Anti-tumor necrosis factor (aTNF) weaning strategy in juvenile idiopathic arthritis (JIA): does duration matter?

BACKGROUND

To compare outcomes of a short and long weaning strategy of anti-tumor necrosis factor (aTNF) in our prospective juvenile idiopathic arthritis (JIA) cohort.

RESEARCH DESIGN AND METHODS

JIA patients on subcutaneous adalimumab with at least 6 months of follow-up were recruited (May 2010-Jan 2022). Once clinical remission on medication (CRM) was achieved, adalimumab was weaned according to two protocols-short (every 4-weekly for 6 months and stopped) and long (extending dosing interval by 2 weeks for three cycles until 12-weekly intervals and thereafter stopped) protocols. Outcomes assessed were flare rates, time to flare, and predictors.

RESULTS

Of 110 JIA patients, 77 (83% male, 78% Chinese; 82% enthesitis-related arthritis) underwent aTNF weaning with 53% on short and 47% on long weaning protocol. The total flare rate during and after stopping aTNF was not different between the two groups. The time to flare after stopping aTNF was not different (p = 0.639). Positive anti-nuclear antibody increased flare risk during weaning in long weaning group (OR 7.0, 95%CI: 1.2-40.8). Positive HLA-B27 (OR 6.5, 95%CI: 1.1-30.4) increased flare risks after stopping aTNF.

CONCLUSION

Duration of weaning aTNF may not minimize flare rate or delay time to flare after stopping treatment in JIA patients. Recapture rates for inactive disease at 6 months remained high for patients who flared after weaning or discontinuing medication.

COVID-19 mRNA vaccine immunogenicity decay and breakthrough illness in adolescents and young adults with childhood-onset rheumatic diseases

OBJECTIVES

To evaluate the humoral immunogenicity for 6 months after the two-dose coronavirus disease 2019 (COVID-19) mRNA vaccination in adolescents and young adults (AYAs) with childhood-onset rheumatic diseases (cRDs).

METHODS

This monocentric observational study was conducted between August 2020 and March 2022. Humoral immunogenicity was assessed at 2-3 weeks after first vaccine dose and 1, 3 and 6 months after the second dose by the cPass™ severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) neutralization antibody (nAb) assay. An inhibition signal of ≥30% defined the seroconversion threshold and the readings were calibrated against the World Health Organization International Standard for SARS-CoV-2 antibodies.

RESULTS. ONE HUNDRED AND SIXTY-NINE

AYAs with cRDs were recruited [median age 16.8 years (interquartile range, IQR 14.7-19.5), 52% female, 72% Chinese]. JIA (58%) and SLE (18%) comprised the major diagnoses. After second vaccine dose, 99% seroconverted with a median nAb titre of 1779.8 IU/ml (IQR 882.8-2541.9), declining to 935.6 IU/ml (IQR 261.0-1514.9) and 683.2 IU/ml (IQR 163.5-1400.5) at the 3- and 6-month timepoints, respectively. The diagnosis of JIA [odds ratio (OR) 10.1, 95% CI 1.8-58.4, P = 0.010] and treatment with anti-TNF-α (aTNF) (OR 10.1, 95% CI 1.5-70.0, P = 0.019) were independently associated with a >50% drop of nAb titres at 6 months. Withholding MTX or MMF did not affect the vaccine response or decay rate. The COVID-19 breakthrough infection was estimated at 18.2 cases/1000 patient-months with no clinical risk factors identified.

CONCLUSION

Over half of AYAs with cRDs had a significant drop in SARS-CoV-2 nAb at 6-month despite an initial robust humoral response. JIA and aTNF usage are predictors of a faster decay rate.

Utility of myxedema score as a predictor of mortality in myxedema coma

OBJECTIVE

Myxedema crisis (MC) is a rare condition. There is a dearth of data regarding the predictors of mortality in MC. Predictive scores for mortality specific to the clinical and biochemical profile of MC are still lacking.

DESIGN AND METHODS

All consecutive patients presenting with MC from September 2006 to December 2020 comprised the new cohort. Patients managed between January 1999 and August 2006 comprised the old cohort. Both cohorts were compared for the determination of secular trends. Combined analysis of both the cohorts was done for clinico-demographic profile and predictors of mortality. Myxedema score (MS) and qSOFA (Quick Sequential Organ Failure Assessment) score were evaluated in all the patients.

RESULTS

A total of forty-one patients (new cohort; n = 18 and old cohort; n = 23) were enrolled into the study. There was a female predominance (80.5%). Nearly half (51.2%) of the patients were newly diagnosed with hypothyroidism on admission. Overall mortality was 60.9%. On comparative analysis among survivors and non-survivors, female gender (OR 20.4, p value 0.018), need for mechanical ventilation (OR16.4, p value 0.009), in-hospital hypotension (OR 9.1, p value 0.020), and high qSOFA score (OR 7.1, p value 0.023) predicted mortality. MS of > 90 had significantly higher mortality (OR-11.8, p value - 0.026) while MS of > 110 had 100% mortality. There was no change in secular trends over last 20 years. There was no difference in outcome of patients receiving oral or IV levothyroxine.

CONCLUSION

Myxedema crisis is associated with high mortality despite improvement in health care services. The current study is first to elucidate the role of the MS in predicting mortality in patients with MC.

Multisystem inflammatory syndrome in children in Singapore

Introduction: Multisystem inflammatory syndrome in children (MIS-C) is a rare inflammatory syndrome with multisystem involvement affecting children exposed to COVID-19. This condition is rarely reported in East Asia and was not detected in Singapore until 2021. We present 12 cases of MIS-C diagnosed in KK Women’s and Children’s Hospital (KKH) from October 2021 to December 2021. Method: We conducted an observational study on cases fulfilling the Singapore Ministry of Health criteria for MIS-C from January 2020 to December 2021 in KKH. Medical records were reviewed to obtain information on clinical presentation, disease course, treatment received and outcomes. Results: In the 12 cases detected, the median age was 7.50 years (interquartile range 4.00–9.25); 8 were male. All patients had mucocutaneous symptoms similar to Kawasaki disease. Other commonly involved systems were: haematological (coagulopathy 100%, lymphopaenia 91.70% and thrombocytopaenia 75.00%), gastrointestinal (75.00%) and cardiovascular (83.30%). Six patients (50.00%) had shock and were admitted to the intensive care unit. The majority of patients received treatment within 2 days of hospitalisation with intravenous immunoglobulin (IVIg) and steroids. All survived; the majority had normal echocardiograms and no long-term organ sequelae at 6 months post-discharge. Conclusion: MIS-C emerged in Singapore as the incidence of COVID-19 in the community increased in 2021. The clinical presentation of our patients is similar to earlier reports, with some significant differences from Kawasaki disease. Multidisciplinary management, timely diagnosis, and early initiation of treatment with IVIg and steroids likely contributed to comparatively good outcomes. Our cases highlight the need for continued awareness of MIS-C among physicians, and surveillance of its incidence, short- and long-term outcomes. Keywords: COVID-19, children, MIS-C, inflammation, paediatrics

Robust neutralizing antibody response to SARS-CoV-2 mRNA vaccination in adolescents and young adults with childhood-onset rheumatic diseases

OBJECTIVES

Immunogenicity to the SARS-CoV-2 mRNA vaccines in adolescents and young adults (AYA) with childhood-onset rheumatic diseases (cRD) is unknown. We aimed to evaluate the humoral immunogenicity and safety of the vaccines in our AYA with cRD.

METHODS

A monocentric observational study with 159 AYA (50.3% female and 70.4% Chinese). Humoral immunogenicity was assessed at 2-3 and 4-6 weeks following first and second vaccination by cPass™ SARS-CoV-2 Neutralization Antibody Assay. Inhibition signal of ≥30% defined the cut-off for positive detection of the SARS-CoV-2 neutralizing antibodies. Vaccine safety and disease activity were assessed within 6 weeks after second vaccination.

RESULTS

A total of 64.9% and 99.1% of 159 patients (median age: 16.9, IQR: 14.7-19.5) mounted positive SARS-CoV-2 neutralizing responses after first and second vaccination, respectively. Most patients (89.8%) had ≥90% inhibition signal after second vaccination. Methotrexate and mycophenolate mofetil increased the risk associated with negative cPass neutralization responses following the first vaccination. Holding both medications after each vaccination did not affect immunogenicity. There was no symptomatic COVID-19 infection. Local reaction remained the most common (23.3-25.2%) adverse event, without serious complication. Two and seven patients flared following the first and second vaccination, respectively. Subgroup analyses of the 12-18-year-old cohort did not show any differences in vaccine efficacy, predictors of poor response and general safety, but higher proportion of disease flares.

CONCLUSIONS

SARS-CoV-2 mRNA vaccines were efficacious after the two-dose regimen in almost all AYA with cRD without serious adverse event. The rate of disease flare observed is 4.4% after the second mRNA vaccine dose.

POS1297 SACROILIITIS AT DIAGNOSIS ASSOCIATED WITH LESS DISEASE FLARE AFTER STOPPING MEDICATION - OUTCOMES AND PREDICTORS OF A SOUTHEAST ASIAN ENTHESITIS RELATED ARTHRITIS (ERA) LONGITUDINAL COHORT

Background

ERA is a subtype of Juvenile Idiopathic Arthritis (JIA) characterized by involvement of entheses and axial skeleton. Outcomes have been shown to be poorer compared with oligoarticular and polyarticular JIA1.

Objectives

To assess short-and long-term outcomes and predictors of ERA in a large monocentric cohort in Singapore.

Methods

Children diagnosed with ERA according to ILAR criteria from 2002 to 2021 at KK Women’s and Children’s Hospital, Singapore, were recruited. Outcome statuses were defined according to the criteria for clinical inactive disease (CID) and complete remission (CR) proposed by Wallace et al.2, with additional criteria of no enthesitis and no active sacroiliitis on MRI. Nonparametric descriptive statistics were used. Univariate and multivariate analysis were performed using logistic regression analyses. The significant level was set at < 0.05.

Results

A cohort of 151 ERA patients (male 86%; Chinese 81%) were included. Median age at onset was 11.9 years (IQR 9.4-13.9) and disease duration was 5.3 years (IQR 2.9-8.4). HLA-B27 was positive in 83% of the patients. At diagnosis, 39% of the patients had sacroiliitis, 46% had hip arthritis, 36% had knee arthritis and 25% had enthesitis. Methotrexate was used in 77% of the patients, while biologics was started in 72% of the patients.

CID was achieved in 92% of the patients, of which 27% achieved CID in 6 months or less. Sacroiliitis at diagnosis is an unfavourable predictor of CID at 6 months but not a significant predictor of ever achieving CID. Older age at diagnosis is also an unfavourable predictor of CID ever.

Medication was totally discontinued in one third of the patients. Half of them went on to have complete remission (CR) off medication. Favourable predictor includes male gender, while positive HLA-B27 and ANA were unfavourable predictors.

Two thirds of the patients with CID had at least one disease flare (23% flared after off medication, 13% flared after CR). Both intra-articular joint injection and anti-TNF use were associated with flare after CID, while anti-TNF use was associated with flare after off medication. Sacroiliitis at diagnosis is a protective predictor of flare after stopping medication.

Conclusion

Despite a high proportion of ERA patients achieving CID, only one third could stop medication completely with high rates of disease flare even after attaining CR. Unfavourable predictors include older age at onset as well as HLA-B27 and ANA positivity. While sacroiliitis at diagnosis is a negative predictor of CID at 6 months, it is protective predictor of flare after discontinuing medication.

References

[1]Teh, Kai Liang, et al. “Outcomes and predictors of juvenile idiopathic arthritis in Southeast Asia: A Singapore longitudinal study over a decade.” Clinical Rheumatology 40.6 (2021): 2339-2349.

[2]Wallace, Carol A., et al. “American College of Rheumatology provisional criteria for defining clinical inactive disease in select categories of juvenile idiopathic arthritis.” Arthritis care & research 63.7 (2011): 929-936.

Table 1.

Predictors of outcomes

Clinical parametersUnivariate analysisMultivariate analysisOR95% CIpOR95% CIpCID at 6 months Sacroiliitis at diagnosis0.1870.048-0.7240.0150.0230.003-0.177<0.001CID ever Age at onset0.7900.626-0.9980.0480.7770.605-0.9970.047Off medication ever Male5.0291.121-22.5660.0357.7031.622-36.5750.010 HLA-B270.3740.158-0.8860.0250.2900.110-0.7640.012 ANA0.1040.013-0.8030.0300.0770.010-0.6130.015Flare after CID Intra-articular injection2.5851.116-5.9880.0273.2051.299-7.9090.011 Anti-TNF3.6831.697-7.9930.0014.3281.905-9.832<0.001Flare after discontinue medication Sacroiliitis at diagnosis0.2220.060-0.8210.0240.0790.009-0.7220.025 Anti-TNF17.3333.696-81.300<0.00137.9424.151-346.8410.001

CID – Clinical Inactive Disease, TNF – Tumor Necrosis Factor, HLA-B27 – Human Leukocyte Antigen-B27, ANA – Antinuclear Antibodies

Figure 1.

Probability of attaining outcomes over time

Disclosure of Interests

None declared

POS0342 ANTI-TUMOUR NECROSIS FACTOR (aTNF) WEANING STRATEGY IN JUVENILE IDIOPATHIC ARTHRITIS (JIA): DOES LONGER DURATION MATTER?

Background

The efficacy of aTNF in the treatment of children with JIA has been demonstrated. However, once the disease is under control, strategy towards discontinuing aTNF should be considered. Thus far, there is no convincing information regarding how biologics should be weaned.

Objectives

To compare the outcomes of a short- and long-weaning strategies of aTNF in our prospective observational JIA cohort

Methods

Children with JIA taking aTNF with at least 6 months follow-up duration were recruited from our JIA registry (May 2010-Jan 2022) at KK Women’s and Children’s Hospital, Singapore. Once remission on medication, ROM1 (including no enthesitis and sacroiliitis by MRI for ERA) was achieved, aTNF was weaned according to 2 different protocols– short (Etanercept every 2 weeks, and Adalimumab every 4 weeks, for 6 months) and long (extending frequency by every 2 weeks for 3 cycles until reaching 12 weekly interval for another 3 cycles then stop biologic thereafter) protocols. Flare (recurrent of arthritis, enthesitis or uveitis) rates were compared, and potential predictors were assessed. Nonparametric statistics were used to described data and logistic regression and Kaplan-Meier analyses were used to assess clinical parameters and outcome association and cumulative probability of disease flare, respectively.

Results

Out of 143 JIA patients, 105 (78% male, 82% Chinese; enthesitis related arthritis 78%, oligoarticular JIA 9%, polyarticular JIA 11%, psoriatic arthritis 1%, undifferentiated JIA 1%) underwent aTNF weaning with 53% on short- and 47% on long-weaning protocol. Median disease duration at aTNF start was 13.5 (10.6-15.8) and duration of follow-up was 6.6 (3.9-9.5) years. There was no significant difference in demographic and clinical parameters between groups. There was none of the short- but 49% of the long-weaning group flared during the weaning period, Table 1. However, no significant difference in the total flare rate (during and after stopping aTNF) was observed between the 2 groups despite less patient flare after stopping aTNF in the later, p=0.004. Median time to flare after stopping aTNF was not different, p=0.270. Furthermore, probability of flare after stopping aTNF was not different as well, Log Rank p=0.095, Figure 1. Positive ANA predicts flare during weaning (OR 5.2, 95%CI: 1.224-22.416, p=0.026), but none of clinical parameters were associated with risk of flare after discontinuing aTNF therapy in our cohort.

Table 1.

Rate of flare and duration related to aTNF between short- and long-weaning groups

FLARETotal (n=105)Short (n=56)Long (n=49)pNumber of JIA patients flared during wean (%)24 (22.9)0 (0.0)24 (49.0)<0.001Time to flare during aTNF weaning after starting (month)*6.5 (4.5-14.5)Number of JIA patients flared after DC aTNF (%)50 (47.6)34 (60.7)16† (32.7)0.004Time to flare after stopping aTNF (month)*6.2 (2.7-11.8)6.9 (5.5-11.6)0.270Total number of patients who flared68 (64.8)34 (60.7)34 (69.4)0.353

*Median (interquartile range), †included 6 patients who flare during weaning and after stopping aTNF, aTNF = anti-tumour necrosis factor

Figure 1.

Cumulative probability of flare between the short- and long-weaning group after discontinuing aTNF therapy

Conclusion

Duration of spacing out the aTNF therapy after achieving ROM may not minimize the flare rate or delay time to flare after stopping the therapy in JIA patients. Further validation in larger multinational longitudinal cohorts is required to confirm our initial findings.

References

[1]Wallace CA, Giannini EH, Huang B, et al. American College of Rheumatology provisional criteria for defining clinical inactive disease in select categories of juvenile idiopathic arthritis. Arthritis care & research 2011;63(7):929-36.

Disclosure of Interests

None declared

AB1235 MULTISYSTEM INFLAMMATORY DISEASE IN CHILDREN (MIS-C) IN SINGAPORE CHILDREN: ARE WE DIFFERENT?

Background

Multisystem Inflammatory Syndrome in Children (MISC) is a hyper-inflammatory state with similarities to Kawasaki Disease, 4 to 6 weeks after Covid-19 infection1. Literature describes a 11:1 Relative Risk for Asian children versus Caucasians2. Since the start of the pandemic, 17,699 children under 12 years were infected with Covid-193.

Objectives

To describe presentation and short term outcomes, for a cohort of children with MIS-C at the sole Children’s Hospital in Singapore.

Methods

Demographic and clinical/lab data were collected from children diagnosed with MIS-C accrording to the WHO criteria4 at KK Woman’s and Children’s Hospital, Singapore. Nonparametric descriptive statistics were used to describe and analyse data.

Results

Eleven patients were diagnosed with MIS-C between October 2021 and Jan 2022. Seven (64%) were male and 4 (36%) were Chinese, with median age at presentation was 8.08 years (IQR 4.54 - 9.79). All patients had positive COVID-19 serology at the time of diagnosis. Median duration of fever prior to diagnosis was 5 days (IQR 4 - 5); Nine (82%) had gastrointestinal symptoms and median number of Kawasaki Disease (KD) features were 2 (IQR 2 - 3.5); common manifestations were conjunctivitis (90%), red lips (55%) and rash (36%). Of note, 8 (70%) patients had KD type peeling on follow-up. No BCGitis was found during acute phase. Seven (64%) were admitted to higher dependency care.

Table 1, all patient received IVIG and IV steroids; 6 (55%) as pulse (30mg/kg/day) therapy. Patient 8, additionally received Anakinra. Median duration of admission was 6 days (IQR 5-13). One patient developed complications post therapy and was re-admitted to hospital for hematochezia. Treatment involved stopping Enoxaparin and Prednisone. Aspirin was resumed as soon as bleeding ceased. Laboratory characteristics and outcomes are denoted in Table 1. All patients had a monophasic course during the median of 10 weeks (IQR 8 - 11.5) of follow-up.

Table 1.NoAge (yr)GI symptomsKD featuresHemoglobin (g/DL)Absolute Lymphocyte (10x9/L)Platelet (10x9/L)CRP (mg/L)D-Dimer (mg/L FEU)Ferritin (ug/L)Enoxaparin startedPeelingAbnormal echo110YES212.20.2367173.2323179.1YESYESYES211NO214.8116694.92.51350NOYESYES34.25YES210.41.02241134.66.05277.2YESNOYES47.67YES5110.41102250.69.323607.6YESYESNO58.58YES411.40.5693105.61.31846.6NOYESNO64.58YES210.33.09198137.41.87291NONONO79.58YES312.21.311191842.51244.3NOYESNO84.5YES411.90.45102181.811.121798.4YESNOYES911YES110.11.235974.24.531445.8YESYESNO103.42NO29.11.09138153.98.66609.4YESYESNO118.08YES211.41.2510166.81.31521.8NOYESYES

Conclusion

1.Asian prevalence of MIS-C is not as high as that reported from the West. Similarities in presentation as to age and gender were noted.

2.Most of our MIS-c patients developed periungual peeling at follow up, similarly to Kawasaki Disease.

3.Different from our typical KD population, no BCG site inflammation was found.

References

[1]Feldstein LR, Tenforde MW, Friedman KG, et al. Characteristics and Outcomes of US Children and Adolescents With Multisystem Inflammatory Syndrome in Children (MIS-C) Compared With Severe Acute COVID-19. JAMA. 2021;325(11):1074-1087.

[2]Middelburg JG, Crijnen TEM, D’Antiga L, et al. Association of Ethnicity with Multisystem Inflammatory Syndrome in Children Related to SARS-CoV-2 Infection Frontiers in Pediatrics Oct 2021 Vol 9.

[3]Ang Qing, Number of children admitted for covid-19 at KKH doubles since December 2021. New Straits Times, 27 Jan 2022.

[4]World Health Organization. Multisystem inflammatory syndrome in children and adolescents with COVID-19: Scientific Brief. 2020

Disclosure of Interests

None declared

POS1294 SAFETY AND EFFICACY OF ADALIMUMAB BIOSIMILAR (AMGEVITA) IN PAEDIATRIC RHEUMATOLOGY PATIENTS

Background

The approval of biosimilars requires pharmacokinetic studies to prove that there are no clinically significant differences to the originator molecule. These studies are also used to extrapolate additional indications and for different populations including paediatrics. Literature is lacking for the efficacy and safety of biosimilars for paediatric rheumatology conditions. Amgevita, a biosimilar of adalimumab, was approved for use in Singapore on 31 July 2019. It was used in KK Women’s and Children’s hospital (KKH), Singapore from 1 September 2020.

Objectives

To report the safety and efficacy of adalimumab biosimilar in children at our centre.

Methods

This is an ongoing prospective, IRB-approved, observation study in a paediatric rheumatology clinic sited within KKH, a tertiary children’s hospital. Patients were reviewed in clinic to determine the need to initiate adalimumab (Amgevita), and completed pre-biologic screening to assess suitability to start. Patients were included if they received minimum 1 dose of adalimumab biosimilar. Safety parameters tracked: allergy, including urticaria, anaphylaxis, severe injection site reactions, rate of new onset infections requiring hospitalization and reactivation of latent infections (e.g., tuberculosis or herpes zoster). Adverse reactions were graded according to CTCAE v5.0. Efficacy parameters were tracked for patients with juvenile idiopathic arthritis (JIA) included JADAS27, JADAS71 and JSpADA.

Results

From 1 September 2020 to 31 October 2021, a total of 187 of 20mg syringes and 1403 pre-filled 40mg pens were dispensed to 117 paediatric rheumatology patients. Mean age was 14.9 years, 53.9% were male, 70.9% were Chinese and ethesitis-related arthritis (46.1%) was the most common indication. There were 68 (58.1%) biologic naïve patients. Two patients experienced injection-site urticaria which prompted discontinuation (grade 2). One patient reported initial injection site soreness which resolved spontaneously (grade 1). One patient developed latent tuberculosis requiring inpatient management and temporary interruption in adalimumab therapy (grade 3). No other adverse events were reported. Efficacy data was available for 96 patients. Median scores at baseline and at 3-months and 6-months are presented in Table 1.

Table 1.

Summary of paediatric patients initiated on adalimumab biosimilar (Amgevita)

Diagnosis, n (%)Enthesitis related arthritisOf which HLA-B27 positive54 (46.1)44 (81.5)Polyarthritis21 (17.9)Extended or persistent oligoarthritis15 (12.8)Undifferentiated JIA6 (5.1)Psoriatic arthritis1 (0.8)Other indications21 (17.9)Concomitant DMARDs, n (%)Methotrexate50 (42.7)Sulfasalazine37 (31.6)*Efficacy, Median (range)Biologic naïveNot biologic naïveMonth number036036JADAS272(0-21.6)0(0-8.5)0(0-6.05)2(0-10.6)0(0-8.4)0(0-12.2)JADAS712(0-27.8)0(0-12.0)0(0-6.08)2(0-10.6)0(0-8.4)0(0-12.2)JSpADA0.25(0-3.5)0(0-1.0)0(0-1.0)0.5(0-1.5)0(0-0.5)0(0-2.0)

DMARDs: Disease modifying anti-rheumatic drugs; JADAS: Juvenile Arthritis Disease Activity Score; JSpADA: Juvenile spondyloarthritis disease activity. *Efficacy data only for patients with juvenile idiopathic arthritis

Conclusion

We report our 14-month experience of using adalimumab biosimilar in a pediatric rheumatology population. Majority of the patients did not report major adverse reactions. Majority of JIA patients responded well when initiated on adalimumab (Amgevita). Rheumatologists should continually monitor patients for latent infections after prescribing biologics including biosimilars.

References

[1]Scientific considerations in demonstrating biosimilarity to a reference product: guidance for industry. FDA website. Apr 2015. https://www.fda.gov/media/82647/download. Accessed 28 Dec 2021.

[2]De Cock D, Kearsley-Fleet L, Baildam E, Beresford MW, et al. Biosimilar Use in Children and Young People with Juvenile Idiopathic Arthritis in aReal-World Setting in the United Kingdom [abstract]. Arthritis Rheumatol. 2017; 69 (suppl 10).

Disclosure of Interests

None declared

Transition readiness assessment in adolescents and young adults with rheumatic diseases: The Singapore experience

BACKGROUND

Transition from pediatric to adult care is a challenging time for adolescents and young adults (AYA) with rheumatic diseases. Validated tools have been developed to assess transition readiness.

AIM

To evaluate transition readiness among AYA with rheumatic diseases and to identify factors associated with transition readiness.

METHODS

Patients ≥15 years old were enrolled into our transition program and administered a Transition Readiness Assessment Tool (TRAT) from July 2017. The TRAT consists of 3 components: (a) patient's perception on importance of transition and confidence toward transition on a Likert scale 0-10; (b) assessment of knowledge on medical and healthcare usage using a set of 23 questions; (c) transition readiness using the Transition Readiness Assessment Questionnaire (TRAQ). Differences between groups were compared to identify factors associated with transition readiness.

RESULTS

Transition readiness assessment was performed in 152 patients. The median score for perception on transition importance was 7.0 (5.0-8.8) and the median score for confidence in transition was 7.0 (5.0-9.0). Majority of the patients (>50%) lack knowledge in health insurance, carrying health information, healthcare privacy changes and making own healthcare decision. Patients <20 years old were also deficient in knowledge in navigating healthcare systems. TRAQ scores were lowest in areas pertaining to healthcare insurance and obtaining financial help.

CONCLUSION

Healthcare insurance literacy and self-management skills were lacking in the assessment of transition readiness in AYA with rheumatic diseases. Targeted intervention in these areas will improve transition readiness and promote successful transition processes.

Results of ala carte Posteromedial Soft Tissue Release in Idiopathic Clubfoot

Introduction

The aim of this study is to assess the outcomes of ala carte posteromedial release in children over two years of age who were not responding to the Ponseti method of treatment of idiopathic clubfoot.

Material and Methods

A retrospective observational study from September 2013 to August 2015 was conducted at a tertiary level medical teaching institution. The clubfeet were classified according to the Harold and Walker classification. Radiographic parameters assessed were the talocalcaneal angle (AP, lateral), talus-first metatarsal angle (AP, lateral) and calcaneal-fifth metatarsal angle. The scar and the functional score, according to Laaveg and Ponseti, were evaluated as outcome measures at the final follow-up.

Results

Twenty-four children with a mean age of 43.7 ± 24.7 months were enrolled in the study. There was a total of 36 clubfeet: 21 (65.6%) with a poor functional outcome; 12 (37.4%) with excellent to good scar in both horizontal and vertical components. There was a statistical significance between the pre-operative and post-operative radiological parameters (p<0.05). None of the patients presented with any limitation of activities of daily living despite the poor functional outcome in many of the children. There was no significant association between the qualities of scar (horizontal, vertical) and the functional outcome with age at presentation, pre-operative Harold and Walker classification and pre-operative radiographic angles.

Conclusion

Surgical intervention in terms of ala carte posteromedial soft tissue release could not produce a good outcome over four years in CTEV. The threshold for surgery in CTEV should be high, given the poor results.

Unconventional Transverse Transport above and below the Magnetic Transition Temperature in Weyl Semimetal EuCd_{2}As_{2}

As exemplified by the growing interest in the quantum anomalous Hall effect, the research on topology as an organizing principle of quantum matter is greatly enriched from the interplay with magnetism. In this vein, we present a combined electrical and thermoelectrical transport study on the magnetic Weyl semimetal EuCd_{2}As_{2}. Unconventional contribution to the anomalous Hall and anomalous Nernst effects were observed both above and below the magnetic transition temperature of EuCd_{2}As_{2}, indicating the existence of significant Berry curvature. EuCd_{2}As_{2} represents a rare case in which this unconventional transverse transport emerges both above and below the magnetic transition temperature in the same material. The transport properties evolve with temperature and field in the antiferromagnetic phase in a different manner than in the paramagnetic phase, suggesting different mechanisms to their origin. Our results indicate EuCd_{2}As_{2} is a fertile playground for investigating the interplay between magnetism and topology, and potentially a plethora of topologically nontrivial phases rooted in this interplay.

Outcomes and predictors of juvenile idiopathic arthritis in Southeast Asia: a Singapore longitudinal study over a decade

OBJECTIVE

To assess short- and long-term outcomes and predictors of juvenile idiopathic arthritis (JIA) children treated with contemporary therapy and compare those with reports elsewhere.

METHODS

Children with JIA were recruited from our web-based REgistry for Childhood Onset Rheumatic Diseases (RECORD) from 1997 to 2015. Disease status was defined using modified Wallace criteria. Nonparametric statistics described the data. Kaplan-Meier survival and logistic regression analyses were used to estimate probabilities and to determine predictors of outcomes.

RESULTS

A total of 251 children with JIA (62% males, 71% Chinese) were included. Median follow-up duration was 2.9 years (range 0.1-17.5). Short-term clinical inactive disease (CID) was attained in 37% with 62% systemic JIA (sJIA) and 47% persistent oligoarthritis (oJIA). Methotrexate (OR 0.34) decreased but sJIA (OR 3.25) increased chance of attaining CID at 6 months. Overall, 79% of patients achieved CID within 2 years (sJIA 92%, the highest, and RF+ polyarthritis 50%, the lowest probability). Biologics were associated with CID attainment (OR 2.73). One-half of patients flare after CID, median 1.2 years (IQR 0.71-1.97). Late CID achievement predicted flare (OR 2.15). Only 15% had clinical remission off medication (none RF+ polyarthritis and 7% ERA). Only 13% of patients had active arthritis as young adults and 22% had active arthritis at last visit.

CONCLUSION

Despite high proportion of JIA patients attaining CID, only one-fourth could stop all medications for at least 1 year. Persistent oJIA patients were less likely to achieve clinical remission on medication and ERA patients had the least chance stopping medications. One-tenth of patients had active arthritis as young adults. Key Points • Majority of Asian children with JIA attained inactive disease within 2 years after diagnosis. • Outcome predictors were different from reports from the West. • Despite high inactive disease numbers, only one-in-four JIA patients discontinued treatment within 5 years.

SAT0498 ENTHESITIS-RELATED ARTHRITIS (ERA) IN SOUTHEAST ASIA: A DECADE OF SINGAPORE EXPERIENCE

Background:

ERA is the most common Juvenile Idiopathic Arthritis (JIA) subtype in Singapore (1), but less common in the West. Clinical characteristics and treatment of ERA in the region is not well-described thus impede the diagnosis and management plan which could lead to poorer outcomes.

Objectives:

To describe the clinical characteristics, joint manifestation and treatment of ERA in a large monocentric cohort in Singapore over 10-year period

Methods:

Children diagnosed with ERA according to ILAR criteria with a minimum follow-up of 3-month duration were recruited from our registry, from 2009 to 2019, at KK Women’s and Children’s Hospital, Singapore. Nonparametric descriptive statistics including median (IQR) were used to described data. Kaplan-Meier survival analyses were used to estimate the probability of ever sacroiliitis development. Multivariate logistic and Cox regression analyses were used to determine predictors as appropriate. The significant level was set at < 0.05.

Results:

A cohort of 147 ERA out of 439 JIA patients (male 88%; Chinese 80%) were included. Median age at onset was 11.9 yrs (IQR9.4-14.0) and disease duration was 6.0 yrs (3.1-8.9). Median lag period was 2.9 mo (1.2-7.4). Family history of HLA-B27 related diseases was positive at 8%. Acute uveitis occurred only 3%. Joint distribution at diagnosis and cumulative involvement were shown in Fig 1. Hip, sacroiliac and knee were the three most common joints involved. 24% presented with enthesitis and Achilles tendon enthesis were the most common. Majority presented with pauciarthritis (84%) while 12% of patients had no peripheral joint involvement. 40% of patients presented with sacroiliitis (SIs) with 59% had bilateral involvement. Median duration to develop SIs was 7.6 mo (IQR 2.0-26.9). Probability of SIs development was 36%, 55% and 70% at 1, 5 and 10 yrs after onset, respectively. Interestingly, neg HLA-B27, female and older age at onset predicted SIs (p=0.001-0.044). Hip arthritis increased (p=0.043) but tarsitis decreased (p=0.031) the risk of SIs. Again, female, hip arthritis at diagnosis and neg HLA-B27 had a shorter time to SIs (p=0.004-0.007). Fig 2 showed medication used in our ERA cohort. Methotrexate (MTX) remained the most common DMARD used. However, 76% required anti-TNF therapy (aTNF) due to MTX failure. For SIs patients, 86% were on MTX but 85% of these, as compared to patients without axial disease, 60%, failed MTX. Only 10% of patients had aTNF without MTX.

Fig 1.

Proportion of joint involvement at onset and cumulative involvement during the course of disease (%)

Fig 2.

Proportion of medications used in ERA cohort during the course of disease (%)

Conclusion:

Our ERA cohort had less uveitis and family history of HLA-B27 associated diseases, but comparable gender and age at onset as compared to reports elsewhere(2). Up to 40% of our patients presented with SIs and/or enthesitis. Majority of SIs developed within the first 5 yrs (88%) for which over one-half developed within the first year. When considering only ERA patients, interestingly that female, neg HLA-B27 and older age increased risk of SIs development. 77% of patients were treated with MTX, but 76% of the patients required aTNF later. As for SIs, concurred with adult AS data, 85% failed MTX. About one-half of non-axial disease patients failed MTX which is less response rate as compared to other JIA subtypes.

References:

[1]Arkachaisri T, Tang SP, Daengsuwan T, Phongsamart G, Vilaiyuk S, Charuvanij S, et al. Paediatric rheumatology clinic population in Southeast Asia: are we different? Rheumatology. 2017;56(3):390-8.

[2]Mistry RR, Patro P, Agarwal V, Misra DP. Enthesitis-related arthritis: current perspectives. Open access rheumatology: research and reviews. 2019;11:19-31.

Disclosure of Interests:

None declared

THU0508 LARGE VESSEL VASCULITIS IN A COHORT OF CHILDREN WITH RESISTANT KAWASAKI DISEASE IN SINGAPORE

Background:

Kawasaki Disease (KD) is one of the most common systemic vasculitidies in children today. IVIG is the mainstay of treatment, however, about 1/5 of patients do not respond resulting in an increased risk of Coronary Artery Abnormalities (CAA)1.

Objectives:

To describe a cohort of infants and young children with resistant Kawasaki Disease (rKD) who were noted to have prolonged difficult courses with resultant CAA and ultimately diagnosed with Aortitis.

Methods:

Demographic, clinical manifestations and imaging data were collected from children seen in Rheumatology clinic with a diagnosis of rKD and aortitis. Nonparametric descriptive statistics were used to describe the data.

Results:

Between 2010-2018, 63 out of 417 KD referrals were diagnosed with rKD. 7 children had prolonged time to CRP normalisation, prolonged admission or recurrence of symptoms (Table 2). All patients underwent Magnetic Resonance Angiography (MRA) and were found to have evidence of large vessel arteritis consisting of wall irregularity, thickness and contrast enhancement.

Table 1IDAge at diagnosis(mo)Number of clinical KD signs**BCG site inflammationLowest Hemoglobin g/DLHighestWBC10 (9)L#Highest Platelet10 (9)LHighest CRPmg/LLowest Albuming/LMaximum ALTU/LMaximum ASTU/LA3130NANANANANANANAB7409.537.3875.0206.021.036.032.0C4419.843.2918.0130.022.044.052.0D3.5419.242.41715.0181.418.061.099.0E5416.717.61413.0148.227.020.024.0F2306.435.6959.0212.115.08.019.0G24NANA8.621.91002.0181.427.017.030.0

5 patients were male; All were Singaporean Chinese except for G who was from the Philippines; A & G were treated in an outside facility/separate service initially and some data was not available; # Blood test results were generally taken at the same time apart from the platelet count; **Only D presented with lymphadenitis.

Table 2IDTIme to CRP normalization(weeks)Number of IVIG givenSteroidsTime to abnormal echo(weeks)Time to aneurysm development(weeks)Other outcomesA*2oral only441stIVIG given 3 weeks after symptom onsetB*2IV/PO22deceased, MI secondary to thrombusC21IV/PO1.10treated with Infliximab and then Methotrexate,post infliximab psoriasis,D51IV/PO0.32treated with Infliximab and then Methotrexate,multiple infections in hospital; BCG reactivation while on InfliximabE92no1.42.7UTI, AIHA, lost to follow upF33IV/PO0.712.5post Infliximab psoriasis, multiple infections in hospitalG72oral only70lost to follow up

*patients A & B had recurrent KD episodes interspersed with short periods of symptom resolution

Conclusion:

While transthoracic echocardiograms remain imaging investigation of choice, for children with recalcitrant or recrudescent KD, especially in the setting of delayed CRP resolution of >2 weeks; an MRA should be considered.

References:

[1]McCrindle BW, Rowley AH, Newburger JW, et al. Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease: A Scientific Statement for Health Professionals From the American Heart Association. Circulation. 2017 Apr 25;135(17):e927-e999.

Disclosure of Interests:

None declared

AB1004 JUVENILE DERMATOMYOSITIS (JDM) IN SOUTHEAST ASIA: A 20-YEAR SINGAPORE EXPERIENCE

Background:

Juvenile dermatomyositis (JDM) is a multisystem inflammatory disease of childhood with variable demographics, clinical features and outcomes. No studies have described the characteristics of JDM patients from Southeast Asia population.

Objectives:

To describe the clinical characteristics and outcomes of JDM patients in Singapore over a 20-year period.

Methods:

Patients diagnosed with JDM from 1999 to 2019 at KK Women’s and Children’s Hospital, Singapore, were recruited. Nonparametric descriptive statistics were used to described data. Kaplan-Meier analyses were used to estimate the probability of remission. Multivariate logistic and Cox regression analyses were used to determine predictors as appropriate. The significant level was set at < 0.05.

Results:

32 JDM were identified. Clinical characteristics and treatment used are shown in Table 1.

All (n=32)Monophasic (n=17)Polyphasic (n=14)Male14 (43.8)7 (41.2)7 (50.0)Age at onset (yrs)*6.4 (4.5 – 9.8)5.4 (4.1 – 8.5)7.4 (5.6 – 12.3)Lag period (mo)*3.5 (1.0 – 12.5)2.0 (1.0 – 16.8)6.8 (1.2 – 15.8)Heliotrope16 (50)9 (52.9)7 (50)Gottron papule23 (71.9)12 (70.6)11 (78.6)Malar rash19 (61.3)9 (52.9)10 (71.4)Vasculitic rash19 (61.3)8 (47.1)11 (78.6)Arthritis10 (31.3)3 (17.6)7 (50)Nailfold changes28 (87.5)15 (88.2)13 (92.9)Calcinosis9 (28.1)4 (23.5)5 (35.7)Positive ANA17 (53.1)10 (58.8)7 (50)Positive Myositis antibodies4 (12.5)2 (11.8)2 (14.3)Laboratory at diagnosis, U/L* CK324 (134 – 2229)746 (139 – 2965)351 (155 – 2622) LDH650 (450 – 943)650 (398 – 1015)714 (512 – 944) ALT28 (16 – 106)35 (18 – 109)38 (15 – 104) AST50 (30 -108)50 (31 – 113)85 (36 – 215) Aldolase13.7 (8.1 – 28.0)14.2 (8.4 – 26.6)16.3 (8.6 – 38.5)CMAS score at diagnosis29 (21 – 43)28 (21 – 35)35 (11 – 43)

*median (IQR), otherwise - n (%)

Pulse methylprednisolone (pMP) was used in 53.1% of patients after diagnosis. Median time to inactive disease (ID) was 5.3 months (IQR 2.8 – 12.8). Male, older age and patients on pMP (p = 0.003-0.044) achieved ID sooner. Older patients also developed disease flare sooner after achieving ID (p =0.024). No clinical features nor lab investigations predicted JDM disease course. Malay patients was associated with higher risk of calcinosis (p = 0.017).

Compared to adult dermatomyositis patients in Singapore1, our cohort had more cutaneous manifestations including malar rash, vasculitic rash and nailfold changes. Table 2 shows the time for each muscle enzymes to normalise.

CK1.49 (0.69 – 3.53)LDH4.53 (2.35 – 25.04)ALT1.71 (0.90 – 4.13)AST0.97 (0.53 – 3.12)Aldolase3.12 (2.35 – 8.30)

median in months (IQR)

Conclusion:

Our cohort of JDM patients had more calcinosis compared to other Asian population2. Malay population is at higher risk of this complication. It is crucial to achieve ID state in the shortest time possible to avoid significant morbidity. Our study suggests that early treatment with pMP is associated with shorter time to ID. There is no predictor identified for disease course, similar to previous studies3.

References:

[1]Liu, Wen Chun, et al. “An 11-year review of dermatomyositis in Asian patients.” Annals Academy of Medicine Singapore 39.11 (2010): 843.

[2]Sun, Chi, et al. “Juvenile dermatomyositis: a 20-year retrospective analysis of treatment and clinical outcomes.” Pediatrics & Neonatology 56.1 (2015): 31-39.

[3]Stringer, Elizabeth, Davinder Singh Grewal, and Brian M. Feldman. “Predicting the course of juvenile dermatomyositis: significance of early clinical and laboratory features.” Arthritis & Rheumatism: Official Journal of the American College of Rheumatology 58.11 (2008): 3585-3592.

Disclosure of Interests:

None declared

Assessment of natural regeneration of mangrove with reference to edaphic factors and water in Southern Gulf of Kachchh, Gujarat, India

The study was carried out to determine the natural regeneration of four species of mangroves along with estimation of physico-chemical characteristics of sediment and water from seven sites of mangroves in the southern Gulf of Kachchh. Spatial variation of different parameters of water and sediment investigated were: water-pH (7.87–8.04); Salinity (37.07–39.42 ppt); Nitrate (1.21–2.71 ppm); Nitrite (0.03–0.08 ppm); Phosphate (0.39–0.95 ppm) and sediment-pH (7.39–7.61); Bulk density (0.36–0.54 g/cc); Particle density (1.19–1.68 g/cc); Organic carbon (0.77–1.05%); and Organic matter (1.06–1.71%). The density (recruit/sq. m) of natural recruitment of four mangrove species was in order of Avicennia marina > Ceriops tagal > Aegiceras corniculatum > Rhizophora mucronata. Cluster analysis grouped seven sites in three major clusters i.e. Group A (Poshitra & Khijadiya - 91% similarity); Group B (Dedeka-Mundeka, Kalubhar & Pirotan- 94% similarity) and Group C (Sikka & Jodiya- 93% similarity) whereas Non-metric multidimensional scaling showed formation of two groups (Coastal and Islands) depending on the environmental conditions and mangrove natural regeneration. Principal component analysis showed the number of parameters such as salinity, texture and organic carbon which affects the natural regeneration of mangrove species in the study area.

Urinalysis monitoring in children with Henoch-Schönlein purpura: Is it time to revise?

OBJECTIVES

To describe the natural history and risk factors of renal involvement in our Henoch-Schönlein purpura (HSP) inception cohort.

METHODS

HSP patients followed at our center for at least 6 months between 1/2009-4/2017 were included. A 2-year urinalysis (UA) monitoring protocol was adopted (6 monthly and another 6 of 3 monthly UA). Renal involvement included minimal renal involvement defined as isolated hematuria (urine red blood cells >5/high-power field or 10/µL) and/or proteinuria (urine protein >1+), and renal impairment defined as nephritic, nephrotic symptoms, or renal insufficiency. Recurrent HSP were excluded. Kaplan-Meier estimates and log-rank test were used to analyze the duration to onset and resolution of abnormal UA. Relationships between demographic and clinical features and renal involvement were studied using logistic regression analyses.

RESULTS

Two hundred and thirty-eight patients (52.9% male) were analyzed. Median duration of follow up was 20.6 (interquartile range 11.3-24.4) months. Eighty-nine children (37.4%) developed abnormal UA either at diagnosis (n = 43), or during follow up (n = 46), mostly (91.0%) within 6 months. Seventeen patients (7.1%) developed renal impairment. Among patients without renal impairment, an earlier subsidence (P = 0.008) was noted in those with normal UA at diagnosis and most abnormal UA resolved by 18 months in this subgroup. Older age at diagnosis was a risk factor of renal involvement (P < 0.001). Prednisolone therapy for non-renal indications did not affect the onset or duration of renal involvement.

CONCLUSIONS

Normal UA at diagnosis indicated a shorter duration of renal involvement. We propose a curtailed duration of follow up for those with normal and abnormal UA at diagnosis.

Unmasking and aggravation of polycythemia vera by canagliflozin

BACKGROUND

Sodium-glucose co-transporter-2 inhibitors are novel antidiabetes drugs that act via inhibition of renal glucose reabsorption. This action causes osmotic diuresis, reduces intravascular volume and is associated with various adverse effects. In the present paper, we describe the first report on the unmasking of underlying polycythemia vera by canagliflozin in a person with Type 2 diabetes mellitus, which was temporally related to the use of the drug.

CASE REPORT

A 51-year-old obese man with Type 2 diabetes was prescribed canagliflozin 100 mg for control of his glycaemia. He presented 6 months later with asymptomatic elevation of his haemogram measurements (haemoglobin: 16.9 g/dl; haematocrit: 55%; red cell number: 8.1 million/mm³ ; total leukocytes: 23010/mm³ ; platelet count: 9.7 *10⁶ /mm³ ). He had no history of smoking, exposure to high altitude or other drugs. Subsequent investigations revealed myeloproliferative neoplasm (polycythemia vera) on trephine biopsy of bone marrow, normal erythropoietin level and JAK2V617F positivity. Because of the possibility that the underlying condition had been unmasked by canagliflozin, the latter was stopped. This led to a remarkable improvement in the man's haematological profile, with no other significant intervention. The man subsequently restarted the drug of his own accord, causing his haematological profile to worsen again and thereby posing a challenge in monitoring of both polycythemia vera as well as diabetes mellitus.

CONCLUSION

This report brings to light unmasking of a new adverse effect of sodium-glucose co-transporter-2 inhibitors in clinical practice caused by volume loss, apart from hypotension and falls.

Direct observation of orbital hybridisation in a cuprate superconductor

The minimal ingredients to explain the essential physics of layered copper-oxide (cuprates) materials remains heavily debated. Effective low-energy single-band models of the copper–oxygen orbitals are widely used because there exists no strong experimental evidence supporting multi-band structures. Here, we report angle-resolved photoelectron spectroscopy experiments on La-based cuprates that provide direct observation of a two-band structure. This electronic structure, qualitatively consistent with density functional theory, is parametrised by a two-orbital (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$d_{x^2 - y^2}$$\end{document}dx2-y2 and \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$d_{z^2}$$\end{document}dz2) tight-binding model. We quantify the orbital hybridisation which provides an explanation for the Fermi surface topology and the proximity of the van-Hove singularity to the Fermi level. Our analysis leads to a unification of electronic hopping parameters for single-layer cuprates and we conclude that hybridisation, restraining d-wave pairing, is an important optimisation element for superconductivity.

The essential physics of cuprate superconductors is often described by single-band models. Here, Matt et al. report direct observation of a two-band electronic structure in La-based cuprates.

Paediatric rheumatology clinic population in Southeast Asia: are we different?

Objectives

To examine the descriptive epidemiology of the patient population referred to paediatric rheumatology centres (PRCs) in Southeast Asia (SEA) and to compare the frequency of conditions encountered with other PRC populations.

Methods

A web-based Registry for Childhood Onset Paediatric Rheumatic Diseases was established in 2009 and seven PRCs in four SEA countries, where paediatric rheumatologists are available, participated in a prospective 24 month data collection (43 months for Singapore).

Results

The number of patients analysed was 4038 (788 from Malaysia, 711 from the Philippines, 1943 from Singapore and 596 from Thailand). Over 70% of patients evaluated in PRCs in Malaysia, the Philippines and Thailand had rheumatic diseases (RDs), as compared with one-half of the proportion seen in Singaporean PRCs, which was similar to the Western PRC experience. Among RDs diagnosed (n = 2602), JIA was the most common disease encountered in Malaysia (41%) and Thailand (61%) as compared with systemic vasculitides in the Philippines (37%) and Singapore (35%) among which Henoch-Schönlein purpura was the most prevalent. SLE and related diseases were more common, but idiopathic pain syndrome and abnormal immunological laboratory tests were rarer than those seen in the West. JIA subtype distributions were different among countries. Among non-RDs (n = 1436), orthopaedic and related conditions predominated (21.7-59.4%).

Conclusion

The frequencies of RDs seen by SEA PRCs were different from those in the West. Systemic vasculitides and SLE were common in addition to JIA. Paediatric rheumatologist availability and healthcare accessibility partially explain these observed discrepancies.

Single Versus Multi-visit Endodontic Treatment of Teeth with Apical Periodontitis: An in vivo Study with 1-year Evaluation

Background:

Apical periodontitis (AP) is one of the most prevalent diseases of the teeth. Treatment of AP is based on the removal of the cause, i.e., bacteria from the root canals. Achievement of adequate bacterial eradication in one appointment treatment remains a controversy.

Aim:

This prospective study was conducted with the objective to compare the periapical healing of teeth with AP treated in (a) single visit versus (b) two visits, either with or without Vitapex as an intracanal medicament.

Subjects and Methods:

Patients were selected randomly from the Department of Conservative Dentistry and Endodontics. Forty-three patients (81 teeth) met the inclusion criteria, i.e., AP (both symptomatic and asymptomatic) visible radiographically size ≥2 mm × 2 mm, not suffering from any immune-compromising disease, age between 16 and 65 years and tooth not accessed previously. Patients were randomly divided into three groups, i.e., single-visit group (Group 1), multi-visit group without any intracanal medicament (Group 2), and multi-visit group with Vitapex as interim intracanal medicament (Group 3). Comparison was done radiographically using periapical index (PAI). The primary outcome measure was the change in periapical radiolucency after 1 year assessed by PAI scores. The Mann-Whitney U-test was used to evaluate differences between groups at baseline (immediate postoperative) and at the 12-month follow-up evaluation. Change in PAI score for each group from baseline to 12-month follow-up evaluation was tested with the Wilcoxon signed rank test. The secondary outcome measures, proportion of teeth in each group that could be considered improved (decreased PAI score) or healed (PAI <2), were assessed with the Chi-square test.

Results:

No statistically significant difference in periapical healing was found between three groups.

Conclusion:

After 1-year evaluation, no difference in periapical healing was found between single-visit treatment and multi-visit treatment groups with the given sample size.

Orbital pseudotumour as a presentation of paediatric ulcerative colitis

A 2-year-old girl presented with a one-day history of acute-onset bilateral painful, swollen eyes and a two‑month history of loose stools. Physical examination revealed a right eyelid swelling with proptosis. Magnetic resonance imaging revealed a right orbital pseudotumour. The patient responded well to treatment with intravenous antibiotics and nonsteroidal anti-inflammatory drugs. However, three weeks later, she was readmitted with a vasculitic lesion over her left upper chest, with mucous-bloody diarrhoea. Histopathology confirmed the diagnosis of ulcerative colitis. The patient was treated with intravenous pulse methylprednisolone and sulphasalazine. Two weeks after discharge, she was readmitted for cutaneous vasculitis and worsening diarrhoea. The patient's bowel and extraintestinal diseases resolved upon addition of infliximab to her treatment regimen. Her inflammatory markers also normalised. Azathioprine was subsequently added. Infliximab was discontinued after four doses and prednisolone was tapered off. The patient remained well without any flare-up after 24 months of follow-up.

Childhood-onset systemic lupus erythematosus in Singapore: clinical phenotypes, disease activity, damage, and autoantibody profiles

Childhood-onset systemic lupus erythematosus (cSLE) is a multisystem autoimmune disease characterized by immune dysregulation affecting patients less than 18 years old. One-fifth of SLE cases are diagnosed during childhood. cSLE presents differently from adults and has a more severe and aggressive course. We describe the clinical and antibody profiles in our cSLE Singapore cohort. All cSLE patients who satisfied the 1997 American College of Rheumatology diagnostic criteria were captured in our lupus registry from January 2009 to January 2014. Data including demographic, cumulative clinical, serologic data, and damage indices were collected. Adjusted mean SLEDAI-2K (AMS) was used to summarize disease activity over multiple visits. Cluster analysis using non-hierarchical K-means procedure was performed on eight selected antibodies. The 64 patients (female:male ratio 5:1; Chinese 45.3%, Malay 28.1%, Indian 9.4%, and other races 17.2%) had a mean onset age of 11.5 years (range 2.1–16.7) and mean age at diagnosis was 11.9 years (range 2.6–18.0). Our study demonstrated differences in clinical manifestations for which hematologic involvement was the most common manifestation with less renal disease and uncommon neurologic manifestation as compared to other cSLE cohorts reported in our region. Antibody clusters were identified in our cohort but their clinical association/discrimination and outcome prediction required further validation study. Outcomes of our cohort in regard to disease activity after therapy and organ damages were comparable if not better to other cSLE cohorts elsewhere. Steroid-related damage, including symptomatic multifocal avascular necrosis and cataract, were not uncommon locally. Infection remains the major cause of death for the continent. Nevertheless, the five year survival rate of our cohort (98.4%) was high.

Characterization and genetic variability analysis in Capsicum annuum L. germplasm

  Fifty three genotypes of Capsicum annuum L. collected from different parts of the West Bengal, India were characterized for 23 characters namely, stem colour, plant growth habit, branching habit, leaf size, leaf shape, leaf margin, leaf colour, leaf pubescence, pigment at node, flower per axil, corolla colour, anther colour, calyx margin, mature fruit colour at intermediate stage, fruit shape, fruit position, fruit adherence to the calyx, fruit shape at pedicel attachment, blossom end fruit shape, ascorbic acid content of the fruit, capsaicin in red fruit and colour value of the ripe fruit. These genotypes upon cataloguing showed distinct variations with respect to vegetative, inflorescence, fruit and quality characters. A wide range of variation was also observed among the genotypes for several morphological, fruit and quality characters. Among the different characters, white corolla colour showed 100 % frequency and higher frequency was also recorded in single flower per axil (86.79 %), number pigmentation at node (83.02 %) and green fruit colour (69.81%) at intermediate stage. Predominance of single descriptor state was found in more than 50 % genotypes for 15 characters. Based on the D2 value 53 genotypes were grouped into 17 clusters and results indicated that Cluster I and Cluster VII comprised with 29 and 9 genotypes respectively. Rest of clusters consisted of one genotype in each case. Variability studies revealed that there was a wide range of variability for all the characters studied. High heritability along with higher genetic advance (as a %age of mean) was found in capsaicin content in fruit, number of fruits per plant, yield per plant and primary branches per plant. These characters may be considered as reliable selection indices as they are possibly governed by additive gene effect. DOI: http://dx.doi.org/10.3329/sja.v11i1.18387 SAARC J. Agri., 11(1): 91-103 (2013)

Microtrap electrode devices for single cell trapping and impedance measurement

This paper reports the design and fabrication of electrode microtraps for single cell trapping and impedance measurement. In this work, the microtrap electrodes of parallel and elliptical geometry have been fabricated by electroplating of gold electrodes of optimum thickness. This has enabled the formation of electrode traps without requiring any precision alignment between separate insulating traps like PDMS and the bottom gold electrodes. Further the improved uniformity of the electric field between the trapping electrodes as observed from COVENTORWARE simulation significantly reduces the effect of cell position inside the microwell on the electrical measurement unlike previous reports. This makes it possible to directly extract the equivalent cell parameters from the electrical measurement without introducing any correction factor corresponding to cell position. We have performed impedance spectroscopy with both the microwell electrode structures with single HeLa cell at two different positions of trapping. It has been observed that there is almost no change in the extracted values of cell resistance and capacitance for different positions within parallel electrodes and there is only 0.7 % and 0.85 % change in cell resistance and capacitance for the two positions within elliptical electrodes. Thus these microwell electrode structures can be used as an improved and a more convenient platform for single cell electrical characterization.

Adenoid cystic carcinoma - Clinical presentation and cytological diagnosis

Adenoid cystic carcinoma is a tumor arising from the minor salivary glands, the palate being the commonest site. It accounts for about 1% of all head and neck malignancies. We report a case with the typical presentation of a palatal growth with extensive intra-cranial invasion. The diagnosis of this case and a brief review of literature is discussed. Final diagnosis of this case was made from cytological reports. The dry smears stained with MGG were found to be definitely superior to the alcohol fixed slides stained with papanicolaou. The aim here is to highlight the importance of cytology in the diagnosis of such tumors.

Laparoscopic appendectomy after conservative management of appendix mass

The purpose of this study was to demonstrate the safety and efficacy of laparoscopic appendicectomy following non-operative management of appendix mass in children. Medical records of 103 consecutive patients (61 males, 42 females) who underwent non-operative treatment of appendix mass followed by laparoscopic elective appendicectomy were examined. Their ages ranged from 2 years 5 months to 15 years (mean 8.3 years). All patients were treated conservatively by close observation, antibiotics and intravenous fluids. Once the child was fit for discharge laparoscopic elective appendicectomy was booked for 4-6 weeks later. Ninety-three children responded to the initial conservative treatment and were discharged after a mean hospital stay of 5.6 days (range 3-10 days). Ten (9.7%) did not respond to initial treatment and developed appendix abscess requiring drainage. Average hospital stay in the 97 patients who had laparoscopic elective appendicectomy was 2.5 days (range 1-5 days). Three patients developed complications after elective appendicectomy, a stitch abscess in one, paralytic ileus in one and wound infection in one. Histological examination revealed fibrosed or resolving appendicitis in 52, acute or subacute appendicitis in 24, carcinoid tumour in two and normal appendix in 19. Laparoscopic elective appendicectomy is a safe and effective method of treatment following conservative treatment of appendix mass. Not only does it make the dissection and resection of the appendix easier but it also has the added advantage of performing adhesiolysis.

Role of cognitive function in assessing informed consent for endoscopy

BACKGROUND

Patient understanding of the consent process is often suboptimal and the reasons for this are poorly understood. In particular the role of cognitive function in assessing the level of understanding of consent has not been evaluated.

AIMS

This study aims to assess the level of patient understanding of the informed consent process and the role of cognitive function in those with low levels of understanding.

METHODS

The study was prospective, interviewing patients immediately after they had given consent but before undergoing their procedure. Understanding of the reason for the procedure, the risks attendant upon it, details of the procedure itself and post procedure care was scored with the total representing overall level of understanding. A mini mental state examination (MMSE) was then performed with the score recorded.

RESULTS

100 patients were interviewed. A low level of understanding was shown in 36%. Ninety two patients had a MMSE score greater than 24. All patients with a high level of understanding had MMSE scores greater then 24 compared with 78% of those with a low level of understanding. All patients (n = 8) who displayed a MMSE score less than 24 had a low level of understanding. Men displayed poorer levels of understanding than women. A subnormal MMSE only identified 22% of those with low levels of understanding.

CONCLUSIONS

Understanding of the consent process is suboptimal. Adequate cognitive function does not predict a high level of understanding of the informed consent process while cognitive impairment precludes it. It is evident, however that factors other than cognitive dysfunction are at play when attempting to explain low levels of understanding.

Successful therapy of lethal murine visceral leishmaniasis with cystatin involves up-regulation of nitric oxide and a favorable T cell response

The virulence of Leishmania donovani in mammals depends at least in part on cysteine proteases because they play a key role in CD4(+) T cell differentiation. A 6-fold increase in NO production was observed with 0.5 microM chicken cystatin, a natural cysteine protease inhibitor, in IFN-gamma-activated macrophages. In a 45-day BALB/c mouse model of visceral leishmaniasis, complete elimination of spleen parasite burden was achieved by cystatin in synergistic activation with a suboptimal dose of IFN-gamma. In contrast to the case with promastigotes, cystatin and IFN-gamma inhibited the growth of amastigotes in macrophages. Although in vitro cystatin treatment of macrophages did not induce any NO generation, significantly enhanced amounts of NO were generated by macrophages of cystatin-treated animals. Their splenocytes secreted soluble factors required for the induction of NO biosynthesis, and the increased NO production was paralleled by a concomitant increase in antileishmanial activity. Moreover, splenocyte supernatants treated with anti-IFN-gamma or anti-TNF-alpha Abs suppressed inducible NO generation, whereas i.v. administration of these anticytokine Abs along with combined therapy reversed protection against infection. mRNA expression and flow cytometric analysis of infected spleen cells suggested that cystatin and IFN-gamma treatment, in addition to greatly reducing parasite numbers, resulted in reduced levels of IL-4 but increased levels of IL-12 and inducible NO synthase. Not only was this treatment curative when administered 15 days postinfection, but it also imparted resistance to reinfection. These studies provide a promising alternative for protection against leishmaniasis with a switch of CD4(+) differentiation from Th2 to Th1, indicative of long-term resistance.

Role of ureogenesis in the mud-dwelled Singhi catfish (Heteropneustes fossilis) under condition of water shortage

The air-breathing Singhi catfish Heteropneustes fossilis was kept inside moist peat for 1 month mimicking their normal habitat in summer and the role of ureogenesis for their survival in a water-restricted condition was studied. The ammonia excretion rate by the mud-dwelled fish increased transiently between 6 and 12 h of re-immersion in water to approximately between eight and 10-fold, followed by a sharp decrease almost to the normal level at the later part of re-immersion. The urea-N excretion by the mud-dwelled fish increased to approximately 11-fold within 0-3 h of re-immersion, followed by a gradual decrease from 9 h onwards. The rate of urea-N excretion by the mud-dwelled fish, however, remained significantly higher (approx. threefold more) than the control fish even after 36-48 h of re-immersion. Although there was a significant increase of both ammonia and urea levels in the plasma and other tissues (except ammonia in the brain), the level of accumulation of urea was higher than ammonia in the mud-dwelled fish as indicated by the decrease in the ratio of ammonia: urea level in different tissues including the plasma. The activities (units/g tissue and /mg protein) of glutamine synthetase and three enzymes of the urea cycle, carbamyl phosphate synthetase, argininosuccinate synthetase and argininosuccinate lyase increased significantly in most of the tissues (except the brain) of the mud-dwelled fish as compared to the control fish. Higher accumulation of ammonia in vivo in the mud-dwelled Singhi catfish is suggested to be one of the major factors contributing to stimulation of ureogenesis. Due to this physiological adaptive strategy of ureogenesis, possibly along with other physiological adaptation(s), this air-breathing amphibious Singhi catfish is able to survive inside the moist peat for months in a water-restricted condition.

Synergistic effect of interferon-gamma and mannosylated liposome-incorporated doxorubicin in the therapy of experimental visceral leishmaniasis

Active targeting of doxorubicin to macrophages was studied by incorporating it in mannose-coated liposomes by use of visceral leishmaniasis in BALB/c mice as the model macrophage disease. Mannosylated liposomal doxorubicin was more effective than liposomal doxorubicin or free doxorubicin. Because leishmaniasis is accompanied by immunosuppression, immunostimulation by interferon (IFN)-gamma was evaluated to act synergistically with mannosylated liposomal doxorubicin therapy. Combination chemotherapy with a suboptimal dose of IFN-gamma resulted in possibly complete elimination of spleen parasite burden. Analysis of mRNA levels of infected spleen cells suggested that targeted drug treatment together with IFN-gamma, in addition to greatly reducing parasite numbers, resulted in reduced levels of interleukin (IL)-4 but increased levels of IL-12 and inducible nitric oxide synthase. Such combination chemotherapy may provide a promising alternative for the cure of leishmaniasis, with a plausible conversion of antiparasitic T cell response from a Th2 to Th1 pattern indicative of long-term resistance.