AB0551 CUTANEOUS LUPUS AREA AND SEVERITY INDEX(CLASI) CORRELATES WITH SELF-IMAGE SCORE BUT NOT QUALITY OF LIFE IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Background

Systemic lupus erythematosus (SLE) has multi-system involvement including skin. We explored how skin involvement influenced with the quality of life of patients with SLE.

Objectives

To correlate the domains of SLE QoL with skin involvement and total lupus disease activity.

Methods

A cross-sectional survey of patients with SLE was carried out to assess Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI) and SLE-QoL. Lupus disease activity and damage were quantified using Mex-SLEDAI (Mexican SLE Disease Activity Index) and SLICC (Systemic Lupus International Collaborating Clinics) Damage Index respectively. Data is expressed as median (IQR).

Results

In the cohort of 35 patients with SLE, with an age of 26(IQR:17-32) years and including eight (22.8%) males, the CLASI score was 5.5(IQR:3-11.5) with an activity score of 3(1-5) and a chronicity score of 1(0-4). The disease duration was 4years (IQR: 2-3) while SLE-QoL was 73(62-86). Overall, most of the patients had active disease at inclusion with a mex-SLEDAI of 8(6.5-11.5). SLICC was 1(0-4).

The correlation matrix of different domains of the SLE-QoL with CLASI, and Mex-SLEDAI is presented in Table 1. Correlation with SLICC was not analysed since it was zero in the majority of participants. Multivariate analyses were not done since there was lack of association on univariate analysis.

Table 1.

Correlations between different domains of the SLE(Systemic Lupus Erythematosus) -QoL(Quality of Life) with CLASI (Cutaneous Lupus Area and Severity Index) and Mexican SLE-DAI(SLE Disease Activity Index).

SLE-QoL DomainsPhysical functioningPhysical activitySymptomsTreatmentMoodSelfimageTotalCLASI Activity.028-.062.242.103.113.252.102(p=0.87)(p=0.73)(p=0.16)(p=0.56)(p=0.52)(p=0.15)(p=0.56)CLASI Damage.125.010.257.239.233.446**.243(p=0.47)(p=0.95)(p=0.13)(p=0.17)(p=0.18)(p=0.007)(p=0.16)CLASI total.047-.062.448*.331.332.315.281(p=0.80)(p=0.75)(p=0.013)(p=0.07)(p=0.07)(p=0.09(p=0.13)Mexican SLEDAI SCORE.001.130.390*.251.115.197.200(p=0.99)(p=0.47)(p=0.025)(p=0.16)(p=0.52)(p=0.27)(p=0.27)

Conclusion

In this cohort of patients with active SLE, the SLE-QoL did not correlate with either the overall disease activity score nor the skin specific score. Only the Self-image domain correlated with the skin score. This implies that in active disease, the skin involvement may have only a minor effect on the quality of life.

References

[1]Klein R, Moghadam-Kia S, LoMonico J, Okawa J, Coley C, Taylor L, Troxel AB, Werth VP. Development of the CLASI as a tool to measure disease severity and responsiveness to therapy in cutaneous lupus erythematosus. Archives of dermatology. 2011 Feb 1;147(2):203-8.

[2]Leong KP, Kong KO, Thong BY, Koh ET, Lian TY, Teh CL, Cheng YK, Chng HH, Badsha H, Law WG, Lau TC. Development and preliminary validation of a systemic lupus erythematosus-specific quality-of-life instrument (SLEQOL). Rheumatology. 2005 Oct 1;44(10):1267-76.

Disclosure of Interests

None declared

Metabonomics and the Gut Microbiome Associated With Primary Response to Anti-TNF Therapy in Crohn's Disease

BACKGROUND AND AIMS

Anti-tumour necrosis factor [anti-TNF] therapy is indicated for treatment of moderate to severe inflammatory bowel disease [IBD], but has a primary non-response rate of around 30%. We aim to use metabonomic and metataxonomic profiling to identify predictive biomarkers of anti-TNF response in Crohn's disease.

METHODS

Patients with luminal Crohn's disease, commencing anti-TNF therapy, were recruited with urine, faeces, and serum samples being collected at baseline and 3-monthly. Primary response was defined according to a combination of clinical and objective markers of inflammation. Samples were measured using three UPLC-MS assays: lipid, bile acid, and Hydrophillic Interaction Liquid Chromatography [HILIC] profiling with 16S rRNA gene sequencing of faeces.

RESULTS

Samples were collected from 76 Crohn's disease patients who were anti-TNF naïve and from 13 healthy controls. There were 11 responders, 37 non-responders, and 28 partial responders in anti-TNF-treated Crohn's patients. Histidine and cysteine were identified as biomarkers of response from polar metabolite profiling [HILIC] of serum and urine. Lipid profiling of serum and faeces found phosphocholines, ceramides, sphingomyelins, and triglycerides, and bile acid profiling identified primary bile acids to be associated with non-response to anti-TNF therapy, with higher levels of phase 2 conjugates in non-responders. Receiver operating curves for treatment response demonstrated 0.94 +/ -0.10 [faecal lipid], 0.81 +/- 0.17 [faecal bile acid], and 0.74 +/- 0.15 [serum bile acid] predictive ability for anti-TNF response in Crohn's disease.

CONCLUSIONS

This prospective, longitudinal cohort study of metabonomic and 16S rRNA gene sequencing analysis demonstrates that a range of metabolic biomarkers involving lipid, bile acid, and amino acid pathways may contribute to prediction of response to anti-TNF therapy in Crohn's disease.

PODCAST

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AB0581 HIGH PREVALENCE OF TUBERCULOSIS IN ADULTS AND CHILDREN WITH IIM AS COMPARED WITH SLE: RETROSPECTIVE DATA REVIEW FROM A LARGE COHORT AT A TERTIARY CARE CENTER IN INDIA

Background:

Infections are the most common cause of morbidity and mortality in idiopathic inflammatory myositis (IIM). India is endemic for Tuberculosis (TB) with a prevalence of 2.3 cases per thousand population.

Objectives:

Thus, we studied the prevalence of TB in our cohort of IIM patients and compared with that in systemic lupus erythematosus (SLE).

Methods:

Medical records from paper charts and electronic medical records were reviewed for adults and juvenile patients with SLE (ACR criteria 1997) and IIM (Bohan and Peter criteria 1975) first presented at a tertiary care hospital in India from 1989 to 2016. Clinical variables including disease characteristics variables, the frequency, site, duration and complication of active TB as well as dose of corticosteroids and other immunosuppressive drugs were extracted retrospectively from the medical records. Descriptive statistics were used to describe the cohort and TB characteristics. Chi-square and t-test were used to evaluate association of TB with clinical diagnosis as well as medication data.

Results:

There were 167 (132 adults and 35 juvenile) IIM and 280 (131 adults and 149 juvenile) SLE in our cohort. Active TB occurred in 24 (14.4%) of all IIM cases (18, 13.6% adults; 6, 17.1% juvenile) as compared to 18 (6.4%) of all SLE cases (8, 6.1% adults; 10, 6.7% juvenile, p value < 0.01). Of all the TB in myositis, most often it was seen in Dermatomyositis (n=11, 45.8%) followed by Polymyositis (5, 20.8%), and occasionally in Overlap myositis (3, 12.5) and juvenile dermatomyositis (1,4.1%).

Considering an annual TB rate of 211 per 100,000 of the general population, the risk of developing active TB was 62-fold higher in patients with IIM and 27-fold higher in those with lupus. Patients with IIM had higher odds of developing TB as compared with Lupus [odds ratio 2.86 (CI 1.5-5.47), p=0.007).

Amongst 24 IIM patients with TB, 10 had pulmonary TB and 14 had extra-pulmonary TB. The median glucocorticoid dose at the diagnosis of TB was 0.25 (0-1.5) mg/kg/day. Half the cases of active TB occurred during inactive myositis. Seventeen patients with active TB were followed up over 27 months (8-184), with remission of TB in all cases but required prolonged courses of Anti-Tuberculous Therapy (ATT) in 25% cases with 10 ATT related adverse events in 8 patients and 5 patients with relapse of myositis due to lowering of immunosuppression.

Conclusion:

Patients with IIM have higher prevalence of active TB as compared with SLE patients. The risk is highest in patients with Dermatomyositis possibly related to high doses of steroids. Extra-pulmonary forms of TB are more common, and patients commonly require prolonged course of ATT and may suffer relapses of myositis during ATT. Screening for latent TB may be useful in IIM patients before prescribing steroids and other immunosuppressive drugs.

References:

[1]TB Statistics India | National, treatment outcome & state statistics [Internet]. TB Facts | TB, tests, drugs, statistics. [cited 2019 Jun 13]. Available from:https://www.tbfacts.org/tb-statistics-india/

[2]Muhammed H, Gupta L, Zanwar A, Misra DP, Lawrence A, Agarwal V, Aggarwal A, Misra R;OPC0243: Infections are leading cause of in-hospital mortality in patients with inflammatory myositis; Indian J Rheumatol 2018;13, Suppl S2:93-241

[3]Gaitonde S, Pathan E, Sule A, Mittal G, Joshi VR. Efficacy of isoniazid prophylaxis in patients with systemic lupus erythematosus receiving long term steroid treatment. Ann Rheum Dis. 2002 Mar;61(3):251–3.

[18]He D, Bai F, Zhang S, Jiang T, Shen J, Zhu Q, et al. High incidence of tuberculosis infection in rheumatic diseases and impact for chemoprophylactic prevention of tuberculosis activation during biologics therapy. Clin Vaccine Immunol CVI. 2013 Jun;20(6):842–7.

Figure 1.

(A) Prevalence and (B) sites of tuberculosis

Table 1.

Table 2.

Clinical profile of patients with Tuberculosis

Disclosure of Interests:

Latika Gupta: None declared, Abhishek Zanwar: None declared, Rohit Aggarwal Grant/research support from: Pfizer, Genentech, BMS, Mallinckrodt, Consultant of: Pfizer, Genentech, BMS, Mallinckrodt, Bristol Myers-Squibb, octapharma, CSL Behring, AstraZeneca, Corbus, Kezar, Abbvie, Able Lawrence: None declared, Durga Misra: None declared, Vikas Agarwal: None declared, Ramnath Misra: None declared, Amita Aggarwal: None declared

SAT0323 MYOSITIS-SPECIFIC AND MYOSITIS-ASSOCIATED AUTOANTIBODIES IN A LARGE INDIAN COHORT OF INFLAMMATORY MYOSITIS REVEAL NOVEL CLINICO-PHENOTYPIC PATTERNS

Background:

Idiopathic Inflammatory Myositis (IIM) are heterogenous, with distinct autoantibodies reflecting upon possible clinical evolution and outcomes. Ethnicity has major influence on both antibody prevalence patterns as well as phenotypic behaviours linked to them.

Objectives:

Thus we sought prevalence and co-existence of myositis specific autoantibodies (MSAs) and myositis associated autoantibodies (MAAs) and associated clinical characteristics in a large cohort of patients with IIM.

Methods:

Adult patients with a physician diagnosis of IIM as per ACR/EULAR classification criteria were investigated for the presence of MSAs/MAAs by Line immunoassay (G4, Euro-Immune, Lubeck, Germany). Anti-Nuclear Antibody (ANA) was tested by Immunofluorescence assay (IFA), and patterns in various antibody subsets explored. Prevalence and associations of different antibodies were assessed in disease subsets and clinical phenotypes.

Results:

MSA and MAAs were tested in 250 IIM patients (F:M 3.8:1) of median age 37 (25-47) and disease duration 6 (3-17) years. Dermatomyositis (DM) was seen in most patients 83 (33.2%) followed by overlap myositis (OM), juvenile DM, Anti-synthetase syndrome (ASS), polymyositis (PM), and cancer associated myositis (CAM). MSAs/MAAs were found in 148 (59.2%) of patients, of which 95 (64.2%) had an MSA and 53 (35.8%) had MAAs (Fig, 1A). 93 (62.8%) of autoantibody positive patients were positive for a single antibody, and only 2 (0.8%) of total had more than one MSA (Table 1).

Table 1.

Multiple antibodies positive upon testing for MSA and MAA by the LIA

Note: ** PL-7 co-exists with Ku + Pm/Scl, **PL-12 co-exists with Pm/Scl + Ro52, **SRP co-exists with Pm/Scl + Ro52

The most frequently detected MSA was anti-Jo-1 (8%), with a further 9 specificities each found in 0.5–7.0% of patients. Amongst the autoantibody positive patients, 21% (n=53) had isolated MAA positivity, anti-Ro52 (33, 62.3%) being the most common, followed by anti-Pm/Scl (11, 20.8%) and anti-Ku (9, 17.0%) (Fig. 1B).

Figure 1.

A. MSA and MAA in Indian cohort of myositis B. ANA patterns in myositis C. MSA in ANA negative IIM

On ANA, 76.0% (172 of 226) were positive, with speckled being the most common pattern (37%,Fig. 1C). Of those ANA negative (n=54), 61% had either MSA or MAA (Fig 1D). 18 (54.6%) had autoantibodies associated with cytoplasmic patterns suggesting that cytoplasmic ANA may be underreported.

Clinical presentation akin to DM was seen with all MSA except anti-SRP. PM group was heterogenous, and included ASS, OM and necrotizing phenotype (Fig. 2A). On occasion, anti-SRP, anti-Mi-2 and anti-MDA5 presented with clinical phenotype of ASS. (Fig 2A,C). Patients with ARS or anti-SAE were often clinically amyopathic (Figure 2B,C)

Figure 2.

A. Phenotypic associated with various antibody subsets B,C,and D. MSA/MAA in muscle weakness, rash and ILD phenotype. E. Unique feature of eye-lid edema in some patients with MDA-5 positive myositis

ARS were associated with mechanic’s hand (p<0.0001,OR 7.6), ILD (p<0.0001,OR 4.4), and arthritis (p=.002,OR 2.6) though there was no difference between Jo-1 and non-Jo-1 ASS. Anti-MDA-5 associated with fever (p=0.003,OR 12) and weight loss (p=0.008,OR 10.2) and unique phenotype of eye-lid edema in some adults (Figure 2E) and arthritis in children (p=0.01, OR 11.5). Anti-TIF-1ɣ associated with alopecia (p=0.007,OR 5.9) and malignancy (p= <0.0001,OR 34) in adults but not children.

Conclusion:

Myositis autoantibodies are seen in two-thirds IIM and identify distinct clinical subsets as well as unique phenotypes. MSA/MAA are positive in two-thirds of those negative on ANA, adding diagnostic value. MSAs are nearly always mutually exclusive and thus useful as biomarkers for diagnosis.

Acknowledgments:

MSA testing supported by grants from APLAR and Association of Physicians of India.

Disclosure of Interests:

Latika Gupta: None declared, Priyanka Gaur: None declared, Vikas Agarwal: None declared, Rohit Aggarwal Grant/research support from: Pfizer, Genentech, BMS, Mallinckrodt, Consultant of: Pfizer, Genentech, BMS, Mallinckrodt, Bristol Myers-Squibb, octapharma, CSL Behring, AstraZeneca, Corbus, Kezar, Abbvie, Ramnath Misra: None declared

SAT0230 MACROPHAGE ACTIVATION SYNDROME IN SLE AND SYSTEMIC ONSET JIA: SIMILAR OR DISSIMILAR

Background:

Macrophage activation syndrome (MAS) is a serious complication in rheumatic disease. Fever and hyperferritinemia are common in systemic onset JIA and cytopenias are common in SLE thus recognising MAS in them is a challenge.

Objectives:

We compared clinical, laboratory parameters, various classification criteria for MAS, and its outcome in SLE and sJIA.

Methods:

Clinical and laboratory data were extracted from clinician diagnosed cases of MAS with SLE/sJIA who were admitted between 2004-2018 at a tertiary care hospital. Percentage of patients satisfying Ravelli, International consensus, HLH 2004 and criteria proposed by Parodi et al1were calculated.

Results:

Among 33 patients (18 females) with MAS 19 had SLE and 14 had sJIA. MAS was more likely to be the presenting manifestation of disease in SLE as compared to sJIA (p<0.05). There were no differences in the clinical features among these two diseases. EBV and CMV were identified in 2 patients each as the trigger for MAS.

Patients with SLE had lower baseline TLC and platelet whereas patients with sJIA-MAS had significantly higher median CRP (p = 0.002), fall in TLC (p=0.012) and delta ESR/CRP ratio (p=0.02) and lower fibrinogen level (p=0.006). Neutrophil to lymphocyte ratio, Ferritin/CRP ratio and number of patients with Ferritin/ESR >80 were similar. Bone Marrow hemophagocytosis was seen in only in 21% of patients.

Only 6/33 fulfilled HLH criteria but criteria meant for sJIA or SLE performed well for both diseases and majority of patients could be diagnosed using them. Treatment included steroids(100%), cyclosporine(30%), Tacrolimus(21%), cyclophosphamide(21%), etoposide(3%) and thalidomide(12%). Mortality was similar in both groups.

Table 1.

Agreement amongst MAS/HLH criteria in SLE and sJIA MAS

SLE-MASHLHRavelli et alConsensusParodi et alHLH4444Ravelli et al4191918Consensus4191918Parodi et al4181818sJIA-MASHLHRavelli et alConsensusParodi et alHLH2222Ravelli et al2121112Consensus2111212Parodi et al2121214Table 2.

Comparison with various other cohorts

Minoia et alsJIAn (%)Our studysJIA, n (%)Our Study SLE, n (%)SLE, n (%) Ai-Chun Liu et alJuvenile SLE n (%)Parodi et alNumber36214193238MAS as presenting feature (%)80 (22)4 (28)12 (63)NA24 (63)Most common manifestation (%)Fever (96)Fever (100)Fever (89)Fever (96)Fever (89)Most common triggerDisease activityDisease activityDisease activityDisease activityDisease activityBM done251 (72.3)8 (57)12 (63)32 (96)38 (100)BM hemophagocytosis150 (60.7)2 (25)5 (41)32 (100)20 (52)Mortality28 (8)2 (14)2 (10.5)4 (12.5)4 (11.4)Patients meeting JIA criteria %NA-100NA100Patients meeting HLH criteria %NA1419NA66

Conclusion:

MAS is more likely to be presenting manifestation in SLE compared to sJIA. Though lab parameters are significantly different in MAS associated with SLE & sJIA, criteria meant for MAS in sJIA or SLE MAS performed equally well in both diseases.

References:

[1]Parodi A et al, Macrophage activation syndrome in juvenile systemic lupus erythematosus: a multinational multicenter study of thirty-eight patients. Arthritis Rheum. 2009 Nov;60(11):3388-99.

Disclosure of Interests:

None declared

International Nosocomial Infection Control Consortium (INICC) report, data summary of 45 countries for 2012-2017: Device-associated module

BACKGROUND

We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2012 to December 2017 in 523 intensive care units (ICUs) in 45 countries from Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific.

METHODS

During the 6-year study period, prospective data from 532,483 ICU patients hospitalized in 242 hospitals, for an aggregate of 2,197,304 patient days, were collected through the INICC Surveillance Online System (ISOS). The Centers for Disease Control and Prevention-National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI) were applied.

RESULTS

Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the medical-surgical ICUs, the pooled central line-associated bloodstream infection rate was higher (5.05 vs 0.8 per 1,000 central line-days); the ventilator-associated pneumonia rate was also higher (14.1 vs 0.9 per 1,000 ventilator-days,), as well as the rate of catheter-associated urinary tract infection (5.1 vs 1.7 per 1,000 catheter-days). From blood cultures samples, frequencies of resistance, such as of Pseudomonas aeruginosa to piperacillin-tazobactam (33.0% vs 18.3%), were also higher.

CONCLUSIONS

Despite a significant trend toward the reduction in INICC ICUs, DA-HAI rates are still much higher compared with CDC-NHSN's ICUs representing the developed world. It is INICC's main goal to provide basic and cost-effective resources, through the INICC Surveillance Online System to tackle the burden of DA-HAIs effectively.

Classification of close binary stars using recurrence networks

Close binary stars are binary stars where the component stars are close enough such that they can exchange mass and/or energy. They are subdivided into semidetached, overcontact, or ellipsoidal binary stars. A challenging problem in the context of close binary stars is their classification into these subclasses based solely on their light curves. Conventionally, this is done by observing subtle features in the light curves like the depths of adjacent minima, which is tedious when dealing with large datasets. In this work, we suggest the use of machine learning algorithms applied to quantifiers derived from recurrence networks to differentiate between classes of close binary stars. We show that overcontact binary stars occupy a region different from semidetached and ellipsoidal binary stars in a plane of characteristic path length and average clustering coefficient, computed from their recurrence networks. We use standard clustering algorithms and report that the clusters formed correspond to the standard classes with a high degree of accuracy.

Weighted recurrence networks for the analysis of time-series data

Recurrence networks (RNs) have become very popular tools for the nonlinear analysis of time-series data. They are unweighted and undirected complex networks constructed with specific criteria from time series. In this work, we propose a method to construct a ‘weighted recurrence network’ from a time series and show that it can reveal useful information regarding the structure of a chaotic attractor which the usual unweighted RN cannot provide. Especially, a network measure, the node strength distribution, from every chaotic attractor follows a power law (with exponential cut off at the tail) with an index characteristic to the fractal structure of the attractor. This provides a new class among complex networks to which networks from all standard chaotic attractors are found to belong. Two other prominent network measures, clustering coefficient and characteristic path length, are generalized and their utility in discriminating chaotic dynamics from noise is highlighted. As an application of the proposed measure, we present an analysis of variable star light curves whose behaviour has been reported to be strange non-chaotic in a recent study. Our numerical results indicate that the weighted recurrence network and the associated measures can become potentially important tools for the analysis of short and noisy time series from the real world.

Outcomes in juvenile onset lupus: single center cohort from a developing country

Introduction

About 10–20% of systemic lupus erythematosus (SLE) patients have onset in childhood and have more severe organ involvement. Survival of juvenile SLE patients is improving worldwide. Long-term data of childhood onset SLE from developing countries is scarce.

Methods

Clinical and laboratory data at initial presentation and follow-up visits were retrieved from clinic files, hospital information system and personal interviews. Treatment received, complications, flares, outcomes and death were recorded. Survival was calculated using Kaplan–Meier survival curves and regression analysis was done for predictors of mortality.

Results

Children with SLE ( n = 273, 250 girls) had a median age at onset of 14 years and duration of illness prior to diagnosis at our hospital of 1 year. Fever and arthritis were the most common presenting manifestations. Renal disease was seen in 60.5% and central nervous system (CNS) disease in 29%. The median follow-up period in 248 patients was 3.5 years. Fourteen children died, and 10 of these had active disease at the time of death. The mean actuarial survival was 24.5 years and survival rates at 1, 5 and 10 years were 97.9%, 95% and 89% respectively. Fever, CNS disease, anti-dsDNA levels and serious infections predicted death on univariate and multivariate analysis. Infections were seen in 72 children (26.3%), and 38 of these infections were serious. One-third of the patients had damage on the last follow-up. Flares were seen in 120 children, the majority being major flares.

Conclusion

Outcomes of pediatric SLE in North Indian children are similar to those seen in developed countries. Infections pose a major challenge in these patients.

Association of ITGAM, TNFSF4, TNFAIP3 and STAT4 gene polymorphisms with risk of systemic lupus erythematosus in a North Indian population

Several susceptibility genes have been associated with systemic lupus erythematosus (SLE) across different populations worldwide. However, data on association between genetic polymorphisms and SLE from Indian population is scarce. We aimed to replicate the association of single nucleotide polymorphisms (SNPs) in ITGAM, TNFSF4, TNFAIP3 and STAT4 genes with susceptibility to SLE in a North Indian population. Three hundred and ninety-four SLE patients and 583 unrelated healthy controls of the same ethnic background were enrolled. All samples were genotyped for SNPs in ITGAM (rs1143679), TNFSF4 (rs2205960), TNFAIP3 (rs5029939) and STAT4 (rs7574865) using TaqMan genotyping assay. At allele level, significant association with susceptibility to SLE was detected with polymorphisms in ITGAM (A vs. G, odds ratio (OR) = 1.73, 95% confidence interval (CI) = 1.30–2.30, p < 0.001), TNFSF4 (T vs. G, OR = 1.33, 95% CI = 1.08–1.64, p < 0.01), TNFAIP3 (G vs. C, OR = 1.91, 95% CI = 1.27–2.85, p < 0.01) and STAT4 (T vs. G, OR = 1.38, 95% CI = 1.13–1.69, p < 0.01). All four SNPs were associated with SLE under a dominant model with an OR of 1.47 (95% CI = 1.07–2.04, p < 0.05) for ITGAM, 1.30 (95% CI = 1.01–1.69, p < 0.05) for TNFSF4, 1.90 (95% CI = 1.25–2.90, p < 0.01) for TNFAIP3 and 1.38 (95% CI = 1.06–1.78, p < 0.05) for STAT4. Under a recessive model, significant association was found with ITGAM (OR = 4.87, 95% CI = 2.17–10.91, p < 0.001), TNFSF4 (OR = 1.84, 95% CI = 1.13–3.00, p < 0.05) and STAT4 (OR = 1.82, 95% CI = 1.19–2.77, p < 0.01). In conclusion, single nucleotide polymorphisms in ITGAM, TNFSF4, TNFAIP3 and STAT4 genes are associated with susceptibility to SLE in a North Indian population.

Arachnoid Cyst Causing Depression and Neuropsychiatric Symptoms: a Case Report

Arachnoid cysts are benign space-occupying brain lesions that contain cerebrospinal fluid. Most cases are congenital in origin, caused by failed fusion of the arachnoid membrane early in fetal development. Cases are often incidentally detected on neuroimaging; however, rarely patients present with neuropsychiatric manifestations when cysts expand and cause a midline shift, compression of nearby brain tissue or cerebrospinal fluid compartments or both. We report a case of a 56-year-old woman with no past history or family history of psychiatric illness who developed acute-onset right-sided weakness, depressive symptoms, and other neuropsychiatric deficits. A diagnosis of organic mood disorder caused by an arachnoid cyst was made. Her symptoms and neuropsychiatric deficits remitted after cyst marsupialisation by open craniotomy. Therefore, it is important to investigate the organic aetiology in elderly patients who present with simultaneous mood disorder and cognitive dysfunction.

Incidence, risk factors and associated mortality of central line-associated bloodstream infections at an intensive care unit in northern India

Objective

To evaluate the incidence, risk factors and associated mortality of central line-associated bloodstream infection (CLABSI) in an adult intensive care unit (ICU) in India.

Design

This prospective observational study was conducted over a period of 16 months at a tertiary care referral medical center.

Setting

We conducted this study over a period of 16 months at a tertiary care referral medical center.

Participants

All patients with a central venous catheter (CVC) for >48 h admitted to the ICU were enrolled.

Intervention and main outcome measures

Patient characteristics included were underlying disease, sequential organ failure assessment (SOFA), acute physiology and chronic health evaluation (APACHE II) scores and outcome. Statistical analysis of risk factors for their association with mortality was also done.

Results

There were 3235 inpatient-days and 2698 catheter-days. About 46 cases of CLABSI were diagnosed during the study period. The overall rate of CLABSI was 17.04 per 1000 catheter-days and 14.21 per 1000 inpatient-days. The median duration of hospitalization was 23.5 days while the median number of days that a CVC was in place was 17.5. The median APACHE II and SOFA scores were 17 and 10, respectively. Klebsiella pneumoniae was the most common organism (n = 22/55, 40%). Immunosuppressed state and duration of central line more than 10 days were significant factors for developing CLABSI. SOFA and APACHE II scores showed a tendency towards significance for mortality.

Conclusions

Our results underscore the need for strict institutional infection control measures. Regular training module for doctors and nurses for catheter insertion and maintenance with a checklist on nurses' chart for site inspection and alerts in all shifts are some measures planned at our center.

PKK deficiency in B cells prevents lupus development in Sle lupus mice

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease characterized by the production of autoantibodies that can result in damage to multiple organs. It is well documented that B cells play a critical role in the development of the disease. We previously showed that protein kinase C associated kinase (PKK) is required for B1 cell development as well as for the survival of recirculating mature B cells and B-lymphoma cells. Here, we investigated the role of PKK in lupus development in a lupus mouse model. We demonstrate that the conditional deletion of PKK in B cells prevents lupus development in Sle1Sle3 mice. The loss of PKK in Sle mice resulted in the amelioration of multiple classical lupus-associated phenotypes and histologic features of lupus nephritis, including marked reduction in the levels of serum autoantibodies, proteinuria, spleen size, peritoneal B-1 cell population and the number of activated CD4 T cells. In addition, the abundance of autoreactive plasma cells normally seen in Sle lupus mice was also significantly decreased in the PKK-deficient Sle mice. Sle B cells deficient in PKK display defective proliferation responses to BCR and LPS stimulation. Consistently, B cell receptor-mediated NF-κB activation, which is required for the survival of activated B cells, was impaired in the PKK-deficient B cells. Taken together, our work uncovers a critical role of PKK in lupus development and suggests that targeting the PKK-mediated pathway may represent a promising therapeutic strategy for lupus treatment.

Urinary haptoglobin, alpha-1 anti-chymotrypsin and retinol binding protein identified by proteomics as potential biomarkers for lupus nephritis

The study was aimed at identification by proteomics and validation by enzyme-linked immunosorbent assay (ELISA) of potential urinary biomarkers for lupus nephritis. Study subjects comprised 88 systemic lupus erythematosus (SLE) patients and 60 controls (rheumatoid arthritis, diabetes mellitus and healthy individuals). Based on the SLE disease activity index (SLEDAI), patients were classified as active renal (AR), active non-renal (ANR) or inactive disease (ID). Urinary proteins from a group of patients with AR or ID were resolved by two-dimensional gel electrophoresis and identified by matrix-assisted laser desorption ionization-time of flight-mass spectrometry (MALDI-TOF-MS/MS). The selected biomarkers were validated by ELISA using samples from all patients and controls. AR patients were followed-up for 12 months after start of therapy. Three urinary proteins, alpha-1 anti-chymotrypsin (ACT), haptoglobin (HAP) and retinol binding protein (RBP), were detected in patients with AR and not ID. Upon validation, ACT levels were higher in AR patients than the other groups (P < 0·001) and showed good correlation with renal SLEDAI (r = 0·577, P < 0·001) as well as SLEDAI (r = 0·461, P < 0·001). Similarly, HAP levels were > 10-fold higher in AR than other groups (P < 0·001) and correlated well with renal SLEDAI (r = 0·594, P < 0·001) and SLEDAI (r = 0·371, P < 0·01). RBP levels were also higher in AR patients than in other groups (P < 0·05), except diabetes, and showed moderate correlation with renal SLEDAI (r = 0·284, P < 0·008) and SLEDAI (r = 0·316, P < 0·003). Upon follow-up with treatment, levels of all three proteins declined at 6 and 12 months (P < 0·01). Multiple logistic regression identified ACT as the best marker to differentiate AR from ANR. Urinary HAP, ACT and RBP are potential biomarkers for lupus nephritis activity.

Measure for degree heterogeneity in complex networks and its application to recurrence network analysis

We propose a novel measure of degree heterogeneity, for unweighted and undirected complex networks, which requires only the degree distribution of the network for its computation. We show that the proposed measure can be applied to all types of network topology with ease and increases with the diversity of node degrees in the network. The measure is applied to compute the heterogeneity of synthetic (both random and scale free (SF)) and real-world networks with its value normalized in the interval [Formula: see text]. To define the measure, we introduce a limiting network whose heterogeneity can be expressed analytically with the value tending to 1 as the size of the network N tends to infinity. We numerically study the variation of heterogeneity for random graphs (as a function of p and N) and for SF networks with γ and N as variables. Finally, as a specific application, we show that the proposed measure can be used to compare the heterogeneity of recurrence networks constructed from the time series of several low-dimensional chaotic attractors, thereby providing a single index to compare the structural complexity of chaotic attractors.

Urinary B cell activating factor (BAFF) and a proliferation-inducing ligand (APRIL): potential biomarkers of active lupus nephritis

B cell activating factor (BAFF) and a proliferation-inducing ligand (APRIL) help in B cell activation, maintenance and plasma cell survival. B cell infiltration has been demonstrated in kidneys of patients with lupus nephritis (LN). Serum levels of BAFF and APRIL have shown inconsistent relationships with lupus disease activity. We evaluated urinary levels of BAFF and APRIL as biomarker for LN. Thirty-six patients with proliferative lupus nephritis (AN), 10 with active lupus without nephritis (AL) and 15 healthy controls (HC) were studied. APRIL and BAFF levels were measured in both serum and urine using enzyme-linked immunosorbent assay (ELISA). Urine levels were normalized for urinary creatinine excretion. Urine levels were correlated with conventional disease activity markers and histology. Levels were reassessed in 20 AN patients at 6 months after treatment with cyclophosphamide. Urinary APRIL (uAPRIL) and BAFF (uBAFF) levels were raised significantly in AN. uAPRIL, but not uBAFF, correlated moderately with renal Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) in AN (r = 0·36, P < 0·05). On receiver operator curve (ROC) analysis, uBAFF and uAPRIL showed an area under the curve (AUC) of 0·825 and 0·781, respectively, in differentiating between nephritis and non-nephritis, which performed better than low C3, C4 and raised anti-dsDNA antibodies. There was no correlation of serum levels with uBAFF (r = 0·187, P = 0·261) and uAPRIL (r = 0·114, P = 0·494). uAPRIL levels reduced after treatment (mean 125 pg/mg to 36 pg/mg, P < 0·05). uBAFF levels reduced in 16 responders while two of four non-responders had increase in levels. Thus, uBAFF and uAPRIL are potential biomarkers of proliferative lupus nephritis.

Intermediate monocytes are increased in enthesitis-related arthritis, a category of juvenile idiopathic arthritis

Microarray of peripheral blood (PB) and synovial fluid mononuclear cells (PBMC, SFMC) of patients with juvenile idiopathic arthritis-enthesitis-related arthritis (JIA-ERA) has shown the involvement of monocytes. On the basis of CD14 and CD16 expression, monocytes are classified as classical, intermediate and non-classical. In response to Toll-like receptor (TLR) stimulation, intermediate monocytes produce proinflammatory cytokines and play a role in inflammatory diseases. Therefore, we have studied the microarray profile of monocytes, the frequency of their subsets and cytokine production. Monocyte-specific microarray analysis was performed in six healthy controls' PBMC and six patients' PBMC and SFMC using Illumina chips WG12. Monocyte subsets were assessed in 46 patients with JIA-ERA and 17 healthy controls and 17 disease controls by flow cytometry. Interleukin (IL)-23 and tumour necrosis factor (TNF) levels were measured in culture supernatants of eight controls and seven patients' PBMC/SFMC with/without lipopolysaccharide (LPS) stimulation. Cytokine-producing intermediate monocytes were assessed by flow cytometry. Genes related to antigen presentation, cytokine signalling and TLR pathway were regulated differentially in PB and synovial monocytes of patients with JIA-ERA. Key genes of intermediate monocytes, such as CLEC10A and MARCO, were expressed three- to fourfold more in JIA-ERA. In PB, the frequency of intermediate monocytes was significantly higher in JIA-ERA (4·90% ± 3·5) compared to controls (1·8% ± 1·06; P < 0·001). Patients' synovial cells also had more intermediate monocytes compared to PB (11·25% ± 11·32, 5·9% ± 4·8; P = 0.004). Intermediate monocytes are the major producers of IL-23. Thus, intermediate monocytes may play an important role in JIA-ERA, possibly by producing cytokines, and contribute to joint inflammation.

Giant metastasizing malignant hidradenoma in a child

An 8-year-old girl presented with a scalp swelling. The swelling was recurrent, reappearing everytime after local excision. She underwent surgery and the histopathologic diagnosis was malignant hidradenoma. This very rare and aggressive tumor is known to occur in elderly population and is histopathologically distinct from its commonly occuring benign counterpart. Malignant hidradenoma is resistant to chemotherapy and radiotherapy. We empahsize that being cognizant of the possibility of this rare tumor would assist in timely action in the form of wide resection, with possible reduction in morbidity and mortality.

Peripheral blood T helper type 17 frequency shows an inverse correlation with disease activity and magnetic resonance imaging-based osteitis and erosions in disease-modifying anti-rheumatic drug- and steroid-naive established rheumatoid arthritis

An increased expansion of T helper type 17 (Th17) cells in the synovium has been shown to play a key role in cartilage and bone destruction in rheumatoid arthritis (RA). Because the correlation of the peripheral blood helper T cell subsets and various inflammatory cytokines with the magnetic resonance imaging (MRI)-based parameters have not been studied adequately to date, we sought to look for the same in this study. RA patients with disease duration less than 36 months, disease-modifying anti-rheumatic drugs (DMARDs) and steroid-naive, were recruited. MRI of the dominant hand and wrist was performed using a 0·2 Tesla MRI machine. Peripheral blood Th1 and Th17 were enumerated by flow cytometry and serum interleukin (IL)-6 and IL-17 by enzyme-linked immunosorbent assay (ELISA). Forty consecutive seropositive RA patients [33 females, mean disease duration 12·2 months, mean disease activity score (DAS)28 = 4·4] were included. MRI revealed erosions in 80% of these subjects. On subgroup analysis, prevalence of erosions (94 versus 68%) as well as mean erosion score (11·5 ± 18·9 versus 3·5 ± 6·0) were significantly higher in established RA (13-36 months' duration) compared to early RA (0-12 months). The median peripheral blood Th17 frequencies were significantly higher in patients (1·4%) compared to healthy controls (0·7%) and had a strong negative correlation with MRI parameters of erosion and osteitis as well as with DAS28 in the established RA subgroup. The frequency of peripheral blood Th17 subset was significantly expanded in established RA which correlated inversely with disease activity as well as MRI based erosions and osteitis.

Recombinant Salmonella typhimurium outer membrane protein A is recognized by synovial fluid CD8 cells and stimulates synovial fluid mononuclear cells to produce interleukin (IL)-17/IL-23 in patients with reactive arthritis and undifferentiated spondyloarthropathy

In developing countries, one-third of patients with reactive arthritis (ReA) and undifferentiated spondyloarthropathy (uSpA) are triggered by Salmonella typhimurium. Synovial fluid mononuclear cells (SFMCs) of patients with ReA and uSpA proliferate to low molecular weight fractions (lmwf) of outer membrane proteins (Omp) of S. typhimurium. To characterize further the immunity of Omp of Salmonella, cellular immune response to two recombinant proteins of lmwf, OmpA and OmpD of S. typhimurium (rOmpA/D-sal) was assessed in 30 patients with ReA/uSpA. Using flow cytometry, 17 of 30 patients' SF CD8(+) T cells showed significant intracellular interferon (IFN)-γ to Omp crude lysate of S. typhimurium. Of these 17, 11 showed significantly more CD8(+) CD69(+) IFN-γ T cells to rOmpA-sal, whereas only four showed reactivity to rOmpD-sal. The mean stimulation index was significantly greater in rOmpA-sal than rOmpD-sal [3·0 (1·5-6·5) versus 1·5 (1·0-2·75), P < 0·005]. Similarly, using enzyme-linked immunospot (ELISPOT) in these 17 patients, the mean spots of IFN-γ-producing SFMCs were significantly greater in rOmpA-sal than rOmpD-sal [44·9 (3·5-130·7) versus 19·25 (6-41), P < 0·05]. SFMCs stimulated by rOmpA-sal produced significantly more proinflammatory cytokines than rOmpD-sal: IFN-γ [1·44 (0·39-20·42) versus 0·72 (0·048-9·15) ng/ml, P < 0·05], interleukin (IL)-17 [28·60 (6·15-510·86) versus 11·84 (6·83-252·62) pg/ml, P < 0·05], IL-23 [70·19 (15-1161·16) versus 28·25 (> 15-241·52) pg/ml, P < 0·05] and IL-6 [59·78 (2·03-273·36) versus 10·17 (0·004-190·19) ng/ml, P < 0·05]. The rOmpA-sal-specific CD8(+) T cell response correlated with duration of current synovitis (r = 0·53, P < 0·05). Thus, OmpA of S. typhimurium is a target of SF CD8(+) T cells and drives SFMC to produce increased cytokines of the IL-17/IL-23 axis which contribute to the pathogenesis of Salmonella-triggered ReA.

Urinary osteoprotegerin: a potential biomarker of lupus nephritis disease activity

OBJECTIVES

Urinary biomarkers may help in identification, treatment and assessment of response in patients with lupus nephritis (LN). Osteoprotegerin (OPG) is produced by the kidneys and lymphoid cells and may reflect renal disease activity better. The data on its utility are sparse.

METHODS

Fifty-eight patients with active LN (AN), 24 with active non-renal disease (ANR) and 39 with inactive disease (ID) were included. Median disease duration was 32 (1-204) months and median age was 27 (12-50) years. AN patients were followed up every three months for one year. Urine and serum samples were collected for OPG measurement by ELISA (pg/ml) and urinary values were normalised for creatinine excretion (pg/mg). Urine samples from 24 healthy individuals (HCs) and 20 patients each of rheumatoid arthritis (RA) and diabetic nephropathy (DM) served as controls. Variables were expressed as median (range).

RESULTS

At baseline, normalised urinary OPG (uOPG) was significantly higher (p < 0.001) in AN (1229 (0-8577)) than ANR (236 (0-14713)), ID (463 (7-4253)), HCs (366 (120-2849)) and DM (350 (127-1577)) but it was not different from RA (1511 (122-8849)). uOPG correlated modestly with rSLEDAI (r = 0.4, p < 0.001) and SLEDAI (r = 0.31, p < 0.001) but not with serum OPG (sOPG). uOPG but not sOPG could differentiate between AN and ANR groups. In the longitudinal study, uOPG and sOPG decreased significantly with treatment at all follow-up visits but the trend of fall in sOPG was erratic. uOPG values at baseline, 3, 6, 9 and 12 months were 1229 (0-8577), 466 (3-4874), 104 (0-1598), 325 (0-4025) and 555 (6-6771) pg/mg, respectively. uOPG but not sOPG rose before conventional markers in three patients who had a relapse of LN. In two patients who developed chronic kidney disease, uOPG remained persistently high. For differentiating AN from ANR patients, uOPG performed the best on receiver operator characteristics analysis (AUC = 0.72) when compared with anti-dsDNA antibodies, C3, C4 and sOPG.

CONCLUSION

uOPG is derived from kidneys and helps differentiate active SLE patients with and without LN. It shows modest correlation with disease activity and has a potential to predict poor response to therapy and relapse of LN.

Uniform framework for the recurrence-network analysis of chaotic time series

We propose a general method for the construction and analysis of unweighted ε-recurrence networks from chaotic time series. The selection of the critical threshold ε_{c} in our scheme is done empirically and we show that its value is closely linked to the embedding dimension M. In fact, we are able to identify a small critical range Δε numerically that is approximately the same for the random and several standard chaotic time series for a fixed M. This provides us a uniform framework for the nonsubjective comparison of the statistical measures of the recurrence networks constructed from various chaotic attractors. We explicitly show that the degree distribution of the recurrence network constructed by our scheme is characteristic to the structure of the attractor and display statistical scale invariance with respect to increase in the number of nodes N. We also present two practical applications of the scheme, detection of transition between two dynamical regimes in a time-delayed system and identification of the dimensionality of the underlying system from real-world data with a limited number of points through recurrence network measures. The merits, limitations, and the potential applications of the proposed method are also highlighted.

Indirect evidence of intravesical ureterocele on99mTc-diethylene triamine pentaacetic acid scan

Ureterocele is a common ureteric anomaly detected in pediatric population. Ureterocele diagnosis and evaluation need a variety of radiological methods. We report a case of 5-year-old female child sent for ^99mTc-diethylene triamine pentaacetic acid scan for evaluation of glomerular filtration rate and excretory function of kidneys in view of right-sided hydroureteronephrosis and pyonephrosis with percutaneous tube in situ. Incidental photopenia was noted in the urinary bladder. On ultrasonography of abdomen cause of this photopenia was found to be an intravesical ureterocele.

Reduction of microalbuminuria in type-2 diabetes mellitus with angiotensin-converting enzyme inhibitor alone and with cilnidipine

The aim of our study was to find out the antiproteinuric effect of enalapril angiotensin-converting enzyme (ACE inhibitor) alone or in combination with cilnidipine in patients with type-2 diabetes mellitus. The study was conducted on 71 patients with type-2 diabetes mellitus patients with hypertension and microalbuminuria. They were divided into two groups randomly as follows: Group I (enalaprilalone, n = 36) and Group II (enalapril with cilnidipine, n = 35). In both the groups, baseline 24 h urinary albumin was estimated and was repeated every 3 months upto 1-year. After 1-year follow-up, reduction in microalbuminuria was found to be greater in Group II. In Group I microalbuminuria came down by 25.68 ± 21.40 while in Group II it reduced by 54.88 ± 13.84 (P < 0.001). We conclude that in diabetic population, cilnidipine has an additive effect in microalbuminuria reduction over and above the well-proven effect of ACE inhibitors.

Outcome of lupus nephritis in childhood onset SLE in North and Central India: single-centre experience over 25 years

INTRODUCTION

Childhood SLE (cSLE) has a higher prevalence of lupus nephritis (LN), and there are ethnic variations in response to treatment as well as outcome of LN. There are limited data on long-term outcome of LN in cSLE from the Indian subcontinent.

METHODS

Retrospective analysis of case records of patients with cSLE (satisfying revised American College of Rheumatology (ACR) 1997 criteria for diagnosis) and age of onset <18 years was conducted from 1989 to 2013. Data on clinical features, renal involvement and biopsy findings, treatment, renal outcome, damage accrual and mortality were collected. End-stage renal disease (ESRD) was defined as the need for renal replacement therapy. Actuarial ESRD-free survival was studied as the primary outcome measure using Kaplan-Meier analysis.

RESULTS

Among 205 children with cSLE, 134 (121 girls) had evidence of LN. The mean age at disease onset was 13.7 ± 3.5 years and the mean disease duration at presentation was 1.9 ± 2.5 years. Kidney biopsy was available for 92 patients, and histology included: 13 (14.2%) Class II, 24 (26%) Class III, 43 (46.7%) Class IV and 12 (13.1%) Class V LN. The mean follow-up period was 6.75 ± 5.7 years. At last visit, 81 (60.4%) children were in complete remission, 28 (20.9%) were in partial remission, 15 (11.2%) still had active nephritis and 10 (7.4%) had progressed to ESRD. Almost two-thirds (62.9%) of patients experienced lupus flares, and mean flare rate was 0.09 flares/patient follow-up year. Fifty-six (43.8%) children accrued damage and the mean Systemic Lupus International Collaborating Clinics (SLICC)/ACR damage score was 0.79 ± 1.13. Actuarial ESRD-free survival at five, 10 and 15 years was 91.1%, 79% and 76.2%, and five-, 10- and 15-year renal survival was 93.8%, 87.1% and 84%, respectively. Although multiple factors individually predicted poor outcome (death/ESRD), only raised serum creatinine at onset (R square = 0.65, p ≤ 0.0001) and damage accrual (R square = 0.62, p ≤ 0.0001) remained significant on multivariate analysis. Eleven (8.2%) children died during the follow-up period, and infections were the leading cause of mortality.

CONCLUSIONS

Long-term outcome of LN in cSLE in our cohort was better than previous reports from India. However, a high rate of major infection still remains the leading cause of mortality.

Midtrimester spontaneous torsion of unruptured gravid rudimentary horn: Presurgical diagnosis on magnetic resonance imaging

Unicornuate uterus with rudimentary horn occurs due to failure of complete development and partial fusion of one of the Müllerian ducts. Pregnancy in a non-communicating rudimentary horn is extremely rare, with a reported incidence of 1 in 76 000-150 000 pregnancies, and usually terminates in rupture during the first or second trimester. Clinical diagnosis of rudimentary horn pregnancy in a woman with history of normal vaginal delivery in prior gestations is difficult. The role of sonography, and more recently, magnetic resonance imaging, in the presurgical diagnosis of rudimentary horn pregnancy is established. We present a case of magnetic resonance imaging diagnosis of 20-week pregnancy in the unruptured non-communicating rudimentary horn in a patient with previous history of two full-term normal vaginal deliveries. The novelty of the case lies in the fact that there was associated torsion of the gravid rudimentary horn and ipsilateral ovary, which has not been reported previously.

Epinephrine-secreting large incidental pheochromocytoma in a normotensive male with stormy intraoperative hemodynamics

Pheochromocytoma is a rare tumour which is usually suggested by sustained or paroxysmal hypertension however the spectrum of the presentation of pheochromocytoma continues to expand and hypertension may be absent despite excess catecholamine secretion. The normotensive pheochromocytoma is a distinct entity and as in the case we report the presentation was quite unique as well as the intraoperative behaviour was stormy.

Urinary sCD25 as a biomarker of lupus nephritis disease activity

OBJECTIVES

T cells play an important role in the pathogenesis of lupus nephritis (LN). We studied the role of urinary soluble CD25 (sCD25) as a biomarker of LN disease activity in a cross-sectional and longitudinal study.

METHODS

Patients with systemic lupus erythematosus were classified as active LN (AN), inactive disease (ID) and active non-renal (ANR) based on disease activity and renal involvement at the time of enrolment. Urine and serum samples were collected at baseline from all patients and at 3-monthly follow-up from patients with AN. SLE disease activity index (SLEDAI) was used for disease activity assessment at all visits. sCD25 was measured by ELISA and normalized to urinary creatinine excretion and is expressed as pg/mg. Urine samples from 10 healthy individuals (HC) served as controls.

RESULTS

There were 119 patients (111 females, median age 27 years, 57 AN, 43 ID, 19 ANR). Median SLEDAI was 18, 2 and 8 in AN, ID and ANR groups, respectively. Median renal SLEDAI in AN was 8. Mean (±SD) urinary sCD25 in the AN, ID, ANR and HC groups at baseline was 741.1 (±794.9), 407.8 (±511.1), 735.4 (±667.7) and 250.9 (±122.2) pg/mg respectively (p = 0.019). Mean (±SD) serum sCD25 in AN, ID and ANR was 8285.25 (±5922.2), 6044 (±3501.92) and 6568.72 (±4333.62) pg/ml, respectively. Urinary sCD25 correlated with SLEDAI (r = 0.22; p = 0.015) but did not correlate with serum sCD25 or proteinuria. Urinary sCD25 compares well with traditional markers of disease activity in differentiating active from inactive renal disease. On follow-up mean urinary sCD25 decreased to 470.0 (±449.6; p < 0.05) at 3 months, 496.7 (±465.8; p = 0.006) at 6 months, 471.9 (±303.2; p = 0.041) at 9 months and 358.6 (±496.9; p = 0.007) at 12 months from baseline value of 741.1 (±794.9). In four patients who either had relapse, persistent disease activity or developed chronic kidney disease, urinary sCD25 showed rise preceding traditional abnormalities on urine examination.

CONCLUSIONS

Urinary sCD25 is a good biomarker for follow-up of LN. It may also have the potential to predict poor response and relapse.

Comparison of foetomaternal circulation in normal pregnancies and pregnancy induced hypertension using color Doppler studies

The aim of present study was to assess fetomaternal blood flows in normal and abnormal pregnancies using color Doppler indices. Subjects were divided into two groups as: Group A of 25 subjects of normal pregnancy as controls and group B of 25 subjects of pregnancy induced hypertension. All the subjects were lying in the age-group of 25-35 years and having 28 to 34 weeks of gestation; the patients were evaluated by detailed history and were subjected to complete general examination. Blood pressure was taken on two occasions at least 6 hours apart. Systemic examination and obstetrical examination was done in all subjects. All cases were subjected to pathological tests- Haemogram, Test for proteins in urine. Ultrasound assessment of fetal growth was done by measuring BPD (Biparietal diameter), HC (Head circumference), FL (Femur length) and AC (Abdominal circumference): Average gestational age and effective fetal weight was then calculated by ultrasound machine. Color Doppler was used to assess the various Doppler indices indices: Pulsatility index (PI), Resistive index (RI) and Systolic diastolic ratio (S/D ratio) in bilateral uterine, umbilical and middle cerebral arteries and compared to the standard normograms. Percentage of subjects having abnormal Doppler indices were calculated. Assessment of percentage of SGA (small for gestational age) fetuses was done in all the three groups. Decline in mean values of all Doppler indices was found with advancing gestational age in normal pregnancy suggesting decreased vascular resistance and increased blood flow in fetomaternal circulation. In pregnancy induced hypertensives, the mean values of Doppler indices showed a decline as in normal pregnancy but showed an increase (more than 2 S.D. of the mean) for that gestational age in comparison to the control group suggesting increased impedance to blood flow in uteroplacental and fetomaternal circulation. Umbilical artery Doppler indices were found to be the most sensitive indicator of uteroplacental and fetoplacental insufficiency in pregnancy induced hypertensives (P = 0.001). Thus we concluded that color Doppler can detect changes in fetomaternal circulation which correlate strongly with the fetal growth and therefore associated with pregnancy outcome.

Comparative proteomic analysis of Clostridium difficile isolates of varying virulence

The soluble proteome of three Clostridium difficile strains of varying pathogenic potential, designated B-1, Tra 5/5 and 027 SM, were compared using differential in-gel electrophoresis in which the proteins of each strain were labelled with CyDyes. This enabled visual inspection of the 2D profiles of strains and identification of differentially expressed proteins using image analysis software. Unlabelled protein reference maps of the predominant proteins were then generated for each strain using 2D gel electrophoresis followed by protein sequencing of each spot using a Reflectron matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometer. Increased coverage of the proteome was achieved using 1D gel electrophoresis in a bottom-up approach using LC-MS/MS of 1 cm gel slices. A total of 888 different proteins were detected by comparative analysis of isolates grown in parallel for 64 h on blood agar plates. Of these, only 38 % were shared between all isolates. One hundred and ten proteins were identified as showing ≥2-fold difference in expression between strains. Differential expression was shown in a number of potential virulence and colonization factors. Toxin B was detected in the more virulent strains B-1 and 027 SM, but not in the lower virulent strain Tra 5/5, despite all strains possessing an intact pathogenicity locus. The S-layer protein (Cwp2) was identified in strains 027 SM and Tra 5/5 but not strain B-1, and differences in the post-translational modification of SlpA were noted for strain B-1. The variant S-layer profile of strain B-1 was confirmed by genomic comparison, which showed a 58 kb insertion in the S-layer operon of strain B-1. Differential post-translation modification events were also noted in flagellar proteins, thought to be due to differential glycosylation. This study highlights genomic and proteomic variation of different Clostridium difficile strains and suggests a number of factors may play a role in mediating the varying virulence of these different strains.

Nature of the metal insulator transition in ultrathin epitaxial vanadium dioxide

We have combined hard X-ray photoelectron spectroscopy with angular dependent O K-edge and V L-edge X-ray absorption spectroscopy to study the electronic structure of metallic and insulating end point phases in 4.1 nm thick (14 units cells along the c-axis of VO2) films on TiO2(001) substrates, each displaying an abrupt MIT centered at ~300 K with width <20 K and a resistance change of ΔR/R > 10(3). The dimensions, quality of the films, and stoichiometry were confirmed by a combination of scanning transmission electron microscopy with electron energy loss spectroscopy, X-ray spectroscopy, and resistivity measurements. The measured end point phases agree with their bulk counterparts. This clearly shows that, apart from the strain induced change in transition temperature, the underlying mechanism of the MIT for technologically relevant dimensions must be the same as the bulk for this orientation.

Metanephric stromal tumor: An unusual pediatric renal neoplasm

A renal tumor in a 14-month- old child, who was initially diagnosed as mesoblastic nephroma, but on review post surgery was diagnosed as hyper-differentiated metanephric stromal tumor, with its excellent prognostic outcome. An attempt is made to document imaging features that may enable one to suspect this rare condition. The literature is reviewed with emphasis on its distinction from its look-alikes in the pediatric age group.

Contraceptive practices and associated social covariates: an experience from two districts of West Bengal, India

Background Contraceptive practice acceptable to Indian society is said to be associated with socio-economic status, education, practice of the area and other factors. Population stabilization and a gradual lowering of population growth is the basic aim behind contraceptive practice. Objectives The study was conducted to assess current status of contraceptive practice and social covariates (age, type of family, religion, socio-economy, education, etc). Materials and Methods A community based cross-sectional study was conducted among four thousand eligible couples in Howrah and Paschim Midnapore districts of state of West Bengal, India from March to September 2009. By stratified multistage random sampling technique, 32 areas were selected from two districts; villages of sub-centre zone and wards of municipality; from each selected area; 125 eligible couples were interviewed by house to house survey. Results The contraceptive acceptance (prevalence) rate (CAR) by any method was 65.3 percent and couple protection rate (CPR) by approved methods was 58.4 percent in these two districts of West Bengal. In Paschim Midnapore district CAR was higher (67.4%) than Howrah district (63.3%). Similarly in Howrah district CPR was less (54.3%) than Paschim Midnapore district (62.6%). Type of family, age and literacy status of female partners, religion and social class were associated with adoption of family planning methods by the eligible couples with inter-district variation. Conclusion Area specific multipronged tailor-made interventions are needed through Behaviour Change Communication (BCC) for promotion of acceptance of both the temporary & permanent methods of contraception at the appropriate time to achieve small family norm.

OHVIRA: Uterus didelphys, blind hemivagina and ipsilateral renal agenesis: Advantage MRI

We present here a case of an uncommon complex uterine anomaly – Obstructed HemiVagina with Ipsilateral Renal Agenesis (OHVIRA), also known as Herlyn-Werner-Wunderlich syndrome in a 14-year-old girl along with sonographic (trans-abdominal and trans labial), and MRI findings. The patient underwent surgery wherein imaging findings were confirmed. An MRI has proved to be of great help in correct diagnosis avoiding surgical interventions/ laparoscopy, which were needed in past to diagnose this rare anomaly. We also discuss the development of this anomaly with the help of a relatively new theory of uro-genital development by Acien and review the literature.

Giant cavernous haemangioma of the wandering spleen

Cavernous haemangioma is a rare disorder of the spleen with fewer than 100 cases reported [1]. Spleen may have an unusual degree of mobility and occupy an atypical location in less than 0.2 % of all the patients [2] Wandering spleen has been associated with incomplete fusion or even absence of gastrosplenic and lienorenal ligaments [3]. A 36-year-old woman presented with a six-month history of pain in the left hypochondrium and a massive splenomegaly. Ultrasonography, Doppler studies, and computed tomography were performed. Ultrasonography showed a large heterogeneous solid cystic mass, measuring 11.2 cm × 10.6 cm, located in the pelvis. Thin soft tissue connecting this mass to spleen noticed. Spleen was malrotated & in left lumbar fossa. Doppler studies shows prominent vessels at the periphery of the mass with high velocity external flow and scanty vascularity at the centre, probably suggesting haemangioma. Contrast-enhanced computed tomography (CECT) of the abdomen showed spleen in left lumbar region with a large heterogeneous, predominantly cystic mass lesion measuring 11.2 x 10.6 cm seen arising from diaphragmatic surface of lower pole of the spleen (Fig. 1), findings were suggestive of wandering spleen with a haemangioma or a hydatid cyst. The patient was explored by a left para-median incision under general anaesthesia. Peroperatively, there was a malrotated enlarged spleen with a large solid lesion confined to the lower half of the spleen (Fig. 2). Gastrosplenic ligament was not visualized. Total splenectomy was done after ligating the splenic artery as the main splenic artery was supplying the mass.