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Sachdeva RK, Naidu GSRSNK, Chauhan P, Kharbanda S, Kaur J, Joseph P, Arora S, Sharma A. Cerebrospinal Fluid Viral Escape on Highly Active Antiretroviral Therapy: Analysis from Single Tertiary Care Centre. AIDS Res Hum Retroviruses 2024. [PMID: 38366730 DOI: 10.1089/aid.2022.0187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024] Open
Abstract
HIV-infected individuals receiving regular antiretroviral therapy (ART) can present with a high viral load in cerebrospinal fluid (CSF) at times when it is suppressed in blood. This study presents data of HIV-infected patients who had undetectable or low plasma viral load in blood but presented with neurological signs and symptoms and were diagnosed to have CSF HIV viral escape. Records were reviewed for clinical manifestations, details of opportunistic or coinfection, and HIV viral copies in plasma and CSF at time of diagnosis of CSF escape. A total of 10,200 HIV-infected individuals were registered in HIV care till December 31, 2021. Nineteen individuals (14 virologically confirmed and 5 clinically) were diagnosed with high viral copies in CSF from June 2014 to December 2021. Mean age was 41.5 ± 9.2 (median, 39.5; range, 30-62) years. Average duration of antiretroviral treatment received at the time of diagnosis of CSF escape was 10.1 years. Median plasma HIV-viral copies were 2,469.8 (undetectable to 29,418) and in CSF were 12,773.7 (n = 14, range, 1,340-48,530) copies/mL. HIV viral copies in CSF were significantly higher than in plasma at the time of presentation (p = .003). ART regimen switch was done after identification of HIV CSF escape. Seventeen patients were alive with a regular follow-up of average 35 (range 7-66) months. All had documented clinical improvement with reversal of neurological impairment after ART switch. There was one death and one lost to follow-up. Early identification and timely intervention in CSF viral escape could revert severe neurological impairment and improves treatment outcome.
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Affiliation(s)
- Ravinder Kaur Sachdeva
- Antiretroviral Treatment Centre (ARTC), Department of Internal Medicine, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - G S R S N K Naidu
- Antiretroviral Treatment Centre (ARTC), Department of Internal Medicine, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Pooja Chauhan
- Antiretroviral Treatment Centre (ARTC), Department of Internal Medicine, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Siftinder Kharbanda
- Antiretroviral Treatment Centre (ARTC), Department of Internal Medicine, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Jasleen Kaur
- Antiretroviral Treatment Centre (ARTC), Department of Internal Medicine, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Prashansa Joseph
- Centre of Excellence in HIV Care, Department of Internal Medicine, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Sunil Arora
- Department of Immunopathology, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | - Aman Sharma
- Antiretroviral Treatment Centre (ARTC), Department of Internal Medicine, Postgraduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
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Khullar A, Dhir V, Saikia B, Yadav AK, Leishangthem B, Prasad CB, Jayaprakash S, Jain S, Naidu GSRSNK, Sharma SK, Sharma A, Jain S. Rheumatoid arthritis synovial fluid shows enrichment of T-cells producing GMCSF which are polyfunctional for TNFα and IFNγ. Clin Exp Rheumatol 2024:20310. [PMID: 38372731 DOI: 10.55563/clinexprheumatol/dyjbvf] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 01/04/2024] [Indexed: 02/20/2024]
Abstract
OBJECTIVES GMCSF+T-cells may be involved in pathogenesis of rheumatoid arthritis (RA), and polyfunctionality may be a marker of pathogenicity. Although, higher frequencies of CD4+GMCSF+ T-cells have been reported, there are no data on CD8+GMCSF+ T-cells or polyfunctionality.Our objective was to enumerate frequencies of CD8+GMCSF+ T cells in RA blood and synovial fluid (SF), and assess their polyfunctionality, memory phenotype and cytotoxic ability. METHODS This study included RA patients (blood samples,in some with paired synovial fluid (SF)), healthy controls (HC) (blood) and SpA patients (SF). In some RA patients' blood was sampled twice, before and 16-24 weeks after methotrexate (MTX) treatment. After mononuclear cell isolation from blood and SF, ex-vivo stimulation using PMA/Ionomycin was done, and cells were stained (surface and intracellular after permeabilisation/fixation). Subsequently, frequencies of GMCSF+CD8+ and CD4+ T-cells, polyfunctionality (TNFα, IFNγ, IL-17), phenotype (memory) and perforin/granzyme expression were assessed by flowcytometry. RESULTS There was no significant difference in frequencies of GMCSF+CD8+ (3.7, 4.1%, p=0.540) or GMCSF+CD4+ T-cells (4.5, 5.2%, p=0.450) inblood of RA and HC. However, there was significant enrichment of both CD8+GMCSF+ (5.8, 3.9%, p=0.0045) and CD4+GMCSF+ (8.5, 4.5%, p=0.0008) T-cells inSF compared to blood in RA patients. Polyfunctional triple cytokine positive TNFα+IFNγ+GMCSF+CD8+T-cells (81, 36%, p=0.049) and CD4+T-cells (48, 32%, p=0.010) was also higher in SF compared to blood in RA. CD8+ T cells showed higher frequency of effector-memory phenotype and granzyme-B expression in RA-SF. On longitudinal follow-up, blood CD4+GMCSF+ T-cells significantly declined (4.6, 2.9%, p=0.0014) post-MTX. CONCLUSIONS We report a novel finding of enrichment of CD8+GMCSF+ in addition to CD4+GMCSF+ T-cells in RA-SF. These cells showed higher polyfunctionality for TNFα and IFNγ, and effector memory phenotype suggesting their involvement in RA pathogenesis.
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Affiliation(s)
- Aastha Khullar
- Division of Rheumatology, Department of Internal Medicine, PGIMER, Chandigarh, India
| | - Varun Dhir
- Division of Rheumatology, Department of Internal Medicine, PGIMER, Chandigarh, India.
| | - Biman Saikia
- Department of Immunopathology, PGIMER, Chandigarh, India
| | - Ashok Kumar Yadav
- Department of Experimental Medicine and Biotechnology, PGIMER, Chandigarh, India
| | | | | | - Sankar Jayaprakash
- Division of Rheumatology, Department of Internal Medicine, PGIMER, Chandigarh, India
| | - Siddharth Jain
- Division of Rheumatology, Department of Internal Medicine, PGIMER, Chandigarh, India
| | - G S R S N K Naidu
- Division of Rheumatology, Department of Internal Medicine, PGIMER, Chandigarh, India
| | - Shefali K Sharma
- Division of Rheumatology, Department of Internal Medicine, PGIMER, Chandigarh, India
| | - Aman Sharma
- Division of Rheumatology, Department of Internal Medicine, PGIMER, Chandigarh, India
| | - Sanjay Jain
- Division of Rheumatology, Department of Internal Medicine, PGIMER, Chandigarh, India
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Hampannavar M, Naidu GSRSNK, Sharma V, Sinha A, Dhir V, Sharma SK, Sharma A, Jain S. Prevalence and patterns of inflammatory arthritis and fibromyalgia in inflammatory bowel disease: A single-center, cross-sectional study. Indian J Gastroenterol 2024; 43:271-273. [PMID: 37466881 DOI: 10.1007/s12664-023-01406-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Affiliation(s)
- Mahesh Hampannavar
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - G S R S N K Naidu
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160 012, India.
| | - Vishal Sharma
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Anindita Sinha
- Department of Radio-Diagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Varun Dhir
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Shefali K Sharma
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Aman Sharma
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Sanjay Jain
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160 012, India
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Mishra S, Taneja S, De A, Verma N, Premkumar M, Naidu GSRSNK, Sharma A, Duseja A, Dhiman RK, Singh V. Efficacy, Tolerability, and Compliance of Direct Acting Antivirals in Patients with HIV and Hepatitis C Coinfection: A Real-Life Experience. AIDS Res Hum Retroviruses 2023; 39:453-458. [PMID: 36511384 DOI: 10.1089/aid.2022.0034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Effective management of HIV and hepatitis C virus (HCV) coinfection warrants special emphasis on interactions between direct acting antivirals (DAAs) and antiretroviral therapy (ART) along with maintenance of treatment compliance. All HIV-HCV coinfected adult patients (2015-2020) were included in this real-life retrospective study. Prevalence of coinfection, proportion of coinfected patients treated, compliance rate, sustained virological response at week 12 (SVR12) after the end of therapy, and adverse events were assessed. Among 4578 HIV patients, 232 (5.1%) had HCV coinfection. Ninety-two (39.7%) were intravenous drug users. One hundred twenty-eight (55.1%) patients presented to the liver clinic. Seventy-six (32.8%) patients [mean age: 36.6 ± 10.4 years; 65 (85.5%) males; mean CD4 count: 396 ± 246 cells/mL] completed DAA therapy, whereas 52 (22.4%) patients defaulted and 75 (32.3%) were lost to follow-up. Sixty-seven (82.2%) patients had chronic hepatitis and 9 (11.8%) had compensated cirrhosis. Median (range) HCV-RNA was 5.9 × 106 IU/mL (2.4 × 105-9.9 × 105). Among 15 (19.5%) treatment experienced patients, 14 were pegylated interferon experienced and one was NS5A-inhibitor experienced. ART regimens comprised a combination of tenofovir (T), lamivudine (L), efavirenz (E), nevirapine (N), and/or zidovudine (Z) at dosage and modifications as applicable [TLE: 63 (82.9%), ZLN:11 (14.5%), and ZLE: 2 (2.6%)]. Overall, 74 (97.4%) out of 76 patients who completed DAA therapy achieved SVR12. Adverse events were minor and well-tolerated. HIV-HCV-coinfected patients demonstrate excellent SVR12 and tolerability with available DAAs, with no major adverse events.
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Affiliation(s)
- Saurabh Mishra
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arka De
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nipun Verma
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Madhumita Premkumar
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - G S R S N K Naidu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aman Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Radha Krishan Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Virendra Singh
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Shrivastava A, Jain S, Damaraju V, Naidu GSRSNK, Dhir V, Rathi M, Grover S, Jain S, Sharma A. Severity and determinants of psychosocial comorbidities in granulomatosis with polyangiitis and their impact on quality of life. Rheumatol Int 2023:10.1007/s00296-023-05341-2. [PMID: 37160468 DOI: 10.1007/s00296-023-05341-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 05/02/2023] [Indexed: 05/11/2023]
Abstract
Depression, anxiety, sleep disturbances, and fatigue are inadequately addressed comorbidities in granulomatosis with polyangiitis (GPA). We determined the prevalence, severity, determinants, and the impact of these comorbidities on quality-of-life (QoL) in GPA. This observational study included adult GPA patients; patients with RA and lupus were included as comparators. Patient Health Questionnaire-9 for depression, Generalized Anxiety Disorder 7-item scale for anxiety, Epworth Sleepiness Scale for sleep disturbances, and Fatigue Severity Scale for fatigue were administered prospectively to estimate prevalence and severity. QoL and disability were estimated using PROMIS-HAQ, HAQ-health and HAQ-pain. Correlations among these parameters were assessed. Stepwise regression analyses were performed to identify determinants of depression, anxiety, excessive sleepiness, and fatigue. One hundred eighty-one patients-62 GPA [mean age 43 (13) years], 57 RA and 62 SLE- were included. The prevalence of depression (47%), excessive sleepiness (21%), and fatigue (39%) in GPA were comparable to RA and lupus; anxiety was less prevalent (29% versus 46% and 53%, p = 0.02). Severity was mostly mild-moderate. Younger age [OR = 0.93 (0.89-0.98)], higher BMI [OR = 1.2 (1.0-1.4)], and greater disease damage [OR = 2.0 (1.3-3.3)] independently predicted presence of depression. Higher BMI [OR = 1.3 (1.1-1.5)] and concomitant FMS [OR = 80.9 (5.1-1289.2)] were independently associated with excessive sleepiness. No association with disease activity, duration, or gender was seen. GPA patients with depression, anxiety, excessive sleepiness, and fatigue had worse PROMIS-HAQ, HAQ-pain, and HAQ-health. In conclusion, depression, anxiety, sleep disturbances, and fatigue are common in GPA. Although their severity is mostly mild-moderate, they impair QoL significantly. Potentially modifiable determinants that can form targets for future interventions have been identified.
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Affiliation(s)
- Abhinav Shrivastava
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Siddharth Jain
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikram Damaraju
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - G S R S N K Naidu
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Varun Dhir
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Manish Rathi
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sandeep Grover
- Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanjay Jain
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aman Sharma
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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Dhir V, Prasad CB, Kumar S, Kaul KK, Dung N, Naidu GSRSNK, Sharma SK, Sharma A, Jain S. Long-term persistence of oral methotrexate and associated factors in rheumatoid arthritis: a retrospective cohort study. Rheumatol Int 2023; 43:867-873. [PMID: 36933068 DOI: 10.1007/s00296-023-05305-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 03/02/2023] [Indexed: 03/19/2023]
Abstract
There is little data on long-term persistence/continuation of methotrexate among Indian Rheumatoid arthritis patients. We assembled a retrospective single-center cohort consisting of RA patients (fulfilling 1987 ACR criteria) started on methotrexate as part of three academic studies (including two RCTs) from 2011 to 2016. Oral methotrexate was started at 7.5 or 15 mg per week with a target dose of 25 mg per week. Between August and December 2020, all patients were contacted (telephonically) and data were obtained from clinic files to evaluate self-reported continuation/persistence of methotrexate and reasons for discontinuation. Survival analysis using Kaplan-Meier and cox-regression were used to assess methotrexate continuation rates and factors associated with its discontinuation. This study included 317 patients with rheumatoid arthritis, with mean age and disease duration (at enrollment) of 43 years and 2 years; And positive rheumatoid factor and anti-CCP in 69 and 75%. At follow-up, 16 patients (5%) had died, whereas 103 (32.5%) had discontinued methotrexate. On Kaplan-Meier survival analysis, the mean survival (continuation) time for methotrexate was 7.3 years (95% CI 7-7.6 years). The actuarial continuation/persistence of methotrexate at 3, 5 and 9 years was 92, 81 and 51%, respectively. Among those who discontinued methotrexate, common reasons were remission of disease, symptomatic adverse effects (intolerance), perceived lack of efficacy and socioeconomic reasons. On multivariable cox-regression, symptomatic adverse effects during the first 12-24 weeks (Hazard ratio, 95% CI 1.8 (1.2-2.8)) and anti-CCP positivity (Hazard ratio, 95% CI 0.6 (0.3-1.0)) were significantly associated with hazard of discontinuation. Persistence or continuation of methotrexate was found to be good and comparable to reports in other centers world-wide. Apart from remission, the most important cause of methotrexate discontinuation was symptomatic adverse effects (intolerance).
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Affiliation(s)
- Varun Dhir
- Clinical Immunology and Rheumatology Unit, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India.
| | - Chandra Bhushan Prasad
- Clinical Immunology and Rheumatology Unit, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Sandeep Kumar
- Clinical Immunology and Rheumatology Unit, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Kavya Kriti Kaul
- Clinical Immunology and Rheumatology Unit, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Neha Dung
- Clinical Immunology and Rheumatology Unit, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - G S R S N K Naidu
- Clinical Immunology and Rheumatology Unit, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Shefali K Sharma
- Clinical Immunology and Rheumatology Unit, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Aman Sharma
- Clinical Immunology and Rheumatology Unit, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Sanjay Jain
- Clinical Immunology and Rheumatology Unit, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
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Samanta J, Naidu GSRSNK, Sood R, Nada R, Sharma A, Jain S. Calcinosis cutis with amyopathic dermatomyositis. QJM 2022; 115:613-614. [PMID: 35731215 DOI: 10.1093/qjmed/hcac148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- J Samanta
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - G S R S N K Naidu
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - R Sood
- Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - R Nada
- Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
| | - A Sharma
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India.
| | - S Jain
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India
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Jain S, Dhir V, Leishangthem B, Kalyan M, Verma I, Naidu G, Sharma SK, Sharma A, Jain S. AB0417 SHORT-TERM EFFECT OF METHOTREXATE ON APOLIPOPROTEINS AND LIPID PROFILE IN PATIENTS WITH ACTIVE RHEUMATOID ARTHRITIS. Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.4367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BackgroundMethotrexate (MTX) forms the first line therapy for rheumatoid arthritis (RA). The cardioprotective effect of MTX is well established, but whether this is just due to control of inflammation, or is also via an effect on serum lipoproteins, is unclear. Although a few studies have studied the effect of the MTX on the traditional lipid profile in RA1, there is no data on the effect of MTX on apolipoproteins (Apo A1, Apo B, ApoB/ApoA1), which are considered better cardiovascular risk predictors than the traditional lipid profile.ObjectivesTo determine the short-term effect of MTX on apolipoproteins and traditional lipid profile in patients with active RA.MethodsDMARD-naïve patients with active RA (SJC≥2 and TJC≥4) who had been enrolled in the multicentre, RCT comparing two different MTX escalation strategies in RA (MEIRA)2 and for whom paired serum samples were available before and after MTX treatment were included. All these patients received MTX monotherapy started at 15 mg/week and escalated to 25 mg/week by 4-8 weeks. Serum levels of apolipoprotein A1 (Apo A1), apolipoprotein B (Apo B), total cholesterol (TC), low-density lipoprotein (LDL), high-density lipoprotein (HDL), and triglycerides (TG) were measured before starting MTX and after 16 weeks of MTX monotherapy. Proatherosclerotic indices (TC/HDL and ApoB/ApoA1) were also calculated.ResultsA total of 103 patients [mean age 40 (8) years, 93 (90%) females, mean BMI 25.1 (4.8) kg/m2, all non-smokers and non-alcoholics] were included. No study participant had comorbid diabetes mellitus or coronary artery disease; none of them were taking glucocorticoids or hypolipidemic drugs. An increase in Apo A1 levels [by a mean of 5.6 mg/dL (p=0.02)], and HDL levels [by a mean of 1.6 mg/dL (p=0.04)] was seen after 16 weeks of MTX monotherapy. Although a numerical increase in levels of TC (mean 4.6 mg/dL, p=0.07), LDL (mean 2 mg/dL, p=0.34) and TG (mean 6.6 mg/dL, p=0.35) was also noted, none of these were statistically significant. No obvious change in Apo B levels and TC/HDL ratio occurred due to MTX therapy. However, the ApoB/ApoA1 ratio decreased significantly from 0.8 to 0.7 (p=0.002) with 16 weeks of MTX therapy (Table 1).Table 1.Baseline and end of treatment values of apolipoprotein A1 (Apo A1), apolipoprotein B (Apo B), total cholesterol (TC), low-density lipoprotein (LDL), high-density lipoprotein (HDL), triglycerides (TG), and proatherosclerotic indices (TC/HDL and ApoB/ApoA1).Parameter (mg/dL)BaselineAfter 16 weeks of MTX therapyp-valueApo A1126.0 (25.1)131.6 (23.4)0.02Apo B92.3 (18.9)92.0 (20.9)0.84ApoB/ApoA10.8 (0.2)0.7 (0.2)0.002TC164.5 (32.4)169.1 (36.8)0.07HDL40.9 (9.8)42.5 (9.7)0.04TC/HDL4.2 (1.1)4.1 (1.1)0.34LDL88.8 (25.2)90.8 (29.8)0.34TG139.8 (69.6)146.4 (91.3)0.35All values represented as mean (SD).Apo A1=apolipoprotein A1, ApoB=apolipoprotein B, TC=total cholesterol, LDL=low-density lipoprotein, HDL=high-density lipoprotein, TG=triglyceridesConclusionMTX therapy led to a mild but significant increase in HDL, ApoA1 and a reduction in ApoB/ApoA1 over short-term. This could potentially represent one of the mechanisms by which MTX exerts its cardioprotective effect; however, these changes need to be carefully interpreted over longer term and in context of the lipid paradox operating in RA.References[1]Navarro-Millán I, Charles-Schoeman C, Yang S, et al. Changes in lipoproteins associated with methotrexate or combination therapy in early rheumatoid arthritis: results from the treatment of early rheumatoid arthritis trial. Arthritis Rheum. 2013;65(6):1430-1438.[2]Jain S, Dhir V, Aggarwal A, et al. Comparison of two dose escalation strategies of methotrexate in active rheumatoid arthritis: a multicentre, parallel group, randomised controlled trial. Ann Rheum Dis. 2021;80(11):1376-1384.Disclosure of InterestsNone declared
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Jain S, Dhir V, Aggarwal A, Gupta R, Leishangthem B, Naidu G, Khullar A, Dhawan V, Sharma SK, Sharma A, Jain S. POS0566 PREDICTORS OF RESPONSE TO METHOTREXATE MONOTHERAPY IN ACTIVE RHEUMATOID ARTHRITIS: RESULTS FROM A MULTICENTRE, RANDOMIZED CONTROLLED TRIAL (MEIRA). Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.4257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BackgroundMethotrexate (MTX) is the gold standard, first-line therapy for rheumatoid arthritis (RA). However, not all patients respond to MTX, and the predictors of its response or non-response have not yet been reliably identified. Identification of these predictors will facilitate personalized therapeutic choices, and improve patient outcomes.ObjectivesTo identify the clinico-laboratory predictors of response to MTX monotherapy in active RA.MethodsThis study included patients with active RA (SJC≥2 and TJC≥4) aged 18-55 years, with disease duration <5 years, who were not receiving DMARDs (except HCQ and low-dose prednisolone) and had been enrolled in the multicentre, parallel group RCT comparing two different MTX escalation strategies in RA (MEIRA)1. All these patients received MTX monotherapy which was started at 15 mg/week, escalated to 25 mg/week by 4-8 weeks, and continued till 16 weeks. MTX response was defined as EULAR good or moderate response (based on DAS28-CRP-3v) at 16 weeks. Stepwise, multivariable logistic regression was done using key demographic (age, gender, BMI, comorbidities), clinical (disease duration, DAS28, HAQ), and laboratory parameters (RF, anti-CCP, ESR, CRP, RBC MTX-polyglutamates 1-4, IL-6, MMP-3) as independent variables to identify predictors of MTX response. A two-tailed p-value <0.05 was used for defining statistical significance. (Trial Reg: CTRI/2018/12/016549)ResultsOut of a total of 178 included patients [84% females, mean age 40 (9) years, mean DAS28-CRP=5.4 (1.1)], 113 (63.5%) were classified as MTX responders at 16 weeks. Age (OR=0.95, p=0.01), BMI (OR=1.12, p=0.006), and RF (OR=0.34, p=0.045) were found to be independent predictors of MTX response on multivariable analysis (Table 1). On sensitivity analysis with DAS28-ESR-based EULAR response, age (OR=0.94, p=0.003) and RF (OR=0.42, p=0.059) were replicated as independent predictors of MTX response, in addition to pre-treatment swollen joint count (OR=0.94, p=0.05).Table 1.Results of multivariable logistic regression analysis for prediction of response (as defined by DAS28-CRP-based EULAR good or moderate response) to methotrexate monotherapy in RAVariableOR (unadjusted)Unadjusted p-valueOR (adjusted)Adjusted p-valueAge0.97 (0.93-1.002)0.060.95 (0.91-0.99)0.01Male sex0.78 (0.35-1.76)0.55-BMI1.1 (1.02-1.19)0.011.12 (1.03-1.22)0.006Presence of comorbidities0.67 (0.31-1.44)0.31-Disease duration0.98 (0.79-1.22)0.87-Baseline DAS281.1 (0.81-1.49)0.54-Baseline HAQ1.04 (0.66-1.64)0.86-Baseline TJC1.01 (0.96-1.05)0.72-Baseline SJC0.97 (0.91-1.02)0.24-Baseline ESR1.01 (1.00-1.02)0.27-Baseline CRP1.00 (0.99-1.01)0.85-RF positive0.31 (0.11-0.85)0.020.34 (0.12-0.98)0.045Anti-CCP positive0.73 (0.27-1.99)0.54-MTX PG1 (16 weeks)0.99 (0.94-1.04)0.69-MTX PG2 (16 weeks)0.98 (0.95-1.02)0.37-MTX PG3 (16 weeks)0.99 (0.96-1.02)0.43-MTX PG4 (16 weeks)0.99 (0.95-1.03)0.62-Serum IL-6 (baseline)0.98 (0.95-1.02)0.33-Serum MMP-3 (baseline)1.00 (1.00-1.00)0.48-BMI= Body Mass Index, CCP= Cyclic Citrullinated Peptides, CRP= C-reactive protein, DAS= Disease Activity Score, ESR= Erythrocyte Sedimentation Rate, HAQ= Health Assessment Questionnaire, MTX= Methotrexate, PG= polyglutamate, OR=Odds Ratio, RF=Rheumatoid Factor, SJC= Swollen Joint Count, TJC= Tender Joint CountNote: Only variables with p-value <0.2 on univariable analysis were included in the multivariable analysis.ConclusionYounger age, RF negativity, higher BMI, and lower pre-treatment swollen joint count are potential predictors of response to MTX monotherapy in RA.References[1]Jain S, Dhir V, Aggarwal A, et al. Comparison of two dose escalation strategies of methotrexate in active rheumatoid arthritis: a multicentre, parallel group, randomised controlled trial. Ann Rheum Dis. 2021;80(11):1376-1384.Disclosure of InterestsNone declared.
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Prabhahar A, Naidu GSRSNK, Chauhan P, Sekar A, Sharma A, Sharma A, Kumar A, Nada R, Rathi M, Kohli HS, Ramachandran R. ANCA-associated vasculitis following ChAdOx1 nCoV19 vaccination: case-based review. Rheumatol Int 2022; 42:749-758. [PMID: 35124725 PMCID: PMC8817770 DOI: 10.1007/s00296-021-05069-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 12/11/2021] [Indexed: 02/06/2023]
Abstract
For the foreseeable future, vaccines are the cornerstone in the global campaign against the Coronavirus Disease-19 (COVID-19) pandemic. As the number and fatalities due to COVID-19 decline and the lockdown anywise rescinded, we recognize an increase in the incidence of autoimmune disease post-COVID-19 vaccination. However, the causality of the most vaccine-induced side effects is debatable and, at best, limited to a temporal correlation. We herein report a case of a 51-year-old gentleman who developed Anti-Neutrophil Cytoplasmic Antibody (ANCA)-associated vasculitis (AAV) 2 week post-COVID-19 vaccination. The patient responded favorably to oral steroids and rituximab. Additionally, we conducted a case-based review of vaccine-associated AAV describing their clinical manifestations and treatment response of this emerging entity.
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Affiliation(s)
- Arun Prabhahar
- Department of Nephology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - G S R S N K Naidu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Prabhat Chauhan
- Department of Nephology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aravind Sekar
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aman Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | | | - Ritambhra Nada
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Manish Rathi
- Department of Nephology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Harbir Singh Kohli
- Department of Nephology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Raja Ramachandran
- Department of Nephology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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Sharma A, Naidu GSRSNK, Deo P, Beck DB. VEXAS syndrome with systemic lupus erythematosus: expanding the spectrum of associated conditions. Arthritis Rheumatol 2022; 74:369-371. [PMID: 34463053 PMCID: PMC8795469 DOI: 10.1002/art.41957] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 08/10/2021] [Accepted: 08/12/2021] [Indexed: 02/03/2023]
Affiliation(s)
- Aman Sharma
- Department of Internal Medicine – Rheumatology wing, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - GSRSNK Naidu
- Department of Internal Medicine – Rheumatology wing, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Prateek Deo
- Department of Internal Medicine – Rheumatology wing, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - David B. Beck
- Inflammatory Disease Section, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
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Relangi HSK, Naidu GSRSNK, Sharma V, Kumar M, Dhir V, Sharma SK, Sharma A, Minz RW, Jain S. Association of immunological features with clinical manifestations in primary Sjogren's syndrome: a single-center cross-sectional study. Clin Exp Med 2021; 22:613-620. [PMID: 34762228 DOI: 10.1007/s10238-021-00772-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 10/27/2021] [Indexed: 11/28/2022]
Abstract
The objectives of this study were to describe the clinical features and evaluate the utility of immunological features as predictors of organ involvement and disease severity in patients with primary Sjogren's syndrome (pSS). In this single-center observational cross-sectional study, subjects fulfilling the 2012 AECG criteria or 2016 ACR/EULAR criteria for pSS were included. Details of glandular, extra-glandular manifestations, ESSDAI, ESSPRI, ANA, anti-Ro/La antibodies, rheumatoid factor (RF), complement (C3 and C4) levels and hyperglobulinemia were noted. Chi-square and Mann-Whitney U tests were performed for determining associations and relative risk (RR) was calculated. Sixty-four subjects with pSS were included in the study. Females constituted 92% and median age at onset was 37.5 (15-74) years. Ocular or oral sicca was noted in 61 (95.3%) subjects and parotidomegaly was noted in 17 (26.5%) subjects. Extra-glandular manifestations noted were: constitutional (85.9%), articular (65.6%), renal (29.6%), hematological (26.6%), cutaneous (12.5%), peripheral nerves (9.3%) and pulmonary (4.7%). Immunological features noted were: ANA (85.9%), anti-Ro (81.3%), anti-La (60.9%), RF (84.4%), hypocomplementemia (39.1%) and hyperglobulinemia (62.5%). Median ESSDAI was 6 (0-23) and ESSPRI was 7 (0-10). ANA was associated with younger age and renal involvement (RR 1.25). Anti-Ro was associated with younger age, renal involvement (RR 1.36) and high ESSDAI. Anti-La was associated with high renal (RR 3.4) and low articular involvement (RR 2.75). RF was associated with hematological involvement and hyperglobulinemia was associated with younger age. Certain immunological features can help predict the organ involvement in patients with pSS. Larger, prospective follow-up studies are needed to clearly understand these associations.
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Affiliation(s)
| | - G S R S N K Naidu
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
| | - Vikas Sharma
- Department of Internal Medicine, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
| | - Mahendra Kumar
- Department of Immunopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Varun Dhir
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shefali K Sharma
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aman Sharma
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ranjana W Minz
- Department of Immunopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanjay Jain
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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van Heerden J, Esterhuizen TM, Hendricks M, Poole J, Büchner A, Naidu G, du Plessis J, van Emmenes B, van Zyl A, Mathews E, Kruger M. The Association of Clinical Characteristics and Tumour Markers With Image-Defined Risk Factors in the Management of Neuroblastoma in South Africa. Clin Oncol (R Coll Radiol) 2021; 34:e149-e159. [PMID: 34750056 DOI: 10.1016/j.clon.2021.10.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 10/04/2021] [Accepted: 10/22/2021] [Indexed: 12/18/2022]
Abstract
AIMS Image-defined risk factors (IDRFs) in neuroblastoma predict surgical complications and management outcomes. As there is a lack of data regarding the association of IDRFs with clinical and pathological factors, this study evaluated the prognostic value of IDRFs to predict neuroblastoma survival outcomes. MATERIALS AND METHODS This was a retrospective study including 345 patients and reviewed diagnostic imaging for 20 IDRFs, pleural effusions and ascites. The IDRFs were grouped into five 'primary IDRFs' cohorts with vascular encasement, involvement of multiple body compartments, organ infiltration, airway obstruction and intraspinal extension. The association between clinical, histopathological and biological characteristics of neuroblastoma and management was evaluated. RESULTS More patients without IDRFs had operations compared with patients with IDRFs, with a trend towards significance (64.4% versus 35.6%, P = 0.082). Patients with multiple compartment tumour involvement (P = 0.003) and organ infiltration (P < 0.001) had a higher risk of surgical complications. The 5-year overall survival of the group with more than one IDRF was 0.0% and those with pleural effusions or ascites 6.7%, associated with the worst outcome (P = 0.005). The total number of IDRFs was not predictive of the metastatic remission rate (P = 0.585) or overall survival (P = 0.142), with no conclusive association found between IDRF groups and clinical or biological markers. CONCLUSIONS Patients with more than one IDRF had the shortest survival time, whereas those with pleural effusions and ascites at diagnosis had a poor outcome. Standardised reporting of IDRFs is crucial for predicting prognosis.
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Affiliation(s)
- J van Heerden
- Paediatric Haematology and Oncology, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Hospital, Cape Town, South Africa; Paediatric Haematology and Oncology, Department of Paediatrics, Antwerp University Hospital, Antwerp, Belgium.
| | - T M Esterhuizen
- Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - M Hendricks
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; Paediatric Haematology and Oncology Service, Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - J Poole
- Faculty of Health Sciences, Division of Paediatric Haematology and Oncology, Department of Paediatrics and Child Health, University of the Witwatersrand, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
| | - A Büchner
- Paediatric Haematology and Oncology, Department of Paediatrics, University of Pretoria, Steve Biko Academic Hospital, Pretoria, South Africa
| | - G Naidu
- Faculty of Health Sciences, Division of Paediatric Haematology and Oncology, Department of Paediatrics and Child Health, University of the Witwatersrand, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
| | - J du Plessis
- Department of Paediatrics, Faculty of Health Sciences, University of the Free State, Division of Paediatric Haematology and Oncology, Universitas Hospital, Bloemfontein, South Africa
| | - B van Emmenes
- Division of Paediatric Haematology and Oncology Hospital, Department of Paediatrics, Frere Hospital, East London, South Africa
| | - A van Zyl
- Paediatric Haematology and Oncology, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Hospital, Cape Town, South Africa
| | - E Mathews
- Paediatric Haematology Oncology, Department of Paediatrics and Child Health, Port Elizabeth Provincial Hospital, Walter Sisulu University, Port Elizabeth, South Africa
| | - M Kruger
- Paediatric Haematology and Oncology, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg Hospital, Cape Town, South Africa
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Jain S, Dhir V, Aggarwal A, Maurya S, Gupta R, Leishangthem B, Khullar A, Dhawan V, Naidu G, Sharma SK, Sharma A, Jain S. AB0276 HOW FAST CAN METHOTREXATE BE ESCALATED IN RHEUMATOID ARTHRITIS? A MULTICENTRE, PARALLEL-GROUP RANDOMIZED CONTROLLED TRIAL (MEIRA). Ann Rheum Dis 2021. [DOI: 10.1136/annrheumdis-2021-eular.3864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
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/2018/12/016549Results: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 outcomesParameterUsualFastp-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 studyITT= intention-to-treat, PP=per-protocol, AE=adverse effectFigure 1.EULAR response and change in DAS28ESR-3 over timeConclusion: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):1086–93Disclosure of Interests:None declared
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Kumar RR, Jha S, Dhooria A, Naidu GSRSNK, Minz RW, Kumar S, Sharma SK, Sharma A, Jain S, Dhir V. Anti-Jo-1 Syndrome Often Misdiagnosed as Rheumatoid Arthritis (for Many Years): A Single-Center Experience. J Clin Rheumatol 2021; 27:150-155. [PMID: 31895110 DOI: 10.1097/rhu.0000000000001234] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Antisynthetase syndrome is characterized by a triad of myositis, arthritis, and interstitial lung disease. Anti-Jo-1 is the most common associated autoantibody. This study planned to look at the presentation of anti-Jo-1 antisynthetase syndrome in a single Indian center. METHODS AND MATERIALS This was a medical records review single-center study that included patients with anti-Jo-1 antisynthetase syndrome over 10 years. RESULTS This study included 27 patients with anti-Jo-1 antisynthetase syndrome, with mean age of 40 ± 9.2 years and female preponderance (female-to-male ratio, 4:1). At presentation, the characteristic triad was present in only 4 patients. A majority presented with the incomplete form, with 2 clinical features (of triad) in 11 and single feature (of triad) being present in 12 patients at initial presentation. Seven presented only with polyarthritis, out of which 6 had been earlier diagnosed as rheumatoid arthritis. Time gap from diagnosis of "rheumatoid arthritis" to antisynthetase syndrome ranged from 3 to 20 years. In patients who had only arthritis in the beginning, there was a significantly longer delay to diagnosis of antisynthetase syndrome, higher frequency of rheumatoid factor, and lower frequency of anti-Ro-52. Overall, outcome was good, with Eastern Cooperative Oncology Group class 1 or 2 in most except 2 patients. CONCLUSIONS Anti-Jo-1 antisynthetase syndrome commonly presented as incomplete (not a triad) and often only with arthritis. These patients are diagnosed and treated as rheumatoid arthritis for many years, before a diagnosis of antisynthetase syndrome is made. Being aware of this presentation may help in earlier diagnosis by actively searching for subtle clues.
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Affiliation(s)
- Rajiv Ranjan Kumar
- From the Clinical Immunology and Rheumatology Division, Department of Internal Medicine
| | - Saket Jha
- From the Clinical Immunology and Rheumatology Division, Department of Internal Medicine
| | - Aadhaar Dhooria
- From the Clinical Immunology and Rheumatology Division, Department of Internal Medicine
| | - G S R S N K Naidu
- From the Clinical Immunology and Rheumatology Division, Department of Internal Medicine
| | - Ranzana W Minz
- Department of Immunopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Susheel Kumar
- From the Clinical Immunology and Rheumatology Division, Department of Internal Medicine
| | - Shefali Khanna Sharma
- From the Clinical Immunology and Rheumatology Division, Department of Internal Medicine
| | - Aman Sharma
- From the Clinical Immunology and Rheumatology Division, Department of Internal Medicine
| | - Sanjay Jain
- From the Clinical Immunology and Rheumatology Division, Department of Internal Medicine
| | - Varun Dhir
- From the Clinical Immunology and Rheumatology Division, Department of Internal Medicine
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Dhir V, V D, Jain S, Pai V, Sharma A, Sharma SK, Naidu G, Jain S. POS0679 A NEW QUESTIONNAIRE AND SCORE (MISA) FOR ASSESSING METHOTREXATE INTOLERANCE IN RHEUMATOID ARTHRITIS. Ann Rheum Dis 2021. [DOI: 10.1136/annrheumdis-2021-eular.4241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
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)<0.001a Available for 262 patients bAvailable for 372 patientsFigure 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
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Teo YH, Naidu G, Tay ELW. Invasive monitoring and dosing strategy to mitigate risks of general anaesthesia in a patient with connective tissue disease and pulmonary arterial hypertension. QJM 2021; 114:206-208. [PMID: 32706889 DOI: 10.1093/qjmed/hcaa230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 07/14/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Y H Teo
- National University of Singapore, Yong Loo Lin School of Medicine, 10 Medical Drive, Singapore 117597, Singapore
| | - G Naidu
- Department of Orthopaedics, Raffles Hospital, 585 North Bridge Road, Singapore 188770, Singapore
| | - E L-W Tay
- Department of Cardiology, National University Heart Centre Singapore, 1E Kent Ridge Road, NUHS Tower Block Level 9, Singapore 119228, Singapore
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Samanta J, Naidu G, Chattopadhyay A, Basnet A, Narang T, Dogra S, Sharma A. AB0545 COMPARISON BETWEEN METHOTREXATE AND APREMILAST IN PSORIATIC ARTHRITIS-A SINGLE BLINDED RANDOMIZED CONTROLLED TRIAL (APREMEPsA STUDY). Ann Rheum Dis 2021. [DOI: 10.1136/annrheumdis-2021-eular.1850] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background:Both methotrexate and apremilast were found to be effective in controlling joint disease in psoriatic arthritis (PsA) patients [1-4]. However, there are no head-to-head trials comparing the efficacy of these two drugs in PsA.Objectives:Primary outcome measure was rate of major cDAPSA response (>85% change in cDAPSA score from baseline) at week 24 and secondary outcome measures were ACR 20 response, change in Psoriasis Area and Severity Index (PASI), Maastricht enthesitis score, Leeds dactylitis index, and health assessment questionnaire-disability index (HAQ-DI) and number of adverse events at week 24 between methotrexate and apremilast groups.Methods:Single blinded (physician), parallel group, randomized controlled trial was conducted at a single centre in India between October 2019 and December 2020. Adult PsA patients (age>18 years), fulfilling CASPAR criteria, not receiving methotrexate/apremilast in last 3 months and never receiving bDMARDs or, JAK inhibitors, having active articular disease (one or more swollen joint or, having one or more tender entheseal point) were recruited in this study.Results:A total of 31 patients were recruited (15 in apremilast arm and 16 in methotrexate arm) amongst whom 26 patients completed 24 weeks follow up (13 patients in apremilast arm and 13 patients in methotrexate arm). At baseline, median (IQR) swollen joints were 2 (1) in apremilast group and 2.5 (4) in methotrexate group. Median cDAPSA score at baseline was 23 (9) in apremilast group and 20 (21) in methotrexate group. Major cDAPSA response at week 24 was achieved in three (20%) subjects in apremilast arm and six (37.5%) subjects in methotrexate arm (p=0.433). Seven (46.67%) subjects in apremilast group and nine (56.25%) subjects in methotrexate group achieved ACR 20 response at 24-weeks (p=0.724). The change of PASI score from baseline was significant in apremilast group (2.0, p=0.003) and methotrexate group (0.35, p=0.003), but when compared between the two groups, there was no significant difference(p=0.378). Change in enthesitis score was not significant in both the groups (0.0 in apremilast group, p=0.285; 0.0 in methotrexate group, p=1.0). The median change in dactylitis score [0.0 (9.1), p=0.028] and HAQ-DI score (0.33, p=0.01) were significant in methotrexate group only. However, when compared to the change in apremilast group, the difference was not significant for both the parameters. A total of 9 minor adverse events, 3 with apremilast and 6 with methotrexate, were observed with transaminitis (number of events) being the commonest event noted with methotrexate. There were no serious adverse events noted in either of the groups.Conclusion:There was no significant difference between methotrexate and apremilast in terms of efficacy as measured by cDAPSA and ACR20 responses. Both the drugs were well tolerated by the study population. A larger study with head-to-head comparison between methotrexate and apremilast is needed to conform these findings.References:[1]Baranauskaite A, Raffayová H, Kungurov NV, et al; RESPOND investigators. Infliximab plus methotrexate is superior to methotrexate alone in the treatment of psoriatic arthritis in methotrexate-naive patients: the RESPOND study Ann Rheum Dis. 2012;71:541-8.[2]Mease PJ, Gladman DD, Collier DH, et al. Etanercept and Methotrexate as Monotherapy or in Combination for Psoriatic Arthritis: Primary Results From a Randomized, Controlled Phase III Trial. Arthritis Rheumatol 2019;71:1112-24.[3]Gladman DD, Kavanaugh A, Gómez-Reino JJ, et al. Therapeutic benefit of apremilast on enthesitis and dactylitis in patients with psoriatic arthritis: a pooled analysis of the PALACE 1-3 studies. RMD Open. 2018;4(1):e000669.[4]Wells AF, Edwards CJ, Kivitz AJ, et al. Apremilast monotherapy in DMARD-naive psoriatic arthritis patients: results of the randomized, placebo-controlled PALACE 4 trial. Rheumatology (Oxford) 2018;57:1253-63.Disclosure of Interests:None declared.
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Mishra D, Dhir V, Naidu GSRSNK, Khullar A, Kumar V, Sharma S, Sharma A, Jain S. Efficacy of a step-down regimen of oral prednisolone in axial spondyloarthritis: result of a double-blind randomized controlled trial (COBRA-AS Study). Rheumatology (Oxford) 2021; 60:1932-1941. [PMID: 33159796 DOI: 10.1093/rheumatology/keaa685] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 10/22/2020] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES To evaluate the efficacy and safety of a step-down regimen of oral prednisolone over 24 weeks in patients of axial SpA (axSpA). METHODS This proof-of-concept double-blind randomized controlled trial enrolled patients with active axSpA (BASDAI ≥4) having predominantly axial disease (≤1 active joint currently) and inadequate response to NSAIDs. They were randomized to receive either oral prednisolone (n = 32) or placebo (n = 33) at a dose of 60, 40, 30, 20, 15 and 10 mg daily for 1 week each, following which they received 5 mg prednisolone (or placebo) daily for 18 weeks. The primary endpoint was a 50% improvement in the BASDAI (BASDAI50) at week 24. Analysis was intention to treat. RESULTS A BASDAI50 was achieved by 12 of 32 patients (37.5%) in the prednisolone arm and 3 of 33 patients (9.1%) in the placebo arm at 24 weeks [difference 28.4% (95% CI 7.9, 46.7)]. However, there was no difference in achieving a 20 or 40% improvement in the Assessment of SpondyloArthritis international Society response between the groups. Although there was a significant intergroup difference in adjusted ΔBASDAI and ΔAnkylosing Spondylitis Disease Activity Score with CRP at 24 weeks, there was no difference at 12 weeks. There was also no significant difference in ΔBASFI, ΔBAS-G or ΔBASMI at 12 or 24 weeks. No serious adverse events were noted. There was significant weight gain in the first 12 weeks in the prednisolone group vs placebo [0.9 (s.d. 0.4) kg], but not at 24 weeks. CONCLUSIONS In this small study, oral prednisolone was efficacious in axSpA in achieving the primary outcome, but many crucial secondary outcomes such as functional improvement were not met. Its impact on bone loss was not studied.Trial registration: CTRI/2018/01/011342.
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Affiliation(s)
- Debashish Mishra
- Division of Rheumatology and Clinical Immunology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Varun Dhir
- Division of Rheumatology and Clinical Immunology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - G S R S N K Naidu
- Division of Rheumatology and Clinical Immunology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aastha Khullar
- Division of Rheumatology and Clinical Immunology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vishal Kumar
- Department of Orthopedics, Postgraduate Institute of Medical Education and Research, Chandigarh, Chandigarh, India
| | - Shefali Sharma
- Division of Rheumatology and Clinical Immunology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aman Sharma
- Division of Rheumatology and Clinical Immunology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanjay Jain
- Division of Rheumatology and Clinical Immunology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Sharma A, Naidu GSRSNK, Sharma V, Jha S, Dhooria A, Dhir V, Bhatia P, Sharma V, Bhattad S, KG C, Gupta V, Misra DP, Chavan PP, Malaviya S, Dudam R, Sharma B, Kumar S, Bhojwani R, Gupta P, Agarwal V, Sharma K, Singhal M, Rathi M, Nada R, Minz RW, Chaturvedi V, Aggarwal A, Handa R, Grossi A, Gattorno M, Huang Z, Wang J, Jois R, Negi VS, Khubchandani R, Jain S, Arostegui JI, Chambers EP, Hershfield MS, Aksentijevich I, Zhou Q, Lee PY. Deficiency of Adenosine Deaminase 2 in Adults and Children: Experience From India. Arthritis Rheumatol 2021; 73:276-285. [PMID: 32892503 PMCID: PMC7902299 DOI: 10.1002/art.41500] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 07/17/2020] [Accepted: 08/20/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Deficiency of adenosine deaminase 2 (DADA2) is a potentially fatal monogenic syndrome characterized by variable manifestations of systemic vasculitis, bone marrow failure, and immunodeficiency. Most cases are diagnosed by pediatric care providers, given the typical early age of disease onset. This study was undertaken to describe the clinical phenotypes and treatment response both in adults and in children with DADA2 in India. METHODS A retrospective analysis of pediatric and adult patients with DADA2 diagnosed at various rheumatology centers across India was conducted. Clinical characteristics, diagnostic findings, and treatment responses were analyzed in all subjects. RESULTS In total, 33 cases of DADA2 were confirmed in this cohort between April 2017 and March 2020. Unlike previous studies, nearly one-half of the confirmed cases presented during adulthood. All symptomatic patients exhibited features of vasculitis, whereas constitutional symptoms and anemia were more common in pediatric patients. Cutaneous and neurologic involvement were common, and 18 subjects had experienced at least one stroke. In addition, the clinical spectrum of DADA2 was expanded by recognition of novel features in these patients, including pancreatic infarction, focal myocarditis, and diffuse alveolar hemorrhage. Treatment with tumor necrosis factor inhibitors (TNFi) was initiated in 25 patients. All of the identified disease manifestations showed marked improvement after initiation of TNFi, and disease remission was achieved in 19 patients. Two cases were complicated by tuberculosis infection, and 2 deaths were reported. CONCLUSION This report presents the first case series of patients with DADA2 from India, diagnosed by adult and pediatric care providers. The findings raise awareness of this syndrome, particularly with regard to its presentation in adults.
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Affiliation(s)
- Aman Sharma
- Clinical Immunology and Rheumatology Services, Department
of Internal Medicine, Postgraduate Institute of Medical Education and Research,
Chandigarh, India
| | - GSRSNK Naidu
- Clinical Immunology and Rheumatology Services, Department
of Internal Medicine, Postgraduate Institute of Medical Education and Research,
Chandigarh, India
| | - Vikas Sharma
- Clinical Immunology and Rheumatology Services, Department
of Internal Medicine, Postgraduate Institute of Medical Education and Research,
Chandigarh, India
| | - Saket Jha
- Clinical Immunology and Rheumatology, Om Hospital and
Research Center, Kathmandu, Nepal
| | - Aaadhar Dhooria
- Department of Rheumatology Santokba Durlabhji Memorial
Hospital, Jaipur, India
| | - Varun Dhir
- Clinical Immunology and Rheumatology Services, Department
of Internal Medicine, Postgraduate Institute of Medical Education and Research,
Chandigarh, India
| | - Prateek Bhatia
- Department of Paediatrics, Postgraduate Institute of
Medical Education and Research, Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of
Medical Education and Research, Chandigarh, India
| | - Sagar Bhattad
- Department of Pediatrics ASTER CMI Hospitals, Bengaluru,
India
| | - Chengappa KG
- Department of Clinical Immunology, JIPMER, Puducherry,
India
| | - Vikas Gupta
- Department of Rheumatology, DMC, Ludhiana, India
| | - Durga Prasanna Misra
- Department of Clinical Immunology and Rheumatology, Sanjay
Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | | | | | | | | | | | - Rajesh Bhojwani
- Santokba Institute of Digestive Surgical Sciences,
Santokba Durlabhji Memorial Hospital, Jaipur, India
| | - Pankaj Gupta
- Department of Gastroenterology, Postgraduate Institute of
Medical Education and Research, Chandigarh, India
| | - Vikas Agarwal
- Department of Clinical Immunology and Rheumatology, Sanjay
Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Kusum Sharma
- Department of Medical Microbiology, Postgraduate
Institute of Medical Education and Research, Chandigarh, India
| | - Manphool Singhal
- Department of Radiodiagnosis and Imaging, Postgraduate
Institute of Medical Education and Research, Chandigarh, India
| | - Manish Rathi
- Department of Nephrology, Postgraduate Institute of
Medical Education and Research, Chandigarh, India
| | - Ritambhra Nada
- Department of Histopathology, Postgraduate Institute of
Medical Education and Research, Chandigarh, India
| | - Ranjana W Minz
- Department of Immunopathology, Postgraduate Institute of
Medical Education and Research, Chandigarh, India
| | - Ved Chaturvedi
- Department of Rheumatology and Clinical Immunology, Sir
Ganga Ram Hospital, New Delhi, India
| | - Amita Aggarwal
- Department of Clinical Immunology and Rheumatology, Sanjay
Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Rohini Handa
- Department of Rheumatology, Indraprastha Apollo
Hospitals, New Delhi, India
| | - Alice Grossi
- IRCCS Istituto Giannina Gaslini, UOSD Genetics and
Genomics of Rare Diseases, Genoa, Italy
| | - Marco Gattorno
- Centro Malattie Autoinfiammatorie e Immunodeficienze,
IRCCS G. Gaslini, Genoa, Italy
| | - Zhengping Huang
- Department of Rheumatology and Immunology, Guangdong
Second Provincial General Hospital, Guangzhou, China
| | - Jun Wang
- Life Sciences Institute, Zhejiang University, Zhejiang,
China
| | | | - VS Negi
- Department of Clinical Immunology, JIPMER, Puducherry,
India
| | - Raju Khubchandani
- Department of Paediatric Rheumatology, SRCC
Children’s Hospital, Mumbai, India
| | - Sanjay Jain
- Clinical Immunology and Rheumatology Services, Department
of Internal Medicine, Postgraduate Institute of Medical Education and Research,
Chandigarh, India
| | - Juan I Arostegui
- Department of Immunology, Hospital Clinic, Barcelona,
Spain
- Institut d’Investigacions Biomèdiques
August Pi i Sunyer, Barcelona, Spain
| | - Eugene P. Chambers
- Department of Surgery, Vanderbilt University Medical
Center, Nashville, Tennessee, USA
- DADA2 Foundation, Nashville, Tennessee, USA
| | - Michael S. Hershfield
- Department of Medicine and Biochemistry, Duke University
School of Medicine, Durham, North Caroline, USA
| | - Ivona Aksentijevich
- Inflammatory Disease Section, National Human Genome
Research Institute, Bethesda, Maryland, USA
| | - Qing Zhou
- Life Sciences Institute, Zhejiang University, Zhejiang,
China
| | - Pui Y. Lee
- Division of Immunology, Boston Children’s
Hospital, Boston, Massachusetts, USA
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Singh H, Dhibar DP, Naidu GSRSNK. Life-threatening corrosive injury with hepato-renal-pulmonary failure in boric acid poisoning. Postgrad Med J 2020; 98:70-71. [PMID: 33184135 DOI: 10.1136/postgradmedj-2020-138470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 09/24/2020] [Accepted: 09/30/2020] [Indexed: 11/03/2022]
Affiliation(s)
| | - Deba Prasad Dhibar
- Internal Medicine, Post Graduate Institue of Medical Education and Research (PGIMER), Chandigarh, India
| | - G S R S N K Naidu
- Internal Medicine, Post Graduate Institue of Medical Education and Research (PGIMER), Chandigarh, India
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Mittal S, Naidu GSRSNK, Jha S, Rathi M, Nada R, Minz RW, Sharma K, Dhir V, Jain S, Sharma A. Experience with similar biologic rituximab in 77 patients of granulomatosis with polyangiitis-a real-life experience. Clin Rheumatol 2020; 40:645-651. [PMID: 32656662 DOI: 10.1007/s10067-020-05261-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 06/22/2020] [Accepted: 06/23/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To present single centre experience on the efficacy and safety of similar biologic of rituximab in patients with granulomatosis with polyangiitis (GPA). METHODS This was a retrospective study of GPA patients who received similar biologic of rituximab as either remission induction or maintenance agent. Demographic parameters, Birmingham Vasculitis Activity Score (BVAS-v3), vasculitis damage index, relapse and adverse events were retrieved from patient records. Outcomes noted were remission at 6 months in remission induction group and rates of relapses, adverse events, serious infections and mortality in both remission induction and maintenance groups. RESULTS Seventy-seven GPA patients were enrolled. Sixty received rituximab for induction and 57 for maintenance; 69% were anti PR-3 positive. In the induction group, median BVAS-v3 reduced from 12 (IQR 6-21.5) to 0 (0-1) at 6 months. At 6 months, 60% patients attained remission, 40% in primary induction group and 74% in re-induction group (p = 0.016%). In the maintenance group, seven (12%) patients had relapses with median time to relapse of 12 (6-22) months. Median relapse free survival was 21 (6-22) months on rituximab maintenance. There were 12 deaths (15.6%) and 18 serious infections. CONCLUSION Similar biologic of rituximab was an effective agent for remission induction and remission maintenance in patients with GPA. Head to head trials with innovator molecule are needed to confirm these results. KEY POINTS • Remission was achieved in 60% of GPA patients who received similar biologic of rituximab as remission induction therapy. • Relapse rate during maintenance phase was 12% with similar biologic of rituximab. Serious infections and mortality with similar biologic of rituximab were comparable with that reported previously in AAV trials.
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Affiliation(s)
- Sakshi Mittal
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - G S R S N K Naidu
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Saket Jha
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Manish Rathi
- Department of Nephrology, PGIMER,, Chandigarh, India
| | | | - Ranjana W Minz
- Department of Immunopathology, PGIMER, Chandigarh, India
| | - Kusum Sharma
- Department of Medical Microbiology, PGIMER, Chandigarh, India
| | - Varun Dhir
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanjay Jain
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aman Sharma
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
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Dhir V, Jha S, Sharma A, Jain S, Sharma SK, Naidu G. AB0570 MIXED CONNECTIVE TISSUE DISEASE: NOT THAT UNCOMMON, A SINGLE-CENTER EXPERIENCE FROM INDIA. Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.5530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
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 MCTDLabs 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,a34b32d38e34f20g34h28Conclusion: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
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Mishra D, Naidu G, Kumar V, Sharma SK, Sharma A, Jain S, Dhir V. OP0108 RANDOMIZED CONTROLLED TRIAL OF ORAL CORTICOSTEROIDS IN AXIAL SPONDYLOARTHROPATHY: MODIFIED COBRA REGIME. Ann Rheum Dis 2020. [DOI: 10.1136/annrheumdis-2020-eular.4746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
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/2018/01/011342Results: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 BASDAITable 1.Changes in disease indices and inflammatory markers at 24 weeksChanges 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 weeksConclusion: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
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Sharma A, Kumar R, Mb A, Naidu GSRSNK, Sharma V, Sood A, Dhir V, Verma R, Singh H, Bhattacharya A, Jain S, Mittal BR. Fluorodeoxyglucose positron emission tomography/computed tomography in the diagnosis, assessment of disease activity and therapeutic response in relapsing polychondritis. Rheumatology (Oxford) 2020; 59:99-106. [PMID: 31236569 DOI: 10.1093/rheumatology/kez243] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 05/08/2019] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE To evaluate 18F-fluorodeoxyglucose (FDG) PET/CT in the assessment of disease activity, extent of the disease and response to therapy in relapsing polychondritis. METHODS Twenty-five patients (9 men, 16 women) with a mean age of 38.2 years (s.d. 13.7; range 18-62), diagnosed to have relapsing polychondritis according to Damiani and Levine's modification of McAdam's criteria, who underwent PET/CT examination were included. Ten patients underwent a second PET/CT examination after therapy or during follow-up. Clinical symptoms and auxiliary examination findings were recorded. PET/CT findings were reviewed and correlated with the clinical symptoms. RESULTS The major symptoms were aural pain (n = 21), nasal pain (n = 10), stridor (n = 5), cough (n = 9), fever (n = 8) and laryngeal tenderness (n = 8). The initial PET/CT was positive in 23/25 patients. PET/CT revealed involvement of auricular (n = 14), nasal (n = 8), laryngeal (n = 7), tracheobronchial (n = 6) and Eustachian (n = 3) cartilages with a mean maximum standardized uptake value (SUVmax) of 4.1 (s.d. 2.5; range 1.7-12.7). Fair correlation of aural/nasal pain/stridor with FDG avidity of cartilage involvement on PET/CT was noted. The key finding was detection of asymptomatic large airway involvement in seven patients (28%). Re-examination PET in 10 patients revealed complete therapeutic response (n = 5), partial response (n = 1), stable disease (n = 1), progressive disease (n = 1) and disease recurrence (n = 2). CONCLUSION FDG PET/CT is a useful tool for the assessment of the disease activity and extent. It identified activity in clinically inaccessible sites that are of clinical significance. It is also useful in assessing treatment response and finding relapse.
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Affiliation(s)
- Aman Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajender Kumar
- Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Adarsh Mb
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - G S R S N K Naidu
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikas Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Apurva Sood
- Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Varun Dhir
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Roshan Verma
- Department of Otorhinolaryngology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Harmandeep Singh
- Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anish Bhattacharya
- Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanjay Jain
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Bhagwant Rai Mittal
- Department of Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Sharma A, Singh H, Naidu GSRSNK. Intravenous immunoglobulin for the rescue in refractory cutaneous lupus. Indian Dermatol Online J 2020; 11:1003-1004. [PMID: 33344358 PMCID: PMC7735007 DOI: 10.4103/idoj.idoj_82_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 04/24/2020] [Accepted: 05/21/2020] [Indexed: 01/10/2023] Open
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Jain S, Naidu GSRSNK, Dhir V, Jain S, Sharma A. Comment on: A novel glucocorticoid-free maintenance regimen for anti-neutrophil cytoplasm antibody-associated vasculitis. Rheumatology (Oxford) 2019; 58:737-738. [PMID: 30649477 DOI: 10.1093/rheumatology/key403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2018] [Indexed: 11/12/2022] Open
Affiliation(s)
- Siddharth Jain
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - G S R S N K Naidu
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Varun Dhir
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanjay Jain
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aman Sharma
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Sharma A, Jha S, Naidu GSRSNK. Is rituximab “The Wonder Drug” for antineutrophil cytoplasmic antibodies-associated vasculitis? Indian J Rheumatol 2019. [DOI: 10.4103/0973-3698.254190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Sharma A, Naidu GSRSNK, Chattopadhyay A, Acharya N, Jha S, Jain S. Novel CECR1 gene mutations causing deficiency of adenosine deaminase 2, mimicking antiphospholipid syndrome. Rheumatology (Oxford) 2018; 58:181-182. [DOI: 10.1093/rheumatology/key258] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Aman Sharma
- Clinical Immunology and Rheumatology Services, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - G S R S N K Naidu
- Clinical Immunology and Rheumatology Services, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arghya Chattopadhyay
- Clinical Immunology and Rheumatology Services, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nupoor Acharya
- Clinical Immunology and Rheumatology Services, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Saket Jha
- Clinical Immunology and Rheumatology Services, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanjay Jain
- Clinical Immunology and Rheumatology Services, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Shrivastava K, Naidu G, Deshpande A, Handa H, Raghuvanshi V, Gupta M. Comparative evaluation of the efficacy of topical amlexanox 5% oral paste and triamcinolone acetonide 0.1% oral paste in the treatment of Recurrent Aphthous Stomatitis (RAS). J Indian Acad Oral Med Radiol 2018. [DOI: 10.4103/jiaomr.jiaomr_40_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
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Naidu GSRSNK, Misra DP, Sharma A. Current and Future Treatment Options for Takayasu Arteritis and Persistent Therapeutic Challenges. Curr Treat Options in Rheum 2017. [DOI: 10.1007/s40674-017-0070-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Palanisamy AM, Doshi HK, Selvaraj D, Chan W, Naidu G, Ramason R. Fixation Versus Replacement in Geriatric Hip Fractures: Does Functional Outcome and Independence in Self-Care Differ? Geriatr Orthop Surg Rehabil 2015; 6:258-62. [PMID: 26623159 PMCID: PMC4647188 DOI: 10.1177/2151458515595435] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Introduction: Although there is evidence of improved functional outcomes with our “integrated care pathway” for geriatric hip fractures, we do not know if there is a significant difference in functional recovery of activities of daily living and attainment of independence in self-care between patients who underwent fixation and those treated with arthroplasty. Objective: To determine whether such a difference exists in surgically fixed hip fractures. Materials and Methods: Patients with hip fracture treated surgically were divided into group A (internal fixation, n = 213) and group B (arthroplasty, n = 199). Demographic data, Charlson comorbidity index (CCI) score, time to surgery, and length of stay were recorded. Inpatient complications and mortality rates were also documented. Modified Barthel Index (MBI) scores were recorded for the following intervals: prefall, discharge, 6-month, and at 1-year follow-up. Results: The mean age (A: 80 years and B: 81years), CCI (A: 5.41 and B: 5.43), and length of stay (A: 13.6 days and B: 15.2 days) were not significantly different. However, there was a significant difference (P < .05) in time to surgery (A: 102.2 hours and B: 86.6 hours). Complication rates were about 6% in both groups (A = 6.57%: urinary infections = 13, wound infections = 1 and B = 6.03%: urinary infections = 10, wound infections = 1, pressure ulcer = 1). The preinjury MBI scores were significantly different (P < .05; A: 91.65 and B: 88.19), however, there was no significant difference in scores measured at discharge (A: 60.79 and B: 59.39), 6 months (A: 77.65 and B: 77.47) and 1 year (A: 80.71 and B: 83.03). Patients who underwent surgery for hip fracture had overall recovered 90.9% of their preinjury function (overall MBI at 1 year: 81.83). Conclusion: The MBI scores reflect the extent of attainment of independence in self-care, and actual functional recovery is gauged from the percentage of recovery of preinjury function at 1 year postsurgery. We conclude that the type of surgery may not be a significant factor in determining independence in self-care although patients who had arthroplasty had recovered more function at 1 year postsurgery than those who underwent fixation (percentage recovery of preinjury function—A: 88.1% and B: 94.1%).
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Affiliation(s)
| | - H K Doshi
- Department of Orthopaedics and Traumatology, Tan Tock Seng Hospital, Singapore
| | - Dahshaini Selvaraj
- Department of Orthopaedics and Traumatology, Tan Tock Seng Hospital, Singapore
| | - William Chan
- Department of Rehabilitation medicine, Tan Tock Seng Hospital, Singapore
| | - G Naidu
- Department of Orthopaedics and Traumatology, Tan Tock Seng Hospital, Singapore
| | - R Ramason
- Department of Geriatric Medicine, Tan Tock Seng Hospital, Singapore
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Seng WRD, Belani MH, Ramason R, Naidu G, Doshi HK. Functional Improvement in Geriatric Hip Fractures: Does Vitamin D Deficiency Affect the Functional Outcome of Patients With Surgically Treated Intertrochanteric Hip Fractures. Geriatr Orthop Surg Rehabil 2015; 6:186-91. [PMID: 26328234 PMCID: PMC4536509 DOI: 10.1177/2151458515584639] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Introduction: The “Integrated Care Pathway” for geriatric intertrochanteric (IT) fractures in Singapore’s Tan Tock Seng Hospital has shown significant functional recovery in patients’ activities of daily living. However, the influence of preoperative vitamin D on functional recovery remains equivocal. This retrospective study therefore aims to determine whether patients with preoperative vitamin D deficiency have poorer functional outcomes. Method: A total of 171 patients who had surgical treatment for IT fractures were recruited in the study. They were categorized into group A (vitamin D deficient) and group B (normal vitamin D). Charlson Comorbidity Index (CCI) score and nutritional parameters including hemoglobin, albumin, and adjusted calcium levels on admission were recorded. The Modified Barthel Index (MBI) score was used to measure functional recovery at the following time intervals: at pre-fall, at discharge after surgery, at 6 months, and at 1-year follow-up. Results: The mean age of both the groups (A: 79.7 years, n = 45; B: 83.0 years, n = 126) was statistically different (P < .05). However, the mean CCI (A: 9.42 and B: 10.13), hemoglobin (A: 12.4 and B 11.1), adjusted calcium (A: 2.39 and B: 2.38), and mean albumin (A: 33.6 and B: 33.0) of the groups were not significantly different. Furthermore, the MBI scores were not significantly different for both groups at preinjury (A: 91.5 and B: 89.4), at discharge (A: 55.2 and B: 58.9), at 6 months (A: 70.9 and B: 75.1), and at 1 year (A: 75.8 and B: 79.4). Conclusion: In our cohort, patients with vitamin D deficiency were younger. However, vitamin D deficiency at time of injury had no significant influence on functional recovery in patients with surgically treated hip fracture in our Integrated Care Pathway. In addition, patients who had a normal vitamin D levels had similar functional scores and improvement postoperatively and at 1 year (A: 82.8% and B: 88.9%).
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Affiliation(s)
- W R D Seng
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital Singapore, Singapore
| | - M H Belani
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital Singapore, Singapore
| | - R Ramason
- Geriatric Medicine Department, Tan Tock Seng Hospital Singapore, Singapore
| | - G Naidu
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital Singapore, Singapore
| | - H K Doshi
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital Singapore, Singapore
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Rathi M, Naidu GSRSNK, Nada R, Sharma A. Pauci-immune glomerulonephritis: Does negativity of anti neutrophilic cytoplasmic antibodies (ANCA) matters? Indian Journal of Rheumatology 2014. [DOI: 10.1016/j.injr.2014.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Naidu GSRSNK, Sharma A, Katoch D, Gupta A. A rare cause of uveitis in a 33 year old male. Indian Journal of Rheumatology 2014. [DOI: 10.1016/j.injr.2014.10.202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Naidu GSRSNK, Sharma A, Nada R, Rathi M. Histopathological classification of pauci-immune glomerulonephritis and its impact on outcome. Indian Journal of Rheumatology 2014. [DOI: 10.1016/j.injr.2014.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Vadlapudi V, Kaladhar D, Behara M, Sujatha B, Naidu G. Synthesis of Green Metallic Nanoparticles (NPs) and Applications. ACTA ACUST UNITED AC 2013. [DOI: 10.13005/ojc/290442] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Khoosal M, Wadula J, Wainwright L, Naidu G. Bloodstream Infections (BSI) in the Pediatric Oncology Unit at C.H. Baragwanath Hospital. Int J Infect Dis 2008. [DOI: 10.1016/j.ijid.2008.05.963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Alli NA, Wainwright RD, Mackinnon D, Poyiadjis S, Naidu G. Skull bone infarctive crisis and deep vein thrombosis in homozygous sickle cell disease- case report and review of the literature. ACTA ACUST UNITED AC 2007; 12:169-74. [PMID: 17454200 DOI: 10.1080/10245330601111912] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Here we describe an 8-year old male child with homozygous sickle cell disease who presented with left parietal skull bone infarction and, during his stay in hospital, developed a right femoral deep vein thrombosis (DVT), both uncommon complications of the disease. He initially presented with severe headache and generalised tenderness of the calvarium, which did not respond to simple analgesics. Scalp swelling in and around the left frontal (including left orbit) and parietal regions developed 24 h after presentation. The differential diagnosis included incipient stroke, acute sickle bone crisis and osteomyelitis, with a possible complication of epidural haematoma, or orbital compression syndrome. An initial exchange blood transfusion did not lead to appreciable reduction in opiate requirements. Significant symptomatic relief was attained only after a second exchange transfusion. The DVT developed at the site of catheterisation (right femoral vein), and this was treated with maximal doses of enoxaparin followed by warfarin. The child is now well and off anti-coagulants. In this article we present a review of the literature and discuss possible mechanisms of these complications in our patient.
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Affiliation(s)
- N A Alli
- Department of Haematology, National Health Laboratory Service & University of Witwatersrand, Johannesburg, South Africa
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Wainwright RD, Poyiadjis S, Naidu G, Mackinnon D. Psychosocial aspects of immune thrombocytopenia and secondary human immunodeficiency virus-related pediatric immune thrombocytopenia in the Republic of South Africa. Pediatr Blood Cancer 2006; 47:692-3. [PMID: 16933250 DOI: 10.1002/pbc.21020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Developing countries with an uncontrolled AIDS epidemic have new challenges to meet in ITP. Secondary ITP, HIV related, becomes an increasing problem, which has many aspects that need addressing, including medical, effective counseling, psychosocial and unresolved management issues. Assistance in developing treatment guidelines is urgently needed.
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Affiliation(s)
- R D Wainwright
- Department of Pediatrics, Chris-Hani-Baragwanath Hospital, Soweto, and University of the Witwatersrand, Johannesburg, Republic of South Africa.
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Mehta SR, Naidu G, Chandar V, Singh IP, Johri S, Ahuja RC. Falciparum malaria--present day problems. An experience with 425 cases. J Assoc Physicians India 1989; 37:264-7. [PMID: 2693436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Clinical details and present day problems encountered in 425 cases of falciparum malaria (PF) are reported. 10.11% had taken chloroquine prior to reporting to us. Parasitic count done in 23.05% cases lacked correlation with severity of disease. Pattern of fever varied markedly but 5.4% were afebrile throughout and presented only with bodyache and malaise. Apyrexial spell was noted in 5.64%. 28.70% had typical facial looks of anaemia and sallow complexion. Cerebral symptoms were noted in 3.05%. Other symptoms were severe headache 33.4%, pain abdomen 3.29%, gastroenteritis 5.64%, jaundice 2.58% and bronchitis in 7.50%. We encountered subconjunctival haemorrhages with purpura and/or urticaria in four cases, symptoms suggestive of shock lung in 3, pulmonary oedema in 2, severe anaemia (HB less than 4 g%) in seven pregnant ladies, extrapyramidal symptoms in follow up period in 5 and congenital malaria in 2 cases. 83.25% were cured with chloroquine and oxytetracycline. 8.47% (who deteriorated despite the above treatment) were treated with quinine for 6 days. 5.17% (with severe disease) were also given quinine as first line drug. 2.82% (unresponsive to chloroquine and oxytetracycline but with mild disease) were treated with pyrimethamine-sulphamezathine combination for 5 days. One case who did not respond to quinine was treated with quinidine. Recrudescence was seen in 3.67% of patients treated with chloroquine and oxytetracycline. There was no case with renal failure, haemolysis due to G6PD deficiency and black water fever. There was only one death (0.23%) in our series. Self-medication, haphazard therapy and the slogan "Fever may be malaria-take chloroquine" can lead to problems in falciparum malaria.
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Mehta SR, Ahuja RC, Krishnan NR, Subramanian AR, Naidu G. Exercise provocation test for clinical malaria. J Assoc Physicians India 1987; 35:205-6. [PMID: 3301796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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