Addressing the unmet needs in medical training for alarmingly widening demand–supply gap in rheumatic diseases: A tale of two countries Shivani Garg, Ram Raj Singh Indian Journal of Rheumatology 2019 14(3):167-171

Rheumatology teaching and training in India – From procrastination to implementation! Rohini Handa Indian Journal of Rheumatology 2019 14(3):172-173

Critical workforce challenges and the impact of rheumatic and musculoskeletal diseases: Urgent call for action Sharad Lakhanpal, Akshai Lakhanpal Indian Journal of Rheumatology 2019 14(3):174-176

CAR T-cells to drive away autoimmunity in lupus Sakir Ahmed Indian Journal of Rheumatology 2019 14(3):177-179

Platelet activation markers in juvenile idiopathic arthritis Pandiarajan Vignesh, Surjit Singh Indian Journal of Rheumatology 2019 14(3):180-181

Platelet microparticles level in juvenile idiopathic arthritis: A pediatric population-based cross-sectional study in a tertiary care center Naresh Kumar, K Anu Punnen, Sukesh Chandran Nair, Visalakshi Jayaseelan, T Sathish Kumar Indian Journal of Rheumatology 2019 14(3):182-186 Background: Platelet-derived microparticles (PMPs) are small vesicles that are released from the plasma membrane upon platelet activation, which are then involved in haemostasis, vascular health, and have recently been shown to be intimately involved in immune responses. Aims and Objectives: We aimed to evaluate the level of plasma Platelet-derived micro particles in children with JIA and to assess the relationship between PMP levels and disease activity in JIA. Materials and Methods: Children with JIA who fulfilled the International League of Associations for Rheumatology (ILAR) classification criteria for juvenile idiopathic arthritis were included. They were categorised into active disease group and inactive disease as assessed by Wallace criteria. Samples were run in Navios flow cytometer (Beckman Coulter). Platelet microparticles were identified by MPs positive for both Annexin V and CD41 antibodies. Results: Out of 26 children with JIA, 12 had active disease group and 14 had inactive disease as assessed by Wallace criteria. Mean PMP level was 83507 cells/μl and 34904 cells/μl in active and inactive disease respectively (P = 0.06). There was no significant correlation between PMP and CRP levels (P = 0.75 and r = 0 .102) or PMP and ESR levels (P = 0.56 and r = -0.186) in JIA children with active disease. Conclusion: PMP levels were significantly elevated in disease activity of JIA and could represent a new biomarker reflecting the state of cell activation in JIA. PMP role in the inflammatory processes needs to be further elucidated.

Conventional synthetic disease-modifying antirheumatic drug use by race/ethnicity and factors associated with initiating biologics in Malaysian patients with rheumatoid arthritis Suad Mohammed, Lydia Say Lee Pok, Ying Chew Tee, Fariz Yahya Indian Journal of Rheumatology 2019 14(3):187-193 Aims: The aim of the study was to evaluate the treatment patterns of conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), drug survival, and the factors in initiating biologic DMARDs based on race and ethnicity in rheumatoid arthritis (RA) patients. Materials and Methods: Data on RA patients, including race/ethnicity, who were attending University Malaya Medical Centre, Kuala Lumpur, Malaysia, and started on csDMARDs between January 2006 and December 2016, were collected retrospectively from the review of patients' medical records. Factors in initiating biologic DMARDs were identified. Results: A total of 369 RA patients received at least one csDMARD; 325 (88.1%) were female, and 271 (73.4%) were seropositive. Three main races were identified: Malay (28.7%), Chinese (33.1%), Indian (36.3%), and others (1.9%). Malay race patients were initiated on a csDMARD at a younger age (48.6 years, standard deviation [SD]: 12.4) due to younger age at onset compared to other races (P < 0.001). Overall, methotrexate was the most common csDMARD used, and 39 (11%) patients were on triple-combination therapy. Disease activity score 28–erythrocyte sedimentation rate improved at 3 months post-csDMARD treatment for all races (P < 0.001). Twenty-six (7%) patients received biologics, with a mean age at initiating first biologic of 49.8 (SD: 18.3) years. There were no significant differences in age at initiating first biologic between the race groups (P = 0.83). In fully adjusted models, race was not a factor in initiating biologics. Conclusion: CsDMARDs in RA were required at a younger age for a certain race due to younger age at onset. However, race does not predict the initiation of biologics and no significant difference in the use of combination csDMARDs between races.

The impact of training through the telegram's virtual network on promoting women's knowledge and perceptions in preventing osteoporosis Zohreh Karimiankakolaki, Maryam Khadibi, Sakineh Gerayllo, Bahareh Motaghi, Fatemeh Heidari Indian Journal of Rheumatology 2019 14(3):194-199 Introduction: Osteoporosis is the most common metabolic bone disease. Therefore, the present study was conducted to determine the effect of training through the Telegram network on increasing the knowledge and perceptions of women in preventing osteoporosis. Methods: This study was an educational intervention, pretest and posttest type with randomized control group. Sixty women who referred to the marginal health centers of Yazd were randomly selected and assigned to intervention and control groups. After completing the questionnaires, a package of educational messages was sent to the intervention group through the Telegram group. A month later, the questionnaires were completed again, and the data were analyzed by SPSS 18 software and Wilcoxon and Mann–Whitney test. Results: The mean age of participants in intervention and control groups was 30.46 ± 5.71 and 29.93 ± 5.02, respectively. The findings showed that the median score of knowledge (3 scores, P= 0.001) and subscales of women's beliefs (perceived sensitivity [1 score, P= 0.046], perceived severity [1 score, P= 0.001], perceived benefits [1.5 scores, P= 0.031], and cues to action [6 scores, P= 0.000]) increased significantly after intervention in the intervention group. The median score of knowledge was significantly higher than the control group (4 scores, P= 0.000). Conclusions: Use of Telegram training and virtual training spaces is effective in promoting women's knowledge and perceptions in the prevention of osteoporosis and contributes to the advancement of women's health beliefs. Therefore, the adoption of this type of training is recommended to overcome the limitations of traditional education in the prevention of osteoporosis.

A study of serum YKL-40 and its correlation with traditional biomarkers in rheumatoid arthritis patients Vinod Narayan, Vasanthi Pallinti, Nalini Ganesan Indian Journal of Rheumatology 2019 14(3):200-205 Background: This study was aimed to measure the serum levels of YKL-40 among early and late rheumatoid arthritis (RA) patients along with other disease activity measures in RA patients. Materials and Methods: It was a cross-sectional study involving 152 RA patients based on the 1987 American College of Rheumatology criteria for the diagnosis of RA and 68 age- and sex-matched healthy controls. The patient group was further subdivided into 75 early (<2 years disease duration) and 77 late (>2 years) RA patients based on the duration of the disease. Clinical examination was performed on RA patients, and traditional markers to measure the disease activity such as Disease Activity Score (DAS)-28, Visual Analog Score (VAS), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), anti-cyclic citrullinated peptide (CCP), and rheumatoid factor (RF) were assessed. Serum YKL-40 level was measured using ELISA method. All the values were expressed as median (25th–75th percentile). Results: In our study, there was a significant increase in serum YKL-40 level in RA patients (200.8 [141.24–282.7] ng/ml) compared to healthy controls (82.2 [49.01–123.78] ng/ml) with P < 0.001. There was no significant difference in serum YKL-40 levels among early and late RA patients. The traditional inflammatory markers such as ESR, CRP, and measures of disease activity such as DAS-28 and VAS were significantly increased in late RA patients than early RA (P < 0.001). Serum YKL-40 levels were not correlated with disease activity measures such as DAS-28, VAS, CRP, and ESR in RA patients. Conclusion: Serum YKL-40 level was significantly higher in RA. However there was no difference between early and late RA. It does not correlate with measures of disease activity.

Correlation of disease activity score using erythrocyte sedimentation rate and C-reactive protein with clinical disease activity index in rheumatoid arthritis patients Viraj Panchal, Puja Srivastava, Dhaiwat Shukla, Devang Rana, Supriya Malhotra, Sapan Pandya Indian Journal of Rheumatology 2019 14(3):206-210 Background: Most patients coming to government hospital are from lower socioeconomic class and do not always get investigations done like ESR or CRP. A purely clinical index like CDAI would be a useful measure in such resource poor settings. Also there is scarce data on patterns of DMARD use from our country. Objectives: To compare Disease Activity Score 28 using erythrocyte sedimentation rate (DAS28-ESR) and Disease Activity Score 28 using C-reactive protein (DAS28-CRP) with CDAI (Clinical Disease activity index) as measures of disease activity of RA and to analyze prescription patterns in RA patients. Methods: Ours was a cross-sectional study of 4 months' duration. DAS28-ESR, DAS28-CRP and CDAI were calculated. The details of DMARDs used were recorded in proformas. Correlation was done using Spearman's Correlation Coefficient Test. To assess agreement between scores Cohen's kappa value was also evaluated. P value obtained <0.05 was considered significant. Results: We evaluated a total of 104 patients most of them being females with a mean age of 45 years. The mean DAS28-ESR was 4.59 ± 1.36, mean DAS28-CRP was 3.86 ± 1.25 and mean CDAI was 16.9 ± 9.26 . The correlation coefficients of DAS28-ESR with DAS28-CRP was 0.894, DAS28-ESR with CDAI was 0.886 and DAS28-CRP with CDAI was 0.910. Methotrexate was the most prescribed drug as a mono therapy or in a combination with Hydroxychloroquine followed by Leflunomide, Sulfasalazine, and Prednisolone in that order. Conclusion: The CDAI can substitute for SDAI or DAS 28 ESR/CRP and this would be very useful in a resource poor setting. Methotrexate was the most prescribed drug in our set up as mono or combination therapy.