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

OP0108 RANDOMIZED CONTROLLED TRIAL OF ORAL CORTICOSTEROIDS IN AXIAL SPONDYLOARTHROPATHY: MODIFIED COBRA REGIME

Background:

There is an unmet need of anti-inflammatory agents in AxSpA after NSAID failure. This is especially true for patients with persisting high disease activity and not having access to anti-TNFα. In this regard, corticosteroids may be helpful as a short-term measure. However, current guidelines recommend against oral corticosteroids citing insufficient evidence of efficacy.1. Also, there is an assumption that the dose required for benefit is much higher than RA, and thus untenable. It is unclear whether starting with a high dose followed by rapid taper would be effective (like the COBRA regime in RA)2.

Objectives:

To study the efficacy of the COBRA regime of oral corticosteroids in axial SpA over 24 weeks.

Methods:

This was a double blind placebo controlled randomized trial. Patients with active axial SpA (BASDAI ≥ 4) despite NSAIDs were randomized to either receive oral prednisolone or placebo as per COBRA regime, started on oral prednisolone at a dose of 60 mg, rapidly tapered weekly to reach a dose of 10 mg by 6 weeks and subsequently maintained on a low dose of 5 mg till 24 weeks. Primary end point was 50% improvement in BASDAI at week 24. Secondary end points were improvement in ASDAS and BASFI. Analysis was by intention-to-treat. Trial Registration# CTRI/2018/01/011342

Results:

This study enrolled 65 patients (62 males) who were randomized to corticosteroid (n=32) or placebo (n=33) with mean ± SD age 28.5 ± 8.4 years and BASDAI 5.4 ± 1.0. Primary end point was reached in 12 (37.5%) and 3 (9%) patients treated with steroids and placebo respectively (p=0.007). On repeated measures analysis by general linear model, there was a significant difference between the two-groups in BASDAI (p= 0.03) (Figure-1). Patients in the corticosteroid group had significant improvement in BASDAI, ESR, CRP, ASDAS ESR and ASDAS CRP at 24 weeks (Table-1). Clinically important improvement in ASDAS CRP was achieved by significantly higher number of patients in steroid group (17 (55%) vs 6 (18%), p= 0.002). Major improvement in ASDAS ESR and ASDAS CRP was also higher in the steroid group (Figure-2). At 24 weeks, patients in the steroid group had significant reduction in IL-6 levels compared to that in placebo group (p= 0.007, data for 41 patients). Patients in the steroid group had more weight gain and facial puffiness, however no serious adverse events were noted in both the groups.

Figure 1.

Change in mean BASDAI

Table 1.

Changes in disease indices and inflammatory markers at 24 weeks

Changes in Parameters (24 weeks-baseline)PlaceboCorticosteroidP valueESR, Median (IQR)0 (-11 to 21)-13 (-37 to 4)0.01CRP mg/LMedian (IQR)0 (-8.8 to 13)-9 (-22.7 to 0)0.03BASDAI (mean ± SD)- 0.51 ± 1.6- 1.88 ± 2.50.03BASMI (mean ± SD)-0.25 ± 0.8-0.56 ± 0.90.23BASFI (mean ± SD)-0.35 ± 2.3-1.48 ± 3.10.28BAS-G (mean ± SD)-1.02 ± 2.7-1.86 ± 2.50.32ASDAS-ESR (mean ± SD)-0.13 ± 1.0-1.11 ± 1.10.001ASDAS-CRP (mean ± SD)-0.24 ± 1.1-1.17 ± 1.30.006Figure 2.

Clinically important and Major improvement at 24 weeks

Conclusion:

Oral prednisolone given by COBRA regime was associated with significant improvement in disease activity scores in axial SpA at 24 weeks. This extends and supports results from a previous short term study.3Thus, corticosteroids may be an option for patients not having access to biologics, atleast for the short-term.

References:

[1]Ward M W, Deodhar A, Gensler L S et al 2019 Update of the American College of Rheumatology/ Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis & Rheumatology; 71:1599-1613(2019).

[2]Landewé RB, Boers M, Verhoeven AC et al. COBRA combination therapy in patients with early rheumatoid arthritis: long-term structural benefits of a brief intervention. Arthritis Rheum.Feb;46(2):347-56 (2002).

[3]H Haibel, C Fendler,J Listing et al. Efficacy of oral prednisolone in active ankylosing spondylitis: results of a double-blind, randomised, placebo-controlled short-term trial. Ann Rheum Dis;73:243–6 (2014).

Disclosure of Interests:

None declared

Efficacy of inactivated trivalent influenza vaccine in rural India: a 3-year cluster-randomised controlled trial

BACKGROUND

Paediatric vaccination against influenza can result in indirect protection, by reducing transmission to their unvaccinated contacts. We investigated whether influenza vaccination of children would protect them and their household members in a resource-limited setting.

METHODS

We did a cluster-randomised, blinded, controlled study in three villages in India. Clusters were defined as households (ie, dwellings that shared a courtyard), and children aged 6 months to 10 years were eligible for vaccination as and when they became age-eligible throughout the study. Households were randomly assigned (1:1) by a computer-based system to intramuscular trivalent inactivated influenza vaccine (IIV3) or a control of inactivated poliovirus vaccine (IPV) in the beginning of the study; vaccination occurred once a year for 3 years. The primary efficacy outcome was laboratory-confirmed influenza in a vaccinated child with febrile acute respiratory illness, analysed in the modified intention-to-treat population (ie, children who received at least one dose of vaccine, were under surveillance, and had not an influenza infection within 15 days of last vaccine dose). The secondary outcome for indirect effectiveness (surveillance study) was febrile acute respiratory illness in an unvaccinated household member of a vaccine study participant. Data from each year (year 1: November, 2009, to October, 2010; year 2: October, 2010, to October, 2011; and year 3: October, 2011, to May, 2012) were analysed separately. Safety was analysed among all participants who were vaccinated with at least one dose of the vaccine. This trial is registered with ClinicalTrials.gov, number NCT00934245.

FINDINGS

Between Nov 1, 2009, to May 1, 2012, we enrolled 3208 households, of which 1959 had vaccine-eligible children. 1010 households were assigned to IIV3 and 949 households were assigned to IPV. In 3 years, we vaccinated 4345 children (2132 with IIV3 and 2213 with IPV) from 1868 households (968 with IIV3 and 900 with IPV) with 10 813 unvaccinated household contacts. In year 1, influenza virus was detected in 151 (10%) of 1572 IIV3 recipients and 206 (13%) of 1633 of IPV recipients (total IIV3 vaccine efficacy 25·6% [95% CI 6·8-40·6]; p=0·010). In year 2, 105 (6%) of 1705 IIV3 recipients and 182 (10%) of 1814 IPV recipients had influenza (vaccine efficacy 41·0% [24·1-54·1]; p<0·0001). In year 3, 20 (1%) of 1670 IIV3 recipients and 81 (5%) of 1786 IPV recipients had influenza (vaccine efficacy 74·2% [57·8-84·3]; p<0·0001). In year 1, total vaccine efficacy against influenza A(H1N1)pdm09 was 14·5% (-20·4 to 39·3). In year 2, total vaccine efficacy against influenza A(H3N2) was 64·5% (48·5-75·5). Total vaccine efficacy against influenza B was 32·5% (11·3-48·6) in year 1, 4·9% (-38·9 to 34·9) in year 2, and 76·5% (59·4-86·4) in year 3. Indirect vaccine effectiveness was statistically significant only in year 3 (38·1% [7·4-58·6], p=0·0197) when influenza was detected in 39 (1%) of 4323 IIV3-allocated and 60 (1%) of 4121 IPV-allocated household unvaccinated individuals. In the IIV3 group, 225 (12%) of 1632 children in year 1, 375 (22%) of 1718 in year 2, and 209 (12%) of 1673 in year 3 had an adverse reaction (compared with 216 [13%] of 1730, 380 [21%] of 1825, and 235 [13%] of 1796, respectively, in the IPV group). The most common reactions in both groups were fever and tenderness at site. No vaccine-related deaths occurred in either group.

INTERPRETATION

IIV3 provided variable direct and indirect protection against influenza infection. Indirect protection was significant during the year of highest direct protection and should be considered when quantifying the effect of vaccination programmes.

FUNDING

US Centers for Disease Control and Prevention.

Outbreak of Norovirus Illness Among Wildfire Evacuation Shelter Populations - Butte and Glenn Counties, California, November 2018

The Camp Fire, California's deadliest wildfire, began November 8, 2018, and was extinguished November 25 (1). Approximately 1,100 evacuees from the fire sought emergency shelter. On November 10, acute gastroenteritis (AGE) was reported in two evacuation shelters; norovirus illness was suspected, because it is commonly detected in shelter-associated AGE outbreaks. Norovirus is highly contagious and resistant to several disinfectants. Butte County Public Health Department (BCPHD), assisted by the California Department of Public Health (CDPH), initiated active surveillance to identify cases, confirm the etiology, and assess shelter infection prevention and control (IPC) practices to guide recommendations. During November 8-30, a total of 292 patients with AGE were identified among nine evacuation shelters; norovirus was detected in 16 of 17 unique patient stool specimens. Shelter IPC assessments revealed gaps in illness surveillance, isolation practices, cleaning, disinfection, and handwashing. CDPH and BCPHD collaborated with partner agencies to implement AGE screening, institute isolation protocols and 24-hour cleaning services, and promote proper hand hygiene. During disasters with limited resources, damaged infrastructure, and involvement of multiple organizations, establishing shelter disease surveillance and IPC is difficult. However, prioritizing effective surveillance and IPC at shelter activation is necessary to prevent, identify, and contain outbreaks.

Do GLP-1RAs and SGLT-2is reduce cardiovascular events in women with type 2 diabetes? A systematic review and meta-analysis

AIMS

The risk of cardiovascular disease is often underestimated in women. This leads to a delay in controlling the risk factors for cardiovascular disease and even delays in prescribing medications with cardiovascular benefit. Our aim was to explore if glucagon-like peptide-1 receptor agonist (GLP-1RA) or sodium-glucose cotransporter-2 inhibitor (SGLT-2i) medications would reduce cardiovascular events in women with type 2 diabetes when atherosclerotic cardiovascular disease (ASCVD) predominates.

MATERIALS AND METHODS

We searched for randomized trials comparing GLP-1RA or SGLT-2i to placebo in people with type 2 diabetes and had a primary outcome exploring major adverse cardiovascular events (MACE). Data concerning women were then extracted. A sensitivity and subgroup analyses were performed according to the class of diabetes medication.

RESULTS

A total of 9 trials (GLP-1RA in 6 trials and SGLT-2i in 3) were included. Of the 84,258 participants enrolled, 30,784 (37%) participants were women. Pooled results showed a statistically significant lower incidence of MACE favouring diabetes medications (GLP-1RA or SGLT-2i) compared to placebo (RR [95%CI]=0.87 [0.80, 0.94]). On restricting the analysis to GLP-1RA then to SGLT-2i, results remained significant with GLP-1RA but not SGLT-2i.

CONCLUSIONS

In women with type 2 diabetes who either have increased cardiovascular risk or established cardiovascular disease and ASCVD predominates, GLP-1RA significantly reduce the incidence of MACE while SGLT-2i result in a non-significant reduction. SGLT-2i may have comparable effect when examined in more studies. GLP-1RA and SGLT-2i should be considered without delay in women with type 2 diabetes and increased risk for cardiovascular disease.

Identification and Monitoring of International Travelers During the Initial Phase of an Outbreak of COVID-19 - California, February 3-March 17, 2020

The threat of introduction of coronavirus disease 2019 (COVID-19) into the United States with the potential for community transmission prompted U.S. federal officials in February 2020 to screen travelers from China, and later Iran, and collect and transmit their demographic and contact information to states for follow-up. During February 5-March 17, 2020, the California Department of Public Health (CDPH) received and transmitted contact information for 11,574 international travelers to 51 of 61 local health jurisdictions at a cost of 1,694 hours of CDPH personnel time. If resources permitted, local health jurisdictions contacted travelers, interviewed them, and oversaw 14 days of quarantine, self-monitoring, or both, based on CDC risk assessment criteria for COVID-19. Challenges encountered during follow-up included errors in the recording of contact information and variation in the availability of resources in local health jurisdictions to address the substantial workload. Among COVID-19 patients reported to CDPH, three matched persons previously reported as travelers to CDPH. Despite intensive effort, the traveler screening system did not effectively prevent introduction of COVID-19 into California. Effectiveness of COVID-19 screening and monitoring in travelers to California was limited by incomplete traveler information received by federal officials and transmitted to states, the number of travelers needing follow-up, and the potential for presymptomatic and asymptomatic transmission. More efficient methods of collecting and transmitting passenger data, including electronic provision of flight manifests by airlines to federal officials and flexible text-messaging tools, would help local health jurisdictions reach out to all at-risk travelers quickly, thereby facilitating timely testing, case identification, and contact investigations. State and local health departments should weigh the resources needed to implement incoming traveler monitoring against community mitigation activities, understanding that the priorities of each might shift during the COVID-19 pandemic.

Health resource utilization of labor induction versus expectant management

BACKGROUND

Although induction of labor of low-risk nulliparous women at 39 weeks reduces the risk of cesarean delivery compared with expectant management, concern regarding more frequent use of labor induction remains, given that this intervention historically has been thought to incur greater resource utilization.

OBJECTIVE

The objective of the study was to determine whether planned elective labor induction at 39 weeks among low-risk nulliparous women, compared with expectant management, was associated with differences in health care resource utilization from the time of randomization through 8 weeks postpartum.

STUDY DESIGN

This is a planned secondary analysis of a multicenter randomized trial in which low-risk nulliparous women were assigned to induction of labor at 39 weeks or expectant management. We assessed resource utilization after randomization in 3 time periods: antepartum, delivery admission, and discharge through 8 weeks postpartum.

RESULTS

Of 6096 women with data available, those in the induction of labor group (n = 3059) were significantly less likely in the antepartum period after randomization to have at least 1 ambulatory visit for routine prenatal care (32.4% vs 68.4%), unanticipated care (0.5% vs 2.6%), or urgent care (16.2% vs 44.3%), or at least 1 antepartum hospitalization (0.8% vs 2.2%, P < .001 for all). They also had fewer tests (eg, sonograms, blood tests) and treatments (eg, antibiotics, intravenous hydration) prior to delivery. During the delivery admission, women in the induction of labor group spent a longer time in labor and delivery (median, 0.83 vs 0.57 days), but both women (P = .002) and their neonates (P < .001) had shorter postpartum stays. Women and neonates in both groups had similar frequencies of postpartum urgent care and hospital readmissions (P > .05 for all).

CONCLUSION

Women randomized to induction of labor had longer durations in labor and delivery but significantly fewer antepartum visits, tests, and treatments and shorter maternal and neonatal hospital durations after delivery. These results demonstrate that the health outcome advantages associated with induction of labor are gained without incurring uniformly greater health care resource use.

Stress amongst adolescents – An alarm for health service preparedness

Adolescence can be described as a transitional period from childhood to adulthood. WHO defines adolescence as the period of life between 10-19 years (1). India alone is home to more than 250 million adolescents or 20% of the global adolescent population (1). It is critically important stage of life as they face rapidly changing challenges in their social, physical mental and psychological environments. Their cultural beliefs, family structure and support, peer relationships and educational opportunities influence their behaviour and adjustment. During this stage of life, they not only develop autonomy, self-control, social interaction and learning, but also the capabilities formed in this period directly influence their mental health for the rest of their lives as many of these tend to run a chronic or relapsing course in adulthood (2).

Enhanced oral bioavailability and hepatoprotective activity of thymoquinone in the form of phospholipidic nano-constructs

Background: The poor biopharmaceutical properties of thymoquinone (TQ) obstruct its development as a hepatoprotective agent. To surmount the delivery challenges of TQ, phospholipid nanoconstructs (PNCs) were constructed.Method: PNCs were constructed employing microemulsification technique and systematic optimization by three-factor three level Box-Behnken design.Result: Optimized PNC composition exhibited nano size (<100 nm), spherical morphology, within acceptable range of polydispersity index (0.55), high drug entrapment efficiency (>90%), controlled drug release pattern, and neutral surface charge (zeta potential of -0.65 mV). After oral administration of a single dose of PNC, it showed a relative bioavailability of 386.03% vis-à-vis plain TQ suspension. Further, TQ-loaded PNC demonstrated significant enhanced hepato-protective effect vis-à-vis pure TQ suspension and silymarin, as evidenced by reduction in the ALP, ALT, AST, bilirubin, and albumin level and ratified by histopathological analysis.Conclusion: TQ-loaded PNCs can be efficient nano-platforms for the management of hepatic disorders and promising drug delivery systems to enhance oral bioavailability of this hydrophobic molecule.

Mycoplasma pneumoniae Among Children Hospitalized With Community-acquired Pneumonia

Background

The epidemiology of Mycoplasma pneumoniae (Mp) among US children (<18 years) hospitalized with community-acquired pneumonia (CAP) is poorly understood.

Methods

In the Etiology of Pneumonia in the Community study, we prospectively enrolled 2254 children hospitalized with radiographically confirmed pneumonia from January 2010-June 2012 and tested nasopharyngeal/oropharyngeal swabs for Mp using real-time polymerase chain reaction (PCR). Clinical and epidemiological features of Mp PCR-positive and -negative children were compared using logistic regression. Macrolide susceptibility was assessed by genotyping isolates.

Results

One hundred and eighty two (8%) children were Mp PCR-positive (median age, 7 years); 12% required intensive care and 26% had pleural effusion. No in-hospital deaths occurred. Macrolide resistance was found in 4% (6/169) isolates. Of 178 (98%) Mp PCR-positive children tested for copathogens, 50 (28%) had ≥1 copathogen detected. Variables significantly associated with higher odds of Mp detection included age (10-17 years: adjusted odds ratio [aOR], 10.7 [95% confidence interval {CI}, 5.4-21.1] and 5-9 years: aOR, 6.4 [95% CI, 3.4-12.1] vs 2-4 years), outpatient antibiotics ≤5 days preadmission (aOR, 2.3 [95% CI, 1.5-3.5]), and copathogen detection (aOR, 2.1 [95% CI, 1.3-3.3]). Clinical characteristics were non-specific.

Conclusions

Usually considered as a mild respiratory infection, Mp was the most commonly detected bacteria among children aged ≥5 years hospitalized with CAP, one-quarter of whom had codetections. Although associated with clinically nonspecific symptoms, there was a need for intensive care in some cases. Mycoplasma pneumoniae should be included in the differential diagnosis for school-aged children hospitalized with CAP.

Immune checkpoint inhibitors and endocrine side effects, a narrative review

Immune checkpoint inhibitors (ICPIs) are novel drugs in the field of oncology however carry the risk of immune-related dermatologic, gastrointestinal, and endocrine side effects which can be fatal. These new innovative immunoregulatory drugs have intertwined the fields of oncology and endocrinology. CTLA-4 and PD-1 are co-inhibitory receptors on T cells that turn the T cell 'off' when binding to receptors on APCs. Tumor cells can also carry receptors for CTLA- and PD-1. By rendering T cells inactive, tumor cells can evade immune attack. Antibodies that bind to CTLA-4 and PD-1 lead to T cell activation and destruction of both tumor and normal host cells. ICPIs have been used in a variety of malignancies including melanoma, kidney cancer, and non-small cell lung cancer. A unique underrecognized side effect of the autoimmune response is hypophysitis leading to central adrenal insufficiency which can be fatal. Additional immune-related adverse events (irAEs) include hypothyroidism, hyperthyroidism, diabetes, and hypoparathyroidism.

Hemoadsorption by extracorporeal cytokine adsorption therapy (CytoSorb®) in the management of septic shock: A retrospective observational study

INTRODUCTION

Sepsis results in immunologic disturbances with the release of various inflammatory mediators such as cytokines. Cytokines can damage the cells, and the continuous release of inflammatory mediators leads to severely impaired immunity. Therefore, the reduction in cytokine levels by hemoadsorption represents a new concept for blood purification. CytoSorb^® as a hemoadsorption device is a detoxification system, which aims to decrease the cytokines levels. This study was conducted to understand any beneficial effects of CytoSorb^® therapy in septic patients.

METHODOLOGY

This was a retrospective and observational study, approved by the scientific and ethics committee of Max Super Specialty Hospital, Patparganj, Delhi, India and conducted in compliance with current International Council for Harmonization, Good Clinical Practice, Schedule Y, and Indian Council of Medical Research guidelines. Subjects of either gender (age > 18 year) were included in the study. The data were presented as mean ± standard deviation and categorical as frequency and percentage (%). A p value less than 0.05 (p < 0.05) was considered to be statistically significant.

RESULTS

A total number of 36 patients were included in the study. Majority of the patients were male with mean age (56.36 ± 14.83). After therapy, procalcitonin and total leucocyte count levels decreased within 24 h. Post therapy, sepsis-related organ failure assessment (SOFA) score of Day (D)1, D2, and D3 reduced to 10.4 ± 3.63, 8.7 ± 4.02, and 7.8 ± 3.67, respectively. The Acute Physiology and Chronic Health Evaluation (APACHE) II score and predicted mortality were lower in the survivor group as compared to the non-survivor group.

CONCLUSION

Hemoadsorption using the extracorporeal adsorption device (CytoSorb^®) might be an effective rescue therapy in stabilizing septic shock patients.

215. Invasive Group A Streptococcus-Associated Hospitalizations and Risk Factors for In-Hospital Mortality Among Adults in California, 2000–2016

Background

Invasive group A Streptococcus (iGAS) causes severe illness and death but is not vaccine preventable or nationally notifiable. We describe the epidemiology of adult patients hospitalized with iGAS in California and risk factors for in-hospital death.

Methods

Using 2000–2016 California hospital discharge data, we extracted records for adults (≥18 years) with ≥1 group A Streptococcus (GAS)-associated International Classification of Diseases, Ninth or Tenth Revision discharge diagnosis code (e.g., unspecified GAS; GAS-specific pharyngitis, pneumonia, and sepsis) or known GAS-associated syndromes (e.g., acute rheumatic fever, erysipelas, scarlet fever). To identify patients hospitalized with iGAS, we selected extracted records that also had codes consistent with invasive disease (e.g., sepsis, pneumonia, intubation, or central line placement). We calculated iGAS-associated hospitalization incidence rates per 100,000 population and described patient demographics and comorbidities. We calculated the odds of in-hospital death using multivariable logistic regression (P < 0.05).

Results

During 2000–2016 in California, 37,532 adults were hospitalized with iGAS; 1,045 (3%) died in-hospital. Mean annual hospitalization incidence was 9.4/100,000 population, and was highest (16.3/100,000) in 2016 (Figure 1). Most patients were male (56%), aged 40–65 (45%) or ≥65 (28%) years, and white (60%); 18% were immunocompromised. The percent of patients who died in-hospital increased with age and was highest among those with comorbidities such as malnutrition, cardiovascular disease (CVD), and chronic kidney disease (CKD) (Figure 2). In a multivariable model including age as a continuous variable, sex, and race-ethnicity, the odds of in-hospital death was significantly increased for patients with diagnosis codes for malnutrition, liver disease, CVD, immunosuppression, and CKD (Figure 2); within the race/ethnicity variable Asian/Pacific Islander patients had a higher odds of death compared with white patients.

Conclusion

Hospitalization and subsequent in-hospital death due to iGAS is substantial in California. Adults with iGAS who have specific comorbidities are at greater risk for death when hospitalized with iGAS.

Disclosures

All authors: No reported disclosures.

1708. Epidemiology of Coccidioidomycosis-Associated Hospitalizations and In-hospital Deaths, California, 2000–2017

Background

Coccidioidomycosis (CM) is caused by inhalation of spores of the soil-dwelling Coccidioides spp. fungus; infection can lead to severe respiratory or disseminated disease. In California, reported cases increased 222% since 2014 (2,316 cases) peaking in 2017 with 7,466 cases (rate 18.1/100,000 population), the highest annual reported cases on record. We reviewed the California hospital CM data to describe trends, demographics, comorbidities, and risk factors for in-hospital death.

Methods

Using 2000–2017 California administrative hospital discharge data, we identified hospitalizations with ≥1 CM-associated International Classification of Diseases, Ninth or Tenth diagnosis code. We calculated incidence rates per 100,000 population, assessed trends by negative binomial regression, and compared patient characteristics for potential risk factors for in-hospital death by calculating age-adjusted odds ratios (aOR) using bivariate logistic regression (significance, P < 0.05).

Results

From 2000 to 2017, 25,372 patients were hospitalized with a CM discharge code in California, and hospitalization rates increased significantly from 2.3 to 5.8/100,000 population (P < 0.01) (Figure 1). Most patients were male (69%), >40 years old (69%), white (40%) or Hispanic (38%), and residents of the higher incidence CM regions in California (52%). Most (83%) were not immunocompromised; only 3% had a human immunodeficiency virus (HIV) diagnosis. A total of 1,951 (8%) patients died in-hospital with more deaths among those with disseminated CM (15%), particularly meningitis (17%), than with pulmonary disease (7%). Frequency of death increased with increasing age (0–19 years [2%], 20–39 years [5%], 40–59 years [7%], 60+ years [13%]). Odds of in-hospital death was highest among patients with HIV (aOR 6.4, 95% CI 5.3–7.7) or chronic kidney disease (aOR 2.6, 95% CI 2.3–2.8) (Figure 2).

Conclusion

CM-associated hospitalization rates have increased in California in the last 18 years, peaking in 2017, with 1 in 12 patients dying in-hospital. Risk factors for death include disseminated CM, older age, HIV infection, and chronic kidney disease. Clinicians should be aware of these risks in caring for patients hospitalized with CM.

Disclosures

All Authors: No reported disclosures.

81. Azithromycin-Nonsusceptible Salmonella Newport Infections Associated with Mexican-style Soft Cheese and Beef—the United States, 2018–2019

Background

Azithromycin is a recommended oral agent for treating nontyphoidal Salmonella (NTS), when antibiotics are indicated. Azithromycin nonsusceptibility among NTS is <1% in the United States. CDC, FSIS, and state health departments investigated an outbreak of azithromycin-nonsusceptible Salmonella serotype Newport infections to determine sources.

Methods

We classified isolates as the outbreak strain if they were within 11 alleles by core genome multilocus sequence typing. We defined a case as infection with the outbreak strain during June 2018–February 2019. After stratifying by gender and ethnicity, we compared food exposures ≤7 days before illness onset with those reported by healthy persons in the Foodborne Diseases Active Surveillance Network population survey (2006–2007). We used broth microdilution to determine antimicrobial susceptibility.

Results

We identified 218 case patients from 31 states; 49 of 176 (28%) were hospitalized and 2 died. Overall, 65% (121/187) were Hispanic, and 41% (70/169) visited Mexico in the 7 days before illness onset. Among travelers to Mexico, 71% (23/32) reported eating Mexican-style soft cheese; 16/23 (70%) recalled obtaining the cheese in Mexico. Among nontravelers, the proportion who ate Mexican-style soft cheese (30%, 18/60) was similar to that reported by healthy persons, whereas the proportion who consumed beef (91%, 60/66) was higher than reported by healthy persons (P = 0.04). The outbreak strain was detected in a sample of soft cheese obtained in Mexico, and in a cecal sample from a steer and a beef sample that was collected at FSIS-regulated establishments in the United States. Isolates were resistant to ampicillin and trimethoprim–sulfamethoxazole, nonsusceptible to azithromycin, and showed decreased susceptibility to ciprofloxacin.

Conclusion

This is the first documented outbreak of azithromycin-nonsusceptible Salmonella infections in the United States. Two food vehicles—soft cheese obtained in Mexico, and beef obtained in the United States—were epidemiologically and genetically associated with this outbreak. Further investigation is warranted to determine the routes of entry, prevalence, and spread of azithromycin-nonsusceptible Salmonella in US and Mexican cattle.

Disclosures

All Authors: No reported Disclosures.

2212. Burden of Community-Acquired Pneumonia Attributable to Co-morbid Conditions in Adults

Background

Few studies have quantified the risk of community-acquired pneumonia (CAP) among adults with co-morbidities. Combining data from the population-based, prospective Etiology of Pneumonia in the Community study (EPIC) and the nationwide health-related Behavioral Risk Factor Surveillance System (BRFSS) telephone-survey, we estimated the annual risk of hospitalization for CAP among adults with co-morbidities.

Methods

We identified adults hospitalized with radiographic and clinical CAP at hospitals in Chicago, IL and Nashville, TN from July 2010 to June 2012. Using 2011 BRFSS data, we estimated the prevalence of the population with selected co-morbidities (chronic lung disease [CLD], cardiovascular disease [CVD], chronic kidney disease [CKD], or diabetes) in the EPIC study catchment counties, as well as the population without co-morbidities. We estimated the incidence of hospitalized CAP, age-adjusted relative risk (RR) using Poisson regression, and population attributable fraction for each co-morbidity.

Results

Among 2,061 adult patients enrolled in EPIC, 1,428 (69%) had at least one selected co-morbidity, most commonly CLD (42%) and CVD (35%). Among the adult population in the EPIC catchment area, 17% had ≥1 selected co-morbidity. The overall incidence of hospitalized CAP was 24.8/10,000, 118.7/10,000 among adults with ≥1 co-morbidity, and 11.2/10,000 among adults without a co-morbidity. Compared with patients without co-morbidities, the incidence of hospitalization for CAP was higher among patients with CLD (aRR: 20.7 [95% confidence interval [CI]: 20.0–21.5]), CKD (aRR: 14.5 [CI: 13.8–15.1]), CVD (aRR: 14.0 [CI: 13.5–14.6]), and diabetes (aRR: 6.2 [CI: 5.9–6.4]). While CLD and CVD accounted for high proportions of the incidence of CAP hospitalizations in the study population, the contribution of the selected co-morbidities varied by age groups (figure).

Conclusion

There is an increased risk of hospitalization for CAP among adults with co-morbidities, particularly chronic lung and cardiovascular disease. As a large portion of CAP is attributable to these co-morbidities, targeted public health interventions, such as vaccination and risk communication, need to be reinforced among these high-risk groups.

Disclosures

All authors: No reported disclosures.

Pneumococcal Community-Acquired Pneumonia Detected by Serotype-Specific Urinary Antigen Detection Assays

Background

Streptococcus pneumoniae is considered the leading bacterial cause of pneumonia in adults. Yet, it was not commonly detected by traditional culture-based and conventional urinary testing in a recent multicenter etiology study of adults hospitalized with community-acquired pneumonia (CAP). We used novel serotype-specific urinary antigen detection (SSUAD) assays to determine whether pneumococcal cases were missed by traditional testing.

Methods

We studied adult patients hospitalized with CAP at 5 hospitals in Chicago and Nashville (2010-2012) and enrolled in the Etiology of Pneumonia in the Community (EPIC) study. Traditional diagnostic testing included blood and sputum cultures and conventional urine antigen detection (ie, BinaxNOW). We applied SSUAD assays that target serotypes included in the 13-valent pneumococcal conjugate vaccine (PCV13) to stored residual urine specimens.

Results

Among 1736 patients with SSUAD and ≥1 traditional pneumococcal test performed, we identified 169 (9.7%) cases of pneumococcal CAP. Traditional tests identified 93 (5.4%) and SSUAD identified 76 (4.4%) additional cases. Among 14 PCV13-serotype cases identified by culture, SSUAD correctly identified the same serotype in all of them. Cases identified by SSUAD vs traditional tests were similar in most demographic and clinical characteristics, although disease severity and procalcitonin concentration were highest among those with positive blood cultures. The proportion of pneumonia cases caused by serotypes exclusively covered by PCV13 was not significantly different between the first and second July-June study periods (6.4% vs 4.0%).

Conclusions

Although restricted to the detection of only 13 serotypes, SSUAD testing substantially increased the detection of pneumococcal pneumonia among adults hospitalized with CAP.

Surveillance for Coccidioidomycosis - United States, 2011-2017

PROBLEM/CONDITION

Coccidioidomycosis (Valley fever) is an infection caused by the environmental fungus Coccidioides spp., which typically causes respiratory illness but also can lead to disseminated disease. This fungus typically lives in soils in warm, arid regions, including the southwestern United States.

REPORTING PERIOD

2011-2017.

DESCRIPTION OF SYSTEM

Coccidioidomycosis has been nationally notifiable since 1995 and is reportable in 26 states and the District of Columbia (DC), where laboratories and physicians notify local and state public health departments about possible coccidioidomycosis cases. Health department staff determine which cases qualify as confirmed cases according to the definition established by Council of State and Territorial Epidemiologists and voluntarily submit basic case information to CDC through the National Notifiable Diseases Surveillance System.

RESULTS

During 2011-2017, a total of 95,371 coccidioidomycosis cases from 26 states and DC were reported to CDC. The number of cases decreased from 2011 (22,634 cases) to 2014 (8,232 cases) and subsequently increased to 14,364 cases in 2017; >95% of cases were reported from Arizona and California. Reported incidence in Arizona decreased from 261 per 100,000 persons in 2011 to 101 in 2017, whereas California incidence increased from 15.7 to 18.2, and other state incidence rates stayed relatively constant. Patient demographic characteristics were largely consistent with previous years, with an overall predominance among males and among adults aged >60 years in Arizona and adults aged 40-59 years in California.

INTERPRETATION

Coccidioidomycosis remains an important national public health problem with a well-established geographic focus. The reasons for the changing trends in reported cases are unclear but might include environmental factors (e.g., temperature and precipitation), surveillance artifacts, land use changes, and changes in the population at risk for the infection.

PUBLIC HEALTH ACTION

Health care providers should consider a diagnosis of coccidioidomycosis in patients who live or work in or have traveled to areas with known geographic risk for Coccidioides and be aware that those areas might be broader than previously recognized. Coccidioidomycosis surveillance provides important information about the epidemiology of the disease but is incomplete both in terms of geographic coverage and data availability. Expanding surveillance to additional states could help identify emerging areas that pose a risk for locally acquired infections. In Arizona and California, where most cases occur, collecting systematic enhanced data, such as more detailed patient characteristics and disease severity, could help clarify the reasons behind the recent changes in incidence and identify additional opportunities for focused prevention and educational efforts.

Etiology and Impact of Coinfections in Children Hospitalized With Community-Acquired Pneumonia

Background

Recognition that coinfections are common in children with community-acquired pneumonia (CAP) is increasing, but gaps remain in our understanding of their frequency and importance.

Methods

We analyzed data from 2219 children hospitalized with CAP and compared demographic and clinical characteristics and outcomes between groups with viruses alone, bacteria alone, or coinfections. We also assessed the frequency of selected pairings of codetected pathogens and their clinical characteristics.

Results

A total of 576 children (26%) had a coinfection. Children with only virus detected were younger, more likely to be black, and more likely to have comorbidities such as asthma, compared with children infected with typical bacteria alone. Children with virus-bacterium coinfections had a higher frequency of leukocytosis, consolidation on chest radiography, parapneumonic effusions, intensive care unit admission, and need for mechanical ventilation and an increased length of stay, compared with children infected with viruses alone. Virus-virus coinfections were generally comparable to single-virus infections, with the exception of the need for oxygen supplementation, which was higher during the first 24 hours of hospitalization in some virus-virus pairings.

Conclusions

Coinfections occurred in 26% of children hospitalized for CAP. Children with typical bacterial infections, alone or complicated by a viral infection, have worse outcomes than children infected with a virus alone.

The Success and Evolution of a Urological "Boot Camp" for Newly Appointed UK Urology Registrars: Incorporating Simulation, Nontechnical Skills and Assessment

BACKGROUND

Urological training has dramatically changed in recent years. Training durations are shorter and a drive toward consultant led care has reduced trainees experience. Within the UK, approximately 50 registrars annually embark on a 5-year Urology training programme, with variable levels of basic urological experience.

OBJECTIVE

To describe a simulation programme aimed at delivering the knowledge and skills necessary to safely and effectively start working as a registrar in Urology by intensive training with a 1:1 faculty to delegate ratio.

DESIGN, SETTING, AND PARTICIPANTS

Our course content mirrors the UK training syllabus for junior Urology registrars. We delivered 8 modules over a 4-day programme with a fifth day of assessments. Delegates level of urological knowledge, operative competency and confidence pre-, immediately post-training and at 3-months postcourse were assessed. Objective delegate and faculty feedback was also collected. Technical skills modules include; inguinoscrotal surgery, ureteroscopy, transurethral resection, urodynamics, and Botox administration as well as basic reconstructive and laparoscopic operative skills. "Nontechnical" skills included simulated ward round, out-patient, and emergency scenarios.

RESULTS

Feedback from delegates and faculty members has been overwhelmingly positive. We have used this feedback to tailor the content of the course for following years. An increased knowledge level (based on mean examination scores [precourse 55.5%, postcourse 70.1%]) and operative competency was observed in all skills assessed (transurethral resection of the prostate, transurethral resection of bladder tumor, Ureteroscopy, laparoscopic skills, and instrument assembly). Operative confidence was increased immediately and at 3-months postcourse.

CONCLUSIONS

Our "boot camp" course provides a realistic introduction and foundation to begin Urological practice. Being delivered at the beginning of the training scheme, prior to intensive patient exposure, registrars are in an optimum position to develop their newly acquired knowledge and skills to enhance training and intends to improve patient safety and satisfaction.

Prevalence, Risk Factors, and Outcomes of Bacteremic Pneumonia in Children

BACKGROUND

Previous studies examining bacteremia in hospitalized children with pneumonia are limited by incomplete culture data. We sought to determine characteristics of children with bacteremic pneumonia using data from a large prospective study with systematic blood culturing.

METHODS

Children <18 years hospitalized with pneumonia and enrolled in the multicenter Etiology of Pneumonia in the Community study between January 2010 and June 2012 were eligible. Bivariate comparisons were used to identify factors associated with bacteremia. Associations between bacteremia and clinical outcomes were assessed by using Cox proportional hazards regression for length of stay and logistic regression for ICU admission and invasive mechanical ventilation or shock.

RESULTS

Blood cultures were obtained in 2143 (91%) of 2358 children; 46 (2.2%) had bacteremia. The most common pathogens were Streptococcus pneumoniae (n = 23, 50%), Staphylococcus aureus (n = 6, 13%), and Streptococcus pyogenes (n = 4, 9%). Characteristics associated with bacteremia included male sex, parapneumonic effusion, lack of chest indrawing or wheezing, and no previous receipt of antibiotics. Children with bacteremia had longer lengths of stay (median: 5.8 vs 2.8 days; adjusted hazard ratio: 0.79 [0.73-0.86]) and increased odds of ICU admission (43% vs 21%; adjusted odds ratio: 5.21 [3.82-6.84]) and invasive mechanical ventilation or shock (30% vs 8%; adjusted odds ratio: 5.28 [2.41-11.57]).

CONCLUSIONS

Bacteremia was uncommonly detected in this large multicenter cohort of children hospitalized with community-acquired pneumonia but was associated with severe disease. S pneumoniae was detected most often. Blood culture was of low yield in general but may have greater use in those with parapneumonic effusion and ICU admission.

Epidemiology of viral acute lower respiratory infections in a community-based cohort of rural north Indian children

Background

In India, community-based acute lower respiratory infections (ALRI) burden studies are limited, hampering development of prevention and control strategies.

Methods

We surveyed children <10 years old at home weekly from August 2012-August 2014, for cough, sore throat, rhinorrhoea, ear discharge, and shortness of breath. Symptomatic children were assessed for ALRI using World Health Organization definitions. Nasal and throat swabs were obtained from all ALRI cases and asymptomatic controls and tested using polymerase chain reaction for respiratory syncytial virus (RSV), human metapneumovirus (hMPV), parainfluenza viruses (PIV), and influenza viruses (IV). We estimated adjusted odds ratios (aOR) using logistic regression to calculate etiologic fractions (EF). We multiplied agent-specific ALRI incidence rates by EF to calculate the adjusted incidence as episodes per child-year.

Results

ALRI incidence was 0.19 (95% confidence interval (CI) = 0.18-0.20) episode per child-year. Association between virus and ALRI was strongest for RSV (aOR = 15.9; 95% CI = 7.3-34.7; EF = 94%) and least for IV (aOR = 4.6; 95% CI = 2.0-10.6; EF = 78%). Adjusted agent-specific ALRI incidences were RSV (0.03, 95% CI = 0.02-0.03), hMPV (0.02, 95% CI = 0.01-0.02), PIV (0.02, 95% CI = 0.01-0.02), and IV (0.01, 95% CI = 0.01-0.01) episode per child-year.

Conclusions

ALRI among children in rural India was high; RSV was a significant contributor.

Pneumococcal and Legionella Urinary Antigen Tests in Community-acquired Pneumonia: Prospective Evaluation of Indications for Testing

BACKGROUND

Adult, community-acquired pneumonia (CAP) guidelines from the Infectious Diseases Society of America (IDSA) and American Thoracic Society (ATS) include indications for urinary antigen tests (UATs) for Streptococcus pneumoniae (SP) and Legionella pneumophila (LP). These recommendations were based on expert opinions and have not been rigorously evaluated.

METHODS

We used data from a multicenter, prospective, surveillance study of adults hospitalized with CAP to evaluate the sensitivity and specificity of the IDSA/ATS UAT indications for identifying patients who test positive. SP and LP UATs were completed on all included patients. Separate analyses were completed for SP and LP, using 2-by-2 contingency tables, comparing the IDSA/ATS indications (UAT recommended vs not recommended) and UAT results (positive vs negative). Additionally, logistic regression was used to evaluate the association of each individual criterion in the IDSA/ATS indications with positive UAT results.

RESULTS

Among 1941 patients, UATs were positive for SP in 81 (4.2%) and for LP in 32 (1.6%). IDSA/ATS indications had 61% sensitivity (95% confidence interval [CI] 49-71%) and 39% specificity (95% CI 37-41%) for SP, and 63% sensitivity (95% CI 44-79%) and 35% specificity (95% CI 33-37%) for LP. No clinical characteristics were strongly associated with positive SP UATs, while features associated with positive LP UATs were hyponatremia, fever, diarrhea, and recent travel.

CONCLUSIONS

Recommended indications for SP and LP urinary antigen testing in the IDSA/ATS CAP guidelines have poor sensitivity and specificity for identifying patients with positive tests; future CAP guidelines should consider other strategies for determining which patients should undergo urinary antigen testing.

Corticosteroid-associated lupus pancreatitis: a case series and systematic review of the literature

BACKGROUND

Acute pancreatitis is an uncommon complication that occurs in 0.85% to 4% of patients with systemic lupus erythematosus (SLE). In some patients, it occurs within days to weeks of starting medium-to-high dose corticosteroids. The authors have used the term 'corticosteroid-associated lupus pancreatitis' for these patients, and they report a case series and perform a systematic review of previously published reports.

METHODS

For the purpose of this study, corticosteroid-associated lupus pancreatitis was defined as occurrence of acute pancreatitis in patients with SLE (fulfilling the 1997 ACR), within 3 weeks of starting therapy with medium-to-high dose corticosteroids - either newly initiated or escalated from a lower dose. All patients with SLE admitted in the last 2.5 years in a North Indian university hospital were reviewed, and those with pancreatitis who fulfilled the above criteria were included in the case series. For the systematic review, a PUBMED search using the keywords 'lupus' and 'pancreatitis' was performed, and reports in English were reviewed for an association with corticosteroids.

RESULTS

Among 420 admissions of SLE patients, six patients (1.4%) fulfilled criteria for corticosteroid-associated lupus pancreatitis. All were female, with mean age and disease duration of 19.7 ± 3.3 and 3.8 ± 2.5 years respectively. All had active disease and developed acute pancreatitis within 48-72 hours of newly initiating medium-to-high dose corticosteroids (in three patients) or escalating them to medium-high dose (in three patients). After the development of pancreatitis, corticosteroids were continued in all except one patient. In addition, two patients received pulse methylprednisolone, two received pulse cyclophosphamide and one was started on azathioprine. Three patients died during hospitalization, all with severe pancreatitis. On systematic review, among 451 cases of lupus pancreatitis reported, 23 (5%) fulfilled criteria for 'corticosteroid-associated lupus pancreatitis'. A majority of them had pancreatitis within 3 days of starting treatment with medium-to-high dose corticosteroids. The mortality in these patients was 37.5%.

CONCLUSION

In a small but substantial proportion of patients with lupus who develop pancreatitis, it occurs within days to weeks of starting medium-to-high dose corticosteroids. Many of these patients continue to receive corticosteroids, and some receive more aggressive immunosuppression. However, they have significant mortality, and further studies are required to identify appropriate treatment in this subgroup of patients.

Zinc Chloride Catalyzed Amino Claisen Rearrangement of 1-N-Allylindolines: An Expedient Protocol for the Synthesis of Functionalized 7-Allylindolines

7-Allylindolines are valuable synthons for designing biologically active molecular libraries. Lewis acid catalyzed amino-Claisen rearrangement provides a one pot synthetic entry to these heteroarenes. In this context, Zinc chloride (ZnCl2)–N,N-dimethylformamide system efficiently catalyzed amino-Claisen rearrangements of 1-N-allylindolines to 7-allylindolines. The rearrangement is influenced by stereoelectronic effects of substituents present in 1-N-allylindolines. The substrates containing electron donating functionalities underwent rearrangement at lower temperature than substrates with electron withdrawing functional groups. The regioselectivity of the process is governed by the substitution pattern on allyl moiety in 1-N-allylindoline as well as ZnCl2 catalyst loading in the reaction system.

Validation of a Metastatic Assay using biopsies to improve risk stratification in patients with prostate cancer treated with radical radiation therapy

Background

Radiotherapy is an effective treatment of intermediate/high-risk locally advanced prostate cancer, however, >30% of patients relapse within 5 years. Clinicopathological parameters currently fail to identify patients prone to systemic relapse and those whom treatment intensification may be beneficial. The purpose of this study was to independently validate the performance of a 70-gene Metastatic Assay in a cohort of diagnostic biopsies from patients treated with radical radiotherapy and androgen deprivation therapy.

Patients and methods

A bridging cohort of prostate cancer diagnostic biopsy specimens was profiled to enable optimization of the Metastatic Assay threshold before further independent clinical validation in a cohort of diagnostic biopsies from patients treated with radical radiotherapy and androgen deprivation therapy. Multivariable Cox proportional hazard regression analysis was used to assess assay performance in predicting biochemical failure-free survival (BFFS) and metastasis-free survival (MFS).

Results

Gene expression analysis was carried out in 248 patients from the independent validation cohort and the Metastatic Assay applied. Ten-year MFS was 72% for Metastatic Assay positive patients and 94% for Metastatic Assay negative patients [HR = 3.21 (1.35–7.67); P = 0.003]. On multivariable analysis the Metastatic Assay remained predictive for development of distant metastases [HR = 2.71 (1.11–6.63); P = 0.030]. The assay retained independent prognostic performance for MFS when assessed with the Cancer of the Prostate Assessment Score (CAPRA) [HR = 3.23 (1.22–8.59); P = 0.019] whilst CAPRA itself was not significant [HR = 1.88, (0.52–6.77); P = 0.332]. A high concordance [100% (61.5–100)] for the assay result was noted between two separate foci taken from 11 tumours, whilst Gleason score had low concordance.

Conclusions

The Metastatic Assay demonstrated significant prognostic performance in patients treated with radical radiotherapy both alone and independent of standard clinical and pathological variables. The Metastatic Assay could have clinical utility when deciding upon treatment intensification in high-risk patients. Genomic and clinical data are available as a public resource.

Epidemiology of coccidioidomycosis among children in California, 2000-2016

We calculated population-based incidence of coccidioidomycosis from the 2000-2016 California surveillance data and compared children (≤17 years) with adults (≥18 years). During that time, the annual pediatric incidence per 100,000 increased from 0.8 in 2000 to 5.2 in 2016, while the adult annual rate increased from 3.2 in 2000 to 16.2 in 2016. Pediatric incidence was higher among children in the 12-17-year age group and among residents of endemic counties. Rates by sex were similar from infancy until adolescence when rates in males became substantially higher than females and remained so into older age; reasons for this are unclear.

A screening-level approach to quantifying risk from glacial release of organochlorine pollutants in the Alaskan Arctic

Widespread distribution of atmospherically mobilized organochlorine pollutants (OCPs) has been documented throughout the Arctic. A fraction of these OCPs have become entrained in glacial ice, and during melting, they can be released into downstream reservoirs. Though this remobilization is known, an assessment of risk from glacial meltwater to collocated human communities in the Arctic, including Alaska, had not been accomplished. Here, we use a screening-level risk assessment model for glacial watersheds, based on US Environmental Protection Agency (EPA) methodology, which we apply to the glaciated Jarvis Creek watershed of interior Alaska. Model results indicate that even with low levels of OCPs in glacial meltwater, high fish consumption by subsistence communities in the area increases the risk of cancer and hazard impacts above acceptable limits. Though this model is specific to one watershed, our results imply that further investigation of an increasing OCP signal in glacial meltwater and fish throughout the North American Arctic is warranted.