Associated Factors of Tophaceous Gout: A Study Involving 20 Primary Care Clinics in an Urbanized State in Malaysia

Objectives: Gout is a treatable disease. A complication of untreated or poorly-controlled gout is tophi formation. We conducted this study to investigate the associated factors of tophaceous gout among patients who attended 20 primary care clinics in Selangor, an urbanized state in Malaysia. Methods: We conducted a cross-sectional study from July to October 2019 that included all patients with gout who attended the clinics. Data on clinical demographics and laboratory results were collected. Comparison between tophaceous and non-tophaceous groups was performed using descriptive analysis. Results: A total of 421 patients with gout were involved in this study, 83 (19.7%) patients had visible tophi and were categorized into the tophaceous group, while the other 338 (80.3%) patients were categorized into the non-tophaceous group. The majority of patients were male with a mean age of 57.6±12.8 years. Three factors found to be significantly associated with tophaceous gout were age at symptom onset [tophaceous (45.6±13.3 years) vs. non-tophaceous (49.7±13.9 years), p =0.026], mean disease duration of gout [tophaceous (105.2±92.6 months) vs. non-tophaceous (77.6±88.6 months), p =0.013], and baseline serum uric acid level [tophaceous (622.3±129.1 µmol/L) vs. non-tophaceous (582.6±102.3 µmol/L), p =0.021]. Conclusions: Tophaceous gout is associated with longer disease duration, higher baseline serum uric acid level, and younger age at symptoms onset. Hence, early initiation of urate-lowering therapy with a treat-to-target approach is crucial to prevent tophi formation

Hoarseness of voice in a patient with mitral stenosis and Ortner's syndrome

Rheumatic mitral stenosis is prevalent in this part of the world and it gives rise to wide array of manifestations. However, hoarseness of voice secondary to recurrent laryngeal nerve paralysis (Ortner's syndrome) is an uncommon manifestation. This case illustrates an uncommon presentation in a common disease. A 29-yearold lady presented with a 2-year history of hoarseness of voice. Physical examination revealed a mid-diastolic murmur and left vocal cord paralysis. Echocardiography confirmed mitral stenosis with pulmonary hypertension. She underwent percutaneous mitral balloon valvotomy in 1991 with return of normal speech after a few months. The recurrent laryngeal nerve paralysis is mainly due to the compression by an enlarged pulmonary artery as initially thought. This complication is rarely seen nowadays due to greater awareness of the disease and earlier intervention. With the advent of percutaneous transvenous mitral valvotomy in the nineties, effective non-surgical intervention is plausible

Shrinking Lung Syndrome – A rare cause of recurrent dyspnoea in SLE / Hazlyna Baharuddin … [et al.]

Here we present a 24-year-old lady with systemic lupus erythematosus (SLE) whom we diagnosed with shrinking lung syndrome (SLS), a rare manifestation of SLE. The initial SLE manifestation was alopecia, thrombocytopenia, serositis and vasculitis. Anti-nuclear antibody (ANA), anti-double stranded DNA (dsDNA) antibody, anti-ribonucleic (RNP) and anti-Ro antibody were positive. A year after diagnosis, she started to develop intermittent dyspnea and was hospitalised on three occasions. Lung examinations revealed reduced breath sounds at both bases and dullness at the right base. Multiple chest radiographs showed bilateral raised hemi-diaphragms. Other investigations including CT pulmonary angiogram, high resolution CT of the thorax, ventilation-perfusion scan and echocardiogram were not significant. On the third hospital admission, we noticed bilateral small lung volumes in the previous high resolution CT scan. Inspiratory and expiratory chest radiographs were performed and showed minimal change in lung volumes and a diagnosis of shrinking lung syndrome (SLS) was made. Her SLE remained active with lupus nephritis despite multiple immunosuppression and she passed away two years later due to sepsis with multi-organ failure

Projecting direct medical costs and productivity benefits of improving access to advanced therapy for rheumatoid arthritis: a projection modelling study

ABSTRACTIntroduction: To ensure the sustainability of the AT access improvement, it is important that health system stakeholders have timely, analyzed information accessible for reference and decision-making support. In this study, we projected the direct costs required as well as the expected direct medical cost-offset and productivity benefits resulting from improving the disease control. Methods: We implemented a deterministic, prevalence-based mathematical model to project the annual cost of rheumatoid arthritis (RA) management within the public healthcare system in Malaysia. We also calculated the annual productivity loss due to uncontrolled RA in monetary value. Using the projection model, we compared the projected costs of the status quo scenario vs. several scenarios of improved advanced therapy (AT) access over a 5-year period. Results: We projected that between 10,765 and 11,024 RA patients in Malaysia over the period of 2020–2024 will need access to AT due to treatment failure with conventional synthetic disease modifying antirheumatic drugs (DMARDs). The projected net total medical cost under the status quo scenario were 163.5 million annually on average (approximately MYR 15,000 per patient per year). Cost related to health service utilization represented the heaviest component, amounting to 71.8% followed by drug cost (24.7%). Under the access improvement scenarios, drug cost constituted a higher proportion of the total medical, ranging from 25.6% to 30.4%. In contrast, the cost of health service utilization shown a reverse pattern (reducing to between 66.3% and 70.1%). Productivity costs were also expected to reduce as AT access improved leading to better outcomes. Treatment shifts to targeted synthetic DMARDs in anticipation of price adjustment appeared to have a cost saving advantage to the health system if all other parameters remain unchanged. Discussion: Improving AT access for RA patients towards the aspirational target appeared to be feasible given the current health budget in Malaysia. Broader socio-economic consequences of productivity and income loss should be included as an important part of the policy consideration. The financial implication of different AT utilization mixes and the anticipated price adjustment will likely result in some cost saving to the health system

Preliminary report: April 2009 - August 2010 National Inflammatory Arthritis Registry (NIAR)

Rheumatoid Arthritis (RA) is the most common form of infl ammatory arthritis. It is estimated to affect about 1% of the population. Of unknown aetiology, it typically affects many joints, causing acute inflammation, in most cases leading to joint erosions and joint damage (1). The NIAR, initiated in 2008, was set up with the aim of obtaining information about patients with Rheumatoid Arthritis. Information about patients with the other inflammatory arthritides will be collected in the future

Does HLA-B*27 subtypes and ethnicity matter in Ankylosing Spondylitis?

Ankylosing Spondylitis (AS) is a chronic, progressive inflammatory disorder that results in ankylosis of the vertebral column and sacroiliac joints. More than 30% of patients with AS carry a heavy burden of disease and have a decreased quality of life. The HLA-B*27 is a well known genetic risk variant for ankylosing spondylitis (AS). However, the degree of association varies for different subtypes and depends on ethnicity. Malaysia is a multi-ethnic country comprises Malays as the largest ethnic group, followed by Chinese, Indians and mixed-ethnicities