Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Risk profiles and incidence of cardiovascular events across different cancer types

BACKGROUND

Cancer survivors are at increased risk for cardiovascular (CV) disease, although additional data are needed to better understand the incidence of CV events across different malignancies. This study sought to characterize the incidence of major adverse CV events [myocardial infarction, stroke, unstable angina (MACE), or heart failure (HF)] across multiple cancer types after cancer diagnosis.

PATIENTS AND METHODS

Patients were identified from a USA-based administrative claims database who had index cancer diagnoses of breast, lung, prostate, melanoma, myeloma, kidney, colorectal, leukemia, or lymphoma between 2011 and 2019, with continuous enrollment for ≥12 months before diagnosis. Baseline CV risk factors and incidence rates of CV events post-index were identified for each cancer. Multivariable Cox hazards models assessed the cumulative incidence of MACE, accounting for baseline risk factors.

RESULTS

Among 839 934 patients across nine cancer types, CV risk factors were prevalent. The cumulative incidence of MACE was highest in lung cancer and myeloma, and lowest in breast cancer, prostate cancer, and melanoma. MACE cumulative incidence for lung cancer was 26% by 4 years (2.7-fold higher relative to breast cancer). The incidence of stroke was especially pronounced in lung cancer, while HF was highest in myeloma and lung cancer.

CONCLUSIONS

CV events were especially increased following certain cancer diagnoses, even after accounting for baseline risk factors. Understanding the variable patient characteristics and associated CV events across different cancers can help target appropriate CV risk factor modification and develop strategies to minimize adverse CV events and improve patient outcomes.

AN IN-DEPTH ASSESSMENT OF THE TUMOR'S IMPACT ON SARCOPENIA

Loss of muscle mass is a typical symptom of cancer and it is strongly correlated with poor prognosis. Cancer-related Sarcopenia is unresponsive to conventional dietary changes and exercise, in contrast to age-associated muscle atrophy. This particular type of weakness differs from different kinds of muscle loss in that it is triggered by a number of interrelated mechanisms, notably inflammatory processes, abnormal metabolic processes, proteolysis, and autophagy. This research is to examine evidence supporting the theory that tumors have a causal role in causing muscular atrophy. It seeks to investigate the precise regulators that the tumour generates and how they affect the processes that result in muscle waste. The evaluation looks for new directions for further studies and medical treatments. The analysis is based on a thorough examination of the scientific literature and research that shows how tumor and muscle atrophy are related. It concentrates on studies that clarify the numerous strategies by which malignancies cause the loss of muscle. This article highlights particular mechanisms by which these tumor-derived substances affect the development of muscle loss, including inflammatory processes, metabolic disturbance, proteolysis, and autophagy. The discovery of such targets offers hope for the creation of efficient treatment strategies that can enhance the long-term outlook and quality of life of cancer sufferers who are experiencing muscle loss.

Dorsal Column Myelopathy Following Intrathecal Chemotherapy for Leukemia

PURPOSE/OBJECTIVE(S)

Intrathecal (IT) methotrexate (Mtx) and/or cytarabine (AraC) improve CNS disease control in patients (pts) with hematologic malignancies. There are increasing number of case reports of irreversible, primarily dorsal column myelopathy in pts treated with IT chemotherapy. By describing the largest case series of myelopathy following IT chemotherapy, we aim to raise awareness about this devastating albeit rare complication.

MATERIALS/METHODS

We retrospectively reviewed 25 pts with leukemia who developed paraplegia following IT chemotherapy between 2/2006 and 9/2021. Clinical/treatment characteristics, response, and toxicity were extracted from the medical records.

RESULTS

Seventeen pts (68%) were male, 16 had B-cell ALL (64%), 4 had AML (16%), 2 had CML (8%), 2 had T-ALL (8%), and 1 had BPDCN (4%). The median age at diagnosis was 38 years (IQR 30-59). All pts required systemic salvage treatment after induction chemotherapy with a median number of 3 regimens received (IQR 2-5.5). In total, the median number of IT treatments was 19 per pt (IQR 14-27). Most pts (84%, n = 21) received single agent IT Mtx alternating with single agent AraC. Fifteen pts (60%) received triple IT therapy with a median of 3 treatments (IQR 0-8). Prior to the onset of myelopathy, 10 pts (40%) received allogeneic SCT and 9 pts (36%) were treated with radiation therapy. Median follow-up from diagnosis was 1.9 yrs (IQR 1.3-4.1). Myelopathy was progressive and irreversible in all pts (n = 25); 84% (n = 21) experienced sensory loss, and all pts had extremity weakness. Symptoms were ascending in 11 pts (44%) and descending in 4 pts (16%). Irreversible bowel/bladder incontinence developed in 12 pts (48%). CSF analysis at the time of symptom onset was negative for leukemia cells in most pts (n = 21, 84%) and showed malignant cells in 4 pts (16%). CSF studies showed elevated protein in 21 pts (84%). Myelin basic protein was elevated in all 13 assessed pts. On T2 weighted spinal MRI, all pts had enhancement of the dorsal columns, including 80% of pts with this dorsal column abnormality reported at the time of the study and 20% of pts (n = 5) with the dorsal enhancement noted retrospectively. Due to concern for occult disease, 20 pts (80%) received additional CNS-directed therapy after symptom onset. Twenty-two pts (88%) died at last follow-up. The time between neurological symptom onset and death was a median 3.5 months (IQR 2.6 and 5). Three pts (12%) are alive with paraplegia at a median of 4.4 years from symptom onset.

CONCLUSION

Dorsal column myelopathy is a rare but devastating condition that can occur after IT chemotherapy in heavily pre-treated leukemia pts. T2 weighted spinal MRI can be helpful in the evaluation of pts that present with unexplained weakness and sensory changes. We recommend delaying additional CNS-directed therapy until work-up to rule out alternative etiologies is complete. Future strategies are desperately needed to address this irreversible treatment complication.

Feasibility of frailty screening among patients with advanced heart failure

BACKGROUND

Frailty is common among patients with advanced heart failure (HF), and screening for frailty to guide care is recommended. Although multiple tools are available to screen for frailty, the feasibility of routinely incorporating frailty screening into daily clinical practice among hospitalised advanced HF patients has not been rigorously tested.

METHODS

This was a prospective, single-centre, quality improvement study. Two brief frailty screening tools were incorporated into palliative care consultations for all patients ≥50 years from August 2021 to October 2022. In the first phase, the Clinical Frailty Scale (CFS) was implemented, followed by the Study of Osteoporotic Fracture (SOF) tool or a modified SOF (mSOF) version in the second phase. The primary outcome was feasibility (%) of performing frailty screenings for this high-risk population.

RESULTS

A total of 212 patients (mean age 69±10 years, 69% male, 79% white, 30% with ischaemic HF) were referred for palliative care consultation during the study period. Overall, frailty screens were completed in 86% (n=183) of patients. CFS and mSOF reached >80% of adoption, while SOF adoption was 54%. Altogether, 52% of the population screened frail by use of CFS and 52% also by mSOF. All clinicians (n=6) participating in the study reported that frailty screening tools were useful and acceptable, and 83% reported plans for continued utilisation in future clinical practice.

CONCLUSIONS

Frailty screening with CFS or mSOF tools was feasible in hospitalised patients with advanced HF. Tools that require physical assessment were more challenging to implement. These data support the feasibility of incorporating questionnaire-based frailty screening in a busy hospital setting.

Top Ten Tips Palliative Care Clinicians Should Know About Delivering Specialty-Aligned Palliative Care

Specialty-aligned palliative care (SAPC) refers to interprofessional palliative care (PC) that is delivered to a specific population of patients in close partnership with other primary or specialty clinicians. As evolving PC models address physical, psychosocial, and spiritual suffering across illnesses and settings, PC clinicians must acquire advanced knowledge of disease-specific symptoms, common treatments, and complications that impact prognosis and outcomes. The tips provided in this article draw on the experience and knowledge of interprofessional PC and other specialist clinicians from diverse institutions across the United States who have developed and studied SAPC services across different disease groups. Recommendations include focusing on approaching specialty team partnerships with humility, curiosity, and diplomacy; focusing on patient populations where PC needs are great; clarifying how work and responsibilities will be divided between PC and other clinicians to the extent possible; using consults as opportunities for bidirectional learning; and adapting workflows and schedules to meet specialty team needs while managing expectations and setting limits as appropriate. Furthermore, to provide effective SAPC, PC clinicians must learn about the specific symptoms, prognoses, and common treatments of the patients they are serving. They must also build trusting relationships and maintain open communication with patients and referring clinicians to ensure integrated and aligned PC delivery.

Abstract 1785: Multi-step engineering of gene-edited CAR T cells using RNA lipid nanoparticles

Autologous chimeric antigen receptor (CAR) T therapies utilize patient cells and can be limited by cell quality, and the high manufacturing burden of viral vectors. As such, there is a need for allogeneic, “off-the-shelf” CAR T cells to make these transformative treatments widely available. However, allogeneic therapies require multiple genetic engineering steps to express CAR and to delete proteins responsible for graft-versus-host disease. Messenger RNA (mRNA) is a promising approach for expression of therapeutic proteins and gene editing nucleases. In this work, we demonstrate a new method for multi-step engineering of gene-edited CAR T cells using RNA lipid nanoparticles (LNPs).

LNPs encapsulating Spy-Cas9 mRNA, TCR and CD52 guide RNA (sgRNA), and CAR mRNA were produced using microfluidics. The CAR construct contained an anti-CD19 scFv binding domain and CD3ζ/4-1BB co-stimulatory domains. Microgram quantities of RNA LNPs were produced to optimize LNP packaging, cargo ratios, and sgRNA combinations. Lead candidates were scaled to milligrams. Purified human primary T cells were cultured, activated, and expanded in serum-free media in plates, flasks and bioreactors. CAR+, TCR− or CD52− cells were generated by addition of the corresponding LNP to activated cells. Cytotoxic killing was determined by co-culture assays with leukemia cells. Gene knockout, CAR expression, viability and cell killing were measured using flow-cytometry.

CD19 CAR was selected as a relevant protein for expression, with TCR and CD52 proteins as gene knockout targets. Single-step addition of CAR LNPs to T cells resulted in transfection efficiencies of 95.0 ± 2.1% and high protein expression. Upon TCR or CD52 LNP addition to T cells, the onset of gene editing was within 48 hours, reaching single target knockout efficiencies of 92.3 ± 3.0% (TCR−), and double knockouts (TCR−/CD52−) of 74.5 ± 6.1%. Similar results were obtained when comparing different LNP batch sizes (microgram to milligram RNA) and cell culture vessels (125,000 to 45 million cells), demonstrating scalability of both the LNP production and cell treatment. Cell viabilities above 90% were maintained at all steps and for all RNA LNPs. Finally, as proof-of-concept for multi-step engineering, sequential addition of TCR LNPs and CAR LNPs resulted in simultaneous CAR expression and TCR gene knockout. These “off-the-shelf” gene-edited CAR T cells were functionally equivalent to non-edited cells in a B cell killing assay, efficiently clearing over 80% of leukemia target cells at a 1:1 ratio.

Our findings demonstrate the advantages of LNPs for RNA delivery to T cells. The simple and gentle nature of LNP cell treatment allows for multiple genetic engineering steps for simultaneous expression and deletion of proteins. Furthermore, LNPs can be easily manufactured using microfluidics, enabling small-scale screening of RNA libraries and rapid scale-up of lead candidates for clinical translation.

Citation Format: Samuel Clarke, R Geczy, A Balgi, S Park, R Zhao, M Swaminathan, R Tieu, N Hoang, C Webb, E Watt, M Wong, M Fujisawa, N Jain, Angela Zhang, Anitha Thomas. Multi-step engineering of gene-edited CAR T cells using RNA lipid nanoparticles [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 1785.

Adaptations within Palliative Care Delivery Models Due to the COVID-19 Pandemic at a Tertiary Care Hospital

Background: Since the onset of the COVID-19 pandemic, all facets of palliative care provision for patients with serious illness have faced unparalleled challenges. Methods: We describe our palliative care program's response to the increased clinical volume associated with the pandemic by adapting workflows for inpatient and outpatient palliative care teams caring for oncology and nononcology populations. Results: During the initial surge, the demand for palliative care consultation for patients affected by SARS-CoV-2 was high, accounting for 75% of all inpatient palliative care referral requests for oncology and nononcology patients. Furthermore, our ambulatory clinic experienced a 40% increase in visits for complex oncology patients between February and December of 2020. Discussion: This article highlights transformations in palliative care delivery implemented in response to the pandemic and reflects on how these transformations have shaped our current care delivery models. We further delineate our intentional reliance on key population health principles to drive ongoing innovation in palliative care provision across our clinical teams.

Long-term passive wastewater surveillance of SARS-CoV-2 for seven university dormitories in comparison to municipal surveillance

Wastewater-based surveillance (WBS) has been an effective tool for monitoring and understanding potential SARS-CoV-2 transmission across small and large-scale communities. In this study at the University of Saskatchewan, the assessment of SARS-CoV-2 was done over eight months during the 2021-2022 academic year. Wastewater samples were collected using passive samplers that were deployed in domestic sewer lines near adjacent campus residences and extracted for viral RNA, followed by Reverse Transcription quantitative Polymerase Chain Reaction (RT-qPCR). The results showed similar trends for SARS-CoV-2 detection frequencies and viral loads across university residences, the whole campus, and from related WBS at Saskatoon Wastewater Treatment Plant. The maximum daily detection frequency for seven dormitories considered was about 75 %, while maximum daily case numbers for the residences and campus-wide were about 11 and 75 people, respectively. In addition, self-reported rates of infection on campus peaked during similar time frames as increases in viral load were detected at the Saskatoon wastewater treatment plant. These similarities indicate the usefulness and cost-effectiveness of monitoring the spread of COVID-19 in small-scale communities using WBS.

Specialty-Aligned Palliative Care: Responding to the Needs of a Tertiary Care Health System

BACKGROUND

Expanding specialty palliative care within complex health systems involves consideration of patients' unmet needs, clinicians' perceptions of palliative care, and the availability of palliative care resources. Prior to this quality improvement (QI) project, palliative care services in our health system primarily served oncology patients.

INTERVENTION

We undertook a prospective strategic planning process that included executive sponsorship and engagement of institutional leaders and clinicians to help define which palliative care services were most needed by the health system.

MEASURES

We interviewed and surveyed a broad range of clinicians including physicians, nurse practitioners, and social workers.

OUTCOMES

The two most prominent themes that emerged from the stakeholder engagement process were clinicians' wish for specialty-aligned interprofessional palliative care teams and for expansion of nononcology palliative care access.

CONCLUSION

Careful needs assessment and stakeholder engagement can result in goal-directed and data-driven expansion of palliative care services within tertiary health care systems.

Top Ten Tips Palliative Care Clinicians Should Know About Solid Organ Transplantation

Solid organ transplantation (SOT) is a life-saving procedure for people with end-stage organ failure. However, patients experience significant symptom burden, complex decision making, morbidity, and mortality during both pre- and post-transplant periods. Palliative care (PC) is well suited and historically underdelivered for the transplant population. This article, written by a team of transplant specialists (surgeons, cardiologists, nephrologists, hepatologists, and pulmonologists), PC clinicians, and an ethics specialist, shares 10 high-yield tips for PC clinicians to consider when caring for SOT patients.

COVID-19 and tobacco cessation: lessons from India

OBJECTIVES

The Government of India prohibited the sale of tobacco products during the COVID-19 lockdown to prevent the spread of the SARS-CoV-2 virus. This study assessed the tobacco cessation behaviour and its predictors among adult tobacco users during the initial COVID-19 lockdown period in India.

METHODS

A cross-sectional study was conducted with 801 adult tobacco users (both smoking and smokeless tobacco) in two urban metropolitan cities of India over a 2-month period (July to August 2020). The study assessed complete tobacco cessation and quit attempts during the lockdown period. Logistic and negative binomial regression models were used to study the correlates of tobacco cessation and quit attempts, respectively.

RESULTS

In total, 90 (11.3%) tobacco users reported that they had quit using tobacco after the COVID-19 lockdown period. Overall, a median of two quit attempts (interquartile range 0-6) was made by tobacco users. Participants with good knowledge on the harmful effects of tobacco use and COVID-19 were significantly more likely to quit tobacco use (odds ratio [OR] 2.2; 95% confidence interval [CI] 1.2-4.0) and reported more quit attempts (incidence risk ratio 5.7; 95% CI 2.8-11.8) compared to those with poor knowledge. Participants who had access to tobacco products were less likely to quit tobacco use compared to those who had no access (OR 0.3; 95% CI 0.2-0.5].

CONCLUSIONS

Access restrictions and correct knowledge on the harmful effects of tobacco use and COVID-19 can play an important role in creating a conducive environment for tobacco cessation among users.

Postprandial endothelial dysfunction and CIMT after oral fat challenge in patients with type 2 diabetes mellitus with and without macrovascular disease - A preliminary study

BACKGROUND

Very few studies have reported on association of postprandial lipids and endothelial dysfunction among patients with diabetes. Whether endothelial dysfunction particularly postprandial FMD is worse in patients with T2DM with macrovascular disease compared to those without and whether this difference is related to postprandial hypertriglyceridemia (PPHTg) is unclear. Therefore, present study was aimed to assess the relationship between PPHTg and endothelial function in patients with T2DM with and without macrovascular disease.

METHOD

Endothelial dysfunction by FMD and CIMT were compared in patients with T2DM with and without macrovascular disease (n = 13 each group) and 13 age, sex and BMI matched healthy individuals after an oral fat challenge.

RESULTS

There was significant postprandial deterioration of FMD 4-hr after fat challenge in patients with diabetes (P < 0.001) as well as healthy individuals (P = 0.004). Patients with diabetes with macrovascular disease had significantly lower fasting (5.7 ± 6.1% vs. 22.7 ± 10.0% and vs. 24.7 ± 5.3%) as well as postprandial (4-hr) (3.1 ± 5.0% vs. 15.3 ± 8.1% and vs. 15.4 ± 5.7%) FMD compared to other two groups. Fasting, postprandial as well as change in FMD and CIMT in patients with diabetes correlated significantly with fasting as well as postprandial triglycerides with stronger correlation in those with macrovascular disease.

CONCLUSION

Study found significant endothelial dysfunction by FMD that shows substantial further deterioration postprandially following high fat meal in patients with diabetes with macrovascular disease compared to patients with diabetes without macrovascular disease and healthy individuals. Study also indicates that PPHTg is a contributor to endothelial dysfunction. However, more studies are required to corroborate these findings.

952 In-Patient Trauma Surgery in COVID-19 Positive Patients Carries A Significantly Higher Mortality Risk When Compared to In-Patient Covid-19 Negative Patients and Day Case Trauma Patients

Introduction

Covid-19 caused many service changes, yet Trauma surgery continued throughout. We compare mortality rates from In-Patient (IP) and Day Case (DC) trauma patients and compare the mortality rates of patients who tested positive or negative for Covid-19.

Method

We reviewed all trauma admissions that underwent surgical intervention in both our IP and DC services during 31 days from March 23^rd 2020. We recorded their sex, age, operation, Covid-19 symptoms, Covid-19 test results and mortality. The findings were compared between the groups.

Results

In total 127 patients underwent surgery (66 IP; 61 DC). There were 6 deaths (9.1%) within the IP group and 0 deaths in the DC group (p = 0.006). In the IP group 8 patients (12.1%) tested positive for Covid-19 of which 4 died (50%) compared to the remaining 58 patients (87.9%) of which 2 (3.4%) died (p < 0.001). A higher mortality rate was observed in patients with symptoms but a negative Covid-19 test (6.7%) than patients in whom a test was never indicated (2.3%).

Conclusion

Covid-19 positive patients requiring in-patient admission for trauma surgery have a significantly higher mortality rate than both in-patient admissions that were Covid-19 negative or asymptomatic and patients that were treated with Day Case Trauma surgery.

866 A Lateral Approach Is More Likely to Be Successful Than A Posterior Approach for An Injection to Reach the Subacromial Space

Background

Subacromial injections are common for diagnosis and therapy of shoulder impingement secondary to subacromial bursitis. We evaluated the likelihood of a successful subacromial injection from both the posterior and lateral injection sites.

Method

We reviewed 100 MRI scans of the shoulder and recorded measurements in both the sagittal (representative of posterior injection) and coronal (representative of lateral injection) orientations. We compared these to the lengths of standard needles.

Multiple measurements were taken:

Results

Measuring along the angle of the acromion demonstrated shorter mean distances from the lateral injection site. The distance from skin to mid-point of the acromion) provided mean values of 51.4mm for posterior and 40.1mm for lateral. A standard 40mm (green) needle would reach the midpoint of the acromion in 58% of lateral measurements and 23% from posterior.

Conclusions

Injections are more likely to enter the subacromial space from a lateral rather than a posterior entry point.

384 Use of A Dry Swab During ACL Hamstring Tendon Graft Preparation May Lead to Decreased Graft Diameter at Implantation with Subsequent Rebound in Graft Diameter When Exposed to Haemarthrosis – A Porcine Tendon Study

Introduction

ACL reconstruction surgery commonly utilises a hamstring tendon graft. Grafts are normally covered with a wet swab prior to implantation. The aim of this study was to determine the variance in graft diameter when comparing the traditional wet swab to a dry swab.

Method

Flexor tendons from a selection of fresh pig trotters were isolated and prepared with a standard ACL graft preparation technique. Half of the grafts were covered with a wet swab; the other half were covered with a dry swab. Graft diameters were measured at 10-minute intervals. After 30 minutes the grafts were submerged in Hartmann’s solution to simulate the post-operative haemarthrosis, diameters were checked again after 1 hour in the solution.

Results

Use of a dry swab resulted in a 0.5mm greater reduction in diameter than the wet swab group. The dry swab group also showed an increase in diameter by 0.5mm when soaked in Hartmann’s solution, this was not seen in the wet swab group.

Conclusions

Using a dry swab produces a smaller graft diameter, this would allow smaller bone tunnels, retaining bone stock. The subsequent rebound in diameter when in solution may increase the press fit mechanism and facilitate improved integration into the bone tunnel.

890 Predictive Factors for Mortality Following Trauma & Orthopaedic Surgery in The Covid-19 Pandemic. The Manchester Equation

Introduction

Covid-19 caused many service changes including limitations on operations due to potential increased mortality risk to patients. We report our findings from Trauma & Orthopaedic (T&O) surgical mortality through this period and the effectiveness of using a scoring system (The Manchester Equation) to predict likelihood of mortality.

Method

We reviewed all T&O admissions that underwent surgical intervention during the height of the pandemic. We recorded numerous factors for each patient including mortality and Covid status. From this we created a scoring system which is the product of Covid status, Anaesthetic type, Medical co-morbidities and other medical factors and ASA Score. We then analysed the findings to determine whether the score could be predictive of mortality rate.

Results

Of 123 patients undergoing surgery 6 deaths were observed (mean score of 51.3) compared to 117 patients surviving (mean score 31.9), p = 0.001. A score of less than 32 carried a 0% chance of death whereas a score of 32 or more resulted in a 14.6% mortality rate (p = 0.01).

Conclusion

The Manchester Equation can be used to help predict the mortality rate of T&O surgery in the presence of Covid-19 and may be useful for clinical decision making and consent purposes.

Differences between patients with cardiovascular disease and cancer referred for palliative care

Our analysis from a national registry shows that compared to cancer, cardiovascular disease patients referred to palliative care are a decade older, have worse functional status and clinician-estimated prognosis. Both groups have very high symptom burden, with cardiovascular disease patients experiencing more dyspnea while pain, nausea, and fatigue are more common in cancer.

Anaemia in patients with type 2 diabetes mellitus without nephropathy is related to iron deficiency

BACKGROUND AND AIMS

Iron deficiency anaemia, although well reported in diabetic nephropathy, has not been well studied in type 2 diabetes patients in the absence of nephropathy. We studied the prevalence of anaemia and iron deficiency in type 2 diabetes patients without nephropathy.

MATERIAL AND METHODS

A total of 89 patients were selected for this study. 24 h urine protein less than 500 mg was used as the criteria to rule out diabetic nephropathy. Complete hemogram, iron profile and high sensitivity C reactive protein (hs CRP) levels were performed in each patient.Functional iron deficiency (FID) was defined as serum ferritin more than 100 μg/l with serum transferrin less than 20% and total iron deficiency state was defined as serum ferritin less than 100 μg/l.

RESULTS

Fifteen patients (16.8%)had anaemia out of which 13 had total iron deficiency and one each had functional iron deficiency and normal iron status respectively. Assessment of the iron status overall showed that 49 patients had TID (55.05%), 16 had FID (17.9%)and 24 (27.05%) had normal iron status. The hs-CRP was significantly higher in those with iron deficiency.

CONCLUSIONS

The present study found a high prevalence of iron deficiency anaemia in type 2 diabetic patients even in the absence of nephropathy. Most of the diabetic subjects also displayed an iron deficiency state the cause of which needs further investigation.

SAT0319 SUBCLINICAL ATHEROSCLEROSIS IN INDIAN PATIENTS WITH SCLERODERMA – CLINICAL AND SEROLOGICAL ASSOCIATIONS

Background:

Scleroderma has been associated with increased risk of cardiovascular events, however,studies on this from India are sparse.We evaluated clinical and serological factors associated with subclinical atherosclerosis in Indian patients with scleroderma, in a cross-sectional design.

Objectives:

To compare carotid intima-medial thickness (CIMT, mean value of both carotids) as a measure of subclinical atherosclerosis (SCA) between patients with scleroderma (n=61) fulfilling 2013 ACR/EULAR criteria, and healthy controls (n=41).

- To compare clinical (body mass index – BMI, waist-hip ratio – WHR, fasting lipid profile) and serological factors (microparticles, endothelial microparticles, inflammatory cytokines associated with increased cardiovascular risk) between patients with scleroderma and healthy controls.

- To identify factors associated with SCA in scleroderma patients.

Methods:

Subclinical atherosclerosis(SCA) was defined by presence of carotid plaques, or increased CIMT >2 standard deviations compared with Indian reference standards for age and sex. Total microparticles (TMP) were measured of plasma after ultracentrifugation as per previously described protocol using microbeads of 3 μm size (TMP were of size 0.1-1 μm); of these, microparticles positive for CD31 and CD142 were endothelial microparticles (EMP). Serum cytokines (IL-1, IL-6, TNF-α, IL-17) were measured by ELISA using manufacturer instructions. Linear regression was used to identify the determinants of CIMT in scleroderma. Binomial logistic regression was used to identify factors associated with subclinical athersclerosis in scleroderma.

VariablePatients with scleroderma (n=61)Healthy controls (n=41)p valueAge37.8 ± 11.9235.37 ± 6.690.2375Gender (M:F)11:506:350.6516Diabetes/Hypertension/Tobacco use1/2/00/0/0NSBody mass index (kg/m2)20.11 ± 3.8224.38 ± 4.45<0.0001Waist-hip ratio0.86 ± 0.110.89 ± 0.070.1251Total cholesterol (mg/dL)142.5 ± 30.7147.3 ± 39.50.4948Triglycerides (mg/dL)99.4 ± 37121.4 ± 460.0087HDL cholesterol (mg/dL)46.9 ± 4.946.1 ± 4.20.4029LDL cholesterol (mg/dL)93.6 ± 10.593.3 ± 7.50.8520VLDL cholesterol (mg/dL)19.9 ± 7.424.7 ± 9.70.0057Carotid intima-medial thickness (mm)0.68 ± 0.100.53 ± 0.03<0.0001Total microparticles (per±L)12913 ± 24936272 ± 1533<0.0001Endothelial microparticles (per±L)2623 ± 1032829 ± 439.5<0.0001Serum IL-1±(pg/mL)38.19 ± 13.4631.38 ± 18.290.0326IL-6 (pg/mL)176.6 ± 85.74128.9 ± 53.610.0020IL-17 (pg/mL)56.3 ± 20.4553.89 ± 20.510.5611TNF±(pg/mL)49.65 ± 26.7142.09 ± 30.410.1879

Results:

Despite lower BMI, triglycerides and VLDL cholesterol, CIMT was significantly higher in patients with scleroderma. Patients with scleroderma had significantly higher total microparticles and endothelial microparticles in plasma, and serum IL-1± and IL-6 (Table 1). On multivariable regression, age was the only significant determinant of CIMT. 28 (45.9%) patients had SCA; 13 (21.3%) had carotid plaques. Patients with SCA had higher proportion of males (9/28 in those with SCA vs 2/33 in those without SCA). Binomial logistic regression did not identify any other significant predictors of SCA.

Table 1

Comparison between patients with scleroderma and healthy controls

Serum IL-1± (pg/mL)38.19 ± 13.4631.38 ± 18.290.0326IL-6 (pg/mL)176.6 ± 85.74128.9 ± 53.610.0020IL-17 (pg/mL)56.3 ± 20.4553.89 ± 20.510.5611TNF± (pg/mL)49.65 ± 26.7142.09 ± 30.410.1879

Conclusion:

Patients with scleroderma had significant burden of subclinical atherosclerosis, which could not be explained by traditional or novel cardiovascular risk factors.

References:

[1]Psarras A, Soulaidopoulos S, Garyfallos A, Kitas G, Dimitroulas T. A critical view on cardiovascular risk in systemic sclerosis. Rheumatol Int. 2017 Jan; 37(1):85-95.

[2]Jung C, Drummer K, Oelzner P, Figulla HR, Boettcher J, Franz M, et al. The association between endothelial microparticles and inflammation in patients with systemic sclerosis and Raynaud’s phenomenon as detected by functional imaging. Clin HemorheolMicrocirc. 2015; 61(3):549-557.

Acknowledgments:

Supported by IRA(Indian Rheumatology Association) Research Grant to DP Misra.

Disclosure of Interests:

None declared

AB1169 RHEUMATOLOGY PATIENT PERCEPTION OF CARDIOVASCULAR RISKS: A SURVEY AT A TEACHING HOSPITAL

Background:

It is well known that individuals with rheumatological conditions are at an increased risk for developing cardiovascular diseases (CVS) and they are the most common cause of mortality. However, there is still lack of awareness about the CVS risk among Rheumatology patients. We carried out a patient survey to assess their awareness and perception of CVS risk associated with their condition. We also assessed if the health professionals attending to these patients gave adequate education to the patients regarding the CVS risk.

Objectives:

To study awareness about CVS risks among rheumatology patients

Methods:

This was a prospective cross sectional survey where in multiple-choice questionnaires were distributed to consecutive patients attending rheumatology clinic. The questionnaire contained 18 questions including demographics, diagnosis, medications and their awareness of cardiovascular risks associated with their underlying rheumatic conditions. We also explored as patient attempted any Primary preventive measures for reducing the CVS risk.

Results:

We collected data of 57 patients with 47% of patients were above 60 years of age with Female: Male ratio of 3:1. Rheumatoid arthritis was the most common diagnosis (60%) with others including AS (22%), SLE(5%). 32% of patients had been suffering from inflammatory disorder for >10 years and 44% believed their disease was still not fully controlled. 37% had family history of heart diseases.

More than half of the patients (56%) were unaware of cardiovascular risks associated with their condition and 65% overall reported that they were not personally informed about these risks by the treating health professionals. When we analysed the newly diagnosed patients (<5years) 64% were unaware about the CVS risks which is higher compared to patients with diagnosis of >5 years. We tried to explore any ethnic differences, however the number is too small to compare. We noted that around 60% of white British with rheumatological diagnosis were not aware of CVS risk in our group. When further asked about the primary preventive measures, only 23% engage in exercise, 21% have made diet changes, 12% take aspirin, 16% have quit smoking and only 5% quit alcohol.

Conclusion:

This was a small pilot study to look at the patient awareness of CVS risks associated with rheumatological conditions. Clearly there is lack of awareness among patients about CVS risks. Furthermore, most of the patients reported they were not educated about the risks from the health professionals. Majority do not engage in any kind of primary preventive measure for heart diseases. It is crucial that the health professionals actively educate patients regarding the CVS risks and the various methods through which these can be prevented. We believe patient-targeted educational programmes and behavioural interventions can be incorporated for holistic patient management.

References:

[1]John, Holly et al. Inflammatory arthritis as a novel risk factor for cardiovascular disease European Journal of Internal Medicine, Volume 23, Issue 7, 575 – 579

Disclosure of Interests:

Nibha Jain: None declared, Anukripa Manivannan: None declared, Aswin Mahesh: None declared, Arumugam Moorthy Speakers bureau: Abbvie, Novartis,UCB,MSD

AB0694 IS THERE ANY HETEROGENEITY OF SPONDYLOARTHRITIS DISEASE MANIFESTATIONS BETWEEN TWO ETHNIC SUBGROUPS?:A MULTICENTRE INTERNATIONAL COMPARATIVE STUDY BETWEEN INDIA AND UK

Background:

Pathogenesis of Spondyloarthritis (SpA) multifactorial and remains unclear. Various hypothesis have been postulated genetics, HLAB27, IL17, Gut microbiome and Biomechanical stress. Many of these factors can be attributed to ethnic background and environment. HLAB27 accounts for 20–25 % of total heritability and 40% of genetic risk while <10% of HLA-B27 carriers in general population develop SpA1. Higher faecal calprotectin levels in SpA compared to control point towards microscopic gut inflammation2. Thus dietary habits and geographical factors can influence pathogenesis of disease. We looked in clinical manifestations of SpA patients of two very different ethnic background Caucasians and Indians from UK and India to shed more light in understanding the disease

Objectives:

To study any differences in the clinical manifestations of SpA patients of two ethnic groups

To compare outcome measure (BASDAI and ASDAS) between Caucasians and Indians

To study the difference in disease activity between Indian patients and British Asians

Methods:

Multicentre observation study where data of SpA patients attending rheumatology clinics from two major teaching hospitals collected. In India data collected from Sheth VS Hospital and NHL Medical College, Gujarat and in United Kingdom from University Hospitals Leicester, NHS trust. Leicester has a multi-ethnic demography wherein almost 30%3of population is of south Asian ethnicity, making this study unique.

Baseline demographic and clinical data was collected. Clinical and outcome measures compared to see any heterogeneity in disease manifestations. SPSS software used

Results:

Total 200 patients analysed with 148 Indians and 52 Caucasians. The Indian cohort was subdivided into British Asians (second generation Indians) and those form Gujarat, India

We found Indian subgroups were younger with shorter disease duration. Comparison in Table 1

Table 1.CaucasianIndianPAge45.9±1231±12<0.001M:F34:193:10.74TDI years9.6 ±5.93.5± 5.2<0.001BASDAI4.05±2.173.1±1.70.002ASDAS2±0.82.4±1.20.02CRP12.8±23.624±12<0.001HLAB2767%26%<0.001Uveitis25%12%0.02IBP78%90%0.03Enthesitis21%60%<0.001Peripheral Arthritis19%36%0.02Dactylitis2%10%0.07Psoriasis10%20%0.1IBD2%5%0.35Comparing British Asians to Indians, Gujarat no significant difference in clinical parameters. (Table 2)British AsianIndianPBASDAI5.16±2.763.1±1.70.006ASDAS2.53±1.32.4±1.20.74CRP15.2 ±15.424±12<0.001

Conclusion:

We found Caucasians had more HLAB27 positivity and extra-articular manifestation of uveitis however the Indian population has more enthesitis and peripheral arthritis. Enthesitis is initiated during a mechano-sensation and the cultural difference including style of footwear could probably be one of the factors explaining our findings inflammatory back pain has been reported to be higher in Indians compared to Caucasians which could be due to life style

The fact that ASDAS CRP behaves similarly in Indian patients across the two countries and is more when compared to Caucasians might point towards overall higher burden of disease in Indian population

To our knowledge this is a first study comparing clinical manifestations of SpA between Indians and Caucasians

References:

[1]Brown MAet al. Susceptibility to ankylosing spondylitis in twins: the role of genes, HLAand environment.Arthritis Rheum 1997;40: 1823–8

[2]J Simione, et al. Fecal Calprotectin, GutInflammation and SpA Archives of Medical Research. 2019;50:41-46

[3]http://www.ons.gov.uk/census

Disclosure of Interests:

Nibha Jain: None declared, Sapan Pandya: None declared, Puja Srivastava: None declared, Prashant Chotalia: None declared, Arumugam Moorthy Speakers bureau: Abbvie, Novartis,UCB,MSD

AB0953 CANNABINOIDS: FRIEND OR FOE OR A BYSTANDER?

Background:

Cannabinoids has recently gained popularity for use in chronic pain. There is a lot of inquisitiveness among our patients wherein health care professionals are asked about its efficacy, side effects and sometimes even ask for a prescription! As there is paucity of data and research about its use in rheumatology, patient reported outcome(PROM) can guide ahead in expanding our knowledge and experience.

Objectives:

To study usage of cannabinoids by rheumatology patients

To study awareness among primary physicians regarding Cannabinoid usage in rheumatology.

Methods:

Cross sectional survey with two arms. Arm 1 Information from patients attending tertiary rheumatology clinic,including perception regarding the use of Cannabinoids.

Arm 2 consisted of collecting data via web-based survey with20-question from 100 GPs of Leicestershire. Questions on demographics, perspectives on and knowledge of cannabinoid use. Statistical analysis SPSS software.

Results:

Arm1 Total 102 rheumatology patients with 60%were females and 45% secondary education. 48% were unemployed. 75% Caucasians, 18% Asians. RA most common diagnosis followed by OA and FMS. 40 % depression and anxiety in addition to Rheumatic disease. 94% reported ongoing pain with 6-8 on a VAS scale. 79% were satisfied with their current therapy. 65% had heard about complementary medicine and 15% reported using cannabinoids.

Most common form Cannabinoids oil 60% followed by smoking 20%. 56% reported using >3 months and majority 72% use daily. Median age 55 years. 88% users Caucasians. Mean disease duration 6.25 years among users indicates chronicity of disease has a direct proportion in usage. All users had ongoing pain of 7 on VAS. 87% believed it helps them managing pain effectively with a pain free state. On an average spends between 50-100 pounds per week. More than half believe cannabinoids should be available as a prescription drug in NHS and 30% interested to know more about it.

In Arm 2 consisting of Primary care physicians, response rate 50%. Average clinical experience 5 years. Only 20% heard about usage of complementary medicine by rheumatology patient. Most replied that 10% of their patients use Cannabinoids for pain management. Most did not believe use of cannabinoids benefited the patients. Only 4% recommend its usage. 25% think it should be available as prescription. 40% experienced patients asking about cannabinoids during appointment. 88% of respondents did not know much about cannabinoid usage in rheumatology and have never prescribed it in their practice.

Conclusion:

Cannabinoids widely used by the rheumatology patients with PROM favouring its efficacy for control of chronic pain. Preclinical data suggest that cannabinoids might have a therapeutic potential RA1, OA, FMS2. Clinical data regarding cannabinoid treatment for rheumatic diseases are scarce, therefore, recommendations concerning cannabinoid treatment cannot be made. All patients who reported using it suffered from moderate to severe chronic pain. Thus main indication of usage was pain rather than recreational purpose. Although a small survey it clearly highlights lack of knowledge among primary physicians. These results emphasise the need for further research regarding the benefits and risks of cannabinoids in rheumatology.

References:

[1]RichardsonD. etal Characterisation ofthe cannabinoid receptor system in synovial tissue andfluid in patients with OA and RA Arthritis Res.Ther. 10, R43 (2008).

[2]Walitt, B etal Cannabinoids for fibromyalgia. Cochrane DatabaseSyst. Rev. 7, CD011694 (2016).

Disclosure of Interests:

Nibha Jain: None declared, Neelima Reddy: None declared, Arumugam Moorthy Speakers bureau: Abbvie, Novartis,UCB,MSD

C00006 PSYCHOLOGICAL IMPACT OF COVID 19 PANDEMIC ON PATIENTS WITH RHEUMATOLOGICAL DISORDERS - A WEB BASED CROSS-SECTIONAL MULTICENTRE SURVEY

Background:

The COVID-19 pandemic has resulted in uncertainty and negative psychological outcomes for patients with autoimmune rheumatic diseases for several reasons.1The anxiety is due to “underlying conditions” that are expected to increase the risk of infection and / or severe complications. Patients with rheumatological disorders fall into this group as they are believed to be immunosuppressed due to disease or the treatment. It is essential to understand the level of anxiety among the rheumatic disease patients at the current situation of COVID-19.

Objectives:

To study difference in Anxiety score (Mean/Avg Score) among following groups-underlying rheumatic disease, age, gender, marital status, educational status, employment status, medications, those who were on steroids/not, those who are Biologicals / Not.

Methods:

A web-based cross-sectional multi-centre survey was done across 5 rheumatology centres in India. The study duration was between 9th May and 16th May 2020.The questionnaire included consent, demographic details, medication history, opinion about tele rheumatology services and anxiety score measured by Beck Anxiety Inventory (BAI)2.

Results:

The survey was sent to 2987 patients, there were 933 responses and 581 were complete (Male =175). Complete responses were considered for data analysis. Most respondents were less than 50 years of age (70.6%). Rheumatoid arthritis (RA) was the most frequent (50.6%) diagnosis followed by other conditions. Most of the patients (43%) were on combination DMARD therapy, 12.7% of patients were on biological drugs and 23.9% of patients were on glucocorticoids. Statistically significant higher anxiety scores were observed in females, patients suffering from fibromyalgia, patients on glucocorticoids and biological agents. There was no difference in the anxiety scores with regard to age, educational status, and employment status.Difficulty in meeting rheumatologists and getting medications was expressed by 327 (56.2%) and 73 (29.7%) respondents respectively. Majority of respondents (86.6 %) agreed/strongly agreed regarding use of telemedicine to access health care during the crisis.

Conclusion:

The findings of the study revealed that anxiety is a major concern in patients with autoimmune rheumatic diseases. Fibromyalgia patients and those who were on glucocorticoids and biological drugs were found to have more anxiety levels compared to other groups of patients. In such periods of public health crises, telemedicine is a great tool for patients to access healthcare without fear of going to hospital. There is a need to intensify the awareness and address the mental health issues of rheumatology patients during this COVID-19 pandemic.

References:

[1]Pope, J.E. What Does the COVID-19 Pandemic Mean for Rheumatology Patients?. Curr Treat Options in Rheum (2020).https://doi.org/10.1007/s40674-020-00145-y.

[2]Oh H, Park K, Yoon S, Kim Y, Lee SH, Choi YY, et al. Clinical utility of beck anxiety inventory in clinical and nonclinical Korean samples. Front Psychiatry.2018;9:666.https://doi.org/10.3389/fpsyt.2018.00666

Disclosure of Interests:

None declared

AB1030 IgG4-RELATED DISEASE: A RETROSPECTIVE CLINICAL CASE SERIES FROM A TERTIARY CARE CENTRE IN INDIA

Background:

IgG4-related disease (IgG4-RD) is an often unrecognized, rare fibro-inflammatory condition that can involve various organ systems.

Objectives:

The aim of this study was to identify the different clinical patterns of this disease in a single centre in North India.

Methods:

70 patients were diagnosed on the basis of published diagnostic criteria for IgG4-RD. Patients’ presenting complaints, epidemiological profiles, laboratory, radiological and histological findings along with the treatment and outcomes were collated and analyzed from 2011 – 2019.

Results:

In a total of 70 patients who were diagnosed with the disease, the ratio of female to male ratio was 1:1. The mean age of patients was 41.4 years. Involvement of orbits and peri-orbital tissues was highest (52.9%) due to large number of referrals from ophthalmology services. 13% of patients had multiple organ involvement. Patients with involvement of retroperitoneal tissues and lymph nodes were 8.5% and 5.7%, respectively. Increased serum IgG4 levels were found in 74.3% of the patients. Histopathological examinations of the affected organs were performed in 44 (62.85%) patients and a diagnosis of possible (38.57), probable (32.85%) and definite (28.57%) IgG4-RD was made. Majority of the patients (94.3%) required immunosuppressive medications along with corticosteroids. Azathioprine was the most commonly used (72.8%) immunosuppressive medication. Rituximab was used in17.1% of the patients, of whom one had multisystem involvement.

Conclusion:

This study depicts the most common patterns of organ involvement along with the epidemiological, laboratory, histological, radiological data and response to treatment, in IgG4-RD, with a definite ophthalmology referral bias, in a tertiary care centre in North India.

References:

[1]Stone JH, Zen Y, Deshpande V. IgG4-related disease. N Engl J Med 2012; 366(6):539-51.

[2]Khosroshahi A, CarruthersMN, Deshpande V, Unizony S, Bloch DB, Stone JH. Rituximab for the treatment of IgG4-related disease: lessons from 10 consecutive patients. Medicine 2012; 91(1):57-66.

Table 1.

Clinical and laboratory characteristics

CharacteristicsNumber of patients (N=70)Age (years)41.4Age group in years, n (%) >5024 (34.28) <5046 (65.71)Sex, n (%) Male36 (51.42) Female34 (47.22) ESR (mm/hr)24.37 CRP (mg/dL)12.31 Serum IgG (mg/dL)1214.2 Serum IgE (IU/L)587.2Type of IgG4 related disease, n (%) Definite20 (28.57) Probable23 (32.85) Possible27 (38.57)

Data represented as mean, unless otherwise specified.

CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; Ig, immunoglobulin.

Table 2.

Distribution of patients according to organ involvement.

Organ involvementNumber (%)Orbital and periorbital37(52.9)Retroperitoneum6 (8.5)Laryngotracheal tissue4 (5.7)Aorta and branches4 (5.7)Lymph nodes3(4.2)Paranasal sinus2 (2.8)Paravertebral tissue2 (2.8)Pancreas2 (2.8)Lung and bronchus2 (2.8)Eye (Scleritis)1 (1.4)Prevesical Mass1 (1.4)Ear polyp1 (1.4)Small Bowel1 (1.4)Primary sclerosing cholangitis1 (1.4)Musculoskeletal1(1.4)Submandibular gland1(1.4)Central nervous system1 (1.4)Multisystem involvement9 (12.86%)Figure 1.

Right eye proptosis

Figure 2.

CT abdomen showing hydronephrosis due to retroperitoneal fibrosis

Disclosure of Interests:

None declared

Goals of Care Conversations in Serious Illness: A Practical Guide

Clinicians working with seriously ill patients need the skills to effectively communicate with patients and their families throughout the trajectory of illness. Common communication tasks that arise in the care of seriously ill patients include advance care planning, delivering serious news, discussing prognosis, eliciting values, and medical decision making. Clinicians often use goals of care conversations to facilitate these tasks. Similar to other procedures, goals of care conversations require a systematic, evidence-based approach to ensure quality and value. This article provides a framework that clinicians can follow to effectively communicate with seriously ill patients and families and promote patient-centered care.