| PC0087: Rituximab in refractory lupus nephritis |  |
Subodh Gururani, D Phani Kumar, Liza Rajasekhar; NIMS, Hyderabad, Telangana, India
Background: Many patients with lupus nephritis(LN) are resistant to initial immunosuppressive therapy.Outcomes with change of treatment in patients with therapy refractory LN(RLN) [no improvement at 3 months, no partial remission (PR) at 6 months or no complete remission (CR) by 2 years] are not well documented.
Objectives: To document outcomes of change in immunosuppressive therapy in RLN patients.
Methods: It is observational, longitudinal, bidirectional study.Patients fulfilling criteria of RLN were enrolled consecutively from August 2018 to January 2019.Patients were observed after enrolment up to August 2019 and followed up three monthly.Treatment details,outcomes [CR, PR,no-response (NR)], doubling serum creatinine and death were recorded.Group comparisons were done using t-test and chi-square test. Factors affecting renal response were studied using linear regression.
Results: Fifty-one patients were enrolled. Duration of follow-up after first change in treatment was1 year (0.5-1.6).Thirteen received rituximab and thirty-eight change in conventional immunosuppressants (CIS):cyclophosphamide,mycophenolic acid,tacrolimus alone or in combination.Baseline characteristics of two groups are shown in [Table 1]. Median duration of nephritis was significantly longer in rituximab group.There were more patients refractory to >1 immunosuppressant in rituximab group (p=0.002). There was no difference in proportion of biopsy classes (proliferative, membranous and mixed) between two groups.CIS group had significantly greater renal response than rituximab group.Raised dsDNA, low complements,number of systems involved, biopsy class and duration of SLE or nephritis did not affect outcomes.Three deaths were recorded in CIS group and none in rituximab group.No patient developed doubling of serum creatinine or ESRD.
Conclusion: Rituximab was given to patients who had longer duration of nephritis and were refractory to multiple immunosuppressants.Renal responses were significantly better in those receiving CIS.A crossover study of early versus late rituximab in RLN is needed.
 | Table 1: Baseline characteristics and outcomes achieved Click here to view |
| PC0088: Retrospective analysis of MAS/2°HLH patients presenting to a rheumatology department in north India over one year | |
Manesh Manoj, Prashant Bafna, Kasturi Hazarika, Rasmi Ranjan Sahoo, Anupam Wakhlu; King George's Medical University, Lucknow, Uttar Pradesh, India
Discussion: We retrospectively analysed 8 patients of MAS/2°HLH who presented to the Rheumatology department of a tertiary care centre over a period of one year. The 8 cases consisted of 3 cases of SLE, 1 case of T cell lymphoma masquerading as SLE, 1 case of probable disseminated TB with granulomatous myositis, 2 cases of AOSD and 1 case of SoJIA. The mean age was 30 years (range 10 - 46 years) with equal number of males and females. The median duration of illness was 12 months (range 1 to 60 months). One patient's diagnosis had to be revised after clinical evolution and another patient's diagnosis could not be conclusively proved by histopathology. The clinical features and lab values are described in [Table 1]. In three (38%), infection was considered the possible triggering factor. One was associated with malignancy. In patients with infections, one had lower respiratory tract infection and two were positive for CMV by PCR. ALT and/or AST were elevated in six patients (75%). Three patients had pancytopenia (38%), four had bicytopenia (50%) and one had only thrombocytopenia. Six patients were treated with 3 to 5 days pulse MPS (30 mg/kg) followed by Inj dexamethasone at 10mg/m2 in five. Two were not pulsed. All except one patient was started on cyclosporine. One patient of SoJIA was put on 2mg/kg prednisolone after initial pulse steroids. Etoposide according to HLH 2004 protocol was used in one patient due to cyclosporine induced PRES (posterior reversible encephalopathy syndrome). Six patients survived (75%). One succumbed to malignancy induced HLH and the second, a case of probable disseminated TB also succumbed to the disease.
 | Table 1: Clinical features and laboratory characteristic of patients Click here to view |
Conclusion: This analysis highlights the varied presentations and the need for a high index of suspicion in order to detect and treat this deadly condition early.
| PC0089: Hypophosphatemic osteomalacia – close mimic of rheumatological disorders | |
Ishita Shah, Vaibhavi Velangi, Yogesh Preet Singh, Abhishek Patil, K Sharath, Vikram Jain, Aditya Hegde, Karthik Prabhakar, Vishad Vishwanath, Pooja Belani; Rheumatology Fellow Manipal Hospital, Bengaluru, Karnataka, India
Background: Hypophosphatemia due to increased urinary phosphate excretion is the predominant cause of the osteomalacia seen with the disorders of vitamin D metabolism. Hypophosphatemic osteomalacia can occur due to hereditary hypophosphatemic rickets syndrome or tumor-induced osteomalacia. Drug-induced Fanconi syndrome can result in renal phosphate wasting and osteomalacia. Here we present 12 cases of hypophosphatemic osteomalacia with different etiologies most of whom were referred to a rheumatologist with a diagnosis of spondyloarthritis.
Methods: Data was collected retrospectively from medical records from January 2015 to September 2019. Osteomalacia was diagnosed by Bingham and Fitzpatrick criteria (2 of the following: low calcium, low phosphate, elevated alkaline phosphatase or suggestive radiographs). The demographic is as per [Table 1].
 | Table 1 Click here to view |
Discussion: Adult onset osteomalacia can be overlooked due to lack of specific clinical features. Axial involvement in osteomalacia is commonly confused with spondyloarthropathy due to overlapping clinical features like back pain and radiological features like fuzzy sacroiliac joint outlines, calcified enthesopathies and subchondral bone resorption. Elevated serum FGF23 level and increased phosphate excretion in urine with tubular maximum phosphate reabsorption per glomerular filtration rate (TMP/GFR) reduction help to confirm the diagnosis of hypophosphatemic osteomalacia. Tumours responsible for oncogenic osteomalacia are slow growing benign tumour and removal of tumour leads to immediate and permanent improvement in the serum phosphate level.
Conclusion: Adult onset hypophosphatemic osteomalacia can be a close mimic of rheumatological condition specially spondyloarthritis (Both clinically and radiologically). Serum calcium and phosphorus level measurement should be part of evaluation of vague aches and pains not responding to analgesics. In patients not improving to phosphate correction FGF23 level should be checked. DOTANOC PET- CT should be performed to look for oncogenic osteomalacia. DOTANOC PET - CT is better modality for tumour detection as compared to FDG PET-CT. Resection of tumour helps considerably to alleviate the patient's condition.
| PC0090: Clinical and autoimmune profile of systemic sclerosis patients from central India | |
Rajat Deb, S S Nelson; Netaji Subhash Chandra Bose Medical College and Hospital, Jabalpur, Madhya Pradesh, India
Background: Systemic sclerosis (SSc) is a disorder characterized by fibrosis of skin and visceral organs. Pathogenesis of Systemic sclerosis is complex and is incompletely understood as yet. Autoantibodies in SSc represent serologic hallmarks which have clinical relevance, with diagnostic and prognostic potential.
Objective: To study Clinical features and Frequency of Autoantibodies among Subtypes of Systemic Sclerosis patients from Central India.
Methodology: 33 SSc patients were clinically classified according to the European League Against Rheumatism (EULAR) criteria. Clinical manifestations were recorded at the time of presentation. Autoantibodies were tested in them. These parameters were further correlated with clinical presentation of the disease.
Results: SSc patients had M: F ratio of 1:15 where mean age was 41.9±15.5.Clinical subtypes showed that 20 patients (60%) had diffused cutaneous (dcSSc) lesions, 13 patients (40%) had limited cutaneous (lcSSc) lesion. The overall frequency of ANA in SSc patients studied was 93.9%. The frequency of Anti-Topoisomerase (anti-Scl70) and anti-centromere were 57.6% and 21.2%, respectively. Anti-Scl70 antibodies were significantly high (90% versus 4%) among dcSSc patients (P < 0.0001) whereas anti-centromere antibodies were significantly high (0% versus 53.8%) among lcSSc patients when these two subtypes were compared (P < 0.0001).
 | Figure 1: Skin sclerosis with finger contracture in a patiny of systemic sglerosis Click here to view |
 | Table 1: Autoantibodies in systemic sclerosis patients Click here to view |
Conclusion: This study supports that there are geoepidemiological variations among scleroderma patients for their clinical presentation, autoantibody profile, and immune parameters across the country.
| PC0091: Efficacy and safety of adalimumab biosimilars in spondyloarthritis | |
P Akshay, G Meghna, R Pratyusha, D Phani Kumar, R Liza; Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India
Objective: The aim of this study was to investigate the safety and efficacy of adalimumab biosimilars (bADA) in SpA pateints and assess their efficacy.
Methods: Consecutive SpA patients who visited the SpA clinic at our centre between July – August 2019 and received bADA for atleast 3 months were enrolled. Demographic, clinical, radiological and disease activity (BASDAI) variables were collected. Descriptive statistics are reported.
Results: 25 patients were enrolled. Median age of the cohort was 25 years (IQR 19 - 33).
Table lists the disease and laboratory variables
Of the 25 patients, 4 stopped treatment abruptly, 2 due to credit issues and 2 were lost to follow up.
The mean (SD) BASDAI at initiation, 3 & 6 months of biologic was 4.8 (1.73), 1.75 (1.41) and 1.37 (1.78) respectively. 18 patients had BASDAI >4 at baseline while only 2 of them persisted to have BASDAI >4 at 3 & 6 months. 3 patients achieved BASDAI of 0 by 3 months and 10 patients by 6 months.
BASDAI 50 response was seen in 17 (68%) patients. Of the rest (early-non responders), 1 had improvement in BASDAI>2 in the next 3 months while others had a mean improvement in BASDAI of 0.25 over the next 3 months.
Seven patients with latent TB received prophylactic ATT a 1 month before biologic initiation. In 2 patients ATT and biologic were simultaneously started in view of very high BASDAI. 1 patient without LTB developed pulmonary tuberculosis 2 months after stopping biologics. He improved with ATT.
Conclusion: Biosimilars are efficacious in achieving short term disease control in 70% patients. Early non responders did not have significant improvement in disease activity even at 6 months. Prevalence of latent tuberculosis was high in this cohort but the risk of tuberculosis was not increased in short term.
 | Table 1 Click here to view |
| PC0092: Comparison of ultrasonology findings with clinical parameters and plain radiograph in patients with knee osteoarthritis | |
Shweta Nakarmi, Binit Vaidya, Rakchya Joshi; National Center for Rheumatic Diseases, Kathmandu, Nepal
Background: Knee osteoarthritis (OA) is one of the commonly encountered joint diseases in people with a prevalence ranging upto 7.9 % in adult population. There are various clinical and radiologic instruments to measure the disease severity of knee OA. Kellgren-Lawrence classification (KL) is commonly used radiographic tool to assess the severity of osteoarthritis. Nowadays, high frequency musculoskeletal ultrasonology (MSUS) is being used as a reliable tool for assessment of osteoarthritis.
Objectives: To compare and correlate musculoskeletal ultrasonology findings with clinical and xray findings in patients with knee OA
Methodology: A prospective, cross sectional study was conducted in patients with knee OA attending a tertiary level rheumatology center in Kathmandu, Nepal. Baseline demographic profile of the patients along with clinical parameters like WOMAC and VAS for pain and stiffness were recorded in predesigned data sheet. An AP view standing xray was obtained for involved knee and KL grading done. High frequency MSUS was done for same knee. Synovial hypertrophy, suprapatellar effusion, cartilage thickness (medial, lateral and intercondylar), Doppler activity and osteophytes were noted. Pearson's coefficient of correlation was calculated to assess correlation between ultrasonology and radiologic parameters.
Results: A total of 138 patients with knee OA were enrolled in the study with female predominance of 83% and mean age of 56.87 ± 10.61 years. The mean VAS for pain and WOMAC scores were 4.95 ± 1.78 and 28.36 ± 13.31, respectively. A negative correlation was observed between cartilage thickness (medial) with joint space narrowing (KL grade) and between WOMAC and VAS scores and cartilage thickness.
Conclusions: MSUS may be used in clinical practice to diagnose and monitor cases of knee osteoarthritis. It is a potential imaging technique which might help in therapeutic interventions and disease monitoring too.
| PC0093: Psychometric assessment of Telugu version of lupus-QOL and its correlation with SLE disease activity measures | |
Rajasekhar Liza1, Baisya Ritasman1, Dhundra Bhavani1, Vineeta Shobha2, Asma Chougle2 Avinash Jain3, Amita Aggarwal3. Department of Clinical Immunology and Rheumatology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana,1St John's Medical College and Hospital, Bengaluru, Karnataka,2Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
Introduction: Lupus-QOL, a newly developed questionnaire for quality of life assessment in SLE patients, has 34 items grouped into 8 domains and is validated in many non-Indian languages. Psychometric assessment is not available in Indian languages. The aim of the study was to determine whether in Telugu version, the items were internally consistent, and they correlated with SLE disease activity measures.
Methodology: Patients from the INSPIRE cohort, which included patients with disease duration less than 3 years and seen in the hospital after August 2018. Demographic status, SLEDAI (Mexican-SLEDAI) and BILAG score were recorded simultaneously. Psychometric testing for internal reliability and correlation of different domains with SLEDAI and BILAG were done using Cronbach alpha statistic and Pearson's correlation coefficient respectively using SPSS.
Results: There were 134 patients with mean (SD) age 26.8 (7.7) years. The median SLEDAI (IQR) was 7 (0-27). The mean scores in each domain indicated significant impairment of QoL with intimacy most affected. There was excellent internal consistency among questions in each domain. The musculoskeletal domain of BILAG correlated with most of the LQOL domains.
Conclusion: Lupus QOL questionnaire is a reliable measure of quality of life in our population. Body image and intimate relationship are the most affected QOL measures in SLE patients. BILAG musculoskeletal domain showed modest correlation with Lupus QOL domains.
Keywords: BILAG, Lupus-QOL, mSLEDAI
| PC0094: ASDAS is better than BASDAI for estimating disease activity in patients with axial spondyloarthritis: An experience from tertiary care centre in western India | |
Prashant Chotalia, Dhaiwat Shukla, Rutwiz Mistry, Sapan Pandya, Puja Srivastava; Smt. NHL Municipal Medical College and its Affiliated Hospitals, Ahmedabad, Gujarat, India
Background: Measuring Disease activity in Axial Spondyloarthritis (AxSpA) is difficult. Hence, we planned to compare the two disease activity parameters in patients with Axial Spondyloarthritis.
Objectives:
- To describe clinical features of patients of Axial Spondyloarthritis
- To correlate disease activity scores BASDAI and ASDAS in these patients
Materials and Methods: Patients fulfilling ASAS criteria for Axial Spondyloarthritis(SpA) were included in the evaluation. Demographic, clinical, radiological and laboratory data of included patients were evaluated. BASDAI score, ASDAS were calculated. Correlation between BASDAI and ASDAS was evaluated.
Results: One hundred and thirty eight patients with median age 28years(IQR: 22-38) and sex ratioM:F of 2.9:1.106(76.81%) were AS and 32(23.18%) were axial SpA not fulfilling modified New York criteria. The demographics are as shown in the table.
Most common extra articular manifestations were uveitis (11.59%) and oral ulcer (9.42%).Sacroiliitis was present on imaging in 68.84 % patients.Mean BASDAI (91/138 patients) was 3.42± 1.75 and Mean ASDAS (82/138 patients) was2.75±1.25.There was no gender difference in disease activity in patients with Axial SpA.
Although, moderate correlation was observed between the two disease activity parameters (0.634), In our study population, 8.53 % had inactive disease, 32.92% had moderate active disease, 29.26 % had high disease and 29.26 % had very high disease activity as per ASDAS. 64.83 % had inactive disease while 35.16 % had active disease as per BASDAI. 87.5 % percentage of patients inactive according to BASDAI was active in ASDAS.
Conclusion: Although BASDAI and ASDAS correlate well for patients with high disease activity, a significant proportion of patients inactive according to BASDAI are still active according to ASDAS. Thus, ASDAS is probably better tool to detect mild and moderate disease activity in Axial SpA.
| PC0095: Assessment of hand dysfunction in systemic sclerosis by Indian version of cochin hand function scale | |
Devender Bairwa, M B Adarsh, K G Chengappa, V S Negi; Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
https://drive.google.com/file/d/1203n8j2VJxRg-KJKr_c0ZWNAFZdvacAA/view?usp=drive_open
Background: Hand dysfunction in Systemic Sclerosis (SSc) is common yet neglected. Cochin Hand Function scale (CHFS) is validated questionnaire consisting of 18 questions regarding day to day activities with a total possible score of 0-90. Considering differences in cultural and ethnical Background, all questions of CHFS may not be applicable to Indian population.
Objective: To assess the hand dysfunction in SSc patients using a modified CHFS (mCHFS) and an Indian version of CHFS (iCHFS) and to correlate it with disease burden.
Methodology: Females fulfilling ACR/EULAR 2013 classification criteria for SSc were enrolled. mCHFS was formulated by removing three questions (questions 7,9 and 10 in CHFS) not suitable in Indian setting (score=0-75) and iCHFS was formulated after replacing the three omitted questions with questions more related to the day to day activities in Indian setting. Clinical parameters like modified Rodnan skin score (MRSS) , finger to palm (FTP) distance, Finger to table (FTT) distance, oral aperture including vertical inter-incisional (VIID) and vertical inter-labial distance (VILD) were recorded. Quality of life was assessed using European quality of life 5 D (Eqol-5D) instrument. Damage was assessed using adjusted Scleroderma Clinical Trial Consortium Damage Index (ad-SCTC-DI).
Results: Thirty females with mean age of 41.33± 7.7 years were enrolled. The mean mCHFS score was 31.67±22.30. Ten patients had mild hand dysfunction (Group1; mCHFS score=0-17) and 20 patients had moderate to severe hand dysfunction (Group 2; mCHFS score= 18-75). Group 2 had statistically more severe skin thickening and reduced oral aperture. iCHFS (n=16) and mCHFS (n=30) showed significant positive correlation with FTP, MRSS, ad-SCTC-DI and EQOL 5D difficulty in usual activity score [Figure 1].
 | Figure 1: Correlation of clinical parameters with modified CHFS and indial version of CHFS. CHFS – Cochin han function scale; VIID-vertical interincisor distance; VILD-vertical inter-labial distance; FTP (F) –finger to palm distance in flexion; FTT- finger to table distance; MRSS – modified rondnan skin score; MHISS-mouth handicap in systemic sclerosis; E qol 5D vas –European qualiry of life 5 dimension visual analogue health scale; adjusted-SCTC-DI-scleroderma clinical trial consortium damage index Click here to view |
Conclusion: Hand dysfunction in systemic sclerosis is substantial. Indian version of CHFS correlated well with the disease burden. But this needs to be validated in a larger population with further modifications.
| PC0096: Non-adherence to treatment is an added risk for serious infection in lupus: result from a retrospective cohort analysis | |
Sanket Shah, K G Chengappa, M B Adarsh, Vir Singh Negi; Department of Clinical immunology, JIPMER, Puducherry, India
Background: Infections impact the disease course, therapeutic outcome, prognosis and socio-economic burden in Systemic Lupus Erythematosus (SLE). Data from high infection settings like India is sparse. Identifying the demography and determinants for infection can help us in better care of patients with SLE.
Objectives:
- To study the profile of infectious burden and its outcome in SLE.
- To identify determinants of serious infections.
Methods: Case records of 530 patients satisfying inclusion criteria were screened for serious infection, requiring hospitalization, surgical intervention or intravenous antibiotics. Demographic information, clinical and serological profile, disease activity, comorbidities, details of treatment including cumulative steroid dose, treatment non-adherence and flares were recorded to assess the determinants of serious infections using analytic statistics.
 | Figure 1 Click here to view |
Results: Out of 530 patients screened, 167 (31.50%) had 195 episodes of serious infections. Patients with serious infections had higher disease activity, major organ involvement, leucopenia, and higher steroid and immunosuppressant use (Table-1). Non-adherence led to a higher incidence of serious infections (53.8% vs 20.1%, p=0.01), of which 60% occurred within 6 months of drug default. The respiratory tract was the commonest site of infection. Higher numbers of infections were observed in the initial year of the treatment with predominant occurrence in months of May, July and September (Figure 1). Majority of the patients were in the induction phase of treatment and 24 (14.67%) patients died of infection.
Conclusions:
- Infection burden in SLE is significantly higher in India compared to the cohorts from the western world.
- Counselling of patients towards compliance and judicious use of immunosuppressant may reduce infection burden.
| PC0097: Prescribing pattern and efficacy of methotrexate in psoriatic arthritis – experience from Karnataka psoriatic arthritis cohort | |
Uma Karjigi, K Chanakya, S Chandrashekhara, K Sharath, H Vikram, V Rao, R Jois, M Daware, B Dharmanand, S Singhai, J Ramya, C Pramod, R Subramanian, A Kamath, D Chetana, Shivaprasad, Srinivas, Vikram R Jain, Harshini, B Pinto, K M Mahendranath, V Shobha Apollo Hospitals, St Johns Medical College Hospital, Chanre Rheumatology and Immunlogy Center, Columbia Asia Hospital, Manipal Hospitals, Vikarm Hospital, Bengaluru, Narayana Health city, Sakra Hospital, Bengaluru, Arthritis Specialty clinic, Hubli, SDM Medical College, Dharwad, JSS medical college, Apollo BGS Hospital, Mysore, Yenepoya Specialty Hospital, Mangalore, Karnataka, India
Introduction: Ideal therapy for psoriatic arthritis (PsA) should ameliorate all aspects of disease process viz both cutaneous and joint disease, peripheral & axial manifestations including dactylitis and enthesitis. Methotrexate is an invaluable anchor in the paradigm for PsA treatment.
Objectives: 1) To describe prescribing pattern of methotrexate and other csDMARDs used for management of PsA among rheumatologists practising in Karnataka, India. 2) To identify the efficacy and safety of methotrexate monotherapy.
 | Figure 1 Click here to view |
Methods: Treatment information was extracted from KPsAC (n=378) which is an ongoing cross sectional, non-interventional study across 17 rheumatology practicing centres in Karnataka. Standard disease activity outcome measures were used for assessing response to therapy (DAPSA, PASI, HAQ, MDA5).
Results: The prescribing pattern of csDMARDs used either alone or in combination is depicted in Figure 1a. Overall, 270 patients were on Methotrexate either alone or in combination with other csDMARDs, median disease duration being 62 months. Three csDMARD combination was used in only 10 patients, all on Background of methotrexate. TNFi were used in 5% of patients and all were anchored on methotrexate. Outcome measures for Mtx monotherapy(n=159) is shown in [Figure 1]b. No major safety concerns were noted.
Conclusion: Methotrexate remained the most frequently used csDMARD in KPsAC associated with low skin scores and low disability in three fourth of the patients when used as monotherapy.
| PC0098: Clinical and immunological profile of patients with idiopathic inflammatory myopathies in a tertiary care hospital | |
D Sai Kumar,M B Adarsh, K G Chengappa, V S Negi; Jawaharlal Nehru Institute of Post Graduate Medical Education and Research, Puducherry, India
Background: Idiopathic inflammatory myopathies (IIMs) are a group of rare and less understood autoimmune disease. The present study was designed to analyse demographic, clinical and serological characteristics and compare anti-synthetase syndrome with anti MDA-5 positive dermatomyositis (aMDA-5 DM).
Methodology: Out of 151 patients screened 116 with adequate records were included. Anti-cellular antibody status was available for 99 and line immune assay for 65 patients.
Results: Demography and clinical characteristics are shown in table 1 and autoantibody profile. Two patients had breast carcinoma, one each had carcinoma cervix and gastric adenocarcinoma. Anti MDA 5 antibody was more prevalent than anti-JO1 antibody (19.5% vs 15.2%) [Table 1].
 | Table 1: Demography of the cohort and comparison between antisynthetase syndrome and anti malondialdehyde-5 dermatomyositis positive dermatomyositis Click here to view |
Conclusions: Anti MDA5 antibody associated IIM is an under-recognized entity in our population. Given its poor prognosis, further characterization in a larger cohort is necessary.
| PC0099: Could apremilast be the first choice DMARD in combination with methotrexate in psoriasis/psoriatic arthritis? - Results: from KPsAC | |
Uma Karjigi, K Chanakya, S Chandrashekhara, K Sharath, H Vikram, V Rao, R Jois, M Daware, B Dharmanand, S Singhai, J Ramya, C Pramod, R Subramanian, A Kamath, D Chetana, Shivaprasad, Srinivas, Vikram R Jain, Harshini, B Pinto, K M Mahendranath, V Shobha Apollo Hospitals, St Johns Medical College Hospital, Chanre Rheumatology and Immunology Center, Columbia Asia Hospital, Manipal Hospitals, Vikram Hospital, Vikram Hospital, Narayana Health city, Sakra Hospital, Sakra Hospital, Aster CMI Hospital, Fortis Hospital, Mahaveer Jain Hospital, Sparsh Hospital, Bengaluru, Arthritis Specialty Clinic, Hubli, SDM Medical College, Dharwad, JSS medical college, Apollo BGS Hospital, Mysore, Yenepoya Specialty Hospital, Mangalore, Karnataka, India
Introduction: Over the last decade, treat-to-target (T2T) strategy has been in the forefront for psoriatic arthritis (PsA). As of now, there is no consensus on use of combination DMARDs in management of PsA.
Objectives: To compare efficacy of combination DMARDS in Karnataka Psoriatic Arthritis Cohort (KPsAC).
Methods: Data collected from 378 PsA patients included in multicentre, cross-sectional, observational study over a period of 6 months using a structured CRF. Efficacy and safety information was extracted for various combinations of csDMARDs. Standard outcome measures were used to compare the efficacy of the treatment groups.
Results: Patients were divided in to three groups based on combination csDMARDs used: Methotrexate(Mtx)+Leflunomide(Lef), Mtx+Sulfasalazine(SSz) and Mtx+Apremilast(Apr). Their characteristics along with outcome measures are depicted in [Table 1]. In Mtx+Apr group: remission or low disease activity was present in 46%, HAQ score of <0.5 was seen in 80%, and no patients had a PASI of > 10. PASI was significantly lower in the Mtx+Apr group compared to Mtx+Lef group (p=0.04). Combination of Mtx with Lef or SSz achieved remission or low disease activity in 37-44% however the HAQ score in both these groups remained high in three fourth patients.
 | Table 1: Characteristics and comparison of combination conventional, synthetic disease modifying anti rheumatoid drugs Click here to view |
Conclusions: Despite the differences between the groups and observational design of the study, skin disease seemed to be lesser in patients on Apremilast and MTX combination.
| PC0100: Comparative analysis of antinuclear antibody tests and their clinical significance in an Indian population | |
Samrat Bordoloi, Sharath Kumar1, S Nagaraj2, G C Yatish3, Sangita Sathyamurthy4, M P Kavitha, Jayaram Iyenger; Anand Diagnostic Laboratory,1Optima Arthritis and Rheumatology Clinic,2TRACC Clinic and Optima Arthritis and Rheumatology Clinic,3optima Arthritis and Rheumatology Clinic and Manipal Whitefield,4Columbia Asia Hospital Whitefield, Bengaluru, Karnataka, India
Background: Detection of Antinuclear antibody (ANA) is the hallmark of laboratory investigations in Connective Tissue Disorders (CTD). However, various methodologies used in both screening tests and specific antibody detection has led to a loss of consensus and poor reproducibility of Results.
Objectives:
- Compare Enzyme Immunoassay with Indirect Immunofluorescence as a screening test.
- Compare 3 different variants of Enzyme Immunoassays used as specific tests.
- Propose disease specific laboratory diagnostic algorithm based on clinical diagnosis.
Methods: 60 cases were recruited by Rheumatologists between April 2019 to July 2019. Two screening tests by Indirect Immunofluorescence (IFA) and Fluorescence Enzyme Immunoassay (CTD Screen) along with three specific antibodies tests a) Line Immunoassay (LIA) b) Enzyme Linked Immunosorbent Assay (ELISA) and c) Fluorescence enzyme Immunoassay (FEIA) were performed. For statistical analysis, clinically confirmed cases of Systemic Lupus Erythematosus (SLE), Sjogren's Syndrome (SjS), Undifferentiated Connective Tissue Disorder (UCTD), Mixed Connective Tissue Disorder (MCTD) were considered disease positive and Rheumatoid arthritis (and other autoimmune inflammatory disorders), as well as Fibromyalgia (and other musculoskeletal conditions), were considered disease negative.
Results: Sensitivity(78%) of CTD Screen was comparable to IFA(78%) and Specificity(73%), PPV(82%) and NPV(69%) was better than IFA(67%,78%,67%). U1RNP and Ro52 were positive irrespective of the diagnosis. CTD Screen was positive in 2 cases of SjS and 2 cases of UCTD which were negative on IFA. All of these cases were positive for SSA/Ro. CTD Screen was negative in 2 clinically proven cases of SLE with high antibody titer on IFA.
Discussion: In this pilot study CTD Screen appeared comparable to IFA as a screening test with better specificity, PPV and NPV. However, in cases of high antibody titer CTD Screen appeared to can give a false negative result. In the current study, U1RNP has shown non specific positivity.
 | Figure 1 Click here to view |
| PC0101: Indian patients perspective towards treatment in ankylosing spondylitis | |
Kamini Reddy, Asawari Raut, Pravin Patil1; Department of Cinical Pharmacy, Bharati Vidyapeeth deemed to be University, Pune, Maharashtra1Apex centre of rheumatology, Chennai, Tamil Nadu, India
Objective: Ankylosing Spondylitis (AS) is a chronic disease & requires long-term treatment. The objective was to understand the patient's perspective towards allopathic medications (modern medicine) and beliefs about complementary medications.
Methods: We conducted a cross-sectional study of 100 consecutive AS patients attending a rheumatology clinic over 3 months. A structured questionnaire was used to explore complementary medicines use, reasons for switching and patient's concern with allopathy medications.
Results: and Discussion: Fifty-six percent patients had tried complementary treatments such as ayurvedic/homoeopathy. In 44 of these patients, medications were prescribed by qualified BAMS/BHMS. Ayurvedic treatment was the preferred option (46%), followed by homoeopathy (25%) and 29% had tried both. Out of 56, 34(61%) patients reported switching to allopathy due to lack of efficacy and two patients stopped the medication due to side effects. A common misconception that 'allopathic medications cause side-effects in all AS patients' was observed in 54%. Thirty-two percent patients believed that doctors hide side-effects of medications. Around 60% believed that damage to internal organs like kidneys and liver occur in all AS patients taking allopathy. A quarter of patients thought gastric problems (acidity) would be the most common potential side effect. Only 39% of patients were willing to continue allopathy treatment for AS until remission is observed by the rheumatologist. About 28% believed that a certain type of diet aggravates their pain and 7% believe that adhering to the specific diet helps relieve pain.
Conclusion: We were able to identify various misconceptions about allopathic medications. Many patients are taking treatment from unregulated practitioners of complementary therapy. Patients are reluctant to take long term allopathic treatment due to fear of side effects. We need to find ways to demystify information regarding allopathy medications and address patient's concerns so that their health-seeking behaviour is appropriately corrected.
| PC0102: Ankylosing spondylitis in India- understanding the patient journey and impact on work productivity | |
Kamini Reddy1, Asawari Raut1, Pravin Patil2;
Department of Clinical Pharmacy, Bharati Vidyapeeth deemed to be University, 1Apex Centre of Rheumatology, Pune, Maharashtra, India
Background: Ankylosing spondylitis (AS) is a progressive inflammatory rheumatic disorder which mainly affects the spine. Worldwide there is an unacceptably long delay in diagnosis.
Objective: Objective was to study the patient’s journey from symptom onset and assess the impact of this illness on work productivity.
Methodology: We conducted a cross-sectional study of 100 consecutive AS patients attending rheumatology clinic. The study duration was 3 months. A structured questionnaire was used to collect patient reported information during face-to-face interview. Data on patient’s journey from symptom onset to diagnosis and impact on work productivity was collected.
Results and Discussion: Average delay in diagnosis was 4.52± 4.42 years and 58 patients had visited 3 different specialists before reaching to rheumatologist. First point of contact for most patients (60%) was an Orthopaedic. About 61 patients had received an incorrect diagnosis before reaching rheumatologist. Fifty-two patients were referred to the rheumatologist by doctors, 32 patients relied on google search, and 16 were referred by other patient/relatives. Out of 100, 81 patients reported work productivity being affected due to AS. Nine patients had to quit work. The work productivity is reduced by 50% in 72 patients. On an average, 4.5 days/month were skipped from work in 16% patients. Remaining patients had no option but to carry on with daily work in pain. Extra-Spinal involvement was seen in 43% patients, peripheral arthritis being the commonest manifestation (31%). Prevalence of extra-spinal manifestations was more common in males.
Conclusion: This is the first study from India attempting to measure the real impact of AS on work productivity. It also reveals the long diagnostic delay for AS and lack of patient referral pathway in India. Being the first point of contact in majority cases, the awareness at the level of orthopaedics should be intensified.
| PC0103: Prevalence and factors associated with anxiety and depression in ankylosing spondylitis | |
Kamini Reddy, Asawari Raut, Pravin Patil1; Department of Cinical Pharmacy, Bharati Vidyapeeth deemed to be University, Pune, Maharashtra,2Apex Centre of Rheumatology, Chennai, Tamil Nadu, India
Introduction: Aim was to determine the prevalence of anxiety and depression in Ankylosing Spondylitis (AS) patients and examine factors associated with it.
Methods: We conducted a cross-sectional study of 85 consecutive AS patients (mean age 35.63 years, 81% males) attending the rheumatology clinic. Two questionnaires (validated in English, Hindi and Marathi) PHQ-9 for depression and GAD-7for anxiety were used as a screening tool. Associations between GAD-7 scores and sociodemographic parameters, extra-spinal involvement (peripheral arthritis, eye inflammation, psoriasis and IBD), fear of medication's side effects and work productivity were assessed. We classified patients in 2 groups; 18-35young adult, >35 older adults.
Results: Out of 85, 62%(n=53) patients had anxiety and 73%(n= 62) had depression. Severe anxiety is more common in young adults [31.65±5.72 years] (p<0.05). χ2 (chi-square) test revealed extra spinal manifestations are associated with severe anxiety (75% with severe anxiety vs. 12% no anxiety). Work productivity due to AS is affected by 63 % in severe anxiety and by 22% in patients with no anxiety. Severe anxiety patients reported a high level of difficulty in performing daily activities whereas patients with no anxiety had no difficulty. Severe anxiety was associated with smoking, lack of exercise, shorter disease duration and having misconceptions that AS medications cause side effects in all patients but these findings weren't statistically significant.
Conclusion: To the best of our knowledge, this is the first report from India that describes the impact of AS on mental health. There is a high prevalence of anxiety and depression in AS patients. The risk factors for severe anxiety are young age and extra-spinal manifestations.
| PC0104: A randomised clinical trial of curcuma longa extract for treating symptoms and effusion-synovitis of knee osteoarthritis | |
Benny Antony, Zhiqiang Wang, Tania Winzenberg, Guoqi Cai, Laura Laslett, Dawn Aitken, Ingrid Hopper1, Rob Jones2, Changhai Ding, Jurgen Fripp3, Graeme Jones; Menzies Institute for Medical Research, University of Tasmania,3Department of Radiology, Royal Hobart Hospital, Hobart,1Drugs and Device Registry, Department of Epidemiology, Monash University, Melbourne,3Department of Biomedical Informatics and Image processing, CSIRO Health and Biosecurity, The University of Queensland, Brisbane, Australia
Background: Pharmacological therapies are limited, associated with off-target effects, and only modestly effective for pain in osteoarthritis (OA).
Objectives: The CurKOA trial aimed to compare the efficacy of Curcuma longa extract versus identical placebo for treating knee pain and effusion-synovitis on MRI.
Methods: In this double-blind trial, we randomised 70 participants with significant knee pain (>40 mm on VAS), knee OA (ACR criteria) and presence of a moderate amount of ultrasound-defined effusion/synovitis (>4 mm thickness in the suprapatellar region) on ultrasound to receive Curcuma longa extract (80% aqueous-based extract standardized to turmerosaccharides + 20% curcuminoids, 2x500 mg capsules/day) (n=36) or identical placebo (n=34) for 12 weeks.
Results: Of the 112 participants screened, 70 participants (age 61.8±8.6 years, 56% female) were randomised, and 68 (97%) completed the study.
There was a reduction in VAS knee pain in the treatment (-23.75[-29.78,-17.73]) and placebo (-14.64[-20.80,-8.47]) group, with a significant between-group difference of -9.11mm[-17.79,-0.44] [Figure 1]a equivalent to a standard effect size of 0.49. There was a no significant between-group difference (1.25 mL[-1.21,3.72]) in the MRI assessed effusion-synovitis volume.
 | Figure 1 Click here to view |
Significant changes favouring the treatment group were seen in WOMAC knee pain (between-group difference: -47.22[-81.22,-13.22]) [Figure 1b], WOMAC function (-112.26[-222.79,-1.74]) and OARSI-OMERACT treatment responders (63% treatment and 38% placebo [Risk Ratio=1.64(1.00,2.70)]. No significant change in T2 relaxation time of the femoral cartilage (-0.38 ms[-1.10,0.34]) was seen. The number of adverse events was similar in the treatment (n=18) and placebo (n=29) groups.
Conclusions: Curcuma longa extract significantly improved knee pain in an inflammatory phenotype of knee OA patients over 12 weeks compared to placebo. There was a moderate standard effect size of the treatment which appears greater than other conventional pharmacological therapies. In this short term study, Curcuma longa extract had no effect on knee structural measures assessed using MRI.
| PC0105: Regeneration of degenerative Joints with Regenerative injection therapies | |
Shashipal Sadana; Ortho Surgeon, Agra, Uttar Pradesh, India
Introduction: Management of degenerative joint disorders has always been a tricky and tedious job for Orthopaedicians. Most of the time degeneration of ligaments, tendons capsules, and other supporting soft tissues around joint leads to the altered biomechanics of joint and then eventual cartilage degeneration. It has become a clinical necessity to develop the novel therapeutic approaches to accelerate the regeneration of these tissues.
Objectives: The study aims to investigate the outcomes of 178 patients with unresolved chronic pain in different regions namely: Knee joint, Lower back, Hip joint, Shoulder joint, and Ankle joint.
 | Figure 1 Click here to view |
Methods: All of these patients underwent one or a combination of the following regenerative therapies: Chemical Regenerative Therapy, Platelet Rich Plasma Therapy (PRP), and Bone Marrow Aspirate Concentrate (BMAC). On average, 26 months following their last RIT (Regenerative Injection Therapy) session, patients were contacted and asked numerous questions. The questions included, but were not limited to, levels of pain, physical and psychological symptoms, and activities of daily living- before and after their last RIT.
Results: The Results: of this study showed that patients had a statistically significant decline in their levels of pain, stiffness, crunching sensation. It also showed improvements in their range of motion, with 82% showing improvements in walking ability, medication usage, anxiety, depression, and overall disability. Apart from that, 74% patients showed radiological improvements.
Conclusion: In this study, patients with unresolved degenerative joints, treated with RIT, showed reasonably good improvements in many clinically relevant parameters and overall quality of life. Degenerative disorders of joints are not merely referred to cartilage but surrounding soft tissues are also important. Regenerating stabilizing tissue of joints should always be considered in management.
| PC0106: Role of on-demand adalimumab in spondyloarthritis – can less be safe and effective? | |
Avik Medda, Rudra Prosad Goswami1, Mehebubar Rahman, Parasar Ghosh1, Rama Prosad Goswami; Department of Tropical Medicine, STM,1Department of Rheumatology, IPGME and R, Kolkata, West Bengal, India
Background: Spondyloarthritis (SpA) is a chronic inflammatory arthritis involving axial skeleton and peripheral joints. Non-steroidal anti-inflammatory drugs and disease modifying agents are moderately useful and pose significant toxicity on long-term use. TNFα inhibitors used in patients with active disease provide fast and often dramatic relief. However continuous use of TNFα inhibitors may inculcate into serious health hazards like infections, especially tuberculosis.
Objectives: To assess the effectiveness, adverse effects of on-demand adalimumab therapy in spondyloarthritis and consequent change in quality of life of the patients.
Methods: In this prospective observational study, we included patients with SpA, fulfilling New York criteria, 1984 with active disease (Bath AS disease activity score ≥ 4) and treated them with on-demand subcutaneous adalimumab (40mg) for 6 months. Outcome measures were attainment of AS disease activity index (ASDAS) low disease activity (<1.3) and ASDAS improvement; change in physical and mental component summaries (PCS and MCS) in SF-12.
Results: We included 30 patients with SpA (median age 36 years, interquartile range (IQR): 29-42; 60% males (18/30)). Baseline extra-articular disease activities were present in 22/30(73.33%). Baseline ASDAS was low in 3.3% (1/30), high 76.7% (23/30) and very high in 20% (6/30). Patients received median 5 injections (IQR 5-6). At the end of follow up after 6 months of treatment, inactive disease state was achieved in 13.3% (4/30), clinically significant improvement occurred in 50% (15/30) and major improvement occurred in 20% (6/30). PCS improved from 25.1±3.34 to 41.56±6.48 (p<0.0001) and MCS improved from 35.12±7.59 to 51.92±4.59 (p<0.0001). There is significant reduction in ESR (pre-treatment mean 60.07±20.7 and post-treatment mean 25.33±12.23, p<0.00001) and CRP (pre-treatment mean 23.78±14.65 and post-treatment mean 8.2±6.41, p<0.00001). There is only one (3.33%) incidence of tuberculosis. No incidence of non-infective adverse reactions.
Conclusions: On-demand adalimumab therapy is safe and effective in the treatment of spondyloarthritis.
| PC0107: Study of intestinal microbiota in juvenile idiopathic arthritis: A cross sectional observational study | |
Malika Yadav, Deonath Mahto, Anu Maheshwari, Ravinder Kaur, Rama Chaudhry, Kamal Kumar Singhal; Lady Hardinge Medical College, New Delhi, India
Background: Juvenile Idiopathic Arthritis (JIA) is the most common chronic rheumatic disease of childhood and there is emerging data that supports the presence of dysbiosis in the pathogenesis of this disease. However, there are limited studies and data on this concept, especially in India.
Objectives: To analyse the composition of fecal microbiome of children with JIA compared to healthy children and to see the correlation of fecal microbiota with disease activity.
Methods: Stool specimens from 30 patients with JIA aged 1-18 years and 60 healthy controls in the same age group were studied. None had any gastrointestinal symptom or history of antibiotic use in preceding 3 months. Relevant clinical data including lab investigations and disease activity status of patients was recorded. Stool specimens were analysed using different culture media and biochemical Methods: for aerobic and anaerobic organisms.
Results: In culture, among anaerobic organisms, growth of Bacteroides (p<0.01) and Lactobacillus (p 0.02) was found to be statistically significant and among aerobic organisms, growth of Klebsiella (p 0.01) was found to be statistically significant as compared to healthy children.
Clostridium perfringens was found in 2 (66.6%) patients of JIA with moderate disease activity and 2 (7.4%) patients with high disease activity. The difference between the two groups was statistically significant (p 0.03). No significant differences were found between growth of other bacteria with disease activity.
Conclusions: Our Results lend support to the hypothesis of gut dysbiosis in JIA patients, in terms of richness and compositional deviation from healthy subjects. However, no significant differences were instead found between active and inactive disease. This indicates that the gut microbiota profile is specific to the individuals with JIA, rather than disease activity status.
| PC0108: Study of cardiovascular risk profile in rheumatoid arthritis | |
Sumanth Madan, Rama Bhat, Rajagopal1, Akhya Sharma, Aditi; Departments of Internal Medicine and1Radiology, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
Background: The problem of increased cardiovascular disease (CVD) in patients with rheumatoid arthritis (RA) is well established.
Scoring systems in RA are an objective interpretation of said risk. The 2 scoring systems included were Extended Risk Score for Rheumatoid Arthritis (ERS- RA) and Atherosclerotic Cardiovascular disease (ASCVD) scores.
CIMT is a non-invasive method used to evaluate for subclinical atherosclerosis, opening opportunity for early intervention and diagnosis of CVD.
Objectives:
- To compare cardiovascular risk in rheumatoid arthritis using CV risk scores and correlating with disease activity
- To study CIMT and relation with CV risk scores
- To assess coexisting cardiovascular disease in rheumatoid arthritis.
Methods: All patients >40 years, satisfying EULAR guidelines were included. They underwent a Carotid ultrasound for CIMT. ASCVD and ERS RA, disease activity was calculated. The scoring systems were compared with CIMT to assess their performance.
Statistically, sample size was determined using kappa. Mean, median, standard deviation and Chi-squared tests were applied, p-value< 0.05 was considered significant.
Results: In this study, 106 patients were included with female predominance (82%), with maximum distribution in the age group 40-50 years. 62.3% were CIMT positive. There was no association between RF, DAS28, CDAI and CIMT, but RF had 80.3% sensitivity for a positive CIMT.
ASCVD had a strong positive predictive value for positive CIMT (p <0.001). Arbitrary cut off of 6.5 had superior sensitivity and specificity. Similarly, ERS-RA had a high sensitivity with a high negative predictive value (p<0.01). A cut off of 7.1 performed better than a cut off of 7.5. Longer duration of RA, translated to a positive CIMT. Comparison of ROC curve showed equal discriminatory ability for ERSRA and ASCVD.
Conclusions: RA was associated with a higher risk of cardiovascular events. ERS- RA performed as good as ASCVD as a CV risk score.
| PC0109: An observational study of ILD in various rheumatic diseases in tertiary care center | |
M Sri Anusha, T N Tamilselvam, R Ramesh, S Mythili; Department of Rheumatology, Madras Medical College, Chennai, Tamil Nadu, India
Background: ILD is one of the pulmonary complication of connective tissue disorders. Common rheumatic disease to cause ILD are SSc, MCTD, Sjogren's syndrome, RA and rarely SLE.
Objectives: In our study we focused on prevalence and clinical profile of ILD among various autoimmune rheumatic diseases.
Methods: This observational study was conducted at Rajiv Gandhi Government Hospital over 4 months between April – July 2019. Patients who are diagnosed as ILD with various autoimmune rheumatic diseases were included in this study.
Results: Total number of patients included in our study was 57 patients, of whom females were 53 (93%). In our study the most common rheumatic disease associated with ILD was Rheumatoid Arthritis - 25 (43.8 %) followed by Systemic Sclerosis - 13 (23%). Others conditions to cause ILD in descending order were SSc/Sjogren syndrome, Sjogren's syndrome, MCTD,UCTD, SSc/SLE overlap, SLE, Rhupus and unclassified vasculitis. Based on imaging (HRCT lungs) study NSIP (58%) was found to be the most common type of ILD, followed by UIP. Other rare types were LIP and BOOP. 30% were found to be asymptomatic(detected on imaging). Among the symptomatic patients, most common presentation was dyspnea followed by dry cough. Among 11 patients who were found to have PHT on cardiac evaluation, majority had systemic sclerosis. On spirometric evaluation, 90% showed restrictive pattern and 10% - combined pattern.
Conclusion: Some patients with autoimmune rheumatic diseases with ILD on evaluation remain asymptomatic in early stages of disease. Among few patients who had irreversible features, pulmonary hypertension played an important contribution.
| PC0110: Is the prevalence of SLE increasing? | |
Ram Raj Singh, Kimngan P Nguyen, Eric Y Yen, Ning Li; UCLA, Los Angeles, CA, USA
SLE prevalence in Indians has varied from 3 (95% CI, 0-7) and 20 (10-30) to 193 (141-258) per 100,000 in population surveys of 91,888 in northern-India in the late-1980s, of 56,541 across India during 2004-2010, and in a cohort of 23,305 Indians living in UK during 1999-2012, respectively (Malaviya, Singh… Kumar. Lupus 1993; Chopra, Ind J Rheumatol 2015; Rees, etal, Ann Rheum Dis 2016). Such wide variations in the prevalence of SLE have been reported from around the world, which is likely due to variabilities in study populations, case definitions, and case ascertainment sources. Most studies have been based on small numbers of prevalent cases in relatively smaller populations. Few studies have attempted to estimate SLE prevalence in large populations, which is an important unmet need.
We used national survey databases based on a multistage probability design to estimate the number of SLE patients across the entire US population. We calculated the cumulative percent change in prevalence (Chi-square test), modeled trends, and calculated the annual percent change using Joinpoint regression analysis.
The overall prevalence rate of SLE during 2001-2011 is 86.4/100,000 persons (95% CI, 69.6-103.3). Annual SLE prevalence increased 6% (95% CI, 2.5-9.5) each year from 2001 through 2011, with a cumulative increase of 59.4% during this period (72.2 in 2001 to 115.1 in 2011, p<0.0001). The period prevalence of SLE during 2001-2011 is 9-fold higher in females (137.5 [95% CI, 109.2-165.9]) than males (15.2 [95% CI, 8.0-22.4]).
The increasing trend in SLE prevalence in US during 2001-2011 may reflect an increased recognition of SLE, decreasing mortality, or actual increases in the prevalence. Such population-based studies are needed to estimate the demand-supply gap of physicians needed to care for lupus that requires intensive management and frequent follow-up to prevent its high premature mortality (Yen…Singh, Ann Intern Med 2017).
| PC0111: Monitoring the weekly progress of rheumatoid arthritis through 3 simple questions | |
S Chandrashekara, Bharath Raj, K R Anupama; Chanre Rheumatology and Immunology Centre and Research, Bengaluru, Karnataka, India
Introduction: DAS score and patients-derived measures are performed once in 3 months and they usually capture only cross-sectional measures. Moreover, the findings are not indicative of the entire time interval. The present study was to derive a tool to measure the progress of RA on weekly basis.
Materials and Methods: The prospective longitudinal study obtained answers for a self-reported questionnaire comprising of six questions every week for 14 weeks from a cohort of RA patients. The questions assessed pain on a scale of 0-10, qualitative response to exercise, feeling (improvement in clinical condition) and stiffness, pain and swelling in 16 joint zones/regions and self-care activities compared to preceding week. The demographic and clinical data were collected at baseline and assessed at 3rd and 6th months. DAS28CRP(3) was calculated and correlation of the demographic, baseline clinical characteristics and follow-up DAS28CRP(3) with questionnaire was verified. Agreement of response to questionnaire with relative change in DAS28CRP(3) was assessed by linear weighted kappa method.
Results: 25 RA patients with mean age 50.8±11.24 years answered the questionnaire. Male to female ratio was 1:11.5. The respondents' median (range) of RA duration was 45 (10-169) months, baseline DAS28CRP(3) 2.3 (1.19-5.08) and the follow-up DAS28CRP(3) 2.31 (1.5-4.71). Response to pain scale, feeling of improvement in clinical condition, pain and swelling in 16 joint zones/regions correlated with clinical measures used in routine RA practice. Feeling of clinical improvement, stiffness, pain in 16 zones/regions and self-care activities had fair agreement with changes as measured by DAS28CRP(3).
Conclusion: The use of the 3 parameters namely stiffness, pain in 16 zones/regions and self-care activities may assist in measuring the clinical, structural and functional aspects of RA disease process on weekly basis. Pain scale could be an additional measure. Validation of the questionnaire in large sample size with a simple application is ongoing.
| PC0112: A prospective study for determining the aetiology of hypokalemic paralysis in patients admitted in Government General Hospital, Guntur | |
Krishna Sagar Gajula, Narmada Nangadda, Mani Kishore Maddirala, Namratha Gogineni; Department of General Medicine, Guntur Medical College, Guntur, Andhra Pradesh, India
Aims and Objectives: To determine the underlying cause for hypokalemia in patients presenting with hypokalemic paralysis to Government General Hospital, Guntur. This helps determine the common underlying disorders which lead to hypokalemic paralysis in patients with such presentation.
Materials and Methods: A total of 20 patients who presented to GGH, Guntur with hypokalemic paralysis were evaluated. Blood and urine samples were collected immediately at the time of presentation. Treatment was initiated immediately with potassium supplements. We simultaneously evaluated for the underlying condition with the help of clinical history, examination and appropriate laboratory investigations which may have predisposed to hypokalemia.
Observations and Results: Of the total of 20 cases Distal Renal Tubular Acidosis (dRTA) was found to be the cause for hypokalemia in 13 (65%) cases, Hypokalemic Periodic Paralysis in 2 (10%) cases, Bartter's syndrome in 2 (10%) cases, Thyrotoxicosis leading to hypokalemia in 2 (10%) cases and Insulin excess in 1 (5%) case.
We further found out that Sjogren's Syndrome was the most common underlying cause for distal RTA. A total of 8 (40% of total cases; 61.5% of dRTA cases) cases were diagnosed as probable Sjogren's Syndrome.
Conclusions: In Conclusion, we found that the most common cause for hypokalemic paralysis in our patients is probable Sjogren's Syndrome (40% of cases). Therefore, extensive workup must be done in every case of hypokalemic paralysis to recognize the underlying condition to direct more specific treatment and prevent further complications.
| PC0113: Predicting response to methotrexate in children with juvenile idiopathic arthritis: Role of biomarkers | |
Narendra Kumar Bagri, Subhradip Karmakar1, Partha Haldar2, Rakesh Lodha, S K Kabra; Departments of Pediatrics and1Biochemistry, All India Institute of Medical Sciences,2Centre for Community Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, India
Background: Methotrexate is the initial choice among the disease-modifying anti-rheumatic drugs (DMARD) for juvenile idiopathic arthritis(JIA). However, nearly 40% of the subjects do not respond to conventional DMARDs like methotrexate and warrants additional therapy. Owing to inability to predict the response to methotrexate upfront; the decision to augment therapy is executed only after a failed trial of methotrexate. This approach exposes some children to ineffective drugs with accompanying side-effects, ongoing inflammation and joint damage. Thus, there is a need of predictive biomarkers and inflammatory cytokines and serum MRP 8/14 may be may potential candidates.
Objective: The aim of our study was to correlate the baseline values of inflammatory cytokines (ILs-2, 6, 12 and TNFα) and serum MRP 8/14 with response to methotrexate at 3 months follow-up in children with JIA.
Methods: We enrolled consecutive children with JIA and withdrew blood samples prior to initiation of methotrexate for biomarker estimation. The response to methotrexate was assessed using the definition of improvement (DOI) as per ACR. Children achieving ACR 50 were classified as responders, while non-responders were defined as those who failed to achieve ACR 30 at follow up. The data were analyzed using STATA 13.
Results: Out of the 69 children (36 boys) with JIA, 48 (69.5%) children met the responder criteria while 18 (26%) were classified as Non-responders. The baseline values [median (IQR)] of serum MRP 8/14, were significantly higher in responders as compared to non-responders [144.34 (88.54, 188.34) ng/ml vs 95.34 (76.54, 130.28) ng/ml; p = 0.047]. The subjects with higher baseline levels of serum MRP 8/14 had a higher odds of achieving ACR 50 response criteria [OR=1.01;95% CI (1.00-1.02)].
Conclusion: The baseline serum levels of MRP8/14 are significantly raised in the children achieving ACR50 and thus it may have prognostic value in predicting response to methotrexate.
| PC0114: Study of prevalence and pattern of haematological profile in patients of rheumatoid arthritis | |
Ganesh Koppad, Silas Nelson, Yashwant Bandole; Netaji Subhash Chandra Bose Govermenet Medical College, Jabalpur, Madhya Pradesh, India
Background: Among all the extra-articular manifestations of rheumatoid arthritis, haematological abnormalities are most characteristic particularly anemia.
Objectives: To study prevalence and pattern of haematological profile in patients of rheumatoid arthritis.
Methods: It is a case-control study involving 50 patients fulfilling inclusion criteria and satisfying the ACR criteria 2010 of Rheumatoid arthritis and 50 age & sex matched controls. DAS 28 score was used for establishing severity. Complete blood count and anaemia profile was done for both cases and controls.
Results: Sex ratio of females:males in this study is 4.55:1. Maximum cases were in the age group of 41-50 years (32%). The mean DAS 28 score for all 50 cases were 4.69±1.03 and p value <0.0001 which was highly significant compared to the control group. Mean Hb in cases was 10.6g/dl and in controls was 12.95 p<0.0001. Mean MCV in cases 78.62 fl in control group was 88.94 fL p<0.0001. Mean MCH in cases was 25.92 pg and in controls was 29.49 pg p<0.0001. Mean value of MCHC in case group was 30.96% and in controls was 33.73% p<0.0001. The prevalence of anemia in RA was 74% most common cause being anaemia of chronic disease (48.60%) followed by iron deficiency anemia (40.50%) and dimorphic anemia (10.80%). The mean DAS 28 score was higher in cases of anemia of chronic disease (5.64) compared to IDA (4.8). Mean TLC of case group was 10308.44±5363.41 while mean TLC of control group was 7650.44±1640.57 with a p value of <0.0001. Mean platelet count in cases was 2.94±0.13 and in controls was 2.61±0.56 p=0.05.
Conclusion: In patients with RA,serious haematological abnormalities were revealed.Therefore,patients with RA require regular haematological monitoring and if necessary,timely and adequate correction of any violations.
| PC0115: Anti-Jo-1 antisynthetase Syndrome often presents with only arthritis: A single center experience | |
Rajiv Ranjan Kumar, Saket Jha, Aadhaar Dhooria, GSRSNK Naidu, Susheel Kumar, Shefali Khanna Sharma, Aman Sharma, Sanjay Jain, Varun Dhir; PGIMER, Chandigarh, India
Background: Antisynthetase syndrome is characterized by a triad of myositis, arthritis and interstitial lung disease. Anti-Jo-1 is the most common associated autoantibody. This study planned to look at the presentation of the anti-Jo-1 antisynthetase syndrome, in a single Indian center.
Materials and Methods: This was a retrospective single-center study that included patients with anti-Jo-1 antisynthetase syndrome over 10 years.
Results: This study included 27 patients with the anti-Jo-1 antisynthetase syndrome; with a mean age of 40±9.2 years and female preponderance (F: M=4:1). At presentation, the characteristic triad was present in only 4 patients. A majority presented with the incomplete form; with two clinical features (of the triad) in 11 and a single feature (of the triad) being present in 12 patients at initial presentation. Seven presented only with polyarthritis –out of which six had been earlier diagnosed as rheumatoid arthritis. The time gap from the diagnosis of 'rheumatoid arthritis' to antisynthetase syndrome ranged from 3 to 20 years. In patients who had only arthritis in the beginning, there was a significantly longer delay to diagnosis of the antisynthetase syndrome, higher frequency of rheumatoid factor and lower frequency of anti-Ro-52. Overall, the outcome was good, with ECOG class 1 or 2 in most except two patients.
Conclusions: Anti-Jo-1 antisynthetase syndrome commonly presented as incomplete (not a triad); and often only with arthritis. These patients were diagnosed and treated as rheumatoid arthritis for many years, before a diagnosis of the antisynthetase syndrome. Being aware of this presentation may help in earlier diagnosis by actively searching for subtle clues.
| PC0116: Rheumatology clinic patients denies to adhere; what we know and do not know | |
Vivek Kattel, Sourabh Malviya; Medanta Superspeciality Hospital, Indore, Madhya Pradesh, India
Background: Autoimmune disease is alarming in developing world reason being high prevalence and inadequate point of care compared to the burden. Early diagnosis and adherence to therapy is key to success against rheumatologic disorders which still remains a current challenges in Indian subcontinent.
Objective: To explore the reason of poor adherence among common rheumatology patients.
Methods: It was a cohort study carried out for 52 weeks among 250 patients of common rheumatological disorders (Rheumatoid Arthritis (RA), axial spondyloarthropathy (axSpA), Primary Sjogrens' Syndrome (PSS) and Sytemic Lupus Erythematosis (SLE)) who presented first time in our clinic. A base line data about treatment history was obtained and the patient was followed up further.
Results: Only 5% (n=12) were adherent to treatment before they visited our clinic. The most common reason of non-adherence as coded by the 95% patients (n=238) were doctor's associated factor (not counselling about disease(84%), inadequate time give for consultation(73%), inadequate physical examination(67%), frequent visit(61%)) followed by drug associated factors (prolong treatment course(96%), side effects(41%), expensive then alternative medicine drugs(37%), inferior to drugs given by alternative medicine in symptom relief(34%)) and patient related factors (belief that allopathic is symptomatic treatment only(68%), financial constrain(21%), inadequate family support(18%), inaccessibility(15%)). Counsel by doctors focused on etiology(74%), disease severity if not treated(96%) and prolong treatment courses(31%). Only 36% doctors mentioned they perform musculoskeletal examination. Adherence was 62% for first two visit followed by 54% over 12 weeks and 37% over 24 weeks. Yearly adherence was maximum with SLE(24%) followed by PSS(17%), RA(14%) and axSpA(12%).
Conclusion: Structured, graded and customized counselling regarding the persistent nature of disease that demands lifelong disease modifying drugs with ample of time possibly can increase the adherence among autoimmune patients.
| PC0117: Widening demand-supply gap in rheumatic diseases: We must act now! | |
Ram Raj Singh1,2, Shivani Garg1,2;1The University of California, Los Angeles, California,2The University of Wisconsin, Madison, Wisconsin, USA
Rheumatic or musculoskeletal conditions comprise over 150 diseases, which are leading causes of morbidity and disability, giving rise to loss of work and income, and enormous healthcare expenditures. Based on a few reports on prevalence of rheumatic diseases and the projected 2020 population of India, we calculated the total number of patients with various rheumatic conditions, total annual visits, and the number of specialists needed to provide rheumatic diseases care (Table). According to these estimates, 26,770 physicians are needed to provide rheumatic disease care, but currently there are <1,000 rheumatologists in India. As a comparison, there are over 6,000 rheumatologists in the United States where >21% of adults (46.4 million) were found to have self-reported doctor-diagnosed arthritis in 2003-2005. This workforce supply of 1.7 rheumatologists per 100,000 rheumatic diseases patients was deemed short by 13% to meet the demand. It is projected that the number of persons with doctor-diagnosed arthritis will increase by ~40% to ~67 million by 2030 in the United States, leading to the demand-supply gap of 102%. A multi-pronged approach must be urgently adopted to address the rheumatology workforce shortfall. These approaches may involve broad-based awareness campaigns to showcase the need as well as the remarkable advances in the management of these diseases over the last two decades. There is also an urgent need to undertake curriculum redesign in undergraduate and postgraduate medical education, in partnership with medical college principals and deans. The use of innovative classroom models in place of traditional hierarchical classroom model will facilitate education and help in attracting and recruiting trainees to rheumatology. Lobbying for resources at the state and national level, efforts by rheumatology societies to increase funding and trainee positions, telemedicine, increasing nurse practitioner and physician assistant training, and outreach clinics will all help in narrowing the rheumatic disease demand-supply gap.
| PC0118: Quality of life in patients with juvenile idiopathic arthritis | |
Debabrata Sarkar, Tapas Kumar Sabui; Department of Pediatrics, R. G. Kar Medical College and Hospital, Kolkata, West Bengal, India
Introduction: Quality of life (QoL) assessment is particularly important in any chronic disease not only because of its chronicity but also for its effects on mental and social health. Most often these domains of health are ignored. Our Objectives were to assess quality of life in patients with different subtypes of JIA and to compare the quality of life between active phase and remission phase of the disease.
Methods: Within the age group of 5-16 years 26 patients with different subtypes of JIA were included. Juvenile arthritis Disease activity score (JADAS 27 score) used for disease activity assessment and Juvenile Arthritis Quality of Life Questionnaire (JAQQ) used for QoL assessment. Both scorings were done at first visit and after 6 months of treatment. Scores of first visit and follow up visit were compared. More JAQQ score indicates poor QoL.
Results: By this observational longitudinal study we found all 26 patients had high disease activity at first visit. There were no cases of psoriatic and unclassified arthritis. Mean JADAS-27 score and JAQQ score at first visit were 26.5538 ± 10.20714 and 4.51 ± 0.69 respectively. Physical domains were more affected than psychosocial domain. Polyarticular JIA had worst QoL than other subtypes. 65% patients achieved remission. With treatment significant improvement in QoL seen in remission phase in every subtypes of JIA (mean follow up JAQQ score: 2.00±0.748).
Conclusion: Poor QoL seen in patients with JIA irrespective of subtypes. Polyarticular JIA had worst QoL than others. Although only 65% patients achieved remission, with treatment significant improvement in QoL found in all major subtypes of JIA irrespective of their final disease activity. Major improvements occurred in physical domains compare to psychosocial domain. Interventions focusing physical and psychosocial rehabilitation may change the outcome further.
| PC0120: A study on clinical profiles of patients with spondyloarthritis at a tertiary care hospital in North India | |
Vijay Karthik Bhogaraju, Venkatesh Srinivasa Pai; Department of Internal Medicine, AIIMS, Rishikesh, Uttarakhand, India
Background: Since 1984 the diagnosis of Ankylosing spondylitis (AS) has been based upon the modified New York (mNY) criteria with mandatory presence of radiographic sacroiliitis, without which the diagnosis is not tenable. However, it may take years or decades for radiographic sacroiliitis to develop delaying the diagnosis for long periods.Assessment of SpondyloArthritis International Society (ASAS) classification criteria published in 2009 was a significant step towards this goal. ASAS criteria described an early stage of the disease where sacroiliitis was demonstrable only on MRI but not on standard radiograph.In this present scenario of newer approach to disease with ASAS criteria and limited studies done in the Indian setting on clinical profiling of patients with SpA, clinical profiling would help us understand the various entities of SpA
Aim: To study and assess the clinical profiles of patients with Spondyloarthritis.
Objectives: (1) To study clinical profiles as per clinical and laboratory entities in patients of spondyloarthritis with subgroup analysis of radiographic and non-radiographic spondyloarthritis.
(2) To study disease severity in patients of spondyloarthritis with subgroup analysis of radiographic and non-radiographic spondyloarthritis.
Methods: This is a prospective, non-interventional, observational, cross-sectional study at A.I.I.M.S, Rishikesh from The first of Jan 2018 – 30th of June 2019.
Recruitment of Patients: Patients diagnosed as SpA (ASAS 2009) by treating physician were recruited from the OPDs/ IPDs of General Medicine,Orthopedics.
Results: Out of 110 cases in our study,56 cases were analysed.The mean age of presentation in both the groups of Nr-ax spA and AS were 24.67 and 26.37 respectively. The mean BASDAI, ASDAS scores weresimilar in both the groups. (4.35 vs 4.56 (p-0.047) respectively. The mean BASMI scores were higher in AS group.
Conclusion: These both groups are likely to have similar clinical activity, however larges studies in Indian setting are required.
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