Hypoalbuminemia and not undernutrition predicts high-dose methotrexate-induced nephrotoxicity in children with acute lymphoblastic leukemia in resource-constrained centers

BACKGROUND

The standard practice to mitigate high-dose methotrexate (HD-MTX)-induced nephrotoxicity (HMN) in acute lymphoblastic leukemia (ALL) is to monitor levels until serum MTX falls below a predefined threshold. It is not feasible in most resource-constrained centers. Literature on the various factors affecting HMN in these centers is limited, retrospective, and heterogeneous. Though hypoalbuminemia has been postulated as a risk factor for HMN, the relationship of undernutrition with HMN has not been studied.

PROCEDURE

This prospective observational study consecutively enrolled children < 12 years old with ALL receiving HD-MTX. Children with preexisting renal disease and exposed to nephrotoxic drugs two weeks preceding HD-MTX infusion were excluded. HD-MTX was administered over 24 hours (BFM-2009 protocol) with 12 hours of prehydration. Solitary MTX levels at 36 hours (MTX36) were outsourced, and 6-8 doses of leucovorin were given six-hourly. Hydration was continued till last dose of leucovorin. Various factors affecting HMN (rise in creatinine to 1.5 times baseline) were recorded: age, sex, type of ALL, risk group of ALL, first dose of MTX, dose of MTX, undernourishment, serum protein, and albumin along with C-reactive protein and MTX36 levels.

RESULTS

Forty-four children who received 150 HD-MTX cycles were analyzed. HMN was seen in 14% of cycles. On univariate analysis, undernourishment, MTX36 levels, hypoproteinemia, and hypoalbuminemia were significantly associated with HMN. On multivariate analysis, hypoalbuminemia and MTX36 levels significantly predicted the development of HMN with odds ratios of 4.71 and 1.45.

CONCLUSION

Hypoalbuminemia and solitary serum MTX levels predict HMN in centers where serial MTX level monitoring is not feasible.

Gestational Age-Specific Nomogram of Transcutaneous Bilirubin in First 120 h of Life for Term and Late Preterm Indian Neonates

OBJECTIVE

To create a nomogram based on transcutaneous bilirubin values (TCB) in first week of life for term and late preterm (>34 weeks) neonates.

METHODS AND DESIGN

Prospective longitudinal study.

SETTING

Four tertiary-care teaching hospitals (one each in eastern and southern India, two in northern India) between February 2019 and March 2020.

PARTICIPANTS

A total of 2492 term and late preterm (>34 weeks) neonates.

INTERVENTION

Bilirubin was measured by transcutaneous bilirubinometer (Drager JM-105, Germany) in all neonates in pre-specified times of the day, 12 hourly every day since birth till discharge between 48 and 72 h, and data were recorded in epochs of 6 hourly intervals. Post-discharge, all neonates were called for review in next 48 h.

OUTCOME MEASURES

Primary-TCB in first week of life. Secondary-factors having significant association with significant hyperbilirubinaemia requiring phototherapy.

RESULTS

Total of 2492 neonates (males 1303 and female 1189), with a total of 14 162 TCB recordings were analysed and mean hourly bilirubin (TCB) at hourly intervals till 120 h and then daily bilirubin values on Days 6 and 7 were tabulated. We have constructed hour-specific bilirubin nomogram with percentiles as per gestational age in term and near-term Indian neonates till 120 h of life. Amongst the known risk factors, delayed cord clamping, primipara and breastfeeding jaundice had significant association for hyperbilirubinaemia needing phototherapy.

CONCLUSIONS

We have created gestation-specific nomogram of TCB levels in 6 hourly intervals for the first 120 postnatal hours, obtained from a large predominantly breast fed healthy, term and near-term Indian neonates.

AB0558 PREVALENCE OF LATENT TUBERCULOSIS INFECTION AND ITS ASSOCIATIONS WITH CLINICAL AND SEROLOGICAL PARAMETERS IN SYSTEMIC LUPUS ERYTHEMATOSUS

Background

Systemic Lupus Erythematosus (SLE) and Tuberculosis are complicatedly related and studies have shown increased risk of TB in SLE. Studies of Latent TB and SLE are inadequate. This study intended to assess the prevalence of latent TB and its association with disease parameters in SLE.

Objectives

To assess the prevalence of latent TB in patients with SLE. To investigate the demographics and clinical characteristics in patients with SLE and concomitant latent TB compared to those without.

Methods

This is a single center cross sectional study. 124 adult patients with SLE without past h/o TB were recruited. SLE demography, disease activity indices, autoantibody profile and steroid use were noted. Presence of Latent TB infection was assessed in all patients based on the IFN-g release assay (TB-IGRA). Based on the results of IGRA, SLE cases were divided into 2 groups-IGRA positive and IGRA negative. The collected parameters were compared between the 2 groups.

Results

Among 124 patients, 19 had latent TB resulting in a point prevalence of 15.4 %. The average disease duration was 4.3 years in IGRA positive and 4.6 in IGRA negative group(p>0.05). Among antibody profile, though no statistical significance among the groups, proportion of antibodies like anti Ku, Ro 60, Ro 52 and La were numerically higher in the IGRA positive group (21.1%, 42.1%, 42.1% and 21.1% respectively) when compared to the IGRA negative group (11.5%, 28.8%, 28.1% and 7.7% respectively). Likewise, anti nucleosome, histone, U1RNP, PCNA, aCLA IgG and IgM, beta 2 GPI IgG and LAC were numerically higher in IGRA negative group (42.3%, 40.4%, 43.3%, 8.7%, 23%, 18.3%, 28.8%, 14.4%) when compared to IGRA positive group (31.6%, 21.1%, 31.6%, 0, 15.8%, 5.3%, 15.8%, 5.3%). Mean clinical SLEDAI was 2.37 ±5.1 in IGRA positive and 3.5 ±5.77 in IGRA negative group. Among clinical features, 1 person in IGRA positive and none in the IGRA negative group had current gastrointestinal involvement. Comparison of other organ manifestations yielded no statistically significant difference in the 2 groups at this point. Serology revealed greater proportion of C4 in IGRA negative as compared to the positive group(p<0.042).

Conclusion

Prevalence of latent TB in SLE cases was 15.4%. Although comparison of demographic, clinical and autoantibody profile did not yield any statistically significant differences, the early turnover from this pilot study mandates further evaluation with larger sample size.

Table 1.

Comparison of clinical and laboratory parameters between IGRA positive and IGRA negative SLE cases

IGRA POSITIVE(n=19)IGRA NEGATIVE(n=105)p VALUEAge(Mean± SD)31.79±9.729.26 ±10.80.199Female Sex n(%)19(100)101(97.1)0.312Anti P0 antibody n(%)3(15.8)14(13.5)0.827Anti Ribo P antibody n(%)2(10.5)13(12.5)0.761Age of disease onset(Mean± SD)25.58± 10.624.62± 10.570.285Disease duration(Mean± SD)4.33 ±4.024.6± 3.530.438Treatment duration(Mean± SD)3.84± 4.124.03± 3.420.439Clinical SLEDAI(Mean± SD)2.37 ±5.13.5 ±5.770.306SLICC ACR DI(Mean± SD)0.105±0.320.231± 0.660.666Current CNS involvement1(5.3)4(3.8)0.781Current renal involvement3(15.8)26(25)0.367Current hematological involvement1(5.3)14(13.5)0.272Current GI involvement1(5.3)00.052Current steroid dose(Mean± SD)11.32± 11.6513.03 ± 11.60.400Serum C3(Mean± SD)0.79 ±0.320.89± 0.470.477Serum C4(Mean± SD)0.19± 0.0720.1635± 0.130.413Anti dsDNA (Mean± SD)458± 400.8379.5± 400.50.454Low C3 n(%)9(52.9)37(38.9)0.108Low C4 n(%)2(11.8)35(36.8)0.042Elevated Antidsdna n(%)6(35.3)37(38.9)3.343

Disclosure of Interests

None declared

POS0773 AUTOANTIBODIES IN A MULTI-INSTITUTIONAL INDIAN COHORT (INSPIRE) OF SLE PATIENTS: PREVALENCE, CLUSTER ANALYSIS AND PHENOTYPE ASSOCIATION

Background

Systemic Lupus Erythematosus (SLE) is characterized by an array of autoantibodies. Different autoantibodies have been associated with different clinical features like anti-dsDNA antibodies with nephritis and anti-phospholipid antibodies with pregnancy loss. However, the prevalence of autoantibodies has been variable across different ethnic groups. Data on the Indian population is limited.

Objectives

To assess the prevalence of different autoantibodies in a multi-institutional cohort (INSPIRE) of Indian SLE patients and to test their association with various clinical features using cluster analysis

Methods

The patients (n=1053) enrolled in a multi-institutional cohort of Indian patients (Indian SLE inception cohort for Research [INSPIRE]) were included.1 Antibodies were assayed using Immunoline (Euroimmune, Germany) 17 antigen kit. Anti-phospholipid antibodies (IgG and IgM anti-cardiolipin antibodies (ACLs), IgG anti-Beta 2 GpI antibodies) were measured using ELISA (Euroimmune). Lupus anticoagulant was available in a subset of patients.

The prevalence data for autoantibodies were analyzed using an intensity of only ++ and above on Immunoline assay as significant. Univariate analysis by Chi-square test was done to identify associations between individual autoantibodies and their clusters with clinical manifestations.

Results

The clinical features were fever in 702, alopecia in 813, oral ulcers in 628, acute cutaneous lupus (ACLE) in 520, proteinuria in 400, pleural effusion in 181, thrombocytopenia in 250 and autoimmune hemolytic anemia in 137 patients.

The prevalence of various autoantibodies by ELISA was anti-dsDNA antibodies in 70.2% (551/784), IgG Anti- beta-2 GpI in 4.47% (42/938), IgG ACL in 6.14% (61/992) and IgM ACL in 7.1% (54/760). Lupus anticoagulant was present in 13.9% (112/ 805). By Immunoline assay, the prevalence for anti-Ro 52, anti-Ro 60, anti-La and anti-Ribosomal P was 28.49%, 33.14%, 10.07% and 24.03% respectively (Table 1).

Table 1.

Prevalence of different autoantibodies in the INSPIRE lupus cohort

S. No.AutoantibodyPrevalence (%) (n=1053)1.dsDNA28.112.Nucleosomes27.833.Histones24.884.Ro_52_SSA28.495.Ro_60_SSA33.146.SSB-La10.077.Ribosomal P24.038.nRNP36.759.Sm33.1410.Scl-703.2311.PM-Scl0.3812.Jo-10.0913.CENP-B0.3814.PCNA1.3315.AMA-M22.28

Cluster analysis (Figure 1) revealed association (Odds ratio with 95% confidence interval) of Cluster 1 (antibodies against dsDNA, histones and nucleosomes) with arthritis (1.51 [1.18-1.94]), proliferative nephritis (3.05[2.08-4.48]) and pleural effusion (1.49[1.08-2.05]), cluster 2 (antibodies against Sm, nRNP, Ro52, Ro60 and Ribosomal P) with ACLE (1.3[1.02-1.65]) and non-proliferative nephritis (1.64[1.09-2.46]) and cluster 3 (antiphospholipid antibodies) with thrombocytopenia (3.34[1.57-7.11]).

Figure 1.

Cluster analysis of autoantibodies (Cluster 1: dsDNA, histone and nucleosome; cluster 2: Sm, nRNP, Ro52, Ro60 and Ribosomal P; cluster 3: cardiolipin, β2GP1 and La and lupus anticoagulant; cluster 4: Scl-70, Jo-1, PCNA, AMA-M2, PM-SCL and CENP-B)

Conclusion

The prevalence of anti-Sm antibody and Anti-Ribosomal P antibody is higher whereas that of anti-La antibody is lesser in the Indian SLE patients as compared to other cohorts of SLE patients with different ethnicities.2 Cluster analysis reveals co-occurrence of different autoantibodies in our patients and their significant association with various clinical manifestations which suggests a possible pathogenic role of autoantibodies or a common genetic basis for it.

References

[1]Shobha V, Aggarwal A, Rajasekhar L, Jain A, Gupta R, Das B, et al. Indian SLE Inception cohort for Research (INSPIRE): the design of a multi-institutional cohort. Rheumatol Int. 2021 May;41(5):887-894.

[2]Yang J, Xu Z, Sui M, Han J, Sun L, Jia X, et al. Co-Positivity for Anti-dsDNA, -Nucleosome and -Histone Antibodies in Lupus Nephritis Is Indicative of High Serum Levels and Severe Nephropathy. PLoS One. 2015 Oct 14;10(10):e0140441.

Disclosure of Interests

Amita Aggarwal: None declared, Ranjan Gupta Grant/research support from: Dr. Ranjan Gupta has received 2 grants for educating patients and primary care physicians about rheumatoid arthritis managment., Rudrarpan Chatterjee: None declared, Vir Negi: None declared, Bidyut Kumar Das: None declared, Parasar Ghosh: None declared, Debashish Danda: None declared, Vineeta Shobha: None declared

POS0775 COMBINED MODEL OF RENAL HISTOPATHOLOGY AND CLINICAL PARAMETERS BETTER PREDICT ONE YEAR RENAL OUTCOMES IN LUPUS NEPHRITIS: ANALYSIS OF 334 KIDNEY BIOPSIES

Background

Diagnosis of Lupus Nephritis (LN) is currently based on laboratory tests and renal histopathology. Role of histopathological features in determining long term outcomes is unclear.

Objectives

1. To assess if clinical and biochemical parameters at baseline can identify renal histopathological class.

2. To assess the clinico-histopathological predictors of renal response.

Methods

This is a single centre retrospective study comprising 334 LN renal biopsies. Clinical and biochemical parameters at the time of biopsy were noted and their association with histopathological class, activity and chronicity scores (AS/CS) (ISN/RPS classification) were evaluated. Complete, partial or no response (CR, PR, NR) for renal outcome (EULAR/EDTA) at 1 year were assessed for 293 patients. Binary logistic regression was done to look for the predictors of NR.

Results

Class III/IV LN was seen in 240(71.8%). Hypertension was seen in (52.1%) of class III/IV and <25% each with class II, V and combined class(p<0.001). Class III/IV had lower eGFR [87.6(62.75-118.8)] (p<0.001) than the other classes. Nephrotic range proteinuria was seen in 32% of class V and 21% in class III/IV (p=0.004). Among class-III/IV, AS had weak correlation with baseline UPCR (r=0.31) and eGFR (r=-0.172) (p<0.01). CS had weak negative correlation with eGFR (r=-0.212, p<0.01). NR at 1 year was higher in males (OR-4.6,95%CI-1.9-10.8, p<0.001), those with abnormal serum creatinine (OR-3.3,95%:CI1.6-7.02, p-0.001), higher renal SLEDAI (p<0.05), higher AS, CS (p<0.001), interstitial inflammation and tubular atrophy(p<0.005) (Table 1). On binary logistic regression a combined clinico-histopathological model comprising of serum creatinine, UPCR, male sex and CS performed best in predicting NR (Figure 1).

Table 1.

Comparison of baseline characteristics among those who attained any response (CR/PR) versus others at 1 year

ParameterAny response Complete Response CR/PR (n=233)Others (No response/rescue) (n=60)OR (95% CI)P valueFemale/male, n (%)221(94.8)/12(5.2)48(80)/12(20)4.6(1.9-10.8)0.001Median age at nephritis onset28(11-65)25(13-67)0.079Median SLE duration12(0-232)18(0-144)0.770Hypertension, n (%)100(42.9)34(56.7)0.061Creatinine>1.3mg/dL (median, IQR)21(9.0)15(25)3.3(1.6-7.02)0.001eGFR categories, n (%)137(58.8)27(45)1.7(0.96-3.03)0.003>9057(24.5)15(25)61-9034(14.6)9(15)30-604(1.7)8(13.3)<30Active urinary sediments, n (%)132(56.7)44(73.3)0.019uPCR g/day (median with IQR)1.38(0.8-2.67)1.95(1.18-4.19)0.098Class III/IV, n (%)167(71.7)49(81.7)0.117Class V, n (%)17(7.3)5(8.3)0.788Combined class, n (%)7(3.0)3(5.0)0.469Activity score, median with IQR3(1-6)6(3-9)0.001Chronicity score, median with IQR0(0-1)1(0-2)5.06(1.49-17.21)0.001Presence of Crescents, no (%)43(18.5)17(28.3)0.104Fibrinoid necrosis, n (%)28(12.0)7(11.7)0.791Interstitial inflammation, n (%)86(36.9)33(55)2.08(1.17-3.70)0.003Interstitial fibrosis, n (%)23(10.7)9(15)0.273Tubular atrophy, n (%)64(27.5)27(45)0.003Blood vessel changes, n (%)2(0.9)1(1.7)0.606Fibrinoid necrosis206(88.4)50(83.3)0.339Other changes*Figure 1.

ROC curve and AUC for the three different models

Model 1: Baseline serum creatinine, urine PCR, male sex; AUC – 0.694(0.609-0.779), p <0.001

Model 2: Baseline serum creatinine, urine PCR, male sex, chronicity score; AUC – 0.740(0.660-0.820), p<0.001

Model 3: Baseline serum creatinine, urine PCR, male sex, chronicity score, crescents, interstitial inflammation; AUC – 0.744(0.664-0.824), p<0.001

Conclusion

Clinical and biochemical parameters can predict the renal histological class to a fair extent but has limited value in predicting the activity and chronicity parameters. Since a combination of clinical and histopathology parameters are better in predicting renal outcomes, performing renal biopsies should be encouraged in LN.

Acknowledgements

I have no acknowledgements to declare.

Disclosure of Interests

None declared

POS0392 ROLE OF SEMIQUANTITATIVE THIGH MAGNETIC RESONANCE IMAGING (tMRI) IN DETERMINING SKELETAL MUSCLE OUTCOMES AT BASELINE AND ON FOLLOW UP IN IDIOPATHIC INFLAMMATORY MYOPATHIES (IIMs)

Background

Idiopathic Inflammatory Myopathies (IIMs) are characterized by muscle inflammation and associated muscle weakness. Semiquantitative scoring of thigh Magnetic Resonance Imaging (tMRI) has shown contradictory results in associating muscle inflammation, damage, and clinically assessed muscle weakness. Moreover, there are no studies assessing the role of tMRI detected muscle damage in determining long-term recovery of muscle strength and endurance.

Objectives

To correlate tMRI scores for muscle edema, fascial edema, muscle atrophy, and fatty infiltration with consecutively collected manual muscle testing 8 (MMT-8) scores and muscle enzymes. To determine the role of baseline tMRI changes in achieving maximum muscle power during follow-up.

Methods

This is a retrospective analysis of a single-center myositis cohort. IIM patients (n=55) who underwent baseline tMRI (STIR and T1 sequences) at the time of diagnosis were included. Baseline demographic, clinical, and serological parameters were noted. MRI T1 weighted sequence and STIR sequence axial and coronal images were assessed for intramuscular and fascial edema, atrophy and fatty replacement using a semiquantitative score and the percentage of muscle involvement for each parameter was calculated. MMT-8 values and muscle enzyme levels which remained unchanged at least for 6 months during follow-up were noted for 42 patients. MMT-8 ≥74 was taken as near normal muscle power based on the fact that 75% of IIM patients in remission for a long duration achieved MMT-8 of≥74 in our cohort. Spearman correlation was done between clinical parameters, muscle enzymes, and tMRI scores. Baseline parameters of patients who achieved and did not achieve MMT8≥74 were compared. Multiple linear regression was performed to assess the tMRI variables predicting a higher MMT-8 during follow-up

Results

The median age was 36 (27.25-44.75) years, median duration of disease at presentation was 4 months (2-10), median duration of follow up was 24 months (6.75-38.25). Dermatomyositis, Polymyositis and Antisynthetase syndrome comprised of 58.2%, 7.3% and 30.9% cases respectively. Baseline muscle enzymes CPK(r=0.531), AST(r=0.535) and ALT(r=0.442) showed significant positive correlation(p<0.01) with muscle edema. Baseline MMT-8 showed significant negative correlation with muscle edema(r=-0.657) and fascial edema(r=-0.522) (p<0.01). Follow up MMT-8 showed significant negative correlation with muscle edema(r=-0.359), muscle atrophy (r=-0.319) and fatty infiltration(r=-0.308) (p<0.05) (Figure 1). Baseline MMT-8 and MRI fatty infiltration were significantly different between patients who achieved and did not achieve MMT-8 of ≥74 on follow-up (Table 1). Multiple regression analysis revealed adjusted R2 value of 0.386. Baseline MMT-8(β=0.372) and muscle atrophy(β=-0.459) significantly predicted MMT-8 on follow-up

Table 1.

Comparison between those who achieved near-normal muscle power versus others

Follow up MMT-8<74 (n=8)Follow up MMT-8 ≥74 (n=34)P-valueAge (years) (median, IQR)36.5(27-47.5)36(28.75-44.25)1.000Duration of disease (months) (median, IQR)6(4-10.5)3.5(2.75-9.75)0.459Baseline muscle enzymes and MMT-8 (median, IQR)CPK (IU/L)1758(116-6160)680(57.5-3595)0.410LDH (IU/L)496(240-823)616.50(289.25-753)0.672AST (IU/L)112(76-201.5)69.5(40.5-226.25)0.352ALT (IU/L)74.50(65.5-139.75)69(36-142.25)0.560MMT-8 baseline (0-80)49.5(47.25-56)63(53.75-73.25)0.007MRI thigh scores (median, IQR)Muscle edema%22.41(5.65-63.33)10.37(0.00-28.70)0.070Fascial edema %43.33(18.61-78.06)33.89(11.49-50.56)0.478Muscle atrophy %2.22(0.28-20.83)0.00(0.00-2.50)0.081Fatty infiltration %6.67(2.78-18.61)0.56(0.00-3.61)0.010Figure 1.

Correlation between baseline and Follow up MMT-8 with tMRI scores.

Conclusion

Low baseline MMT-8 and presence of muscle atrophy at baseline are predictors of poor outcome. Hence performing a baseline MRI will help in the prognosis.

Disclosure of Interests

None declared

Tensile behavior of non-crosslinked networks of athermal fibers in the presence of entanglements and friction

Many biological and soft artificial materials contain a random network of non-crosslinked fibers as their main structural component. The excluded volume interactions (contact forces) at fiber contacts control the mechanical behavior of these systems. This physics has been studied extensively in compression, but little is known about the relation between network structure and its mechanical response in tension. In particular, although occasionally used conjecturally, the notion of fiber entanglements in athermal networks is not well defined, nor is it clear what role entanglements play in athermal network mechanics. The primary contribution of this work is the introduction of a measure of the degree of entanglement of a system of random athermal fibers, and the definition of its relationship with the mechanical behavior of the network. Entanglements confine the fibers during tensile loading, reduce the auxetic effect in mat-like networks, and maintain the inter-fiber contact density. In the absence of this contribution, reduction of the contact density during tensile loading due to auxeticity results in stress reduction. Entanglements stabilize the network via a tensegrity mechanism similar to that operating in woven materials and lead to network stiffening. The relation between the proposed measure of entanglements and the fiber volume fraction is defined. The effect of inter-fiber friction on the mechanics of entangled mat-like non-crosslinked fiber networks is also evaluated.

POS0880 TWO-MINUTE WALK TEST AS A SIMPLE AND OBJECTIVE OUTCOME MEASURE IN IDIOPATHIC INFLAMMATORY MYOSITIS

Background:

Manual muscle testing (MMT) and Functional index 2(FI-2) are the usual methods in assessing disease activity in IIM1. Limitations of MMT8 include low sensitivity to change, floor/ceiling effect, and under-representation of certain important muscle groups1 while FI-2 takes a longer time to administer. Several Timed function tests (TFTs) like the 2-minute walk test (2MWT) or 30s raise from a chair test and 30s 1kg arm rise test may be better alternatives and less time taking2. Data looking at the performance of these tests are limited to small controlled studies.

Objectives:

To assess the performance of timed function tests against MMT8 and FI-2 in assessing muscle strength and endurance at baseline, 3 and 6 months of therapy.

Methods:

An observational cohort study, included 41 patients with polymyositis and dermato-myositis attending OPD and IPD service of tertiary centre. MMT8, FI-2 and Timed function tests were done at baseline, at 3 months and at 6 months. (Figure 1)

Figure 1.

Consort diagram showing the workflow in study population

Results:

Forty one patients included in the study had completed three month follow-up assessment, while 17 patients achieved a six-month evaluation. Out of 41 patients, 11 (27%) were polymyositis, and 30 (73%) were dermatomyositis. The mean MMT8 of the total study population at baseline was 57±15, at three months (n=41) was 66 ±10 and at six months (n=17) was 71 ± 10, while in active subgroup was 50 ± 18, 64 ± 9 (n=41), 67 ± 9.6 (n=17)at baseline, three months and six months respectively. The change in TFTs showed a moderate to strong correlation with the change in Fi-2 among the study population at three months and six months (Table 2). Among the TFTs 2MWT showed moderate correlation with both MMT8 and FI-2 in active disease.

Table 1.

Spearman Rho Correlation between change in timed function tests with change in MMT8, change in FI-2 at 3 months and 6 months

At 3 months (n=41)At 6 months (n=17)Active disease(n=18)Inactive disease(n=23)Active disease(n=7)Inactivedisease(n=10)Correlation of Δ MMT8 withΔ30s rise form chair0.1430.3460.2000.347Δ30s1kg arm lift0.0180.2840.3620.168Δ2MWD0.755*0.3130.482*0.334Correlation of ΔFI-2 withΔ30s rise form chair0.784*0.495*0.486*0.424*Δ30s1kg arm lift0.671*0.1070.704*0.301Δ2MWD0.834*0.623*0.808*0.506*

*p<0.05

Conclusion:

Using timed function tests can be an excellent alternative to FI-2 in assessing muscle endurance. 2-minute walk distance is a better alternative to conventional muscle testing as it measures both power and endurance, and this can overcome the ceiling effect of MMT-8.

References:

[1]Rider LG, Aggarwal R, Machado PM, Hogrel J-Y, Reed AM, Christopher-Stine L, et al. Update on outcome assessment in myositis. Nat. Rev. Rheumatol. 2018;14:303–18.

[2]Agarwal S, Kiely PD. Two simple, reliable and valid tests of proximal muscle function, and their application to the management of idiopathic inflammatory myositis. Rheumatology. 2006 Jul 1;45(7):874-9.

Acknowledgements:

I would like to acknowledge my patients, my teachers, colleagues, and paraclinical staff of the department of Clinical Immunology JIPMER

Disclosure of Interests:

None declared

POS0890 MACROVASCULAR DYSFUNCTION AND ITS CLINICAL IMPLICATION IN SYSTEMIC SCLEROSIS

Background:

Even though microvascular dysfunction has been implicated in pathogenesis of scleroderma (SSc), there is minimal evidence to suggest presence of macrovascular dysfunction. The clinical implication of macrovascular dysfunction in SSc is unknown. Moreover, data on the correlation between dysfunction in small and large blood vessel is inconclusive. [1-2]

Objectives:

To study the correlation between macrovascular dysfunction as assessed by percent change in flow mediated vasodilation (FMD) of brachial artery and microvascular dysfunction as assessed by nail fold capillaroscopy (NFC) findings in SSc. To assess the clinical impact of macrovascular dysfunction.

Methods:

This cross-sectional comparative study enrolled patients with SSc and age and gender matched healthy controls. FMD change was calculated using standard USG probe of 5 to 6 MHz in right brachial diameter from the average of 3 consecutive end diastolic frames. NFC was performed using portable nail fold capillary microscope at 800X magnification. Clinical features of SSc were compared between SSc patients with and without macrovascular dysfunction.

Results:

This study enrolled 59 SSc patients including 29 (49.2%) diffuse, 20 (20.4%) limited, 08 (10.2%) sine SSc and 2 patients (3.4%) with myositis overlap. SSc patients had significantly (p-<0.0001) lower % FMD change compared to healthy controls. NFC showed significantly higher architecture distortion (p-<0.0001), loss of capillaries (p-<0.0001) and abnormal capillaries (p-<0.0001). There was no correlation between FMD change and capillary density (p-0.381), avascular area (p-0.266) and abnormal capillaries (p-0.899). None of the clinical features like pulmonary hypertension, digital ulcer burden, acro-osteolysis and auto amputation were different between SSc with and without macrovascular dysfunction.

Conclusion:

Macrovascular dysfunction in SSc is substantial and it seems to be independent of the microvascular dysfunction. The clinical implications of macrovascular dysfunction are yet to be identified.

References:

[1]Schioppo T, Orenti A, Boracchi P, De Lucia O, Murgo A, Ingegnoli F. Evidence of macro- and micro-angiopathy in scleroderma: An integrated approach combining 22-MHz power Doppler ultrasonography and video-capillaroscopy. Microvasc Res. 2019 Mar;122:125–30.

[2]Rollando D, Bezante GP, Sulli A, Balbi M, Panico N, Pizzorni C, et al. Brachial Artery Endothelial-dependent Flow-mediated Dilation Identifies Early-stage Endothelial Dysfunction in Systemic Sclerosis and Correlates with Nailfold Microvascular Impairment. J Rheumatol. 2010 Jun 1;37(6):1168–73.

Table 1.

Comparison of various parameters between the SSc patients with healthy controls.

ParameterFrequency (percentage)/median (interquartile range)SSc patients (n=59)Healthy controls (n=64)Demographic detailsAge in years38 (27-46)36.5 (28.25-42)Gender Male03 (5.1%)03 (4.7%) Female56 (95.1%)61 (95.3%)FMD findings FMD % change*4.54 (3.13-8.82)10.30 (8.33-13.16)NFC findings Number of capillaries*51 (38-63)121 (113-128) Average capillary density*3.19 (2.38-3.94)7.56 (7.06-8) Disorganized architecture (%)*37.5 (12.5-37.5)0 U shape (%)*50 (36.59-68.09)85.51 (82.97 – 88.53) Abnormal (%)*36.11 (14.03-55.26)0 Enlarged (%)*10.63 (2.94-23.68)0 Giant (%)*21.05 (0-45.45)0 Microhemorrhages (%)*6.25 (0-12.5)0 Neoangiogenesis (%)*3.85 (0-20)0 Avascular area (%)*50 (31.25- 75)0

*parameters with statistically significant (p value< 0.0001) difference among two groups. SSc; Systemic Sclerosis, FMD; flow mediated vasodilatation, NFC; nail fold capillaroscopy

Figure 1.

Scatter plot showing correlation between FMD percentage change and average capillary density. (r= 0.116) (P-value - 0.381)

Disclosure of Interests:

None declared

Dual mutation (MTHFR A1298C with PAI (4G) mutation) manifesting with bilateral lower limb gangrene in a neonate

Neonates are at highest risk of thrombosis among paediatric patients. The relative prothrombotic state in a well neonate is compensated by other factors preventing spontaneous thrombosis; however, in a neonate with genetic predisposition, the balance is tilted predisposing them to a life-threatening thrombotic episode. We describe a rare case of methylenetetrahydrofolate reductase A1298C (homozygous) mutation along with plasminogen activator inhibitor (4G) mutation in a neonate who developed bilateral lower limb gangrene following thrombosis of the iliac vessels without any triggering factor. The neonate underwent thrombectomy as debulking measure along with thrombolytic therapy followed by unfractionated heparin and low-molecular-weight heparin which is still being continued along with oral aspirin. The neonate had to undergo amputation of both the involved lower limbs in view of dry gangrene. This case highlights that the dual mutations causing the prothrombotic state predispose the individual to the spontaneous life-threatening thrombotic episode as compared with the single mutation.

AB0094 FUNCTIONAL TREG CELLS MAY BE CONVERTED INTO T EFFECTOR PHENOTYPE ON EXPOSURE TO INFLAMMATORY MILIEU IN RHEUMATOID ARTHRITIS (RA) SYNOVIAL FLUID: IN-VITRO STUDY

Background:

The debate on functional versus numerical difference in T regulatory cell population among patients with Rheumatoid arthritis (RA) is not clear. Tregs expressing Inflammatory subset phenotype markers, such as Th1(cxcr3, Tbet) and Th17(ccr6,Rorϒ) are reported. (1) Though the reported numbers of synovial fluid tregs are higher in RA, (2) the fate of Tregs on entering the synovial inflammatory milieu from peripheral blood (PB) has not yet been investigated.

Objectives:

To compare Treg frequencies in PB and synovial fluid between osteoarthritis (OA) and RA

To compare cytokine levels in PB and SF between OA and RA

To study the effect of autologous synovial fluid on RA and OA Treg isolated form peripheral blood

Methods:

The Peripheral Blood (PB) and synovial fluid (SF) of RA (n=80) and OA (n=30) patients were analyzed for CD4+T-cell subset frequencies and phenotypes by flow cytometry. Cytokine concentrations in plasma and SF were measured by cytometric bead array. Tregs from 5 RA-PB and 5 OA-PB were isolated and cultured in autologous synovial fluid for 24 hrs. Phenotypic expression of Th1 and Th17 chemokines on the cell surface were analyzed by flow cytometry and expression levels of T-bet, RORγ and FOXP3 in those Treg cells were measured with quantitative real-time PCR (RT-qPCR).

Results:

The PB and SF frequencies of Th1, Th17 and Tregs are shown in Table 1. The pro-inflammatory cytokines were high in the plasma and SF of RA but the anti-Inflammatory cytokines were similar (Fig 1.A&B). Treg cells were isolated from RA and OA PB and cultured in autologous SF for 24 hrs. RA Treg showed increased cell surface expression of CXCR3+ and CCR6+ (Fig 1C) and there was no difference in OA Treg. Gene expression studies showed an increased expression of T-bet, RORγ and decreased expression of Foxp3 in RA Tregs while there was no difference in OA Tregs before and after in-vitro culture (Fig 1D).

Table 1.

Tcell subsets in Rheumatoid Arthritis and Osteoarthritis.

CD4 subtypeRAOAPBSFPBSFN=80N=30N=30N=30Th126.65 ± 5.5934.99 ± 1.3025.97 ± 7.2426.45 ± 1.87*Th25.19 ± 1.916.36 ± 1.735.24 ± 2.151.44 ± 0.10*Th1714.05 ± 3.2921.18 ± 2.0410.81 ± 2.78*2.45 ± 0.23*Treg10.68 ± 2.4712.53 ± 2.1011.162.9513.04 ± 2.57

*P<0.05

Conclusion:

Tregs in RA may be converted to Th1 and Th17 phenotype on exposure to inflammatory cytokine in the synovial fluid, thus losing their regulatory functions. Understanding factors influencing stability of Treg cells may help improve future therapeutics.

References:

[1]Jinlin Miao & Ping Zhu. Functional Defects of Treg Cells: New Targets in Rheumatic Diseases, Including Ankylosing Spondylitis. Current Rheumatology Reports 2018; 20: 30

[2]Penatti et al. Differences in serum and synovial CD4+ T cells and cytokine profiles to stratify patients with inflammatory osteoarthritis and rheumatoid arthritis. Arthritis Research & Therapy.2017; 19:103

Acknowledgments:

Department of Science and technology, India for the research grant.

Disclosure of Interests:

None declared

SAT0314 TIMED FUNCTION TESTS ARE AN ALTERNATIVE TO MMT8 AND FI-2 IN INFLAMMATORY MYOSITIS - AN OBSERVATIONAL COHORT STUDY

Background:

Inflammatory myositis are heterogenous group of diseases affecting skeletal muscles and multiple different organs1. Manual muscle testing (MMT) is the common tool used for assessment of muscle strength. Its limitations include poor sensitivity to change, floor/ceiling effect, and under representation of certain important muscle groups2. Functional index 2(FI-2) is an objective measure of dynamic repetitive muscle function at 11 proximal and distal muscle groups which correlates well with patient-reported physical function3. Since MMT8 is inadequate and FI-2 takes longer time to administer, several timed tests to assess muscle function, endurance and fatiguability like the 2- minute walk test (2MWT) or 30s raise from a chair test and 30s arm rise test are viable alternatives to be tested. Data looking at the performance of these tests are limited to small controlled studies.

Objectives:

To study correlation of timed tests with MMT8 and FI-2 in assessing muscle strength, endurance at baseline and at 3 months of therapy.

Methods:

An observational cohort study, included 19 patients with polymyositis and dermatomyositis attending OPD and IPD service of tertiary center. Patients with nclusion body myositis, overlap myositis, chronic kidney disease, coexisting myocarditis, sepsis, malignancy, pregnancy were excluded. MMT8, FI-2 and Timed function tests were done at baseline and after 3 months.

Results:

The study had 19 patients of which 6 were polymyositis and 13 were dermatomyositis. Male to female ratio was 1:2.1. Anti-cell antibody was positive in 16 patients. The mean MMT8 of the study group at baseline was 60.84±16.77 and after 3 months was 67.05±11.7. Out of 19 patients, all received prednisolone as induction agent followed by Methotrexate in 13, cyclophosphamide in 9, azathioprine in 5, Rituximab by one patient. Mean scores of 30s arm lift, 30s rise from chair test and 2 min walk test were 11.7±6.39,14±7.29,101.5± 46.48 respectively at baseline and 13.05±6.5,15.6±7.1,117.84±38.4 after 3 months.

Table 1.

Spearman Rho Correlation between timed function tests and MMT8, FI-2, patient and physician VAS

Δ 30s rise from chair testΔ 30s arm lift testΔ 2 min walk testΔ MMT80.3820.3370.724**Δ FI-2Hip flexion right0.3880.4130.314Hip flexion Left0.503*0.4160.422Neck flexion0.600**0.590**0.610**Shoulder flexion right0.1830.3000.239Shoulder flexion left0.3930.2220.207Shoulder abduction right0.2360.2220.348Shoulder abduction left0.1820.2360.273Step test right0.744**0.489*0.326Step test left0.8400.500*0.378Heel rise0.4420.2940.388Toe rise0.4460.2910.419Δ Physician VAS-0.508*-0.506**-0.215Δ Patient VAS-0.600**-0.597**-0.249

Δ → change from baseline to 3 months *→ Correlation is significant at the 0.05 level **→ Correlation is significant at the 0.01 level

Conclusion:

Timed function tests correlated well with MMT 8 and parameters with in FI-2. Thus these tests are good alternatives in assessing disease activity and response assessment in inflammatory myositis.

References:

[1]Selva-O’Callaghan A, Pinal-Fernandez I, Trallero-Araguás E, Milisenda JC, Grau-Junyent JM, Mammen AL. Classification and management of adult inflammatory myopathies. Lancet Neurol. 2018; 17:816–28.

[2]Rider LG, Aggarwal R, Machado PM, Hogrel J-Y, Reed AM, Christopher-Stine L, et al. Update on outcome assessment in myositis. Nat. Rev. Rheumatol. 2018;14:303–18.

[3]Alexanderson H, Broman L, TollbÄck A, Josefson A, Lundberg IE, StenstrÖm CH. Functional index-2: Validity and reliability of a disease-specific measure of impairment in patients with polymyositis and dermatomyositis. Arthritis Rheum. 2006;55:114–22.

Disclosure of Interests: :

None declared

Mechanical behavior of nonwoven non-crosslinked fibrous mats with adhesion and friction

We present a study of the mechanical behavior of planar fibrous mats stabilized by inter-fiber adhesion. Fibers of various degrees of tortuosity and of infinite and finite length are considered in separate models. Fibers are randomly distributed, are not cross-linked, and interact through adhesion and friction. The variation of structural parameters such as the mat thickness and the mean segment length between contacts along given fibers with the strength of adhesion is determined. These systems are largely dissipative in that most of the work performed during deformation is dissipated frictionally and only a small fraction is stored as strain energy. The response of the mats to tensile loading has three regimes: a short elastic regime in which no sliding at contacts is observed, a well-defined sliding regime characterized by strain hardening, and a rapid stiffening regime at larger strains. The third regime is due to the formation of stress paths after the fiber tortuosity is pulled out and is absent in mats of finite length fibers. Networks of finite length fibers lose stability during the second regime of deformation. The scaling of the yield stress, which characterizes the transition between the first and the second regimes, and of the second regime's strain hardening modulus, with system parameters such as the strength of adhesion and friction and the degree of fiber tortuosity are determined. The strength of mats of finite length fibers is also determined as a function of network parameters. These results are expected to become useful in the design of electrospun mats and other planar fibrous non-cross-linked networks.

Strength of filament bundles - The role of bundle structure stochasticity

Most biological fibrous materials are hierarchical, in the sense that fibers of finite length assemble in bundles, which then form networks with structural role. Examples include collagen, silk, fibrin and microtubules. Some artificial fiber-based materials share this characteristic, examples including carbon nanotube (CNT) yarns and unidirectional composites. Here we study bundles in which filaments do not break, while bundle rupture happens by the failure of inter-filament crosslinks, followed by pull-out. In all cases, the crosslinks are randomly distributed along interfaces. The strength of such bundles depends on material parameters of the filaments and crosslinks, such as their stiffness and strength, and on the cross-link density. We focus on the dependence of the bundle strength on two parameters: filament waviness and filament staggering. Bundles with regular staggering are stronger than those with stochastic staggering. We identify the optimal regular staggering that maximizes the strength. Filament waviness increases the strength of stochastically staggered bundles at constant crosslink density but decreases the strength of regularly staggered bundles. Results for bundles with permanent crosslinks, which never reform once they break, as well as transient crosslinks capable of reforming during deformation are presented, and it is shown that the general trends are independent of the nature of the crosslinks. The results are discussed in the context of collagen and carbon nanotube bundles.

Reduction in polyamine catabolism leads to spermine-mediated airway epithelial injury and induces asthma features

BACKGROUND

Airway epithelial injury is a crucial component of acute and severe asthma pathogenesis and a promising target for treatment of refractory asthma. However, the underlying mechanism of epithelial injury remains poorly explored. Although high levels of polyamines, mainly spermine, have been found in asthma and comorbidity, their role in airway epithelial injury and the cause of their altered levels in asthma have not been explored.

METHODS

We measured key polyamine metabolic enzymes in lung samples from normal and asthmatic subjects and in mice with OVA-induced allergic airway inflammation (AAI). Polyamine metabolism was modulated using pharmacologic/genetic modulators. Epithelial stress and apoptosis were measured by TSLP levels and TUNEL assay, respectively.

RESULTS

We found loss of the polyamine catabolic enzymes spermidine/spermine-N (1)-acetyltransferase-1 (SAT1) and spermine oxidase (SMOX) predominantly in bronchial epithelial cells (BECs) of human asthmatic lung samples and mice with AAI. In naïve mice, SAT1 or SMOX knockdown led to airway hyper-responsiveness, remodeling, and BEC apoptosis. Conversely, in mice with AAI, overexpression of either SAT1 or SMOX alleviated asthmatic features and reduced TSLP levels and BEC apoptosis. Similarly, while pharmacological induction of SAT1 and SMOX using the polyamine analogue bis(ethyl)norspermine (BENSPM) alleviated asthmatic features with reduced TSLP levels and BEC apoptosis, pharmacological inhibition of these enzymes using BERENIL or MDL72527, respectively, worsened them. Spermine accumulation in lungs correlated with BEC apoptosis, and spermine treatment caused apoptosis of human BEAS-2B cells in vitro.

CONCLUSIONS

Spermine induces BEC injury. Induction of polyamine catabolism may represent a novel therapeutic approach for asthma via reversing BEC stress.

Study of pain response in neonates during venipuncture with a view to analyse utility of topical anaesthetic agent for alleviating pain

Background

Neonates being nonverbal are unable to express their pain leading to underestimation of their pain and hence insufficient pain relief. Neonatal pain is assessed by pain scales based on the behavioural and physiological changes that occur in response to painful stimuli. This cross sectional study was conducted at a tertiary care centre using Premature Infant Pain Profile (PIPP) score with 4% lidocaine as local anaesthetic agent to produce surface anaesthesia of skin prior to intravenous cannulation.

Methods

Sample size was collected by simple randomisation method. Our study groups included 50 term and 50 preterm neonates with POG of 28-40 weeks requiring IV cannulation. Heart rate (HR), SpO₂, facial expressions and behavioural state were noted before venipuncture and after venipuncture using PIPP scale. Same cohort of patients was assessed for pain response after applying 4% lidocaine cream during future venipuncture with help of PIPP score.

Results

The PIPP score in preterm group before and after anesthesia was 11.28 ± 3.72 and 9.58 ± 3.39. PIPP score in term group before and after anesthesia was 11.54 ± 2.84 and 9.04 ± 2.97. There was reduction in mean PIPP score after using topical anesthetic agent in both study groups and the results were statistically significant.

Conclusion

This study found that topical anesthetic agents were effective in reducing pain during venipuncture. Based on the facts of the study, it is recommended that pain scoring should be a part of routine monitoring in neonatal intensive care units and appropriate measures should be used to reduce pain.

An outbreak of hepatitis A virus among children in a flood rescue camp: A post-disaster catastrophe

We report an outbreak of acute viral hepatitis among children in a flood rescue camp at Rudraprayag district of Uttarakhand State, India. In May 2013, there was a disastrous natural calamity, The Himalayan Tsunami in Himalayan and Sub-Himalayan region of Uttarakhand. More than 5700 people were feared dead, and thousands were sheltered in different rescue camps. A linkage was hypothesised between the infected individuals and the common water sources feared of being contaminated faecally. Aetiological agent of the present outbreak was HAV that is emerging in an outbreak form in India, emphasizing a definite need for formulating mandatory vaccination and proper control strategies. The report exemplifies the basic problems encountered after a natural calamity.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

An Interesting Observation of PDA Closure with Oral Paracetamol in Preterm Neonates

Patent ductus arteriosus (PDA), in which there is a persistent communication between the descending thoracic aorta and the pulmonary artery that results from failure of normal physiologic closure of the fetal ductus, is one of the more common congenital heart defects in preterm neonates. The closure of PDA can be done with either Indomethacin or Brufen which are cyclooxygenase 1, 2 inhibitor; however these drugs are associated with side effects. We report an interesting findings of ductal closure in 10 preterm neonates (gestational age 27-33 wks) presenting with significant large PDA who had failed or had absolute contraindication with Brufen. These preterm neonates were treated with oral paracetamol in the dose of 15 mg/kg 8 hourly. The PDA closure was achieved within 48 h and there was no complication.

Effect of bioadhesion on initial in vitro buoyancy of effervescent floating matrix tablets of ciprofloxacin HCL

The purpose of this study was to investigate effect of bioadhesion on the initial in vitro buoyancy behaviour of effervescent matrix tablets of ciprofloxacin HCl (CIPRO). Tablets were prepared by direct compression using HPMC K4M and Carbopol 971P as hydrophilic-controlled release polymers, sodium bicarbonate (NaHCO₃) as gas-generating agent, polyplasdone XL, Explotab and Ac-Di-Sol as swelling agents. Tablets were evaluated for normal and modified initial in vitro floating behavior, floating duration, swelling behavior and in vitro drug release studies. A modified buoyancy lag time for tablets was determined in order to include the effect of bioadhesion on initial buoyancy. The initial buoyancy was found depended on bioadhesion ability of tablets. The lowest modified buoyancy lag time of 20 seconds was obtained for Formulation F7 having both NaHCO₃ and polyplasdone XL. The floating duration was also found dependent on concentration of NaHCO₃ and swelling agents. The drug release of F7 was also sustained up to 12-hr duration with anomalous drug transport mechanism.

A Rare Case of Idiopathic Congenital Complete Heart Block in a Neonate

Congenital complete heart block in utero has become diagnosed more frequently with the clinical use of fetal echocardiography. Autoimmune-associated congenital complete heart block (CHB) is a rare but important disease that can now be diagnosed in utero using fetal echocardiography1,2,3,4. The overall incidence of isolated CHB has been reported to be approximately 1:15,000 to 20,000 live births5. Several reviews have shown that children diagnosed prenatally have an increased mortality compared to those diagnosed immediately after birth or later in childhood1,2,3,4. At birth, some neonate with complete heart block may remain asymptomatic and may not require a pacemaker but majority require pacemaker to increase the heart rate. We report a rare case of idiopathic congenital complete heart block in a newborn male. J Nepal Paediatr Soc 2012;32(2):163-165 doi: http://dx.doi.org/10.3126/jnps.v32i2.5992

A Rare Association of Hydrops of Gall Bladder with Hepatitis E Infection

Gall bladder distension with acute viral acalculous cholecystitis is an extremely rare event especially with Hepatitis E infection in paediatric cases with a high incidence of perforation, gallbladder necrosis and mortality. We report a four year old male child presenting with fever, vomiting, pain abdomen, mild hepatosplenomegaly and tenderness in right hypochondrium. Laboratory investigations revealed hyperbilirubinemia and elevated liver enzymes, but there was no evidence of bacterial or parasitic infection. Serology for viral hepatitis suggested acute Hepatitis E infection. Ultrasonographically distended inflamed gallbladder without calculous was observed. Finally acute acalculous cholecystitis due to Hepatitis E virus was diagnosed and the child responded to the conservative management. Key words: Acalculous cholecystitis; Hepatitis E; Pericholecystic fluid; Gallbladder thickening.DOI: http://dx.doi.org/10.3126/jnps.v31i3.5362 J Nep Paedtr Soc 2011;31(3): 216-222-223

Congenital segmental dilatation of jejunoileal region in a newborn: Unusual clinical and radiologic presentation

Segmental dilatation of the ileum is one of the uncommon causes of intestinal obstruction in neonates. We present a case of slow transit of bowel contents leading to suspicion of functional bowel obstruction in a new born, which on exploration turned out to be a case of segmental dilatation of the jejuno-ileal region. The clinical and radiological evaluation was suggestive of hypomotility disorder of gut, resulting in diagnostic dilemma and delayed surgical intervention.