Indonesia over the past 15 years, analyses its clinicopathologic features, and predicts future trends. This retrospective study collected lymphoma patients diagnosed at the Department of Anatomical Pathology Dr. Cipto Mangunkusumo National Central General Hospital, Indonesia, from 2009 until 2023. All lymphoma diagnoses were confirmed by using ancillary tools classified as an enhanced lymphoma panel according to a resource-stratified guideline. We analyzed the clinicopathologic features of each NHL type and further applied the Autoregressive Integrated Moving Average model to predict future incidence trends. The study consisted of 7,368 NHL patients. Among these, B-cell lymphomas accounted for 90.6%, with diffuse large B-cell lymphoma being the most prevalent subtype (68.8%), followed by follicular lymphoma (8.8%) and marginal zone lymphoma (5.8%). Extranodal natural killer/T-cell lymphoma, nasal type, is the most common T-cell lymphoma found (26.3%). All types of lymphoma were found to be more common in males (57.7%). Extranodal involvement, particularly in the tonsil and upper respiratory tract, was frequently observed. Projection analysis indicates a steady increase in lymphoma patients in the future. This study highlights the distribution and burden of NHL in Indonesia over 15 years. The overall epidemiologic pattern of NHL in this study aligns with the results observed in other Asian countries. The rising incidence of lymphoma requires improved health care infrastructure and prevention strategies.

Radiotherapy for hypopharyngeal carcinoma in Senegal: Experience of the main cancer care facility

Objectives: To describe the epidemiological, diagnostic, therapeutic, and prognostic factors associated with patients treated for hypopharyngeal carcinoma at the Radiotherapy Department of the National Hospital Center Dalal Jamm. Patients and Methods: Data from 50 consecutive patients treated for hypopharyngeal carcinoma between 2018 and 2022 were retrospectively analyzed. All patients received three-dimensional conformal radiotherapy (3DCRT) with or without chemotherapy. Epidemiological and diagnostic data, treatment details, and therapeutic outcomes were collected in an Excel 2016 database created for the study. Statistical analyses were performed using SPSS version 20.0. Overall survival estimates were generated using the Kaplan-Meier method. Statistical significance was considered at p = 0.05. Uni- and multivariate analyses were conducted to identify prognostic factors associated with survival. Results: The average age of the patients was 44 years (± 14.4 years), with a male-to-female ratio of 0.56. Sixteen percent of the patients were active smokers and 4% were alcohol consumers. The mean delay to the first consultation was 6 months, and dysphagia was the primary symptom (92%). The majority of patients (89.8%) were classified as stage IVa, and 10% had metastases at diagnosis. Treatment consisted of curative concurrent chemoradiotherapy (95.92%), preceded by induction chemotherapy in 58% of patients. A radiation dose of 70 Gy was utilized in 75% of cases. The 2-year overall survival rate was 25%. Multivariate analysis indicated that the presence of feeding gastrostomy (p=0.044), use of induction chemotherapy (p=0.012), and radiation dose less than 70 Gy (p=0.020) were associated with poorer survival. Conclusion: Concurrent chemoradiotherapy using 3D conformal techniques improved management, although outcomes remain unsatisfactory. Prospective cohort studies are imperative to identify specific risk factors in our population. Additionally, timely access to appropriate treatment modalities could enhance prognosis.

UNNECESSARY USE OF ANTIMICROBIALS – COMPARISON OF THE PREDICTIVE PERFORMANCE OF QSOFA AND APACHE SCORE FOR EVALUATION OF DISEASE PROGNOSIS PATTERNS IN CRITICAL ILLNESS

In critical care, accurate prognosis assessment, including antimicrobial therapy, is vital for guiding treatment decisions. The Acute Physiology and Chronic Health Evaluation (APACHE) and quick Sequential Organ Failure Assessment (qSOFA) scores are widely used for predicting patient outcomes. Yet, their relative performance and potential implications for antimicrobial stewardship need further exploration. Objective: To evaluate the disease prognosis patterns in critically ill patients by comparing the predictive performance of APACHE and qSOFA scores and to explore their correlation with antimicrobial misuse. Methods: A comparative study was conducted at the National Hospital and Medical Center in Lahore from January to November 2023. The study included 138 critically ill patients. Demographic information, clinical parameters, and medical history were collected, explicitly focusing on APACHE and qSOFA scores recorded at admission and during follow-up. Statistical analysis, including Pearson's and Spearman's correlation coefficients and logistic regression models, was performed using RStudio to assess the predictive ability of these scores for disease progression and patient outcomes. Results: The analysis revealed a moderate positive correlation (r=0.51) between qSOFA and APACHE-II scores, suggesting that both scores align in assessing the severity of illness in critically ill patients. The predictive models indicated that combining qSOFA and APACHE-II scores enhanced the accuracy of predicting critical outcomes, such as shortness of breath (SOB), with a combined model AUC of 0.659 compared to 0.601 for the APACHE-II model alone. Conclusion: The findings underscore the value of integrating multiple clinical scoring systems in managing critically ill patients. Such integration can aid in more judicious use of antibiotics, potentially mitigating the risk of antimicrobial resistance. The study advocates incorporating these insights into clinical guidelines and decision-making processes in critical care settings.

Initial Experience of Robot-Assisted Surgeries.

To present initial experience with the first 100 cases of robotic-assisted surgery by the Department of General Surgery. Descriptive study. Place and Duration of the Study: Department of Surgery, National Hospital and Medical Centre, Lahore, Pakistan, from May 2022 to August 2023. Demographic and postoperative details of the first 100 patients to undergo robotic-assisted surgery by the Department of General Surgery were reviewed. Prospective data were collected from the hospital information database as well as the CMR database. The data collected in the hospital database included the patients' age, diagnoses, genders, complications during hospital stay as well as 90-day readmission, morbidity, and mortality. Data collected by CMR via Versius robotic surgery console or internal databases included operative minutes using the console. The average age of patients undergoing robotic surgery was 44.26 ± 14.08 years. Cholecystectomy (78%) was the most commonly performed robotic-assisted procedure. Only one patient had blood loss of more than 100ml. There was no postoperative complication, readmission or mortality during the study period. With proper patient selection, robotic-assisted surgery is safe and feasible even in low-middle-income countries (LMICs). Robotic-assisted surgery, Pakistan, Initial experience, Outcomes, Versius.

The Effect of Bridging Exercise on Muscle Strength and Body Balance in Stroke Patients at National Brain Center Hospital Prof. DR. Mahar Mardjono East Jakarta

Aims: The study aimed to determine the effect of bridging exercise on muscle strength and body balance in stroke patients at national brain center hospital Prof. DR. Mahar Mardjono East Jakarta. Methods: This study used experimental design aimed to test the application of bridging exercise to body balance and muscle strength in stroke patients. This study was conducted in one group with pre and post-test design. This study was conducted at National Brain Center hospital Prof. DR. Mahar Mardjono East Jakarta. The bridging exercise was conducted at 2-weeks, with light tp moderate intensity, three times a week, with 30 to 45 minutes every session. Results: The result of the statistical test with the Paired Samples t-Test P value resulted in 0.001. These result mean that bridging exercise has a significant effect on muscle strength in stroke patients with a mean difference of -0.63 (CI: -0.91-0.34) and a significantly improved the balance of patients with a mean difference of 17 (CI 12.1-21.9) and a high magnitude of effect (1.69). Conclusion: These result mean that bridging exercise has a significant effect on muscle strength in stroke patients.

Elevated neutrophyl-to-lymphocyte ratioand smoking are associated with chronic total occlusion in patients with ST elevation myocardial infarction

BackgroundAtherosclerosis is a progressive disease characterized by the build-up of lipids and connective tissue in the large arteries. Some patients experience chronic total occlusion (CTO). Inflammation plays a key role in the development and complications of atherosclerosis. Neutrophil-to-lymphocyte ratio (NLR) is a marker of systemic inflammation associated with the development of acute coronary syndrome (ACS). We aimed to assess the relationship between NLR and CTO in ACS patients with ST elevated myocardial infarction (STEMI) in Indonesia.MethodsThis cross-sectional study was performed with secondary data obtained from patient medical records at Cipto Mangunkusumo National Central Hospital, Jakarta. Inclusion criteria were patients with ACS and STEMI who underwent coronary angiography in 2015–2018.ResultsA total of 98 patients were enrolled in the analysis. Most subjects with CTO were male, elderly (> 60), smoking, had no history of diabetes mellitus (DM) or hypertension, no family history of coronary heart disease (CHD), but had a history of ACS and had never consumed statin or antiplatelet medications. Bivariate logistic regression analysis revealed that male gender (PR = 1.820; 95%CI 0.871–3.805; p = 0.025) and smoking (PR = 1.781; 95%CI 1.028–3.086; p = 0.004) were significantly correlated with CTO. Receiver operator characteristic (ROC) curve revealed that higher NLR (≥ 6.42) could predict a CTO diagnosis with positive predictive value (PPV) of 91%. Multivariate analysis revealed that NLR was correlated with an 11.2-fold increase in occurrence of CTO (95%CI 3.250-38.303; p < 0.001). Additionally, smoking was correlated with a 7-fold increase in CTO (95% CI 1.791–30.508; p = 0.006).ConclusionNLR value of ≥ 6.42 is potentially useful as a marker of CTO in STEMI patients. In addition, smoking increases the risk of CTO in ACS/STEMI patients.

Effectiveness of Standard Therapy for Acne Vulgaris Based on Clinical Practice Guidelines in Indonesia.

To evaluate the effectiveness of standard therapy for acne vulgaris based on Indonesian guidelines. New patients with acne vulgaris at Dr. Cipto Mangunkusumo National Central General Hospital, the national referral center in Indonesia, who met the criteria were included in this study. Patients were treated with standard therapy for acne vulgaris based on the 2017 guidelines of Dr. Cipto Mangunkusumo Hospital, depending on severity. Changes in the number of non-inflammatory, inflammatory, and total lesions and the proportion of acne severity after three months of therapy were analyzed retrospectively. Among the 131 subjects, 63.4% had moderate acne; 20.6% had mild acne, and 16% had severe acne at baseline. Most patients (29 (22.2%)) received a combination of retinoic acid, benzoyl peroxide, and topical or oral antibiotics. Standard therapies reduced the median of non-inflammatory (25 (5-135) vs 8 (0-53)), inflammatory (10 (0-93) vs 2 (0-22)), and total lesions (41 (10-160) vs 10 (1-71)) at week 12 (all p < 0.001). The proportion of acne severity differed significantly after three months, with an increasing proportion of mild acne (20.6% vs 93.1%) and a decreasing percentage of moderate and severe acne (moderate = 63.6% vs 6.1%; severe, 16% vs 0.8%; p < 0.001). Standard therapy for acne vulgaris based on the clinical practice guidelines in Indonesia improved acne lesions and severity after 12weeks. These results support the implementation of national guidelines for acne management in Indonesia, with the practice of improving antimicrobial stewardship.

Evaluation of The Integrated Protocol for The Management of Severe Malnutrition in Children at The National Hospital of Nouakchott-Mauritania

Malnutrition is a worldwide concern with worrisome outcomes that affect substantially the lifestyle of infants. The main aim is to investigate the efficacy of the IMSAM protocol over malnourished Mauritanian children during hospitalization. A cohort of 230 participants, including 126 boys and 104 girls collected from rural and urban areas with an average age of 15.52 ± 7.727 months were enrolled. The study is carried out in the Pediatric Service of the National Hospital Center of Nouakchott, Mauritania on children who have undergone the national protocol for the Integrated Management of Severe Acute Malnutrition (IMSAM). In addition, the medical and nutritional treatment, and body measurements were appreciated as well as the anthropometric parameters. The findings exhibit during nutritional-based intervention significant differences between the mean of weight during the pre- and post-intervention (P &lt; 0.001). Moreover, through a regression test, we found a negatively predicted weight gain (P &lt; 0.05) by the variables Z-score of weight to height (P / T) Edema after Nutritional Support and final health status. Last, but by no means least, the IMSAM-based intervention with rational management might make inroads into mitigating adverse outcomes of malnutrition through maximizing social skills.

Management of pituitary adenoma: Preliminary experience with endoscopic endonasal transphenoidal surgery in a developing country. Example of Senegal about 180 cases

IntroductionEndoscopic endonasal transsphenoidal surgery is currently the gold-standard therapeutic approach for pituitary adenomas. Although being spread worldwide, the endoscopic endonasal approach for pituitary adenomas is recently implemented in Senegal.This study aimed to report our results and the complications observed in the context of an under-equipped facility. Materials and methodsWe conducted a retrospective study including all patients with a pituitary adenoma treated who underwent endonasal transsphenoidal resection under a single endoscopic approach from January 2014 to May 2022, in the Neurosurgery Department of Fann National Hospital Centre, Dakar. All patients were assessed according to clinical, radiological, and endocrinological criteria. They all were operated by the same team with an average follow-up of 24 months. ResultsIn this series of 180 patients, including 57.7 % women and 42.3% men with a mean age of 44.8 years (extremes of 18 and 76 years), the visual deficit was the most frequent onset symptom (69.4 %), followed by clinical forms of hormone hypersecretion (30.5 %). Twelve cases of pituitary apoplexy and 1 case of incidentaloma were reported. The most frequent tumors were non-functional tumors (61.6 %). Among the functional adenomas, the most frequent was prolactinoma (15.5 %). Regarding tumor size, 75 % were macroadenomas, 15.5 % were microadenomas, and 9.5 % were giants. Cavernous sinus invasion (Knosp grade ≥ 3) and suprasellar extension were noted in 14.4 % and 53.3 %, respectively. The resection was total in 80 % of cases, subtotal in 18.8 %, and partial in 1.2 %. Partial improvement of sight was observed in 91.1% and endocrine hypersecretion remission in 76.6 %. As for complications, the most frequent was transient diabetes insipidus (32.7 %). ConclusionDespite the scanty resources, our results are similar to the best-reported series and strengthen scientific evidence on the efficacy and safety of performing this technique in an under-equipped setting context.

A five-year study of Kikuchi Fujimoto Disease in Dr. Cipto Mangunkusumo National Central General Hospital

Link of Video Abstract: https://youtu.be/4GFvBGh4sdI Background: Kikuchi Fujimoto Disease (KFD) is a disease characterized by regional lymphadenopathy and fever. KFD is often misdiagnosed as tuberculosis because of the symptom’s similarities. Several studies have shown KFD prevalence in Asia, however, not much is known about KFD characteristics in Indonesia. This study aimed to determine KFD clinicopathological characteristics in an Indonesian National Central General Hospital and to determine the association between clinical characteristics and KFD histopathological features. Methods: Samples were taken from the medical records of patients with KFD in the span of 2016–2020. The data collected includes age, gender, lymphadenopathy location, clinical diagnosis, clinical symptoms, lymph node size, number of lymph nodes involved, histopathology, and immunohistochemical examination. Data were analyzed using Chi-square and Fisher exact test. Result: It was found that KFD mainly occurred in young women, mean age 25 years old, located in cervical lymphadenopathy, ≤ 2 cm size, and solitary. The main histopathological appearance is phagocytic subtype and necrotic phase, with &lt; 50% coagulative necrosis area. It also appeared KFD with &lt; 50% coagulative necrosis area was found significantly in ≤ 2 cm lymph nodes (p = 0.008). Conclusion: Clinical characteristics and complete histopathological features are important to be assessed in KFD to achieve accurate diagnosis.

Neutrophil Lymphocyte Ratio as an Inflammatory Marker in Rheumatoid Arthritis

Objective: To determine the role of Neutrophil Lymphocyte Ratio as an inflammatory marker in Rheumatoid Arthritis. Study Design: Cross-sectional analytical study. Place and Duration of Study: Rheumatology Department, National Hospital and Medical Center, Lahore Pakistan, from Mar to Sep 2021. Methodology: After approval from Institutional Ethical Review Board, 160 patients diagnosed with rheumatoid arthritis, aged 21-80 years, were enrolled. Demographic information and medical history were obtained and divided into two groups: Active disease (DAS-28 score&gt;3.2) and LDA/remission (DAS-28 score&lt;3.2). Clinical parameters of the DAS-28 score and CBC, including NLR, were assessed and recorded. Results: Out of 160 patients, there were 132(82.5%) females. The duration of disease was 8.4±6.8 years. Mean VAS score, tender joint count, swollen joint count, and DAS-28 score were 3.8±2.6, 4.2±4.1, 2.4±2.7 and 4.0±1.6 respectively. RA Factor was positive in 121(75.6%) and Anti-CCP antibody in 102(63.8%). Anaemia was found in 45(28.1%). Mean platelet and TLC were 357.1+99.3 ×109/L and 9.0+2.9 ×109/L respectively. On division into groups, the mean NLR in LDA/Remission-Group and Active Disease-Group were 2.5±1.4 and 3.9±2.1, respectively. High NLR was seen in 46 (57.5%) with Active Disease-Group compared with 13 (16.3%) in LDA/Remission-Group (p-value&lt;0.001). Conclusion: High NLR was more common in active RA than LDA/remission, and NLR is useful in indicating disease activity.

HYPOTHYROÏDIES AU SERVICE DE MEDECINE INTERNE/ENDOCRINOLOGIE-DIABETOLOGIE NUTRITION DU CENTRE HOSPITALIER NATIONAL DE PIKINE-SENEGAL : ETUDE RETROSPECTIVE DU 01JANVIER 2011 AU 30 JUIN 2019

SummaryIntroduction: Hypothyroidism is the most common thyroid dysfunction. It is important to determine the cause because some forms are reversible. The objective of our study was to establish the profile of hypothyroidism in our practice. Methods: this was a retrospective study during the period from January 1, 2011 to June 30, 2019 including all patients with hypothyroidism confirmed by hormonal assays and followed at the Internal Medicine, Endocrinology, Diabetology and Nutrition department of the National Hospital Center of Pikine. Results: we retained 292 files of patients monitored for hypothyroidism. The average age of the patients was 49.7 years. There were 276 women and 16 men. Hypothyroidism was peripheral in 289patients (98.97%) and central in 3 patients (1.03%). Concerning the aetiologies of peripheral hypothyroidism, it was a thyroidectomy in 70 patients (23.97%), radio-iodine therapy in 7 patients (2.39%), Hashimoto’s disease in 58 patients (19.86%), atrophic thyroiditis in 10 patients (3.42%) and a thyroid hormone synthesis disorder in 2 patients (0.68%). In 140 patients suffering from peripheral hypothyroidism (47.94%), no aetiology could be retained. Hashimoto’s disease was associated with other autoimmune diseases in 3 patients including myasthenia gravis, Addison’s disease and Goujerot syndrome. For the three patients presenting thyrotropic insufficiency, Sheehan syndrome was suggested in the face of a notion of haemorrhagic delivery, followed by an absence of milk flow. Pituitary magnetic resonance imaging showed an empty Sella turcica appearance. Conclusion: we can conclude that the aetiologies of hypothyroidism in our practice are dominated by thyroidectomy and Hashimoto’s disease. The aetiology was undetermined in 48% of patients due to insufficient exploration Keywords: Hypothyroidism, Hashimoto disease, Sheehan, Dakar, Senegal

Assessment of the Efficiency of Application of the National Protocol for Integrated Management of Severe Acute Malnutrition in National Hospital Center of Nouakchott -Mauritania

Assessment of the Efficiency of Application of the National Protocol for Integrated Management of Severe Acute Malnutrition in National Hospital Center of Nouakchott -Mauritania

The SOAP Feedback Training Program.

Accessible and efficient opportunities for health professional faculty to hone feedback skills are limited. In addition, feedback models to apply to the objective structured clinical examination (OSCE) setting are lacking. Annually, paediatric interns from Children's National Hospital and Walter Reed National Military Medical Center participate in an OSCE, which includes faculty observation and immediate feedback to trainees. In 2018, we incorporated the subjective, objective, assessment, plan (SOAP) Feedback Training Program during 20 min of the pre-OSCE faculty orientation. The SOAP Feedback Training Program introduced the SOAP feedback model (subjective, objective, assessment, plan), facilitated practice in pairs and distributed a cognitive aid referencing the model. We evaluated the quality of faculty feedback exchanges during the 2018 OSCE via retrospective video review using the Direct Observation of Clinical Skills Feedback Scale (DOCS-FBS). We compared the results to the 2015 initial evaluation and used focus groups to understand how and why faculty feedback changed. Comparison of the initial evaluation to the post-SOAP Feedback Training Program intervention data using a Wilcoxon signed rank test showed statistically significant improvement in six of eight feedback items on the DOCS-FBS. Causal coding of focus group transcripts revealed that the SOAP Feedback Training Program evoked affective responses, reinforced prior practice in feedback delivery, improved feedback organisation and increased feedback delivery preparation. The SOAP Feedback Training Program is an effective intervention to teach the SOAP feedback model and improve faculty feedback quality in an OSCE setting. It is efficient and low resource, facilitating its potential use in settings beyond the OSCE.

A cross-sectional analysis in order to validate the translation of FSFI-6 to Bahasa Indonesia

Background: Numerous tools have been developed to assess female sexual dysfunction. Several of them have also conducted validity tests. Female Sexual Function Index (FSFI) is one of these surveys that has been effectively translated into several different languages. The previous study on the translation and validation of the FSFI-6 questionnaire into Bahasa Indonesia used the original form (FSFI-19), which had many questions. Thus, this study was done to validate and translate a condensed version of the original questionnaire to make it more practicable for individuals to complete in a clinical context. Methods: FSFI-6 was translated into Bahasa Indonesia. Then the data were collected via questionnaires by 72 women in Rumah Sakit Cipto Mangunkusumo (RSCM or Mangunkusumo National Central General Hospital) during the data collection period (January 2018 until April 2018). The data obtained were processed for validity and reliability using the SPSS software program 20. The tests conducted on the data included a normality test, a validity test, descriptive analysis, and reliability testing. The r-value and the value of Cronbach’s Alpha were the parameters used to determine the validity and reliability of the questionnaire. Results: The r-value on each question in the translated FSFI-6 questionnaire was greater than 0.3, while the value of Cronbach's Alpha of the questionnaire FSFI-6 was greater than 0.6, equal to 0.831. Conclusions: The FSFI-6 questionnaire short version that has been translated into Bahasa Indonesia is valid and reliable.

Short-term Efficacy and Safety of Secukinumab in Pakistani Patients with Ankylosing Spondylitis and Psoriatic Arthritis

Objective: To determine the short-term efficacy and safety of Secukinumab in Pakistani patients with ankylosing spondylitis and psoriatic arthritis in regular clinical practice.&#x0D; Study Design: Case series.&#x0D; Place and Duration of Study: Department of Rheumatology, National Hospital and Medical Centre, Lahore Pakistan from Aug 2019 to Feb 2021.&#x0D; Methodology: Patients diagnosed with ankylosing spondylitis according to assessment of spondyloarthritis International Society criteria and psoriatic arthritis according to classification criteria for psoriatic arthritis (CASPAR), who were started on Secukinumab, were enrolled. Disease activity scores and adverse events were recorded in the 12th and 24th weeks. The primary outcomes were remission and low disease activity, and the secondary outcomes were the recording of Adverse events on each visit.&#x0D; Results: There were 42 patients registered. The mean duration of disease was 11.86±7.31 years for AS and 9.19±4.87 years for PsA patients. At 24 weeks of follow-up, 10% of patients discontinued treatment, 73.7% of AS patients, and 94.7% of PsA patients achieved complete remission or low disease activity. No significant AEs were noted at 24 weeks, except for upper respiratory tract infections. One patient developed a lower respiratory tract infection after 24 weeks of treatment, and one died during treatment (possible myocardial infarction).&#x0D; Conclusion: Secukinumab was effective and safe in patients with Ankylosing Spondylitis and Psoriatic Arthritis in this study,despite advanced disease with long disease duration.Keywords: Ankylosing spondylitis, Efficacy, Psoriatic arthritis, Safety, Secukinumab.

Short-Term Efficacy and Safety of Subcutaneous Tocilizumab in Rheumatoid Arthritis Patients in Pakistan: A Real-World Experience

Objective: To determine the real-world efficacy and safety of subcutaneous Tocilizumab in patients with rheumatoid arthritis.&#x0D; Study Design: Case series.&#x0D; Place and Duration of Study: Department of Rheumatology, National Hospital and Medical Centre, Lahore Pakistan, from Aug 2019 to Dec 2020.&#x0D; Methodology: In this study, 33 patients receiving subcutaneous Tocilizumab 162 mg every two weeks as monotherapy or with conventional synthetic disease modifying anti-rheumatic drugs were followed per standard study protocol. Increasing or decreasing the dosing interval was allowed according to disease activity at the discretion of the treating rheumatologist. The primary outcome was patients achieving Low Disease Activity as per Clinical Disease Activity Index (&gt;2.8-10.0) and Disease Activity Score-28(&gt;2.6-3.2). The secondary outcome was a clinically meaningful improvement in Disease Activity Score -28 (reduction of ≥1.2 units in Disease Activity Score-28 score). Adverse events were recorded at each follow-up visit.&#x0D; Results: Of the 33 patients, 25(75.8%) were biologics-naive, 9(27.2%) patients achieved the target of Low Disease Activity as per Clinical Disease Activity Index (2.9-10.0) and 8(24.2%) patients achieved Low Disease Activity as per Disease Activity Score-28(2.7-3.2). At six months, the proportion of patients achieving clinically meaningful improvement (decrease ≥1.2) in Disease Activity Score -28 was 13(54.2%). Overall, 14(42.4%) patients developed adverse events and 3(9.1%) patients discontinued Tocilizumab owing to adverse events.&#x0D; Conclusion: Tocilizumab has been seen to be an effective biologic in only one-third of patients, and it was tolerated in twothirds of the patients.Keywords: Conventional synthetic disease modifying anti-rheumatic drugs, Efficacy, Rheumatoid arthritis, Safety, Subcutaneous tocilizumab.

Joint Hypermobility and Musculoskeletal Pain in Paramedical Students and Staff at a Tertiary Care Hospital

Objective: to determine the frequency of joint hypermobility in paramedical students and staff at National Hospital Lahore.&#x0D; Study Design: Cross-sectional study.&#x0D; Place and Duration of Study: Department of Rheumatology, National Hospital and Medical Center, Lahore Pakistan, from Mar to Sep 2021. Methodology: Two hundred fifty paramedical students and staff of either gender, aged between 16 years to 35 years were enrolled. Localized Joint Hypermobility was defined as &lt;3 Score and generalized Joint Hypermobility were defined as &gt;4 scores on the Beighton Score Scale. Demographic information was obtained from each participant, and joint hypermobility was assessed by using the Beighton score.&#x0D; Results: Mean age of the study participnats was 26.6±4.6 years with 146(58.24%) females. Mean BMI was 23.9±4.0 kg/m2. Generalized Joint Hypermobility was seen in 51(20.4%), and 31(12.4%) had localized hypermobility. Out of 250 participants, 33 (13.2%) had musculoskeletal pain, while among 51 patients with generalized hypermobility, 12(23.5%) had musculoskeletal pain.&#x0D; Conclusion: One out of every five young healthy paramedics enrolled had generalized joint hypermobility. One-third of subjects had at least one clinically documented hypermobile joint. Almost every fourth person with generalized joint hypermobility has musculoskeletal pain compared to 1 in 10 persons without generalized hypermobility.&#x0D; Keywords: Beighton score scale, Generalized joint hypermobility, Localized joint hypermobility, Musculoskeletal pain.

Noninfectious Uveitis in Rheumatology: Patterns, Treatment, and Outcomes.

The present study aimed to determine the pattern and cause of noninfectious uveitisin rheumatology practice. The secondary objective was to identify the pattern of treatment and outcomes. This retrospective cross-sectional study was conducted in the Department of Rheumatology, National Hospital and Medical Centre, Lahore, Pakistan. After receiving consent, electronic medical records (EMRs) of all patients with a diagnosis of noninfectious uveitis (NIU) from November 2019 to January 2023 were reviewed,and a total of 52 patients labeled as having noninfectious uveitis were identified. The collected data included age at diagnosis, anatomical location of uveitis, associated systemic disease, used medications, and outcomes.All cases had been diagnosed and assessed mutually by a rheumatologist and an ophthalmologist using the International Uveitis Study Group classification system to classify the pattern of uveitis by location, clinical course, and laterality and rule out the possibility of other ophthalmologic diseases. Disease activity was defined using the Standardization of Uveitis Nomenclature (SUN) guidelines. Data was analyzed on SPSS Statistics version 23 (IBM Corp, Armonk, NY, USA). The mean age of the patients in this study was 36.02 ± 43.31 years, with31 (59.6%) male patients. Anterior uveitis was the most common type observed among the patients at 55.8%,panuveitis was found in 25%, intermediate uveitis and posterior uveitis were seen in 9.6% each. Based on laterality, unilateral eye involvement was identified in 53.8% of patients. Spondyloarthritis (SpA)and idiopathic uveitis were observedin 34.6% and 28.8%, respectively. In this study, 28 (54.9%) patients were on conventional disease-modifying antirheumatic drugs (cDMARDDs), and 23 (45.1%) were on biological DMARDs. In the biologics group, 82% of patients were in remission in comparison to 60% in the cDMARDs group. To the best of our knowledge, this is the first report onnoninfectious uveitis in the Pakistani population. The study concluded that anterior uveitis is the most common type of uveitis and is more common in males. Spondyloarthropathy is one of the most common underlying systemic diseases. Human leukocyte antigen (HLA)-B27is associated more with uveitis. Biologics are more effective than cDMARDs in controlling the disease.Collaborative work between different specialties resulted in early diagnosis of underlying systemic disease, better management plans, and disease outcomes. To obtain further details on noninfectiousuveitis, a population-based study is needed in Pakistan.

Modification of BACAP score as a predictor of pancreatic carcinoma resectability at Dr. Cipto Mangunkusumo National Center Hospital Jakarta

Link of Video Abstract: https://youtu.be/wBzC28ImZ7Q Background: Surgery remains the best choice curative treatment for pancreatic cancer. Therefore, it is crucial to establish accurate diagnosis from the beginning. BACAP score and CA 19-9 have been identified as good predictors of pancreatic cancer resectability, and their accuracy is expected to increase when combined. This study aimed to determine the outcomes produced by the combination of the BACAP score and CA 19-9 tumor marker. Methods: This was retrospective cross-sectional study involved pancreatic cancer patients who underwent surgery between January 2017 and April 2023. Logistic regression analysis was performed on all variables of the BACAP score and CA 19-9. The primary outcomes were demographic characteristics, predictive value of BACAP score, Modified BACAP score, and CA 19-9 Results: A total 87 patients were included. BACAP score yields a sensitivity of 50.0%, specificity of 100%, positive predictive value (PPV) of 100%, negative predictive value (NPV) of 73.8%, and accuracy of 75.9% (AUC 94.6%). While modified BACAP score yielded a sensitivity of 83.1%, specificity of 85.7%, PPV of 70.5%, NPV of 92.5%, and accuracy of 83.9% (AUC 89.4%). Conclusion: The combination of CA 19-9 and the BACAP score yields a modified score with better outcomes compared to the BACAP score alone in predicting the resectability of pancreatic carcinoma.