The Emirates Mars Mission

The Emirates Mars Mission (EMM) was launched to Mars in the summer of 2020, and is the first interplanetary spacecraft mission undertaken by the United Arab Emirates (UAE). The mission has multiple programmatic and scientific objectives, including the return of scientifically useful information about Mars. Three science instruments on the mission's Hope Probe will make global remote sensing measurements of the Martian atmosphere from a large low-inclination orbit that will advance our understanding of atmospheric variability on daily and seasonal timescales, as well as vertical atmospheric transport and escape. The mission was conceived and developed rapidly starting in 2014, and had aggressive schedule and cost constraints that drove the design and implementation of a new spacecraft bus. A team of Emirati and American engineers worked across two continents to complete a fully functional and tested spacecraft and bring it to the launchpad in the middle of a global pandemic. EMM is being operated from the UAE and the United States (U.S.), and will make its data freely available.

Peripheral Perfusion Index as a Marker of Sepsis in Preterm Neonates

BACKGROUND

Neonatal sepsis is a major contributor to neonatal mortality in India. Blood culture, the gold standard for the diagnosis of sepsis takes 48-72 h while the serological markers have suboptimal diagnostic test characteristics. Perfusion index (PI) is a real time, non-invasive marker that can detect microcirculatory changes before other clinical manifestation of sepsis.

OBJECTIVE

To determine the diagnostic accuracy of PI in detecting hospital-acquired sepsis before overt clinical manifestations.

STUDY DESIGN

A prospective observational study conducted in the Neonatal Intensive Care Unit (NICU) of a tertiary care hospital.

PARTICIPANTS

Preterm neonates admitted to NICU.

METHODS

PI was continuously monitored in all enrolled neonates. Clinical sepsis was defined using the NeonatalKrankenhaus-Infektions-Surveillance-System (NeoKISS). The time of fall of PI below 0.88 and time of clinical sepsis as per NeoKISS were noted and the difference was calculated.

RESULTS

Among 65 preterm neonates (gestational age: 31.5 ± 2.6 weeks, birth weight: 1350, IQR 1100-1700 g), a total of 86 events of suspected sepsis were noted, of which 69 were sepsis screen positive. Fifteen events were associated with culture positive sepsis. PI yielded a sensitivity of 89.47% (95% CI 78.48-96.04%), specificity of 56% (95% CI 34.93-75.60%), positive predictive value of 82.26% (95% CI 74.70-87.92%) and negative predictive value of 70% (95% CI 50.36-84.29%) in detection of hospital-acquired sepsis.

CONCLUSION

PI might serve as an early, non-invasive marker of hospital-acquired sepsis in preterm neonates.

Articular spacers in two-stage revision arthroplasty for prosthetic joint infection of the hip and the knee

Use of articular antibiotic-eluting cement spacers during two-stage revision arthroplasty for prosthetic joint infection (PJI) is a long-established and proven adjunctive technique during first-stage surgery. Articular spacers come in many forms, either static or dynamic. The authors present an instructional review of current evidence regarding their use.

A total of 45 studies (for spacer use in PJI involving either hip or knee) were analysed for data regarding eradication rate, functional outcomes, mechanical complications and the impact on second-stage surgery. A large number of case series and retrospective cohort studies were retrieved, with only a small number of prospective studies (2).

High levels of infection eradication were commonly reported (>80%). Outcome scores were commonly reported as indicating good-to-excellent function and pain levels. Second-stage procedures were often not required when dynamic spacers were used. Static spacers were associated with more mechanical complications in both the hip and the knee. In the hip, dynamic spacers were more commonly associated with instability compared to static spacers. Consideration should be given to the use of dual-mobility or constrained definitive acetabular components in these cases at second-stage surgery.

The use of antibiotic-eluting polymethylmethacrylate articular spacers in two-stage revision for PJI of hip and knee arthroplasty achieves a high rate of infection eradication. Dynamic spacers may confer a variety of benefits compared to static spacers, with a similar rate of infection eradication.

Comparison of Hematocrit Change in Preterm Neonates with Birth Weight Based Versus Formula Based Packed Red Blood Cell Transfusion: A Randomized Control Trial

Conventionally the packed red blood cell (PRBC) transfusion volume given to neonates is 10 ml/kg to 20 ml/kg. The weight-based formulae underestimate the volume of PRBC required to achieve a target hematocrit (Hct) in preterm neonates. The study was done to compare the rise in Hct after transfusing PRBC volume calculated either based on body weight or using formula considering Hct of blood bag and Hct of preterm neonates. This prospective study included a total of 68 preterm neonates requiring transfusion for the first time having ≤ 34 weeks of gestational age. Neonates were randomized using block randomization, to receive 15 ml/kg of PRBC transfusion (group A) or transfusion based on the formula (group B). The primary outcome of interest was post-transfusion rise in hematocrit. The secondary outcome was the effect of transfusion on neonatal morbidities in terms of retinopathy of prematurity, bronchopulmonary dysplasia, intraventricular hemorrhage, necrotizing enterocolitis, and death. Baseline variables (birth weight, gestation age, APGAR score and score of neonatal acute physiology) pre-transfusion hemodynamics and hematocrit of the bag were comparable in both groups. The mean volume of PRBC in group A was 18.8 ± 4.9 ml, whereas in group B it was 29.6 ± 7.3 ml, p = 0.0001. Group B transfusions had a statistically significant change in 24 h post-transfusion hematocrit. Secondary outcomes were comparable in two groups. Post transfusion rise in Hct of the patient in group B was significant as compared to group A. The study needed huge sample size to establish a difference in the number of re-transfusions required across two groups. The trial was registered under the clinical trial registry of India (CTRI/2018/01/011,063).

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s12288-021-01420-1.

Assessment of prescribing pattern of drugs and completeness of prescriptions as per the World Health Organization prescribing indicators in various Indian tertiary care centers: A multicentric study by Rational Use of Medicines Centers-Indian Council of Medical Research network under National Virtual Centre Clinical Pharmacology activity

OBJECTIVE

The rational use of medicines as per the World Health Organization (WHO) should be practiced globally. However, data regarding the completeness of the prescriptions and their rational use is lacking from developing countries like India. Thus, the aim of this study was to assess the prescribing patterns of drugs and completeness of prescriptions as per WHO core drug use and complementary indicators to provide real-life examples for the Indian Council of Medical Research (ICMR) online prescribing skill course for medical graduates.

METHODS

Prescriptions of the patients, fulfilling inclusion criteria, attending Outpatient Departments of various specialties of tertiary care hospitals, were collected by thirteen ICMR Rational use of medicines centers located in tertiary care hospitals, throughout India. Prescriptions were evaluated for rational use of medicines according to the WHO guidelines and for appropriateness as per standard treatment guidelines using a common protocol approved by local Ethics committees.

RESULTS

Among 4838 prescriptions, an average of about three drugs (3.34) was prescribed to the patients per prescription. Polypharmacy was noted in 83.05% of prescriptions. Generic drugs were prescribed in 47.58% of the prescriptions. Further, antimicrobials were prescribed in 17.63% of the prescriptions and only 4.98% of prescriptions were with injectables. During the prescription evaluation, 38.65% of the prescriptions were incomplete due to multiple omissions such as dose, duration, and formulation.

CONCLUSION

Most of the parameters in the present study were out of the range of WHO-recommended prescribing indicators. Therefore, effective intervention program, like training, for the promotion of rational drug use practice was recommended to improve the prescribing pattern of drugs and the quality of prescriptions all over the country.

Epidemiological and diagnostic aspects of feline leishmaniasis with emphasis on Brazil: a narrative review

The leishmaniases are a group of diseases caused by the protozoan parasite belonging to the genus Leishmania. In the New World, although dogs are considered the main parasite reservoir, in the last two decades, several studies have confirmed the role of cats (Felis catus) in the epidemiology of the disease and feline leishmaniasis (FeL) is now considered to be an emerging disease. The present review summarizes the current knowledge about FeL, focusing on important immunopathological aspects, epidemiology, and diagnostic methods applied for felines in Brazil. Cats are infected with the same species of Leishmania found in dogs (i.e., Leishmania infantum). Like dogs, skin lesions are the most common in cats with clinical FeL, mainly affecting the cephalic region and less frequently the legs which may be accompanied by generalized signs or visceral involvement. Information on the immune response of cats to Leishmania infection is scarce; however, efficient infection control is seen in most cases. For diagnosis, generally, the same methods as those in dogs are used, mainly serological tools. But there is a lack of studies focusing the performance of these methods for diagnosing FeL. The estimated overall prevalence of FeL in Brazil is 8%, with L. infantum being the most prevalent species. However, infections with Leishmania braziliensis and Leishmania amazonensis have also been reported. In conclusion, although there has been an increase in the publication related to FeL in Brazil in recent years, there is a lack of research relating immune response and diagnosis of these animals. Cats have been shown to be competent hosts for Leishmania parasites, and their role in the epidemiology of the disease cannot be underestimated, especially in areas of Brazil where the disease is historically endemic.

High spatial-density, cladding-pumped 6-mode 7-core fiber amplifier for C-band operation

We present a C-band 6-mode 7-core fiber amplifier in an all-fiberized cladding-pumped configuration for space division multiplexed transmission supporting a record 42 spatial channels. With optimized fiber components (e.g. passively cooled pump laser diode, pump coupler, pump stripper), high power multimode pump light is coupled to the active fiber without any noticeable thermal degradation and an average gain of 18 dB and noise figure of 5.4 dB are obtained with an average differential modal gain of 3.4 dB.

Multicentric Hospital-Based Surveillance of Pertussis Amongst Infants Admitted in Tertiary Care Facilities in India

OBJECTIVE

To estimate the disease and economic burden of pertussis amongst hospitalised infants in India.

DESIGN

Multicentric hospital-based surveillance study.

PARTICIPANTS

Hospitalised infants with clinical suspicion of pertussis based on predefined criteria.

OUTCOME MEASURES

Proportion of infants with laboratory-confirmed pertussis, economic burden of pertussis amongst hospitalised infants.

RESULTS

693 clinically suspected infants were recruited of which 32 (4.62%) infants had laboratory-confirmed pertussis. Progressive cough with post-tussive emesis (50%) and pneumonia (34%) were the common clinical presentations; apnea in young infants was significantly associated with pertussis. Infants with pertussis were more likely to be younger (median age 102.5 days vs.157 days) and born preterm (42.9% vs 24.5%). Almost 30% infants with pertussis had not received vaccine for pertussis with 50% of these infants aged less than 2 months. Pertussis was associated with higher costs of hospitalisation, pharmacy and loss of working days by caregivers as compared to non-pertussis cases.

CONCLUSIONS

Younger infants, those born preterm and those inadequately immunised against pertussis are at higher risk of pertussis infection. Timely childhood immunisation and introduction of maternal immunisation for pertussis can help in reducing the disease burden.

AB0276 HOW FAST CAN METHOTREXATE BE ESCALATED IN RHEUMATOID ARTHRITIS? A MULTICENTRE, PARALLEL-GROUP RANDOMIZED CONTROLLED TRIAL (MEIRA)

Background:

Literature regarding the optimal dose escalation strategy of methotrexate (MTX) in RA is scant and ambiguous (1). Concerns regarding the safety of rapid escalation may lead to delayed attainment of the optimal dose and treatment target.

Objectives:

To compare the efficacy, safety and tolerability of fast versus usual dose escalation of oral MTX in RA.

Methods:

This multicenter, open-label (assessor blinded) RCT included patients with active RA (SJC≥2 and TJC≥4) aged 18-55 years, not on DMARDs (except HCQ and/or low-dose prednisolone) and with disease duration <5 years. Patients were randomized 1:1 into two groups with the same starting dose of oral MTX (15 mg/week), but escalated either by 5 mg every 2 weeks (fast escalation group) or 5 mg every 4 weeks (usual escalation group), till a maximum of 25 mg/wk. Primary outcome was proportion of EULAR good responders at 16 weeks. Secondary outcomes were change in DAS28-3 and EULAR responders (good or moderate) at 8 and 16 weeks, change in Indian HAQ at 16 weeks, and symptomatic (questionnaire based) and laboratory adverse effects over 16 weeks. RBC MTX polyglutamate-3 levels were measured using HPLC in both groups. There was an open-label extension phase till 24 weeks (use of other DMARDs was permitted beyond 16 weeks if target was not met), and DAS28-3 at 24 weeks was compared.

Trial Reg: CTRI/2018/12/016549

Results:

178 patients (mean age 39.8 (8.6) years, 84% females) with mean disease duration of 1.9 (1.4) years were randomized (89 in each group). Mean DAS28ESR-3 and DAS28CRP-3 at enrollment were 6.3 (0.9) and 5.4 (1.1). At 16 weeks, there was no significant difference in good EULAR response by DAS28ESR-3 (5.6, 7.9%, p=0.9) or DAS28CRP-3 (28.1, 22.5%, p=0.8) between the two groups (Figure 1). The change in DAS28-ESR-3 at 8, 16 and 24 weeks (or by DASCRP-3, not shown) and improvement in HAQ at 16 weeks were also not significantly different (Table 1). Notably, there was no significant difference in symptomatic GI or CNS adverse effects, incidence of cytopenia, transaminitis or rates of drug discontinuation. RBC MTX polyglutamate-3 levels at 8 and 16 weeks were also similar (Table 1).

Table 1.

Key secondary efficacy and safety outcomes

ParameterUsualFastp-valueEfficacyDelta DAS28-ESR-3 (Mean±SD) -8 wk  -ITT (n=178)-0.9 ± 1.0-0.8 ± 0.90.5  -PP (n=139)-1.2 ± 1.0-1.1 ± 1.00.5 -16 wk  -ITT-1.3 ± 1.1-1.3 ± 1.00.9  -PP-1.6 ± 1.1-1.6 ± 0.91 -24 wk  -ITT-1.6 ± 1.3-1.5 ± 1.10.3  -PP-2.1 ± 1.2-1.8 ± 1.10.14Delta Indian HAQ (16 wk)-0.7 ± 0.6-0.8 ± 0.60.2Adverse effectsSerious AE00-Death00-Symptomatic AE ever* n (%)Vomiting7 (8)7 (8)1Nausea22 (26)26 (30)0.5Stomach ache16 (19)17 (20)0.9Loss of appetite/bad taste21 (25)27 (31)0.3Lethargy20 (24)21 (25)1Dizziness19 (23)16 (19)0.5Irritability/anxiety14 (16)14 (16)1Laboratory AE ever* [n/N times done (%)]Transaminitis episodes (>40IU/L)52/224 (23)52/219 (24)0.9  -Significant (>80 IU/L)5/224 (2)8/219 (4)0.4Thrombocytopenia episodes (<150000/uL)10/224 (5)13/218 (6)0.5 -Significant (<100000/uL)2/224 (1)2/218 (1)1Leucopenia episodes (<4000/uL)2/224 (1)3/220 (1.5)0.8 -Significant (<3500/uL)1/224 (0.5)2/220 (1)0.8Methotrexate levelsMTX-polyglutamate-3 (nmol/L)-8 wk25.8 ± 10.526.9 ± 13.60.6-16 wk40.7 ± 20.940.1 ± 23.40.9

*Ever=any time during the study

ITT= intention-to-treat, PP=per-protocol, AE=adverse effect

Figure 1.

EULAR response and change in DAS28ESR-3 over time

Conclusion:

A faster escalation of MTX (5 mg every 2 weeks) reaching 25 mg/week by 4 weeks did not have a significantly higher rate of adverse effects (symptomatic or laboratory) compared to an escalation by 5 mg every 4 weeks. Although not more efficacious, it may shorten the time to recognize MTX failure, and optimize treat-to-target.

References:

[1]Visser K, Katchamart W, Loza E, et al. Multinational evidence-based recommendations for the use of methotrexate in rheumatic disorders with a focus on RA: integrating systematic literature research and expert opinion of a broad international panel of rheumatologists in the 3E Initiative. Ann Rheum Dis. 2009;68(7):1086–93

Disclosure of Interests:

None declared

POS0679 A NEW QUESTIONNAIRE AND SCORE (MISA) FOR ASSESSING METHOTREXATE INTOLERANCE IN RHEUMATOID ARTHRITIS

Background:

Methotrexate (MTX) intolerance refers to unpleasant symptoms that accompany use of MTX and may lead to its discontinuation. However, it lacks a validated score in RA patients; with the only option being to use the MISS score which was validated for use in children and not adults.

Objectives:

To develop and validate a questionnaire and score (s) for measuring MTX intolerance and its severity in rheumatoid arthritis.

Methods:

A 10-item questionnaire called ‘Methotrexate Intolerance and Severity assessment in Adults’ (MISA) was validated in 105 RA patients. A score was calculated by adding the scores of first 7 questions (0 to 3 based on severity on symptoms), to last 3 questions (0 or 1); it ranged from 0 to 24 (MISA score) and was assessed for correctly classifying MTX intolerance (compared to an interview) by ROC analysis. Its area-under-curve (AUC) was compared with ‘Methotrexate Intolerance Severity Score’ (MISS), developed for children. Subsequently, it was administered to 414 RA patients to assess the prevalence and associations of MTX intolerance. In addition, the MISA cross-products score, that was calculated by adding the cross-products (severity (1 to 3) x duration per week (0.5 to 7 days)) of symptoms, was compared to MISA and MISS for assessing severity of intolerance.

Results:

In the initial phase, 105 RA patients on MTX≥6 months were included, a majority were female (87%), mean age was 51 (13.4) years and methotrexate dose was 18.8±6 mg/week. Thirty-five (33%) were found to be intolerant to MTX based on interview. MISA score had a good predictive ability (AUC of 0.904), to correctly classify MTX intolerance, and was better than MISS score (AUC of 0.823) (Figure 1A). The optimal cut-off for MISA was ≥1, with a sensitivity and specificity of 91.4% and 84.3%. Using the MISA score (≥1), 38.4% of 414 RA patients were found to have MTX intolerance: with nausea, lethargy and irritability being common symptoms. (Figure 1B, C) On multivariable analysis, age (OR 0.972) and BMI (OR 1.061) were significant predictors of MTX intolerance. (Table 1) On assessing for severity of intolerance, MISA cross product score performed the best, with an area-under-curve of 0.899 (95% CI 0.831-0.966), being higher than AUC for MISS and MISA score which were 0.847 (95% CI 0.768-0.927) and 0.837 (95% CI 0.754-0.920).

Conclusion:

MISA is the first validated questionnaire for assessing methotrexate intolerance in rheumatoid arthritis, with the MISA score having a good accuracy (at cut-off ≥1), to detect MTX intolerance. Methotrexate intolerance was present in more than one-third of RA patients, with nausea, lethargy and irritability being most common.

Table 1.

Baseline characteristics of 414 RA patients.

VariableAll(n=414)Tolerant(n=255)Intolerant(n=159)p-valuetol. vs ntol.P-valuemultivariablemodelFemales, n (%)370 (89)231 (91)139 (87)0.31Age, yrs, mean (SD)50 (12.5)51.2 (12.6)48.2 (12.2)0.016*0.008**Duration of RA, yrs, mean (SD)10.0 (7.0)10.8 (7.4)9.6 (6.3)0.168BMI, Kg/m2a, mean (SD)24.0 (4.9)23.6 (4.9)24.6 (4.7)0.1070.03*RF positiveb, n (%)300 (73)191 (82)109 (78)0.29CDAI, mean (±SD)14.0 (11.8)14 (12.1)14.1 (11.4)0.69Dose of MTX, mg/wk, mean (SD)18.6 (5.6)18.6 (5.5)18.7 (5.8)0.83Injectable MTX, n (%)47 (11)25 (10)22 (14)0.21Use of FA, n (%)395 (95)241 (95)154 (97)0.27Use of other DMARD, n (%)272 (66)160 (62)112 (70)0.11HCQ n (%)209 (51)123 (48)86 (54)0.25Prednisolone n (%)156 (38)87 (34)69 (43)0.0580.21Using antiemetics, n (%)12 (3)1 (0.5)11 (7)<0.001

a Available for 262 patients bAvailable for 372 patients

Figure 1.

Figure showing the ROC curve for MISA and MISS questionnaires for MTX intolerance (A), Bar diagram showing the prevalence of various symptoms of intolerance in 414 RA patients (B), and Box-and-whiskers plot showing the duration of unpleasant symptoms (C).

Disclosure of Interests:

None declared

Use of an online screening algorithm - Weight, Insulin-derived growth factor 1, Neonatal Retinopathy of Prematurity (WINROP) for predicting retinopathy of prematurity in Indian preterm babies

Purpose:

Inopathy of prematurity (WINROP) Weight, insulin-derived growth factor 1, neonatal ROP algorithm is an online tool that has been validated as a predictor of retinopathy of prematurity (ROP) in various countries. The current study was designed to evaluate the predictive ability of WINROP algorithm (http://winrop.com) using postnatal weight gain in detecting Type 1 ROP in Indian babies.

Methods:

Prospective single centre observational study of 153 consecutive preterm babies who were eligible for screening for ROP as per the standard guidelines. Sixteen babies were excluded from the study because of various reasons. Thirty-five babies had gestational age ≥32 weeks and were ineligible for WINROP algorithm. Online WINROP algorithm was used for 102 babies with gestation at birth less than 32 weeks. The alarms triggered by WINROP were documented.

Results:

Laser treatment was done in 30 babies who developed Type 1 ROP. Of these, WINROP alarm was signaled in 24 babies and 6 babies developed ROP without any WINROP alarm. These babies had associated comorbidities like respiratory distress syndrome, patent ductus arteriosus, bacterial sepsis, and ventilatory support. WINROP alarm was significantly associated with Type 1 ROP (P < 0.001). The sensitivity of WINROP was 80% and specificity was 80.6% with a positive predictive value of 63.2% and negative predictive value of 90.6% in detecting Type 1 ROP. In the present study, no baby who was ineligible for WINROP developed Type 1 ROP.

Conclusion:

WINROP provides a novel online monitoring screening tool for identifying babies at risk of developing Type 1 ROP. In our cohort, none of the babies whose period of gestation was more than or equal to 32 weeks developed sight threatening Type 1 ROP. WINROP algorithm may also be useful in Indian population.

Mental health impact of covid on athletes

Introduction

The coronavirus pandemic continues to impact all aspects of the daily life of the public worldwide. With decreased economic activity, the sports industry faces significant challenges of maintaining athletes’ mental health while seeking the best strategies for eventual return to sports competition.

Objectives

We aim to evaluate COVID-19 related factors impacting on the mental health of athletes and provide appropriate management steps.

Methods

We examined MeSH terms “Athletes,” “Sports,” “COVID-19,” in the context of “Mental Health,” “Mental Disorders,” “Behavioral Medicine,” “Risk Factors.” We identified seven studies for the qualitative synthesis per the PRISMA guidelines, searching Medline, PubMed, PubMed Central, and PsychInfo databases until July 2020.

Results

The pandemic has negatively impacted athletes’ mental wellbeing due to decreased physical activities, limited resources, fears, and delays or cancellations of the sporting event. The negative psychological impact on athletes is due to self-isolation measures leading to worries of less preparedness for the lockdown, reduced physical activity, loss of competitive advantages, fear of being infected, social isolation, and loneliness. During this period, athletes struggled to maintain baseline routine and engaged in excessive calorie intake, eating low-quality food, substance use, and sleep disruption. It has caused anxiety, depression, PTSD, and mood disorder at varying degrees of severity in athletes.

Conclusions

Limited resources during a pandemic have caused adverse mental impact on athletes. We recommend improving physical activity through confined or virtual training programs with colleagues. A collaborative approach is required by clinicians, psychologists, coaches, sports organizations, government bodies to limit the pandemic’s mental health impact.

Chest shielding in preterm neonates under phototherapy-a randomised control trial

Shielding the precordium can effect manifestation of haemodynamically significant patent ductus arteriosus (hsPDA). Preterm neonates born at ≤ 32 weeks of gestation if needed phototherapy within 72 h of birth and had no echocardiographically proven hsPDA were eligible to be enrolled in this open-label randomised controlled trial. In chest shielding group, in addition to the standard care, left side of the chest was covered using food grade aluminium foil during phototherapy while control group received standard care. Mean gestational age (weeks; 30.1 ± 1.5 vs 30.1 ± 1.6) was comparable in the two groups. However, neonates in the chest shield group had lower birth weight (g; 1281 ± 259 vs 1422 ± 307) and were more likely to be small-for-gestational age (21.6% vs 8.0%). It was seen that 4 (7.8%) babies in the chest shield group and 5 (10%) babies in the standard group developed hsPDA after starting phototherapy with relative risk (RR) of 0.78 (95% CI 0.22-2.75). The left atrium to aortic ratio was significantly different in the two groups with 1.5 ± 0.1 in the chest shield group and 1.8 ± 0.2 in standard group (p value 0.03).Conclusion: Chest shielding of preterm babies during phototherapy has no effect on the incidence of haemodynamically significant patent ductus arteriosus.Trial registration: Trial was registered with Clinical trial registry of India (CTRI/2018/01/011069). What is Known: • Chest shielding in preterm neonates under phototherapy has inconclusive effect on the manifestation of patent ductus arteriosus. What is New: • Preterm neonates under phototherapy have no significant difference in manifestation of haemodynamically significant patent ductus arteriosus if precordium is shielded.

Effect of fetal growth restriction on urinary podocalyxin levels at birth in preterm neonates

BACKGROUND

Small-for-gestational-age (SGA) neonates are at a higher risk of adult-onset metabolic disorders because of fetal programming in the presence of growth restriction. Nephrogenesis may also be affected in fetal growth restriction. This study hypothesized that urinary podocalyxin levels, a marker of nephrogenesis, would be lower among preterm SGA neonates as compared to appropriate-for-gestational-age (AGA) controls.

METHODS

This cross-sectional study enrolled gestation-matched SGA (n = 90) and AGA (n = 45) neonates born at 26⁰-36⁶ weeks of gestation. The SGA group comprised of 45 neonates with birth weight between 3^rd and 10^th centile and 45 neonates with birth weight <3^rd centile. The primary outcome of the study was the difference in urinary podocalyxin levels between SGA and AGA neonates. Glomerular and tubular functions were also assessed.

RESULTS

Urinary podocalyxin levels were similar in SGA and AGA neonates (ng/mg of creatinine; median [interquartile range]: 28.7 [4.8-70.2] vs. 18.7 [3.1-55.9]), P value 0.14). No correlation was observed between birth weight centile and urinary podocalyxin levels (r: -0.06). Glomerular filtration rate, fractional excretion of sodium, and serum β-2-microglobulin levels were comparable across the study groups.

CONCLUSIONS

Glomerular development as assessed by urinary podocalyxin levels and renal functions are comparable in SGA and AGA preterm neonates.

IMPACT

Neonates born with fetal growth restriction are at a higher risk of adult-onset metabolic disorders because of fetal programming. This cross-sectional study investigated the effect of presence and severity of fetal growth restriction on glomerular development by measuring urinary podocalyxin levels in preterm infants. This study did not observe any effect of the presence or severity of fetal growth restriction on urinary podocalyxin levels and other markers of glomerular and renal tubular functions.

Increasing Resistance to Reserve Antibiotics: The Experience of a Tertiary Level Neonatal Intensive Care Unit

BACKGROUND

Blood stream infections are considered as a major cause of morbidity and mortality in neonates. Recent trend shows increasing resistance to commonly used antibiotics.

AIMS AND OBJECTIVES

The aim of this study is to find the antibiotic susceptibility pattern of various bacteria from blood samples in neonates and associated risk factors.

METHODS

All consecutive cases of intramural neonatal sepsis were enrolled for >12 months. Before starting or changing antibiotic, blood sample under all aseptic precautions was taken for culture. Clinical and demographic details were recorded to analyze risk factors for sepsis. Antibiotic sensitivity tests were done as per CLSI 2019 guidelines.

RESULTS

Of the 898 participants, 107 showed culture positivity. Klebsiella pneumoniae (25.2%) and Coagulase-negative Staphylococcus (23.3%). The blood culture positivity rate was 11.9%. Approximately 79% of isolates were multidrug-resistant: extended-spectrum beta-lactamase 90%, carbapenemase-resistant Enterobacteriaceae 27.7% and MRSA 43%. The risk factors found to be associated with sepsis were period of gestation ≤37 weeks, meconium-stained liquor, birth weight <1500 g, mechanical ventilation, partial exchange transfusion, duration of antibiotics for >10 days and duration of both NICU stay and hospital stay for >10 days. The case fatality rate (CFR) was more due to K. pneumoniae (19.2%) and the relative risk of death was 2.53 in culture-positive cases with an attributable risk of 60% and the population attributable risk of 15.4%.

CONCLUSION

Increase in antibiotic resistance organisms can lead to an increase in the neonatal CFR, so regular surveillance is needed.

Practical consensus recommendations regarding the management of sentinel lymph node issues in early breast cancer

Axillary lymph node involvement is a very important poor prognostic factor in the clinical staging and management of breast cancer patients. Traditionally, axillary lymph node dissection (ALND) has been used for determining the status of the axillary lymph nodes. More recently the sentinel lymph node biopsy (SLNB) procedure has gained wider acceptance as the standard of care, having the advantage of being less invasivewhile providing good accuracy. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at these practical consensus recommendations in regards with the use of the two different procedures and other issues in patients with early breast cancer for the benefit of community oncologists.

Practical consensus recommendations regarding the use of hormonal therapy in metastatic breast cancer

Metastatic breast cancer (MBC) is cancer that has spread from the breast to another part of the body or has come back in another distant location. Treatment options for MBC depend on several factors. One of these factors is the levels of hormone receptors (HRs) in the tumor. Cancers with high levels of HRs, called HR-positive, use the hormones estrogen and progesterone to grow and spread. Hormonal therapy is a type of treatment specifically for HR-positive breast cancer. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at these practical consensus recommendations in regards with the use of hormonal therapy and the management of HR-positive MBC for the benefit of community oncologists.

Incidental Anaplastic Lymphoma in a Case of Herpetic Hepatitis

Introduction/Objective

The role of Herpes Simplex Virus (HSV) virus in the development of lymphomas is unclear and poses a diagnostic challenge along with limited literature explaining the relationship between HSV and Anaplastic large-cell lymphoma (ALCL).

Methods

A 26-year-old female admitted for intractable fever (103.7 F), chills, and dysuria; her urine analysis was suggestive of a mild urinary tract infection. During the admission, she developed abdominal pain with subsequent CT- scan showing thickening of the gallbladder and possible cholecystic fluid. Her liver function tests were: albumin 2.8 g/dL, AST 394 U/L, ALT 303 U/L, ALP 156 U/L, total bilirubin 0.3 INR 1. A subsequent Magnetic Resonance Cholangiopancreatography (MRCP) showed heterogeneous enhancement pattern of the liver without any masses following which she underwent cholecystectomy, during which her liver was abnormal along with an enlarged peri- cholic lymph node. Intraoperative biopsy of the liver showed patchy hepatocyte necrosis and occasional hepatocytes with ground-glass nuclei. The morphologic features were suggestive for Herpes Simplex Virus (HSV) hepatitis, and an HSV immunohistochemical stain confirmed this diagnosis. Removal of the lymph node showed a sinusoidal infiltrate of atypical lymphohistiocytic cells with abundant pale cytoplasm and large moderately irregular nuclei and occasional prominent amphophilic nucleoli. A few “hallmark”-like cells with curved nuclei were noted with rare mitosis. A panel of adequately controlled immunohistochemical stains showed positivity for CD4, CD30 (variable), and CD45. CD2, CD3, CD5, CD7, CD8, CD10, CD15, CD20, CD68 (positive in adjacent macrophages), BCL2, ALK1 were negative.

Results

Flow cytometry was negative for a neoplastic leukocyte population with a polytypic B-cell population. Taken together, a diagnosis of ALK1 negative, ALCL was made. A subsequent CT scan revealed borderline enlarged para- aortic lymph nodes along with an increased number of non-enlarged lymph nodes in the bilateral axillary, mediastinal, lower neck, and subpectoral regions. A bone marrow biopsy performed was negative for lymphoma.

Conclusion

Off note, her hepatitis serology panel, CMV, and HIV screens were negative. Thus, with her unusual presenting symptoms and no signs of malignancy led to numerous workups, which further led to an infectious cause, however, the patient was ultimately discovered to have an occult ALCL.

A Rare Case of Chronic Lymphoproliferative Disorder of NK Cells with an Unusual Expression of CD57

Introduction/Objective

Natural Killer cells (NK-cells) malignancies are extremely rare and the two NK-cell disorders involving the peripheral blood and bone marrow include chronic lymphoproliferative disorder of NK-cells (CLPDNK) and aggressive NK-cell leukemia (ANKL). ANKL is EBV associated with a prevalence in Asian adults and a fulminant clinical course leading to death within 2 months.

Methods

A 76-year-old female with a history of iron deficiency anemia presented for evaluation of lymphocytosis (78 TH/mm) and negative EBV with extreme fatigue, weight loss, and worsening weakness from the past 8 months.

Results

The peripheral and bone marrow aspirate showed an increase in granular lymphocytes with bland nuclei and abundant pale-staining cytoplasm containing fine to coarse azurophilic granules with no evidence of nuclear atypia. Flow cytometry demonstrated an atypical lymphocytic cell population comprising &gt;50% of total marrow and peripheral blood lymphocytes demonstrating loss of CD56 and diminished CD7 expression. The analysis showed atypical lymphocytes with the following immunophenotype: CD2, CD8 (the majority, at least 75%),CD7 (dim), CD38, CD11c (subset) with no expression of CD3, CD5, CD4, CD56, or CD11c. Flow cytometry is important as it helps in the phenotypic detection of aberrancy. A broad panel of immunohistochemical stains revealed scattered positivity for CD3, CD4, CD7, CD8, TIA-1, granzyme, perforin, and tryptase and negative for CD56 and CD57. Our top differential with a similar clinical course included T-cell large granular lymphocytic leukemia which is characterized by a clonal proliferation of mature cytotoxic T cells and also has an indolent course. They show CD3 positivity by flow cytometry along with co-expression of NK cell-associated markers (CD16 and CD57), and variable expression of other pan T cell markers such as CD2, CD5, CD7. It is found incidentally in patients having cytopenias with a persistent increase in circulating mature NK-cells. Of note, the PET scan revealed splenomegaly with no other significant findings.The patient was started on steroids and is currently doing well.

Conclusion

Thus, overall morphologic, immunophenotypic, and molecular results with negative expression of surface or cytoplasmic CD3 as well as the absence of TCR expression were most consistent with CLPD-NK with an unusual expression of CD57 expression detected in flow cytometry.

Risk Factors for Revision of Polished Taper-Slip Cemented Stems for Periprosthetic Femoral Fracture After Primary Total Hip Replacement: A Registry-Based Cohort Study from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man

BACKGROUND

Total hip replacement (THR) with a cemented polished taper-slip (PTS) femoral stem has excellent long-term results but is associated with a higher postoperative periprosthetic femoral fracture (PFF) risk compared with composite beam stems. This study aimed to identify risk factors associated with PFF revision following THR with PTS stems.

METHODS

In a retrospective cohort study, 299,019 primary THRs using PTS stems from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man (NJR) were included, with a median follow-up of 5.2 years (interquartile range [IQR], 3.1 to 8.2 years). The adjusted hazard ratio (HR) of PFF revision was estimated for each variable using multivariable Cox survival regression analysis.

RESULTS

Of 299,019 THR cases, 1,055 underwent revision for PFF at a median time of 3.1 years (IQR, 1.0 to 6.1 years). The mean age (and standard deviation) was 72 ± 9.7 years, 64.3% (192,365 patients) were female, and 82.6% (247,126 patients) had an American Society of Anesthesiologists (ASA) class of 1 or 2. Variables associated with increased PFF were increasing age (HR, 1.02 per year), intraoperative fracture (HR, 2.57 [95% confidence interval (CI), 1.42 to 4.66]), ovaloid (HR, 1.96 [95% CI, 1.22 to 3.16]) and round cross-sectional shapes (HR, 9.58 [95% CI, 2.29 to 40.12]), increasing stem offset (HR, 1.07 per millimeter), increasing head size (HR, 1.04 per millimeter), THR performed from 2012 to 2016 (HR, 1.45 [95% CI, 1.18 to 1.78]), cobalt-chromium stem material (HR, 6.7 [95% CI, 3.0 to 15.4]), and cobalt-chromium stems with low-viscosity cement (HR, 22.88 [95% CI, 9.90 to 52.85]). Variables associated with a decreased risk of PFF revision were female sex (HR, 0.52 [95% CI, 0.45 to 0.59]), increasing stem length (HR, 0.97 per millimeter), and a ceramic-on-polyethylene bearing (HR, 0.55 [95% CI, 0.36 to 0.85]).

CONCLUSIONS

Increased risk of PFF revision was associated with PTS stems that are short, have high offset, are used with large femoral heads, are made of cobalt-chromium, or have ovaloid or round cross-sectional shapes. Large increases in PFF risk were associated with cobalt-chromium stems used with low-viscosity cement. Further study is required to confirm causation.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Structure-Altering Mutations of the SARS-CoV-2 Frame Shifting RNA Element

With the rapid rate of Covid-19 infections and deaths, treatments and cures besides hand washing, social distancing, masks, isolation, and quarantines are urgently needed. The treatments and vaccines rely on the basic biophysics of the complex viral apparatus. While proteins are serving as main drug and vaccine targets, therapeutic approaches targeting the 30,000 nucleotide RNA viral genome form important complementary approaches. Indeed, the high conservation of the viral genome, its close evolutionary relationship to other viruses, and the rise of gene editing and RNA-based vaccines all argue for a focus on the RNA agent itself. One of the key steps in the viral replication cycle inside host cells is the ribosomal frameshifting required for translation of overlapping open reading frames. The frameshifting element (FSE), one of three highly conserved regions of coronaviruses, includes an RNA pseudoknot considered essential for this ribosomal switching. In this work, we apply our graph-theory-based framework for representing RNA secondary structures, "RAG" (RNA-As Graphs), to alter key structural features of the FSE of the SARS-CoV-2 virus. Specifically, using RAG machinery of genetic algorithms for inverse folding adapted for RNA structures with pseudoknots, we computationally predict minimal mutations that destroy a structurally-important stem and/or the pseudoknot of the FSE, potentially dismantling the virus against translation of the polyproteins. Additionally, our microsecond molecular dynamics simulations of mutant structures indicate relatively stable secondary structures. These findings not only advance our computational design of RNAs containing pseudoknots; they pinpoint to key residues of the SARS-CoV-2 virus as targets for anti-viral drugs and gene editing approaches.

Ensuring Exclusive Human Milk Diet for All Babies in COVID-19 Times

The coronavirus disease (COVID-19) pandemic has ramifications for the delivery of newborn nutrition and care services. World Health Organization recommends continuation of breastfeeding in these difficult times, with due precautions. If direct breastfeeding is not possible, milk expression should be explored. Pasteurized donor human milk from milk banks may be fed if mother's own milk is not available. To universalize access to human milk, the Indian government has proposed the establishment of comprehensive lactation management centers/milk banks, lactation management units, and lactation support units at all levels of the public health system. Due to COVID-19, these centers are encountering additional challenges cutting across interventions of rooming in, breastfeeding, milk expression, and provision of donor milk and kangaroo mother care. We discuss issues faced and alleviation measures taken by these centres in relation to provision of an exclusive human milk diet for infants during the pandemic.

The evolution of white matter microstructural changes after mild traumatic brain injury: A longitudinal DTI and NODDI study

Neuroimaging biomarkers that can detect white matter (WM) pathology after mild traumatic brain injury (mTBI) and predict long-term outcome are needed to improve care and develop therapies. We used diffusion tensor imaging (DTI) and neurite orientation dispersion and density imaging (NODDI) to investigate WM microstructure cross-sectionally and longitudinally after mTBI and correlate these with neuropsychological performance. Cross-sectionally, early decreases of fractional anisotropy and increases of mean diffusivity corresponded to WM regions with elevated free water fraction on NODDI. This elevated free water was more extensive in the patient subgroup reporting more early postconcussive symptoms. The longer-term longitudinal WM changes consisted of declining neurite density on NODDI, suggesting axonal degeneration from diffuse axonal injury for which NODDI is more sensitive than DTI. Therefore, NODDI is a more sensitive and specific biomarker than DTI for WM microstructural changes due to mTBI that merits further study for mTBI diagnosis, prognosis, and treatment monitoring.

Mixed higher-order anisotropic flow and nonlinear response coefficients of charged particles in PbPb collisions at s NN = 2.76 and 5.02 TeV

Anisotropies in the initial energy density distribution of the quark-gluon plasma created in high energy heavy ion collisions lead to anisotropies in the azimuthal distributions of the final-state particles known as collective anisotropic flow. Fourier harmonic decomposition is used to quantify these anisotropies. The higher-order harmonics can be induced by the same order anisotropies (linear response) or by the combined influence of several lower order anisotropies (nonlinear response) in the initial state. The mixed higher-order anisotropic flow and nonlinear response coefficients of charged particles are measured as functions of transverse momentum and centrality in PbPb collisions at nucleon-nucleon center-of-mass energies s NN = 2.76 and 5.02 TeV with the CMS detector. The results are compared with viscous hydrodynamic calculations using several different initial conditions, as well as microscopic transport model calculations. None of the models provides a simultaneous description of the mixed higher-order flow harmonics and nonlinear response coefficients.

Ensuring Exclusive Human Milk Diet for All Babies in COVID-19 Times

The coronavirus disease (COVID-19) pandemic has ramifications for the delivery of newborn nutrition and care services. World Health Organization recommends continuation of breastfeeding in these difficult times, with due precautions. If direct breastfeeding is not possible, milk expression should be explored. Pasteurized donor human milk from milk banks may be fed if mother’s own milk is not available. To universalize access to human milk, the Indian government has proposed the establishment of comprehensive lactation management centers/milk banks, lactation management units, and lactation support units at all levels of the public health system. Due to COVID-19, these centers are encountering additional challenges cutting across interventions of rooming in, breastfeeding, milk expression, and provision of donor milk and kangaroo mother care. We discuss issues faced and alleviation measures taken by these centres in relation to provision of an exclusive human milk diet for infants during the pandemic.

THU0299 MYOCARDIAL INVOLVEMENT IN TAKAYASU ARTERITIS PATIENTS ASSESSED BY MAGNETIC RESONANCE IMAGING AND ITS RELATION WITH DISEASE ACTIVITY

Background:

Cardiac involvement in Takayasu arteritis(TA) is the major cause of morbidity and mortality. [1] Cardiovascular magnetic resonance (CMR) is an excellent modality for the assessment of myocardial involvement. Studies have shown subclinical myocardial scarring in 25-27% of patients.[2,3] There is no such study from India.

Objectives:

To evaluate the prevalence of myocardial involvement in TA, as detected by CMR and its correlation with disease activity score (ITAS 2010 and ITAS-A).

Methods:

Patients classified as Takayasu arteritis according to Sharma et al. criteria [4] were included after an informed consent. Demographic, clinical, laboratory data were documented in the predesigned proforma. CMR was done on a dedicated CMR machine. Disease activity was recorded by ITAS2010 and ITAS-A.[5] Ethical clearance has been obtained from the ethics committee of the institute (INT/IEC/2018/001538).

Results:

In the present study, 37 TA patients were included. Mean(±SD) age was 29 ±11 years. Female to male ratio was 3:1. The most frequent presenting symptom was upper limb claudication (49%), and vessel involved was left subclavian and descending thoracic aorta(75% each). Of the total cohort, 65% had hypertension, 35% had dyslipidemia and 19% had valvular involvement. Five patients (14%) had myocardial involvement as detected by CMR. Three (8%) patients had late gadolinium enhancement(LGE) on CMR suggestive of myocardial fibrosis. In the current study, both the CMR and echocardiography performed equally in detecting various valvular heart disease, whereas only CMR had detected subclinical myocardial fibrosis in two patients. Details of different risk factors and relation with disease activity provided in table 1.

Conclusion:

To the best of our knowledge, this is the largest cohort on CMR in TA. Prevalence of subclinical myocardial involvement in Indian patients was much less(8% vs 25-27%) compared to the previous studies. The higher percentage of LGE detected by the earlier studies may be a reflection of cumulative damage with increasing age, prolonged hypertension, and disease duration. Myocardial involvement trend towards early age of onset, less disease duration, lack of classical risk factors, and more with disease activity. Judicious use of CMR may help in detecting subclinical myocardial involvement.

Table 1.

Relation of different risk factors with myocardial heart disease.

ParametersMHD - (n=32)MHD + (n=5)pDisease duration>5 yr13(41)2(40)0.98Age at onset<18 yr7(22)3(60)0.07BMI>23kg/m219(59)1(20)0.1Hb<12gm/dl16(50)2(40)0.68Platelets>450x 109/L4(13)0(0)0.40ESR>20 mm in 1sthour28(88)4(80)0.65CRP>10 mg/dl16(50)4(80)0.21Cholesterol>200 mg/dl10(31)1(20)0.61LDL>130 mg/dl9(28)0(0)0.17BNP>125 pg/ml11(34)3(60)0.27ITAS2010-Active17(53)3(60)0.77ITAS-A-Active11(34)3(60)0.27

[MHD: myocardial heart disease]

References:

[1]Cong XL, Dai SM, Feng X et al. Takayasu’s arteritis: clinical features and out- comes of 125 patients in China. Clin Rheumatol 2010;29:973–81.

[2]Keenan NG, Mason JC, Maceira A et al. Integrated cardiac and vascular assessment in Takayasu arteritis by cardiovascular magnetic resonance. Arthritis Rheum. 2009;60:3501-9.

[3]Comarmond C, Cluzel P, Toledano D et. al. Findings of cardiac magnetic resonance imaging in asymptomatic myocardial ischemic disease in Takayasu arteritis. Am J Cardiol. 2014;113:881-7.

[4]Sharma BK, Jain S, Suri S et al. Diagnostic criteria for Takayasu Arteritis. Int J Cardiol 1996;54: S141-7.

[5]Misra R, Danda D, Rajappa SM, et al. Development and initial validation of the Indian Takayasu Clinical Activity Score (ITAS2010). Rheumatology 2013;52:1795-801.

Disclosure of Interests:

None declared

AB0395 SYSTEMIC LUPUS ASSOCIATED MACROPHAGE ACTIVATION SYNDROME – A SINGLE CENTRE EXPERIENCE FROM INDIA

Background:

Macrophage activation syndrome (MAS) is a potentially fatal complication of systemic lupus erythematosus (SLE).(1) Overlapping clinical features of SLE activity with MA makes it a clinical diagnosis. There is limited data from developing countries like India.

Objectives:

To study the clinical features, treatment, and outcomes in SLE-MAS.

Methods:

This single-centre, retrospective study included patients fulfilling SLICC 2011 criteria for SLE, admitted from January 2017 to November 2019, and diagnosed as MAS by a team of attending physicians. Their demographic and clinical data, treatment, and outcomes were recorded. H score and SLEDAI were calculated. Patients were assessed for HLH classification criteria (2004) and preliminary diagnostic criteria for MAS in childhood SLE (cSLE).

Results:

Sixteen patients (median age – 26 years, 15 females) were included. Twelve patients (75%) had MAS as the initial presentation of SLE. The common clinical features were fever (100%) and cytopenias (100%). The mean duration of symptoms was 60 days. The most frequent biochemical abnormalities were high ferritin (>500 ng/ml, 100%) and elevated transaminases (100%, aspartate transaminase > alanine transaminase). Common complications were renal (43.8%), neurological (43.8%), and coagulopathy (43.8%). Seven and 16 patients fulfilled the HLH 2004 and cSLE – MAS preliminary criteria, respectively. The median H score was 222, giving a cumulative probability of 96%. All the patients received high-dose steroids. Cyclophosphamide pulse and cyclosporine were administered to 8 (50%) and 6 (37.5%) patients respectively. There were four (25%) in-hospital mortalities.

CharacteristicN=16Age (years)26 (19.5 – 30)Duration of symptoms (days)60 (18.7 – 90)Fever16 (100)Pancreatitis1 (6.3)Renal7 (43.8)Neurological7 (43.8)Myocarditis6 (37.5)Hepatomegaly7 (43.8)Splenomegaly3 (18.8)Lymphadenopathy12 (75)Anaemia16 (100)Leukopenia13 (82)Thrombocytopenia14 (88.2)Coagulopathy7 (43.8)Concomitant infection3 (18.8)H score222 (193 – 254)cSLE-MAS diagnostic criteria16 (100%)HLH 2004 (≥5)7 (43.8)Corticosteroids16 (100%)Cyclophosphamide8 (50%)Intravenous immunoglobulin2 (12.5%)Cyclosporine6 (37.5%)Death4 (25%)

All data presented as n (%) and median (IQR)

cSLE-MAS – Childhood systemic lupus erythematosus – Macrophage activation syndrome, HLH – Hemophagocytic lymphohistiocytosis

ParameterN = 16Haemoglobin (g/dL)6.9 (5.7 – 7.8)Total leucocyte count (cells/mm3)1400 (1025 -3175)<10003 (18.8)1000 – 25009 (56.3)2500 - 40001 (6.3)Platelet (cells/mm3)57500 (23500 – 95250)<200003 (18.8)20000 – 500003 (18.8)50000 – 1 lac8 (50)Serum ferritin > 500 ng/ml16 (100%)Fibrinogen2.48 (1.6 – 4)Triglycerides (mg/dL)375 (294 -470)AST/ALT (U/L)153 (113 – 234) / 90 (68 – 170)Procalcitonin (pg/mL)0.8 (0.3 – 1.4)Lactate dehydrogenase (U/L)1674 (1081 – 2184)Erythrocyte sedimentation rate (mm in 1sthour)61 (44 – 69)C- reactive protein (mg/L)36 (6.3 – 52)Bone marrow examination14 (87.5)Increased histiocytes with hemophagocytosis5 (32.5)

All data presented as n (%) and median (IQR)

ALT – Alanine transaminase, AST – Aspartate transaminase

Conclusion:

Fever, cytopenia, high ferritin, and elevation of transaminases were the commonest features in this series of SLE-MAS. SLE-MAS carried a high mortality (25%) despite aggressive treatment.

References:

[1]Gavand P-E, Serio I, Arnaud L, Costedoat-Chalumeau N, Carvelli J, Dossier A, et al. Clinical spectrum and therapeutic management of systemic lupus erythematosus-associated macrophage activation syndrome: A study of 103 episodes in 89 adult patients. Autoimmun Rev. 2017;16(7):743–9.

Acknowledgments:

NONE

Disclosure of Interests:

None declared

AB0570 MIXED CONNECTIVE TISSUE DISEASE: NOT THAT UNCOMMON, A SINGLE-CENTER EXPERIENCE FROM INDIA

Background:

Mixed connective tissue disease (MCTD) is considered to be uncommon; specifically there is sparse data on MCTD from developing countries like India.

Objectives:

This study examines the clinical and serological features of these patients in a single center in North-India.

Methods:

This was a retrospective single-center study of patients diagnosed as MCTD in last 20 years. The patients included fulfilled at least one of the diagnostic criteria namely Alarcón-Segovia, Kasukawa, and Kahns. Demographic details, clinical signs and symptoms, laboratory parameters, treatment and outcome were extracted from medical records and clinic files in a pre-designed proforma.

Results:

This study included 41 MCTD patients. There was a marked female preponderance (F: M=40:1), and mean age of disease onset and diagnosis was 33.8 ± 10.7 and 39.3 ± 10.2 years. 39 (92%) of the patients fulfilled both Kahn and Kasukawa criteria, while 31 (76%) fulfilled Alarcon-Segovia criteria. Initially patients had been (mis)diagnosed as rheumatoid arthritis, systemic lupus erythematosus (or UCTD) (in five patients each), overlap syndromes or myositis (in 4 patients). ANA was commonly high-titer and specked, U1RNP was positive in all. (Table 1) Other autoantibodies on immunoblot included SSA and Ro52 in half the patients. Raynaud’s was seen in three-fourth at presentation and all the patients over time. Digital gangrene and puffy fingers were seen in 8 (20%) and 18 (46%) patients. Other clinical features included arthritis in 33 (81%), sclerodactyly in 23 (56%) and proximal weakness in 20 patients (49%). Interstitial lung disease and pulmonary arterial hypertension were seen in 20 (57%) and 15 (44%) patients. All patients (except one) received prednisolone, and it was currently used in almost 90%. Intravenous cyclophosphamide was used in one-third, commonly for ILD.

Table 1.

Laboratory features of patients with MCTD

Labs n (%)Leucopenia9 (22)Thrombocytopenia10 (24)Raised globulinsb22 (69)Mean globulins, mean (SD)a5±3.4Elevated CPKb10 (31)CPK Levels U/L, median (IQR)256 (57.5-1036)ANA Speckled Pattern N (%)31d(82)U1RNP N (%)b32 (100%)U1RNP Blot Intensity1+8 (25%)2+1 (3.2%)3+7 (21.8%)4+16 (50%)U1RNP EIA, mean(SD), n=19141.3 ± 82.4Raised RF Titersh10 (35.7%)Low C3 mg/dlf8 (40%)Low C4 mg/dlf3 (15%)FVC, mean (SD) n=2082.4 ± 18.9 ILD on HRCTg20 (57) Dilated PA on CTf10 (50)PAHeon ECHO15 (44.1%)RA/RV Dilated5 (18)

SD-standard deviation, IQR- Interquartile range, CPK- Creatinine phosphokinase,, ILD- Interstitial lung disease, PAH- Pulmonary arterial hypertension, ANA- Anti nuclear antibody, IIF- Indirect Immunofluorescence, PA- pulmonary artery, RA/RV- Right atrium/Right Ventricle,a34b32d38e34f20g34h28

Conclusion:

MCTD was not uncommon in the single-center in North India. Kahn and Kasukawa criteria were found to be the most sensitive for its diagnosis. Digital gangrene was relatively common and sometimes the presenting feature; whereas puffy fingers was present in only half the patients.

Disclosure of Interests:

None declared