Burden of osteoarthritis in India and its states, 1990-2019: findings from the Global Burden of disease study 2019

OBJECTIVE

To describe the burden of osteoarthritis (OA) in India from 1990 to 2019.

DESIGN

Data from Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 were used. The burden of OA -knee OA, hip OA, hand OA, and other OA- was estimated for India and its states from 1990 to 2019 through a systematic analysis of prevalence, incidence, years lived with disability (YLD), and disability-adjusted life years (DALY) using methods reported in GBD 2019 study.

RESULT

Around 23.46 million individuals in India had OA in 1990; this increased to 62.35 million in 2019. The age-standardised prevalence of OA increased from 4,895 (95% uncertainty interval (UI):4,420-5,447) in 1990-5313 (95%UI:4,799-5,898) in 2019, per 100,000 persons. Similarly, DALYs due to OA increased from 0.79 million (95%UI:0.40-1.55) to 2.12 million (95%UI:1.07-4.23); while age-standardised DALYs increased from 164 (95%UI:83-325) to 180 (95%UI:91-361) per 100,000 persons from 1990 to 2019. OA was the 20^th most common cause of YLDs in India in 2019, accounting for 1.48% (95%UI:0.88-2.78) of all YLDs; increasing from 23rd most common cause in 1990 (1.25%(95%UI:0.74-2.34)). Knee OA was the most common form of OA, followed by hand OA. The prevalence, incidence, and DALYs for OA and knee OA were consistently higher in females than males.

CONCLUSION

The burden and impact of OA in India are substantial and is increasing. Adopting suitable control and preventive community measures to reduce modifiable risk factors (obesity, injuries, occupational stress) are needed to reduce the current and future burden of OA in India.

AB1582-PARE ASSIGNING A VALUE TO THE ‘PASS’ CONCEPT IN PSORIATIC ARTHRITIS PATIENTS: A SINGLE CENTER DATA

Background

Psoriatic arthritis (PsA), a chronic, heterogeneous disease, needs long-term management. The concept of ‘Patient acceptable symptom state’ (PASS), evaluated with a dichotomized question on patients’ overall satisfaction with their current state of symptoms, represents the overall health state at which patients consider themselves well. Therapeutic compliance improves when the patient’s perspective of wellness is recognized while modifying treatment.

Objectives

To identify cut-off points for composite disease activity scores (DAS) and patient reported outcomes (PROs) that can reciprocate the PASS status of a patient with PsA.

Methods

A cross sectional study was conducted in patients with PsA attending a rheumatology centre in Kerala between March 2020 and Aug 2021. Baseline demographics, clinical characteristics, composite DAS [disease activity index for PsA (DAPSA), clinical (c) DAPSA] and PROs [PsA impact of disease (PsAID), patient pain visual analogue scale (VAS), patient global assessment (PGA), 12-item short-form survey (SF-12)] were compared in patients who responded ‘yes’ and ‘no’ to the ‘PASS’ question. Cut-off values for PASS in composite DAS and PROs were quantified using the Receiver Operator characteristic curve (ROC) curve. Regression models assessed the impact of different variables on the PASS status.

Results

From a total of 314 patients, 302 who fulfilled the inclusion, exclusion criteria were chosen for analysis. Of them, 171 (56.62%) patients were males. Mean age (S.D) and median disease duration (range) were found to be 50.50 ±11.77 years and 8 (4-14) years respectively. Among the study patients, 215 (70.46%) had acceptable PASS status. Median values for composite scores and patient reported characters in patients who accepted their symptoms and in patients who did not accept their symptoms, are represented in Table 1. Cut-off values for patient pain VAS, Pat GA, DAPSA, cDAPSA and PsAID, with the best tradeoffs between sensitivity and specificity, were found to be 17.5, 25, 10.95, 4.75 and 1.95, respectively (Figure 1A and B). Patients with active psoriatic lesions indicated by higher PASI score, presence of nail involvement, and moderate to high disease activity DAPSA value tended not to attain PASS (OR: 0.793; 95% CI: 0.67-0.93, OR: 0.438; 95% CI: 0.22-0.87, OR:0.168; 95% CI: 0.081-0.349).

Figure 1.Table 1.

Patient characteristics according to PASS status

parameters (median (IQR)PASS+vePASS –vep valueN=215N= 87DAPSA6.7 (3.54 -11.10)13 (7.15-18.85)0.00cDAPSA3 (1-7)11(6-15)0.00Dactylitis0 (0-0)0 (0-1)0.00HAQ0.25 (0-0.5)0.5 (0.13-0.88)0.00PsAID1 (0.5-1.9)2.55 (1.6 -4.3)0.00VAS (0-100)10 (0-20)40 (10-50)0.00Pat GA (0-10)1 (1-2)3 (2-5)0.00SF 12 PCS (physical component score)49.67 (42.99-54.31)40.77 (34.58)-50.12)0.00SF12MCS (mental component score)58.82 (53.96-60.73)47.16 (39.65-54.83)0.00Physician global assessment (1-10)1 (0-2)3 (2-4)0.00PASI0.30 (0-0.8)1 (0.2-4.9)

*P<0.05 is considered as significant

Conclusion

The determined cut-off values for PASS lay in the low disease activity range. A significant number of patients who did not attain PASS, received treatment intensification. Patients with increased PASI, presence of nail dystrophy, and moderate to high disease activity DAPSA value tended to not accept their state.

References

[1]Fei JZ, Perruccio AV, Ye JY, Gladman DD, Chandran V. The relationship between patient acceptable symptom state and disease activity in patients with psoriatic arthritis. Rheumatology. 2020 Jan 1;59(1):69-76.

[2]Lubrano E, Scriffignano S, Azuaga AB, Ramirez J, Cañete JD, Perrotta FM. Assessment of the Patient Acceptable Symptom State (PASS) in psoriatic arthritis: association with disease activity and quality of life indices. RMD open. 2020 Mar 1;6(1):e001170.

[3]Maksymowych WP, Richardson R, Mallon C, van der Heijde D, Boonen A. Evaluation and validation of the patient acceptable symptom state (PASS) in patients with ankylosing spondylitis. Arthritis Care & Research: Official Journal of the American College of Rheumatology. 2007 Feb 15;57(1):133-9.

Disclosure of Interests

None declared

LB0003 WITHDRAWING METHOTREXATE AFTER BOTH VERSUS ONLY SECOND DOSE OF THE ChAdOx1 nCoV-19 VACCINE IN PATIENTS WITH AUTOIMMUNE INFLAMMATORY ARTHRITIS: TWO INDEPENDENT RANDOMIZED CONTROLLED TRIALS (MIVAC I AND II)

Background

Pausing methotrexate (MTX) for two to four weeks, improved immunogenicity of influenza vaccination in patients with rheumatoid arthritis (RA), albeit a risk of disease flare (1). This guided the framing of guidelines on MTX withdrawal for COVID-19 vaccination (2). However, evidence for MTX withdrawal for COVID-19 vaccination is limited to observational studies only.

Objectives

To compare the efficacy and safety of holding MTX after each (MIVAC 1) and only after the second dose (MIVAC II) of the ChAdOx1 vaccine versus continuation of MTX in two randomized controlled trials (RCTs).

Methods

Two single centre, investigator-blinded, RCTs were conducted in patients with RA or Psoriatic arthritis (PsA) on stable doses of MTX without prior COVID-19 (CTRI reg. no. MIVAC I: CTRI/2021/07/03463 & MIVAC II: CTRI/2021/07/035307). In MIVAC I, unvaccinated patients were randomised (1:1) to hold or continue MTX for two weeks after each dose of the vaccine. MIVAC II included patients who had continued MTX during the first dose of ChAdOx1 and were randomised (1:1) to hold or continue MTX for 2 weeks after the second vaccine dose. The primary outcome for both the trials was the anti-Receptor Binding Domain (RBD) antibody titres measured four weeks after the second vaccine dose (per protocol analysis). Secondary outcome was the flare rate, defined as an increase in disease activity scores (DAS28/cDAPSA) or physician intent to hike DMARDs.

Results

250 patients were randomized for MIVAC 1 and 178 for MIVAC II and after due exclusions, 158 and 157 were eligible for analysis respectively (Figure 1). In MIVAC I, median anti-RBD titres were significantly high in the MTX hold group [2484 (1050-4388) versus 1147(433-2360), p=0.001] but the flare rate was higher in the hold group [20 (25%) versus 6(8%) p=0.005] compared to continue group. In MIVAC II median anti-RBD titres were significantly high for the MTX hold group [2553 (1792-4823) versus 990 (356-2252), p=0.001] when compared to continue group but there was no difference in the flare rate between the groups [9(11.8%) and 4(7.9%), p=0.15] (Table 1). Since both were parallel studies in similar population, MTX hold arms across both the trials were compared for anti-RBD titres and flare. There was no difference in the anti-RBD titres [p=0.2] between the groups. In MIVAC I, 29(36.25%) patients had reported flare (19 in either first or second dose, 10 for both doses) when compared to MIVAC II where only 9(11.84%) patients had reported flare after the second dose (P <0.001).

Table 1.

Baseline demographics and key results

VariableMIVAC IMIVAC IIMTX HoldMTX ContinuePMTX HoldMTX ContinueP valueN=80N=78valueN=76N=81Age†48 (38-53.3)49 (39-59)0.1953 (42.3-59)53(50-62)0.14Female (%) ‡73 (91.3)75 (96.2)0.3365 (85.5)70 (86.4)>0.99RA (%) ‡69(86.3)69 (93.2)70 (85.6)80 (87.7)PsA (%) ‡11(13.8)6 (8.1)0.316 (7.9)1 (1.2)0.057DAS28†2.7 (2.4-3.2)2.6 (2-3.3)0.62.7(2.3-3.4)2.8 (2.1-3.5)0.78cDAPSA †2(3-4.5)2.5(1.3-3.8)0.463(2.8-3)30.15Prednisolone (%) ‡29 (36.3)23(31.1)0.424(31.6)26 (32.1)>0.99MTX mg/week†17.5 (10-25)15 (10-20)0.05715 (9.4-25)17.5(7.5-25)0.92Anti- RBD antibody titres post second dose (IU/mL) †2484 (1050-4388.8)1147.5 (433.5-2360.3)<0.0012553.5 (1792.5-4823.8)990.5 (356.1-2252.5)<0.001Flare (N%) ‡Post first dose20 (25)6 (8)0.005NANAPost second dose19 (23.8)10(13.3)0.19 (11.8)4 (7.9)0.15

All analysis as per protocol population.

†Median (interquartile range): Mann Whitney U test.

‡ N (%): Fisher Exact test

. Bolded if p<0.05.

Conclusion

Holding MTX after both the doses or only after the second dose of ChAdOx1 yields higher anti-RBD antibody titres as compared to continuing MTX. Comparing across the trials, holding MTX only after the second dose appears to be non-inferior to holding MTX after both doses of the vaccine with a lesser risk of flare.

References

[1]Park JK et al. Clin Rheumatol. 2020 Feb; 39(2):375-379.

[2]Curtis JR, et al. Arthritis & Rheumatology. 2021 Oct;73(10): e60-75.

Acknowledgements

Acknowledgments to all participating investigators, patients and their families

Disclosure of Interests

Anu Sreekanth: None declared, Teny Skaria: None declared, Sneha Joseph: None declared, Rashwith Umesh: None declared, Manju Mohanan: None declared, Aby Paul: None declared, Sakir Ahmed Speakers bureau: Sakir Ahmed had received honorarium as speaker from Pfizer, Dr Reddy’s, Cipla, and Novartis unrelated to this Comment, Pankti Mehta: None declared, Seena Oomen: None declared, Janet Benny: None declared, Justin George: None declared, Anagha Paulose: None declared, K Narayanan: None declared, Sanjana Joseph: None declared, Anuroopa Vijayan: None declared, Kaveri Nalianda: None declared, Padmanabha Shenoy: None declared

POS1425 THE BURDEN OF OSTEOARTHRITIS ACROSS THE STATES OF INDIA, 1990–2019: FINDINGS FROM THE GLOBAL BURDEN OF DISEASE STUDY 2019

Background

Few studies have reported the burden of osteoarthritis (OA) in different parts of India. However, no study has reported the detailed estimates of incidence, prevalence, and years lived with disability (YLDs) and its trends for OA (and its various sites) across the states of India over a long period of time.

Objectives

We aim to describe the state-wise prevalence, incidence, and YLDs for osteoarthritis (OA) in India from 1990 to 2019 according to age and sex.

Methods

Data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 were used. The burden of OA –including knee OA, hip OA, hand OA, and other OA– was estimated for India and its states from 1990 to 2019 through a systematic analysis of prevalence, incidence, and YLDs modelled data using the methods reported in the GBD 2019 Study. All estimates are presented as counts and age-standardised rates per 100,000 population, with uncertainty intervals (UIs).

Results

Around 23.46 million individuals in India had OA in 1990; this increased to 62.35 million in 2019. The age-standardised prevalence of OA increased from 4,895 (95% uncertainty interval (UI): 4,420–5,447) in 1990 to 5313 (95%UI: 4,799–5,898) in 2019, per 100,000. OA was the 20th most common cause of YLDs in India in 2019, accounting for 1·48% (95%UI: 0·88–2·78) of all YLDs; increasing from 23rd most common cause in 1990 (1·25% (95%UI: 0·74–2·34)). Knee OA was the most common form of OA, followed by hand OA. The prevalence, incidence, and YLDs for OA and knee OA were consistently higher in females than males. Uttar Pradesh (8.53 million (95%UI: 7.63–9.53), Maharashtra (6.37 million (95%UI: 5.75–7.06), and West Bengal (4.90 million (95%UI: 4.39–5.46) had the three highest levels of OA prevalence. Goa (5689 (95%UI: 5,125–6,282)), Rajasthan (5667 (95%UI: 5,097–6,305)), and Kerala (5658 (95%UI: 5,107–6,263)) had the highest age-standardised prevalence of OA in 2019, per 100,000 (Figure 1 A and B).

Conclusion

The burden and impact of OA in India are substantial and is increasing; however, it varied among states. Females were affected more commonly than males. Knee OA was the most prevalent site. With improvement in life expectancy and population ageing, greater increases are expected. Adopting suitable control and preventive community measures to reduce modifiable risk factors (such as obesity, injuries, occupational stress) are needed now to reduce the current and future burden of OA in India.

Disclosure of Interests

None declared

POS0889 CO PRESCRIPTION OF ANTI-ACID THERAPY REDUCES THE BIO AVAILABILITY OF MYCOPHENOLATE MOFETIL IN SYSTEMIC SCLEROSIS PATIENTS

Background:

Mycophenolate mofetil (MMF) is an effective treatment option for systemic sclerosis (SSC). However, many patients require co administration of proton pump inhibitors (PPI) or H2 receptor blockers (HRB) because of significant gastrointestinal manifestations in SSC. Co-treatment with PPI or HRB have shown to be associated with reduced drug exposure in post-transplant patients.1, 2 There is scarcity of data among patients with SSC. We evaluated the drug concentration of MMF over 12 hours of exposure and assessed the impact of ranitidine and PPI in twenty patients with SSC.

Objectives:

To assess the effect of esomeprazole or ranitidine on the bioavailability of MMF in SSC patients who are on a stable dose of MMF.

Methods:

Twenty SSC patients, who were on a stable dose of MMF (1.5-3 g) for the past 3 months were selected for the study after obtaining informed written consent. All patients were given either MMF (without PPI or HRB), MMF + esomeprazole, MMF + ranitidine for one month each. At the end of each month, EDTA plasma samples were collected at various time points including 0, 1/2, 1, 1½, 2, 2½, 3, 4, 5, 6, 8 and 12 hours following drug administration to determine the 12-hour area under curve (AUC) of mycophenolic acid (MPA) levels. Estimation of MPA levels was carried out using reverse phase high performance liquid chromatography (HPLC). Total gastrointestinal score was calculated at the end of each month using UCLA Scleroderma Clinical Trial Consortium GIT 2.0 scoring. To compare the mean AUC, linear mixed effect model was fit by considering treatment as the fixed effect and subject as the random effect. MMF was set as the reference treatment for the other three treatments and these were analysed together using Linear mixed effect model.

Results:

All patients were females with mean age of 45 years. Addition of either ranitidine or esomeprazole significantly reduced the mean AUC and C max of the MMF over 12-hour time period. On the other hand, PPI or HRB helped in reduction of the total GI score at the end of 1 month. Details of pharmacokinetics are depicted in the table 1.

Table 1.

Pharmacokinetics and GI score with MMF in combination with PPI / HRB

MMFMMF+ RMMF + EpAUCmean (95% CI)67.97 (62.73, 73.20)53.04 (44.80, 61.27)45.69 (41.10, 50.28)<0.001*T- MAXmean (95% CI)42.00 (33.60, 50.40)46.50 (32.48, 60.52)79.50 (58.99, 100.01)<0.001*C-MAXmean (95% CI)29.61(26.74, 32.48)15.14 (11.32, 18.97)12.62 (10.58, 14.66)<0.001*Mean GI scoremean (95% CI)0.28 (0.15,0.40)0.19 (0.09, 0.30)0.14 (0.06,0.23)0.009

AUC, area under curve Mycophenolic acid; C-MAX, maximum concentration of MPA in 12 hours following MMF; CI confidence interval;Mean GI score, UCLA Scleroderma Clinical Trial Consortium GIT 2.0 scoring; MMF, mycophenolate mofetil; MMF+E, mycophenolate mofetil + esomeprazole; MMF+R, mycophenolate mofetil+ ranitidine;

*p value < 0.05 considered as significant

Conclusion:

As co administration of PPI or HRB can significantly reduce the bioavailability of MMF in patients with systemic sclerosis. To avoid therapeutic failure of MMF drug level monitoring is essential when these agents re prescribed with MMF.

References:

[1]Schaier M, Scholl C, Scharpf D, Hug F, Bönisch-Schmidt S, Dikow R, et al. Proton pump inhibitors interfere with the immunosuppressive potency of mycophenolate mofetil. Rheumatology (Oxford, England). 2010;49:2061–7.

[2]Rissling O, Glander P, Hambach P, Mai M, Brakemeier S, Klonower D, et al. No relevant pharmacokinetic interaction between pantoprazole and mycophenolate in renal transplant patients: a randomized crossover study. British Journal of Clinical Pharmacology. 2015;80:1086–96.

Disclosure of Interests:

None declared

In Vitro Evaluation of Substantivity, Staining Potential, and Biofilm Reduction of Guava Leaf Extract Mouth Rinse in Combination with its Anti-Inflammatory Effect on Human Gingival Epithelial Keratinocytes

This study aimed to assess the biofilm reduction, staining potential, and cytotoxicity of guava extract mouth rinse compared to chlorhexidine (CHX). Substantivity, staining, and antibiofilm potential were investigated by spectrophotometry, colony-forming units, and luminosity color meter, respectively. The cell viability assay was conducted using a colorimetric assay to determine nontoxic levels of guava (0.15%) and CHX in human gingival epithelial keratinocytes (HGEK-16). Cells were treated with lipopolysaccharides (LPS, 1μg/mL) and guava to assess inflammatory gene expression levels of interleukin-β1, tumor necrosis factor-α, and Prostaglandin E2. A scratch wound healing assay investigated the effects of guava on cell migration. The teeth coated in guava mouth rinse displayed 19.4% higher substantivity compared to CHX (0.2%), and the anti-biofilm reduction was observed with both guava and CHX mouth rinses (P < 0.05). The overall discoloration changes were higher with CHX and distilled water compared to guava. Also, guava significantly enhanced HGEK-16 cell viability (P < 0.05), and IL-β1, TNFα and PGE2 expression presented a 0.6-fold decrease when exposed to guava and LPS (P < 0.05). The present study showed that guava mouth rinse fulfilled the requirement for an effective and useful oral care product with desirable substantivity and anti-biofilm action. In addition, guava reduced the inflammation response in HGEK-16 and may be a potential oral rinse for oral anti-inflammatory therapies.

Rare case of atypical femoral fracture with blocked medullary canal associated with bisphosphonate therapy

Bisphosphonates are widely used for treatment of osteoporosis and its use is increasing in geriatric population. Atypical femoral fractures are associated with bisphosphonate therapy. We report an unusual case of femoral shaft fracture following bisphosphonate therapy where the femoral canal of the proximal and distal fracture fragments was blocked and its management.

Staphylococcal toxic shock syndrome presenting as acute respiratory distress and cor pulmonale

We describe a 7-year-old boy with staphylococcal toxic shock syndrome who presented with acute respiratory distress and cor pulmonale. We wish to highlight this unusual presentation as the diagnosis of toxic shock syndrome depends chiefly on a high degree of clinical suspicion. Early diagnosis and prompt institution of appropriate therapy will significantly reduce morbidity and mortality.

Bortezomib plus modified R-CHOP as initial therapy for indolent B-cell lymphomas: Phase I results

8577

Background: Adding rituximab (R) to chemotherapy improves survival for patients (pts) with follicular lymphoma (FL) and other indolent non-Hodgkin lymphomas (NHL), but not all pts respond. Bortezomib (B) + RCHOP has a high complete response (CR) rate, but higher doses of B with standard vincristine produced severe neuropathy. We developed a phase I/II trial to test if adding B to RCHOP with modified vincristine dosing can be well-tolerated and yield a high CR rate. Methods: Untreated pts with indolent NHL and indications for treatment based on GELF criteria or FLIPI ≥3 received R 375mg/m2, cyclophosphamide 750mg/m2, doxorubicin 50mg/m2, vincristine 1.4mg/m2 (capped at 1.5mg) on day 1, B 1.0- 1.6mg/m2 days 1 and 8, and prednisone 100mg days 1–5 for 6–8 cycles. The maximum tolerated dose (MTD) was defined as the regimen at which <30% grade ≥3 non-hematological or grade ≥4 hematological toxicity (>14 days) occurs. Dose escalation used the Escalation with Overdose Control Bayesian method with upper bound (θ=0.3). This facilitated MTD finding with fewer pts given prior data on B+RCHOP. Functional Assessment of Cancer Therapy (FACT) Neurotoxicity (11-item; 4 point scale), EMG, nerve conduction velocity and epidermal nerve fiber density measures were taken at baseline and after cycle 4. Results: 11 pts with FL (n=6) or other indolent NHL enrolled in phase I. Median age was 59 years (range 29–69). 6 pts (55%) had stage IV disease; 8 (64%) had FLIPI ≥2. Pts received RCHOP + B at 1.0 mg/m2 (n=1), 1.3 mg/m2 (n= 6) or 1.6 mg/m2 (n= 4) and together completed 67 cycles. Treatment was well tolerated. Neuropathy occurred in 4 pts (36%), with 2 grade 1, 1 grade 2 and 1 grade 3 toxicity ( Table ). Grade 4 neutropenia occurred in 4 pts (36%), but none >14 days. Overall response rate was 100% with 5/8 finished pts (63%) achieving CR. 3 continue on treatment. Mean FACT Neurotoxicity after cycle 4 remained < 1 for all items. Conclusions: Adding bortezomib to RCHOP produces limited toxicity when vincristine is capped at 1.5 mg. Phase II will explore the efficacy of this regimen.

[Table: see text]

[Table: see text]

Differences in phosphatase modulation of alpha4beta1 and alpha5beta1 integrin-mediated adhesion and migration of B16F1 cells

It is well established that a biphasic relationship exists between the adhesive strength of beta1 integrins and their ability to mediate cell movement. Thus, cell movement increases progressively with adhesive strength, but beyond a certain point of optimal interaction, cell movement is reduced with further increases in adhesive function. The interplay between the various kinase and phosphatase activities provides the balance in beta1 integrin-mediated cell adhesion and migration. In the present study, the significance of protein tyrosine phosphatases (PTP) and ser/thr protein phosphatases (PP) in alpha4beta1 and alpha5beta1 integrin-mediated mouse melanoma B16F1 cell anchorage and migration on fibronectin was characterized using phosphatase inhibitors. At low fibronectin concentration, alpha5beta1 functioned as the predominant receptor for cell movement; a role for alpha4beta1 in B16F1 cell migration increased progressively with fibronectin concentration. Treatment of B16F1 cells with PTP inhibitors, sodium orthovanadate (Na3VO4) and phenylarsine oxide (PAO), or PP-1/2A inhibitor, okadaic acid (OA), abolished cell movement. Inhibition of cell movement by PAO and OA was associated by a reduction in the adhesive strength of alpha4beta1 and alpha5beta1. In contrast, treatment of B16F1 cells with Na3VO4 resulted in selective stimulation of the adhesive function of alpha5beta1, but not alpha4beta1. Therefore, our results demonstrate that (i) both PTP and PP-1/2A have roles in cell movement, (ii) modulation of cell movement by PTP and PP-1/2A may involve either a stimulation or reduction of beta1 integrin adhesive strength, and (iii) distinct phosphatase-mediated signaling pathways for differential regulation of the various beta1 integrins exist.

First cleft branchial fistula in a child--a modified surgical technique

Congenital first branchial cleft fistulae, their embryology, anomalies, varied relationships to the facial nerve and surgical techniques for their excision have been well described in the literature. We report a case of a type II first cleft fistula in a three-year-old child which required a modification of the standard surgical approach to achieve safe and complete excision with identification and preservation of the facial nerve.

A case of quinsy in a fifteen-month old child

A case of peritonsillar abscess in an infant is described, which is a rare lesion in infants and young children. To our knowledge this is the youngest child described in the English literature. The clinical presentation and treatment of peritonsillar abscess in infants and young children are discussed. Serious complications can occur early in the course of the disease because of physiological and anatomical factors and thus early aggressive treatment is required.

Pre-operative nasal preparation--nasal packing and spraying compared

Fifty patients were included in a single blind study to evaluate the effectiveness of ephedrine-naphazoline (0.5 and 0.125 per cent respectively) nasal spray as against nasal packing with lignocaine (4 per cent) and adrenaline solution (1:50,000).

Osteoma of the ear canal presenting with headache

Osteoma of external auditory canal is a rare benign tumour. Usually it is found incidentally and often symptomless. Here we have a case of osteoma arising from the anterior wall of the bony external auditory canal, causing ipsilateral temporal headache which was relieved by removal of tumour.

Maxillary antral lavage--infiltration and surface anaesthesia compared

A prospective study on 210 patients was conducted to determine the relative efficacy of infiltration anaesthesia as against surface anaesthesia for antral lavage. The patients were categorized into three groups and comparisons were made on patient response and our observations. This study confirms that infiltration technique is superior to surface anaesthesia and is, also, less time consuming.

Mycotic infection of the ear (otomycosis): a prospective study

Otomycosis (fungal infection of the ear) is not uncommon clinical problem encountered in our ENT practice. It makes up to 6 per cent of all patients with symptoms of ear disease seen in the Outpatient Clinic. Of the 193 patients with a clinical diagnosis of otomycosis, 171 cases produced positive fungal isolates. In this study Aspergillus species (niger and fumigatus) have been the most common fungal pathogens. Various aetiopathological factors have been examined in detail, and the available literature reviewed. The results of the treatment by nine antifungal agents currently available in Bahrain have been analysed.

Odontogenic keratocyst involving the maxillary antrum

An unusual case of odontogenic keratocyst arising from the maxilla, involving the maxillary antrum has been reported. Presence of an ectopic canine tooth under the orbital floor was a noticeable feature of this case. The clinical presentation, radiological, and histological aspects and treatment have been reviewed.

Haemangiopericytoma of the nasal septum

Haemangiopericytoma is a rare vascular tumour originating from pericytes which are cells surrounding the capillaries. Only 23 cases of haemangiopericytoma arising from the nose and sinuses have been reported in the literature, of which three are from the nasal septum. We are pleased to report one more case.