Rheumatology

PC0038: Reinforcing clinical skills into research: A survey of the musculoskeletal abnormalities in school going boys using PGALS in urban population

B Nithya, P Umapathy, J Mahesh; Department of Rheumatology, Division of Pediatric Rheumatology, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India

Background: pGALS (Pediatric Gait, Arms, Legs and Spine) – a simple quick musculoskeletal system assessment. Musculoskeletal pain affects between 10% and 20% of pediatric populations. The use of pGALS is aimed as a basic clinical skill to be used to identify various musculoskeletal pathologies.

Objective: To identify the musculoskeletal abnormalities using (pGALS) screening tool and to identify hypermobility using beighton's scoring in apparently healthy school going boys

Methods: A prospective cross-sectional study was conducted in school going boys aged between 7 to 17 years of age in Chennai enrolling 1547 children from 3 schools. History, general examination, screening questions were recorded in the proforma. Pgals was demonstrated in groups and was asked to perform and the Results were recorded in the screening Proforma and Results were analyzed.

Results: The pGALS examination was completed in 1547 boys, detecting Hypermobility (11.1%) Growing pain (4.6%), mechanical pains (12%). Overweight and obese children had higher incidence of pain or stiffness of joints (P value: 0.012). Maximum prevalence of hypermobility was in 7-9-year age group. We were able to identify one case of inflammatory (Enthesitis related arthritis) and one case of Non inflammatory pathology(Slipped Capitofemoral epiphysis)

Conclusion: pGALS is an Excellent screening tool for detection of musculoskeletal abnormalities on apparently healthy children.

PC0039: Symptom avoidance behavior of patients with very early rheumatoid arthritis

Akshay Saxena, Arup Mahapatra, Prasanta Padhan, Sakir Ahmed; Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India

Introduction: Patients with rheumatoid arthritis(RA) often present late especially in our country. All guidelines recommend initiation of disease modifying drugs as early as possible. Recognition of symptom avoidance behavior can help plan strategies to increase earlier presentation.

Objective: To identify the common symptom avoidance behavior in patients with very early RA

Methodology: All patients meeting the ACR/EULAR2010 criteria for RA and presenting to the hospital within 12 weeks of onset of symptoms were queried with a questionnaire about their symptom avoidance behavior. These were compared against age, gender, occupation and educational status using standard statistical tests

Results: 250 patients with mean(SD) age[median age : 49] with 88.4% females were included. The median time from onset of symptoms to first visit to a rheumatologist was 46 days. The first allopathic doctor visited was a non-rheumatologist in (147) 59%.The prevalence of common symptoms avoidance behavior is summarized in [Table 1]. Females were more likely to use self-administered splints(p=0.03), and to presented only when their daily activities were disrupted(p=0.005). Married persons were more likely to take self-prescribe drugs(p=0.04) and present only after their daily activities were disrupted (p=0.01). Employed persons were more likely to consider themselves too young to have arthritis(p=0.04) and to present only after disruption of daily activities(p=0.01). Paradoxically persons with higher education were more likely to consider themselves too young to have arthritis(p=<0.001) and to try to treat themselves by limiting their mobility or with the help of exercises(p=0.001).Also more educated persons were more likely to search for self-treatment on the internet(p=<0.001) and less likely to try to treat themselves by restricting their diet(p=0.01).

Table 1: Frequencies of common avoidance behaviours Click here to view

Conclusion: Even in this cohort of early RA, most patients did not visit rheumatologist first. Being female or married or employed was associated with presentation only after disruption of activities of daily living.

PC0040: Mixed connective tissue disorder: Clinical features and short-term follow-up of 27 patients

Shreyansh Deosale, Sakir Ahmed, S S Panda, Prasanta Padhan; Kalinga Institute of Medical Sciences, Bhubaneswar, Odisha, India

Background: Mixed connective tissue disorder(MCTD) is a well-defined entity with varied clinical manifestations. Though understanding of this disease has improved in the last decades, there is still limited data on MCTD.

Objective: To enumerate the clinical features at presentation and short term follow-up of a cohort of MCTD patients.

Methods: All patients with minimum 12 months follow-up at a tertiary care centre, and meeting Alarcon-Segovia classification criteria for MCTD were included. Uncontrolled diabetes and hypertension were excluded. Clinical features at diagnosis were noted, and current status was found out from patient interview.

Results: Of 27 MCTD patients, median age was 40(IQR:20.5) years with 23(88.46%) being female. Median time to presentation was two months(IQR:3.5). 6 patients were diagnosed at 6 months or more after onset of symptoms. Median follow up duration was 12months(IQR:1.25).Fever was the presenting symptom in 21 patients. All patients had arthralgia but only 8 had arthritis (most common affecting knee). Raynaud phenomenon(RP) was absent in 1 patient. Concomitant depression was diagnosed in 10 patients. 10 patients had swollen hands. 14 patients had symptomatic interstitial lung disease(ILD). Pulmonary arterial hypertension was present in 11 patients. One patient had myositis. All patients had anemia on presentation but no other cytopenia. Among autoantibodies, besides U1RNP positivity, five patients had Ro-52 positivity. All patients received steroids and hydroxychloroquine; 20 received mycophenolate.During the follow-up period, 3 patients had severe infections requiring hospitalization. 6 patients had relapse of disease that was managed with dose adjustments. Arthritis, and Raynaud are in remission in all patients. All patients with ILD had improvement in functional parameters.

Conclusion: Arthralgia, fever and RP are the major presenting features in our cohort. All patients were in clinical remission and seem to have good response to therapy on short term follow-up.

Table 1: Comparison with similar studies Click here to view

PC0041: Subacute psychiatric presentation-treat them or leave them?

AdamyaGupta, Archana Verma, V P Pandey; MGM Medical College and My Hospital, Indore, Madhya Pradesh, India

Introduction: Subacute presentation of psychiatric complaints like behavior abnormalities, cognitive dysfunction along with neurological complains like seizure,headache,fever with normal csf sugar with variable combinations of proteins and cells, with/without mri brain findings, should be highly suspected for treatable like herpes simplex encephalitis and autoimmune encephalitis.

Materials and Methods: 6 months study of 30 cases visiting my hospital with encephalitis along with psychiatric manifestations. exclusion of all bacterial encephalitis & tubercular encephalitis.

Observation: In our case series of 30 cases we found:73% behavior abnormalities,73% fever,46% seizures, 36% headache. On imaging 60% normal brain imaging, 40% meningeal enhancement.

0n csf examination, normal glucose 93%, normal protein 53%, normal cells 56%,those with increased cells(43%) had 100% lymphocytic predominance. EEG s/o diffuse cerebral dysfunction 9%.6% csf anti NMDA antibody positive, 12% csf anti VGKC antibody positive, out of which 3% positive for autoimmune antibodies in serum. Only 6-9% positive for csf HSVPCR.

Conclusion: Subacute psychiatric manifestations treated by acyclovir and steroids for HSV encephalitis and autoimmune encephalitis showed good response and fair recovery, even with normal csf and mri brain with negative HSVPCR and negative autoimmune encephalitis.

PC0042: Comparison between intraarticular and intramuscular depot methyl prednisolone injection in functional improvement of hand in patients suffering from early rheumatoid arthritis

Swarnali Mandal, Biswadip Ghosh¹, R N Halder² Deptartment of Physical Medicine and Rehabilitation, Murshidabad Medical College, Berhampore, Deptartments of¹Rheumatology and²Physical Medicine and Rehabilitation, IPGME and R, Kolkata, West Bengal, India

Aim: Primary aim in management of Rheumatoid Arthritis is to decrease inflammation and thereby, to prevent joint damage.

Objective: The objective of this study was to compare the improvement in hand function and disease activity among patients receiving intra-articular with intramuscular depot methyl prednisolone injections.

Design: A prospective cohort of 136 patients with RA were randomly allocated in two parallel groups intra-articular (IA) and intra-muscular (IM) who were given depot methyl prednisolone injection either IA or IM after assessment of wrist Range of motion (ROM), grip strength, Clinical disease activity index (CDAI) & Keitel functional test (KFT) scores on 1st visit and reassessed at 1 month and 3 months post injection.

Results: Wrist flexion and extension, power grip and all pinch grips of both hands have shown statistically significant improvement over time between any 2 visits, except right wrist extension, right and left lateral pinch grip did not have statistically significant improvement between 2nd and 3rd visits. CDAI scores reduced & KFT scores improved in persistent manner more in IM group over time between any 2 visits which is statistically significant. It is also seen that with decrease in disease activity there is improvement of functional ability in the subjects.

Conclusion: Intra-articular injections have sustained effects throughout the study period in ROM improvement and intramuscular injections have short-lived effects but are more effective in improving outcomes of functional status and disease activity. So, we think, IA corticosteroids should be used more frequently in early rheumatoid arthritis, to prevent joint damage.

PC0043: Anti beta-2 glycoprotein antibodies and not lupus anticoagulant associate with digital gangrene in systemic lupus erythematous

M Praveen Kumar, Liza Rajasekhar, D Phanikumar; Department of Clinical Immunology and Rheumatology, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India

Background: Previous studies ^[1,2] showed inconsistent association of antiphospholipid antibodies with digital gangrene (DG) in lupus patients.

Objective: Using all three tests for anti-phospholipid antibodies we aimed to assess their association with DG in lupus patients.

Methods: Lupus patients identified from lupus registry/ outpatients or inpatients, with an episode of DG after January 2008 and seen between to August 2018 to April 2019 were enrolled as cases. Age and sex matched lupus patients without digital gangrene were included as controls. Both were followed prospectively for 6 months. Clinical, laboratory variables at episode of DG and disease activity (SLEDAI) and damage index(SLICC-DI) at enrollment and last follow-up were recorded. Serum titers of anticardiolipin antibodies(aCL ab),beta-2 glycoprotein 1 antibodies (B2GPI ab) and lupus coagulant (LA) were done for all cases and controls.Statistical analysis done using chi-square test for categorical variable, Mann-Whitney test for continuous variable.

Results: Forty cases and 40 controls were enrolled and included in analysis. Median (IQR) disease duration before onset of DG was 8 months (1-37) months with median(IQR) duration till last follow-up 32 (24-64) months. Four cases had multiple episodes of DG. Cutaneous vasculitis Raynaud's phenomenon and mononeuritis multiplex (MNM) occurred more frequently in cases. Clinical and laboratory parameters are mentioned. Baseline aptt was higher in cases( p=0.005). The titres of anticardiolipin antibodies (aCL ab) and beta 2 glycoprotein (B2 GPI) were significantly higher among cases.

Conclusion: Digital gangrene occurs very early in course of lupus. It is clinically associated with Raynaud's phenomenon, cutaneous vasculitis and MNM.B2GPI ab and aCL antibodies but not LA associated with DG in lupus.

References

1. Jeffery RC, Narshi CB, Isenberg DA. Prevalence, serological features, response to treatment and outcome of critical peripheral ischaemia in a cohort of lupus patients. Rheumatology (Oxford) 2008;47:1379-83.
2. Rajasekhar L. Prevalence,serologicalfeatures,and outcome of critical peripheral ischemia in chort of lupus patients. Rheumatology 48:451-7.

PC0044: Treatment response to conventional DMARDs in psoriatic arthritis

Taral Parikh, Sapan Pandya, Rakesh Solanki; Vedanta Institute of Rheumatic diseases, Ahmadabad, Gujarat, India

Background: soriatic arthritis (PsA) is a heterogonous disease, so are the treatment options. DMARDs are indicated for multiple domains in PsA, however studies have shown conflicting Results: and so are the current guidelines.

Objective: This study was undertaken to study the efficacy of DMARDs in a cohort of PsA patients.

Methods: 80 patients, from 2012-2019, fulfilling the CASPAR criteria, were analysed. Treatment response was assessed as per the (psoriatic arthritis response criteria) PSARC criteria, at the first follow up visit. Secondary outcome assessed was improvement in (psoriatic arthritis skin index) PASI and dactylitis.

Results: (n=80) Male 66/ female 24. Mean age 42.1(±10.90), weight 68.9(±13.9), duration of PsA 3.83(±4.14). 28% -family history of psoriasis/PsA.Pattern of PsA:Polyarthritis 22 (30%), oligoarthritis 11(15%), axial 5 (7%), polyarticular +axial 13 (18%), oligoarticular +axial 17 (23.4%), axial + DIP 4 (5.4%)Baseline:PASI 3.39 (±5.86), SJC 4.73(±4.49), TJC 4.49(±7.65), dactylitis 18, physician global assessment (Ph GA) 3.28(±.0.79), patient global assessment of PsA (Pt GA) 3.49(±0.78). Mean duration of follow up 2.8(±1.35) months.Treatment response:42(67%) patients were started on NSAIDs, 4(6%) on prednisolone, 47(81.5%) on methotrexate, 17(32.5%) on sulfasalazine, 13(26.5%) on combination (MTx + Ssz) and 3(4%) on leflunomide.At first follow up visit 49 (61.25%) were PSARC responders.PASI reduced from 3.39(±5.86) to 1.58 (±4.20). 21 (26.2%) PASI 90%, 2 (2.5%) achieved PASI 75 and 3 (3.75%) PASI 50, dactylitis improved in 14 (17.5%) patients.

Conclusion:

After 3 months 61.25% patients were PSARC responders, with conventional DMARDs. There was improvement in other domains of PsA as well.

subtilis   1972 and  Bacillus coagulans  1969) as an adjunctive therapy in the treatment of rheumatoid arthritis: A prospective study">  PC0045: To evaluate the efficacy of probiotic- BIOTHERAPI® (combination of bacillus subtilis 1972 and bacillus coagulans 1969) as an adjunctive therapy in the treatment of rheumatoid arthritis: A prospective study

Arindam Nandy Roy, Yarram Ashok Kumar, Syeda Sana Fatima; Yashoda Hospitals, Secunderabad, Telangana, India

Background: The concept that microorganisms play a role in etiology, pathogenesis, and treatment of RA has been advanced over 100 years. There is good evidence that Probiotics reduce gut permeability and modulate immunity. Therefore, it might be speculated that Probiotics may down regulate the abnormal inflammatory response and alleviate the symptoms of RA.

Objective: To evaluate the effects of BIOTHERAPl® (Combination of Bacillus Subtilis 1972 and Bacillus Coagulans 1969) on disease activity and functional ability of RA patients when used in combination with pharmacological anti-rheumatic medications.

Methods: This was a prospective, randomized, single centre, two arm, open label trial to evaluate the efficacy of Probiotic supplement to standard of care (Biotherapi group) Vs standard of care alone (Nonbiotherapi group) in patients with active RA. 250 male and female subjects on RA treatment for at least 3 months were randomized to receive 1 capsule orally, twice daily containing Probiotics supplements. Examinations were performed at Day 0, day 45±3, and day 90± 3.The Primary outcome was to see the number of patients who shows improvement in DAS28-ESR score. Secondary outcome was to see the changes in CDAI, HAQ and physician global assessment. Student t test was applied to see the difference between these two groups.

Results: At day 90, 26% cases among Biotherapy and 4.7% cases among Nonbiotherapi achieved DAS-28 remission(p=0.001) whereas 29.2% cases VS 7.1% cases achieved CDAI remission respectively (p=0.001).Mean HAQ and Physician general assessment showed a significant fall of 44.0% and 69.1% among Biotherapi VS 12.7% and 42.3% among Nonbiotherapi (p=0.001) during the same period. Six subjects had Giddiness, leg swelling, constipation and abdominal bloating in the Biotherapi group.

Conclusion: Overall, this study proved that BIOTHERAPI® has significant effect on disease activity and functional ability of RA patients when used in combination with pharmacological anti-rheumatic medications.

PC0046: Myositis specific antibodies and muscle biopsy improve subclassification in ACR/EULAR IIM classification criteria in adults

M Irfan, L Rajasekhar, M Uppin, A Desai, D Phani Kumar, M Gavali; Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India

Background: The ACR/EULAR criteria capture the most frequent IIM subgroups but a subset remains unclassified.Myositis specific antibodies may improve the precision of classification.

Objectives: To describe clinical and serologic profile of idiopathic inflammatory myositis (IIM) patients and sub classifying them as per the ACR/EULAR criteria.

Methods: All consecutive patients diagnosed as IIM as per ACR/EULAR criteria between August 2018 to August 2019 were included. Myositis associated with other CTD were excluded.

Results: 27 patients were enrolled. Using criteria cut offs for with and without biopsy, 21 patients were definite and 6 probable IIM.Mean (SD) age was 42.4 (±11.9) years. Median (IQR) time to diagnosis was 7.8 (2-9) months.Mean MMT8 was 37/80. Muscle enzymes were elevated in 25, median(IQR) CPK 3513 (258-5099) IU/ml and LDH911 [76-293] IU/ml. 18 patients had skin manifestations:13 (9 adults) had DM specific rash (heliotrope, gottron sign/ gottron papule), 3 skin ulcers, 2 calcinosis, 1 digital gangrene.All 4 patients less than 18 years had classic DM rash.Of 27 patients, 9 were subclassified as DM, 4 JDM, 1 PM, 1 IMNM [Figure 1]. Twelve remained unclassified.Myositis Antibody profile (16 Antigen) was done in 20 patients (6 Mi2+,8 negative, Ro52 positive in 9). Muscle biopsy was done in 19 patients.

Figure 1 Click here to view

In patients without classic DM rash, MSA helped in classifying 4 as DM (Mi2 positive) and 2 as ASS (OJ, PL7 positive). Findings of Perifascicular atrophy (2) and Perivascular inflammation (1) sub classified further 3 patients as DM and probable DM. Three remained unclassified despite MSA or biopsy being done.

Conclusion: Mi2 is the most frequent MSA observed in this cohort. MSA and biopsy improved subclassificationfrequency from 47% to 87% in adult patients with IIM. These Results: should be validated in larger cohorts and included in future revisions of IIM criteria.

PC0047: A study of disease profile of adult and juvenile lupus patients at disease onset at tertiary care centre of northern India

Jeet Patel, Lalit Duggal, Neeeraj Jain, Mayank Gupta; Sir Gangaram Hospital, New Delhi, India

Objectives: to study disease profile of 100 adult and pediatric SLE patients at disease onset to find any significant difference in organ involvement in both cohorts.

Methods: 100 adult and 100 pediatric patients who classified SLE-SLICC criteria were recruited in study after taking consent at tertiary care centre in northern India. Demographic data and clinical profiles were recorded. Patients were asked direct questions related to different organ involvement (SLICC features and non-SLICC features like fatigue, Raynaud's Phenomenon etc.) at disease onset. Retrospective review of initial blood reports, including initial ANA, initial complements and anti-dsDNA were done. Fisher's test was used to find p value and p value less than 0.05 was taken as statistical significance.

Results: Out of 100 patients, females were 85% in adult cohort Vs 76% in pediatric cohort (with no statistical difference for sex distribution). Median delay in diagnosis was more with adult than pediatric cases. Lupus nephritis, mouth ulcers, NPSLE was common in pediatric SLE patients but lacked statistical significance. In adult cohort, there was significant association for fatigue, RP, and thrombosis. Average initial SLEDAI was higher in pediatric (16.59) than adult (12.9) SLE patients. Higher SLEDAI in Pediatric cases was might be due to weight based SLEDAI (CNS and lupus nephritis), even though the difference was not statistically significant. Results: suggest that pediatric and adult lupus patients differ in multiple aspects, and recognition of these differences helps in optimal treatment.

PC0048: Comparing performance of UK FRAX versus Indian FRAX score for guiding treatment of osteoporosis in South Asian population living in United Kingdom

Suvrat Arya, Samantha Smitten, Srinivasan Venkatachalam; Cannock and Wolverhampton Rheumatology Centre, United Kingdom

Background: Osteoporosis is described as a 'progressive systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture. 'Osteoporosis' denotes a value for BMD (bone mineral density) that is 2.5 SDs or more below the young adult mean value for women. The FRAX tool (www.shef.ac.uk/FRAX) computes the 10-year probability of hip fracture or a major osteoporotic fracture.

Objectives: To compare performance of UK (United Kingdom) FRAX versus Indian FRAX score for guiding treatment of Osteoporosis in 100 South Asian patients living in United Kingdom.

Methods: Retrospective data of 100 consecutive South Asian patients who underwent DEXA (dual energy X-ray absorptiometry) Scan at Cannock& Wolverhampton Rheumatology Centre between April to July 2019 was analysed.

Results: Mean age of patients was 64.5 ± 10.8 years. Female to male ratio was 79:21. Mean BMI of patients was 27.7 ±5.1 kg/m2. 45% patients had previous fragility fracture, 12% had history of parental hip fracture. Only 9% patients had rheumatoid arthritis. Mean neck BMD and T- score were 0.85 ± 0.15 gm/cm2 and -1.24 ± 1.22 respectively. Correlation between UK and Indian FRAX was 0.76. Assessing fracture risk by UK FRAX and Indian FRAX recommended treatment in 34 and 23 patients respectively. There were 23 patients which warranted treatment in accordance with both UK and Indian FRAX, 11 patients by UK FRAX alone and none by Indian FRAX alone.

Conclusion: Assessing fracture risk in South Asian population by UK FRAX tool leads to more patients getting treated as compared to using Indian FRAX tool. Indian FRAX tool should be used for patients of South Asian ethnicity in UK to avoid over treating osteoporosis in this population subset.

PC0049: Clinical features, management and follow-up of SLE patients seen at a rheumatology clinic

Anuj Shukla, Priyanka Gaur; Niruj Rheumatology Clinic, Ahmedabad, Gujarat, India

Background: Systemic Lupus Erythematosus (SLE) is a complex autoimmune disease characterized by antibodies to nuclear antigens with remitting-relapsing clinical course. It is a heterogenous disease with variable clinical presentation. Here we share the experience of managing these patients.

Objective: To share the experience of patients presenting with the clinical features of SLE.

Methods: Clinical data of patients with the diagnosis of SLE from July2016 to June2019 was collated using clinical notes and personal interviews. EULAR-ACR Classification criteria, 2019 was used for inclusion in the study as SLE.

Results: 55-patients were diagnosed as SLE with mean age of 31+11years and disease duration 29+10months. 4-patients (7%) had juvenile onset of SLE. Among clinical features: 69%(n=38) had arthritis, 62%(n=34) skin rash, 49%(n=27) fever, 38%(n=21) oral ulcers, 34%(n=19) lymphopenia, 15%(n=8) nephritis, 9%(n=5) myositis, 9%(n=5) hemolytic anemia and 9%(n=5) thrombocytopenia. 11%(n=6) had secondary Anti-phospholipid-antibody syndrome.Kidney biopsies were available in 6-patients. Complement levels were low in 67%(n=37) patients and Anti dsDNA was positive in 69%(n=38) patients. Baseline SLEDAI score was 12+6.Mean follow-up duration was 15+11months. Immuno-modulators used for induction were mycophenolate mofetil(MMF) 34%(n=19), azathioprine 25%(n=14), cyclophosphamide 14.5%(n=8) and rituximab 9%(n=5). Immuno-modulators used for maintenance were azathioprine 41%(n=23), MMF 36%(n=21), methotrexate 11%(n=6), tacrolimus 1.8%(n=1), MMF+tacrolimus 1.8%(n=1) and hydroxychloroquine(HCQ) alone 1.8%(n=1). Mean prednisolone dose used during maintenance is 5+5mg/day.Out of 55-patients, 34(62%) are in remission (on drugs, n=27; off steroid, n=6; off treatment, n=1), 7(13%) have active grumbling disease, 13(24%) patients are on induction-phase and 1(1.8%) patient expired. 2-patients had pregnancy with successful outcome. Complications were infections 5%(n=3), hyperpigmentation 5%(n=3), osteonecrosis of hip 3.6%(n=2) and glucocorticoid-induced-osteoporosis 1.8%(n=1).

Conclusion: Thus, we collated data of patients with the diagnosis of SLE for better understanding of their clinical presentation, management and outcome. This will help in future to better formulate this cohort and plan a focused research topic.

PC0050: Epidemiology and outcome of chronic nonhealing vasculitic ulcers: A retrospective study from tertiary care centre

C Saranya¹, C Balaji¹, M Vignesh¹, R Shanmugesh², R Ramu², Mukaaram³, R Shankar³, S Rajeswari^{4 1}Assistant Professor,²Senior resident,³Medical officer,⁴Professor and Head

Background: Cutaneous vasculitis due to primary or secondary vasculitis can manifest as chronic nonhealing ulcers.

Objective: To study the epidemiology and outcome of patients with chronic nonhealing vasculitic ulcer.

Methods: A retrospective medical record review study was done over a period of 1 year in our centre. We included patients with chronic nonhealing ulcer for more than 3 months with biopsy proven vasculitis. Patients with poor compliance and irregular follow up were excluded. We analyzed the clinical, laboratory parameters, treatment and outcome of these patients.

Results: 12 patients were analyzed, of which 25% were males and 75% were females. Mean age of the patients was 45+8.6 years. The mean duration of ulcers was 1.8years. 50% had unilateral leg ulcers and 50% had bilateral leg ulcers. Most common systemic involvement was musculoskeletal system(83.3%). The final diagnoses in our cohort were connective tissue diseases(CTDs) associated secondary vasculitis(50%), primary vasculitis(25%) and unclassified vasculitis(25%). Among the patients with CTDs associated vasculitis, 50% had Systemic lupus erythematosus, 33.3% had Rheumatoid arthritis and 8.3% had primary Sjogren's syndrome. Cutaneous manifestations other than ulcers include palpable purpura(25%) and digital gangrene(16.6%). Most common laboratory findings were anemia(75%) and leukocytosis(66.6%). 83.3% had bacterial superinfection of ulcer, of which 70% had polymicrobial infection. Most common organisms cultured were pseudomonas(60%), klebsiella(40%) and enterococcus(30%). Common comorbidities associated were hypothyroidism(25%), hypertension(25%), hyperthyroidism(8.3%) and gout(8.3%). Cyclophosphamide (66.6%) and mycophenolate mofetil (33.3%) were used as the immunosuppressive therapy in our cohort. 16.6% patients received surgical treatment(skin grafting) and 8.3% received platelet rich fibrin therapy. 66.6% patients showed complete resolution of ulcer following immunosuppression, while 25% had recurrence inspite of therapy. One patient died due to sepsis and high disease activity.

Conclusion: We analyzed the epidemiology of chronic nonhealing vasculitic ulcers. CTDs associated vasculitic ulcer was the most common cause and most amenable to treatment.

PC0051: Factors influencing the damage and quality of life of patients with rheumatoid arthritis for more than five years, including adherence to treatment

Ram Krishna Giri, S Chandrashekara, C Renuka¹, K R Anupama, Sani-E-Zehra, Veena Ramachandran, J Prakruthi; ChanRe Rheumatology and Immunology Centre and Research,¹ChanRe Diagnostic Centre, Bengaluru, Karnataka, India

Background: Rheumatoid arthritis in long term causes joints damages and impairs the quality of life. The low compliance to drug is often attributed as one of the detrimental factors. The present study analyzed the factors influencing the cumulative damage and quality of life (QoL), including medication adherence.

Materials and Methods: Cross-sectional retrospective cohort study considered RA patients undergoing treatment for more than 5 years. Demographic details including. disease duration at presentation (DOP) and total disease duration (TDD) were collected from patient records. At the point of recruitment, patients' cumulative damages were assessed using Rheumatoid Arthritis Articular Damage (RAAD) score, QoL was assessed using the Indian Health Assessment Questionnaire (HAQ) Disability Index and Short Form of Arthritis Impact Measurement Scales 2 (AIMS2-SF). Medication adherence was evaluated using 8-Item Morisky Medication Adherence Scale (MMAS-8).

Results: 579 patients, (females 543, males 36) , mean age of 57 years and total duration of disease of 151 months. RAAD score moderately correlated (P <0.01) with DOP and TDD, while age and follow-up duration demonstrated week correlation (P <0.01) (Table 1). The Indian HAQ DI correlated weakly with age (P <0.01), gender (P <0.05), DOP and TDD (P <0.01); however, MMAS-8 had weak inverse correlation (P <0.01). AIMS2-SF normalized physical score correlated weakly with age, TDD (P <0.01), and DOP (P <0.05). AIMS2-SF normalized affect score was inversely weakly correlated (P <0.01) with age. AIMS2-SF normalized social interaction score was weakly correlated (P< 0.05) with follow-up duration.

Conclusion: Age, gender, duration of disease at presentation and total duration of disease influence the cumulative damage and QoL in RA patients. Medication non-adherence influenced the disability but had no significant influence on the damage. The study emphasizes the fact that early intervention is the key.

PC0052: Factors predicting long-term outcome in patients with undifferentiated connective tissue disease

J Prakruthi, S Chandrashekara, C Renuka¹, K R Anupama; ChanRe Rheumatology and Immunology Centre and Research,¹ChanRe Diagnostic Centre, Bengaluru, Karnataka, India

Background: Undifferentiated connective tissue diseases (UCTD) include a wide variety of conditions that share clinical features and autoantibody profile with other connective tissue diseases, but do not fulfil their criteria. However, it is difficult to predict the duration of treatment and involvement of other organs and the need for regular medications.

Objective: To verify the factors associated with complications or those requiring additional DMARD treatment in patient with UCTD.

Materials and Methods: The longitudinal retrospective study considered an interim analysis of 57 patients (48 females and 9 males) diagnosed with UCTD during the period June 2004 and January 2015. The corresponding mean±sd age and median (range) total disease duration noted for the subjects were 48.4±13.36 yrs and 82 (29-300) months. Demographic, laboratory and clinical parameters were extracted at baseline and last follow-up visit. The patients' outcome was grouped into group 1, who either discontinued medications or could be maintained only with hydroxychloroquine and group 2 who developed into definable CTD or complication or required higher DMARD. Comparison and univariate and multivariate logistic regression were performed to assess the factors associated with disease complications p <0.05 was considered statistically significant.

Results: Twenty were in group 1, 37 in group 2. Group 2 had significantly increased ESR (48 (9-120) vs. 27.5 (10-70)) and follow-up duration (71 months (26-179) vs. 50 (25-179)) than less severe UCTD patients. Logistic regression showed that NLR, ESR, and presence of any autoantibody at presentation were associated with increased likelihood of complications in UCTD patients by 17%, 4% and 41% respectively.

Conclusion: Female gender, NLR, high inflammation parameters like ESR, and presence of any autoantibodies at presentation predicts the patients diagnosed to be UCTD for future organ involvement. Further studies with large sample size and individual autoantibody markers are underway.

PC0053: Factors predicting the pattern of outcome of rheumatoid arthritis: A more than five-year follow-up study

Veena Ramachandran, S Chandrashekara, C Renuka, Ramya Rao, Ramkrishna Giri; ChanRe Rheumatology and Immunology Centre and Research, Bengaluru, Karnataka, India

Background: With regard to long-term outcome of rheumatoid arthritis (RA), patients follow three classical patterns. Type 1: patients who attain remission can be either maintained on minimum or no DMARDs, type 2: patients having an undulant course of remission and relapse, and need to switch over to alternate DMARD, and type 3: patients who have an aggressive course and remission is hardly achieved. The present study has investigated the factors influencing the final outcome.

Materials and Methods: Seven hundred and fifty RA patients fulfilling the 2010 ACR/EULAR criteria were recruited. The study was approved by the institutional ethics committee and informed consent was obtained from all patients. The demographic details and duration of illness at diagnosis, duration of first symptom and the treatment given were retrieved from their records. The laboratory parameters obtained at the recruitment phase and at fixed intervals were RF, ANA, ESR, CRP, and NLR. The DAS scores at the specified intervals were also obtained, and average DAS scores were calculated. Interim analysis of the data of first 84 patients was done. P<0.05 was considered for statistical significance. One-way ANOVA was performed.

Results: Eighty-four patients (mean age:54.75±12.76) with mean duration of illness(13.26±6.92) and mean duration of first symptom (5.49±6.04) were grouped as type 1(n=22, 26.2%), 2(n=22, 26.2%)and 3(n=32, 38.1%) based on the average DAS scores. 8(9.5%) were excluded from the study. Age (P<0.001), duration of first symptom (P<0.005), NLR (P<0.001) rheumatoid factor (P<0.001) at presentation, total duration of disease (P<0.021), CRP (P<0.024) and ESR (P<0.042) were found to be significant with regard to the disease outcome.

Conclusion: Age, duration of first symptom, CRP, NLR, ESR, and rheumatoid factors at presentation may assist in predicting the probable course of RA.

Keywords: Disease activity score, neutrophil to lymphocyte ratio, rheumatoid arthritis

PC0054: The clinical profile of macrophage activation syndrome secondary to systemic lupus erythematosus

Soumya Dey, Basil Paul, Dipendranath Ghosh, Alakendu Ghosh, Parasar Ghosh, Pradyot Sinhamahapatra; IPGMER and SSKM Hospital, Kolkata, West Bengal, India

Objective: To investigate the clinical profile of macrophage activation syndrome (MAS) associated with systemic lupus erythematosus (SLE).

Methods: The clinical profile of 10 patients with SLE associated MAS diagnosed in the Department of Rheumatology, IPGMER and SSKM Hospital, Kolkata from September 2018 to August 2019 was retrospectively analyzed.

Results: Seven patients were female and three were male. There were 3 cases of Juvenile SLE. The average age was 22.2 years. The average disease duration of SLE before the occurrence of MAS was 2.9 years, and the average SLE disease activity index (SLEDAI) was 15.6. The mean complement levels at the time of onset of MAS was 49.5 and 8 for C3 and C4 respectively. Six out of 10 patients had a major organ involvement secondary to SLE, nephritis being the most common. All patients developed fever, cytopenias, elevated triglycerides, hyperferritinemia, transaminitis and elevated LDH. Splenomegaly was found in 9 patients. Six patients developed coagulopathy. Only one patient had a bone marrow picture suggestive of hemophagocytosis. Glucocorticoids were used in all patients, in the form of initial intravenous pulse Methylprednisolone therapy for 3-5 days followed by oral Prednisolone at 1 mg/kg/day. All ten patients responded to therapy and had improvement in clinical as well as laboratory parameters. There was no mortality.

Conclusion: In patients with SLE, MAS was most commonly seen in young females with active disease. Fever and splenomegaly were the most consistent symptom and examination finding respectively. Consistent lab findings included cytopenias, elevated triglycerides, hyperferritinemia, transaminitis and elevated LDH, with low complements. Although the typical bone marrow picture of hemophagocytosis was found in only one patient, early therapy with high dose glucocorticoids was instituted on the basis of initial clinical suspicion and fulfillment of the other lab criteria for diagnosis, leading to improved clinical outcomes in all the patients.

PC0055: Interstitial lung disease in sjogrens syndrome: A descriptive analysis of a retrospective cohort from a tertiary centre

Prathyusha Manikuppam, Aswin Nair, G Arvind, Ashish Jacob Mathew, Ruchika Goel, DebashishDanda, John Mathew; CMC, Vellore, Tamil Nadu, India

Introduction: Pulmonary disease affects 10% to 20% of patients with Sjogren's syndrome.

Aim: To describe the different characteristics of patients with interstitial lung disease in Sjogren's syndrome.

Patients and Methods: A retrospective chart review of Sjogren's patients with interstitial lung disease was done using hospital records between the years 2014 to 2019.

Results: and Conclusion: We observed that there were 30 Sjogren's patients with interstitial lung disease.Age of onset was in range of 40 to 60 years of age. There were 27 females and 3 males.21 of 30 patients had Anti- SSA positivity. Anti – SSB was done for 26 patients , 17 patients had positive antibodies.The following patterns of ILD were observed:NSIP – 14 patients, LIP – 4 patients, UIP – 3 patients, Early ILD – 3 patients, Undifferentiated pattern – 4 patients. 26 patients received 0.5mg/kg prednisolone equivalent at the time of diagnosis except in 4 patients where 1mg/kg was used. This was for vasculitis in 2, immune mediated neuropathy in 1, and BOOP in 1.Mycophenolate mofetil was started in 24 out of the 30 patients as first steroid sparing agent. One patient developed immune mediated neuropathy when on azathioprine , so 4 doses of pulse cyclophosphamide were given followed by Mycophenolate mofetil.One patient was given 4 doses of pulse cyclophosphamide followed by MMF.Two patients received Rituximab , one received in view of leucocytoclastic vasculitis and ILD NSIP , one received for arthritis and ILD NSIP followed up with MMF.7 patients received azathioprine as first steroid sparing agent, 1 patient received azathioprine after he had symptomatic arthritis on MMF.We will be describing the response of ILD to different second line agents , MMF,azathioprine, and rituximab.

PC0056: Profile of antisynthetase syndrome in a tertiary care centre

K S Sreejitha, D Phani Kumar, Meghna Gavali, Liza Rajasekharl; NIMS, Chennai, Tamil Nadu, India

Introduction: Antisynthetase syndrome (ASS) is characterized by antibodies against different aminoacyl-tRNA synthetases and presents with arthritis, myositis,and interstitial lung disease (ILD). Raynaud's phenomenon,mechanic's hands, and fever are other findings in ASS.

Materials and Methods: Patients with ASS were identified based on diagnostic criteria proposed by Connors et al.^[1] 2014 to 2019.Patients' demographic details, clinical features, autoantibody profile, treatment & outcomes were noted.

Results: There were a total of 23 patients and 18 of them were females. The median age was 44 years(37.5-53) and disease duration 18 months(12-39). The most common presenting complaint was arthritis (18/23) followed by fever (14/23).On examination, mechanics hand was found in 12,myositis in 10 and Raynaud's in 4 patients. 18 patients had ILD, with 17 having NSIP and 1 with UIP pattern on HRCT chest.PFT values were available at baseline for 9 patients (mean FVC 65± 3.6%, mean FEV1/FVC 0.94). Anti Jo1 antibodies were the commonest(14/23) followed by PL-7 (5/23),PL-12 (3/23) and EJ (1/23).Ro 52 was positive in 10 patients and ANA in 11,the commonest being cytoplasmic pattern. The combination of arthritis, myositis and ILD was present only in 6 .In the non Jo1 group, all patients had ILD (9/9) and only 2/9 had myositis, compared to 9/14 and 8/14 respectively in Jo1 group (p=0.06) .In a median follow-up of 26 months(4-24) ,2/23 expired and the rest have good response to immunosuppressive treatment.

Conclusion: ASS is more common in females.Arthritis was the most common initial manifestation. Arthritis and myositis are more common among Jo1 positive patients.ILD is more common than myositis in nonJo1 patientsNSIP pattern in HRCT is the most common type of ILD seen.

Reference

1. Connors GR, Christopher-Stine L, Oddis CV, Danoff SK. Interstitial lung disease associated with the idiopathic inflammatory myopathies: What progress has been made in the past 35 years? Chest 2010;138:1464-74.

PC0057: A single centre study to assess therapeutic outcomes in patients with idiopathic inflammatory myositis on CRD Pune Indian HAQ

Nachiket Kulkarni, Anuradha Venugopalan, Manjit Saluja, Arvind Chopra; Centre for Rheumatic Diseases, Pune, Maharashtra, India

Objectives: To assess therapeutic outcome In patients with Idiopathic Inflammatory Myositis on CRD Pune Indian HAQ.

Materials and Methods: Data from 108 patients of connective tissue disorders (CTD) with dominant Inflammatory Myopathy(IM) evaluated in CRD with patient database since 1996. Data obtained for period 2004-2016. Center for Rheumatic Diseases (CRD) Pune developed a modified version of the Health Assessment Questionnaire(HAQ) catering customs, lifestyle of the Indian community (CRDHAQ). It was recorded in all patients. It is a validated instrument and available in many Indian languages. Physician Global recorded on Likert scale of five-category response with an ascending score ranging from 1 to 5 (asymptomatic to severe). Patient Global health recorded on horizontal 100-mm line (VAS), anchored at 0 for 'extremely poor health' and 100 for 'perfect health. Indices recorded at first visit, on 6 monthly visit and at 1 year.

Results: Dermatomyositis (DM), Polymyositis (PM) and Overlap Myositis (OCTD) noted in 36, 28 & 41 patients respectively. All Patients received glucocorticoids. Methotrexate prescribed in (92%), Azathioprine in (28%), hydroxychloroquine in (88%) Mycophenolate Mofetil in (6%). IVIG in 2 patients for acute IIM with interstitial pneumonitis. Rituximab in 4 resistant cases; all responding favorably.The average CRDHAQ scores at first visit, 6th month and 1 year for DM, OM & OCTD were( 10, 18 & 16), (2, 10, 4) and (2, 8, 2) respectively. The Physician Global for these groups at first visit, 6th month and 1 year were (moderate, severe, moderate), (mild, moderate, mild), (mild, mild, mild) respectively. The Patient Global Scores were (70, 80, 70), (40, 50, 30), (20, 30, 10) respectively in these three visits.

Conclusion: The therapeutic outcome of IIM in current cohort was favorable. CRD Pune Indian HAQ could be used as an easy office based patient centric tool for monitoring response to therapy in patient with IIM.

[TAG:2]PC0058: Clinical, laboratory profile and treatment response of a South Asian sarcoid cohort from a tertiary centre: A retrospective study [/TAG:2]

Silas Vinay Vidyadhar Rao, Rahul Sahu, Aswin Nair, G Arvind, Debashish Danda, John Mathew; Department of Clinical Immunology and Rheumatology, CMC, Vellore, Tamil Nadu, India

Background: Sarcoidosis is a heterogeneous multisystem inflammatory disease of unknown etiology.

Objectives: To study the epidemiological, clinical, laboratory and histopathological profile of patients diagnosed to have sarcoidosis.To assess the outcome and treatment response of these patients on follow up.

Methods: Patients diagnosed as Sarcoidosis under the department of Clinical Immunology and Rheumatology at CMC, Vellore were retrospectively chosen from the institutional electronic medical records. Demographic profile, clinical features, laboratory parameters, management and outcome of these patients categorized definite or probable sarcoidosis were analysed.STUDY DURATION: 10 yrs –June 2009 to June 2019

Results: A total of 181 patients with sarcoidosis were identified. Mean age of our cohort of patients was 43.8 yrs (SD+-11.19); 62(34.3%) were male and 119(65.7%) were female. Angiotensin Converting Enzyme (ACE) levels were elevated in 80(44.1%) patients. 103 (56.9%) patients underwent biopsy, of which 93 (90.3 %) had non caseating granulomas. HRCT was done in 164(90.6%), with findings as mentioned in [Table: 1]. 11(6 %) patients each had hepatic and skin granulomas, cardiac involvement was noticed in 7(3.8%), and 2(1.1%) had vasculitis.In this study the different second line immunosuppressive agents used and their response will be described. We will also be looking at the total steroid dosage and the duration of use.

Table 1 Click here to view

Conclusion: This is the largest South Asian cohort till date to the best of our search. The male to female ratio was 1:2. Among those patients with a definitive diagnosis of sarcoidosis less than half patients had elevated ACE levels.

PC0059: Diffuse alveolar haemorrhage in systemic lupus erythematosus: A single centre retrospective study

Saurabh Chahande, Aswin Nair, G Arvind, Ruchika Goel, Ashish Mathew, Debashish Danda, John Mathew; Christian Medical College, Vellore, Tamil Nadu, India

Introduction: Diffuse Alveolar haemorrhage (DAH) is a rare, but serious manifestation of SLE. It may occur early or late in disease evolution.

Aim: Reporting our experience with Diffuse Alveolar Haemorrhage in patients with Systemic Lupus Erythematosus.

Patients and Methods: Records of SLE patients admitted between years 2005 and 2019 were reviewed. 18 patients of SLE were admitted with episodes of DAH. For all study subjects, the demographic, clinical, laboratory, therapeutic and outcome data were Abstracted.

Results and Conclusion: All 18 patients were females. Their age ranged from 14 to 50 years and disease duration ranged from 3 to 84 months. All our patients presented with pulmonary infiltrates and hemoglobin drop. 4 out of 18 patients had Central Nervous System involvement. 12 out of 18 patients had renal involvement which was the most common extra pulmonary SLE manifestation. 8 out of 18 patients were admitted in ICU. Average stay of patient in hospital ranged from 7 to 32 days. 6 out of 18 patients had APS serology positivity (4 lupus anticoagulant, 1 anti ps/pt, 1 beta-2 glycoprotein, 1 anticardiolipin ). All patient had low C3 levels. Initial treatment included intravenous methylprednisolone in 16 out of 18 patients. Plasmapheresis in 8 patients, Cyclophosphamide was given in 4 patients, Rituximab in 3 patients and intravenous immunoglobulin in 1 patient. There were 4 deaths in the 18 patients.Out of 8 patient who received Plasmapheresis, 4 patient who received only plasmapheresis died, while one who received only plasmapheresis survived. Two patients with Cyclophosphamide along with Plasmapheresis survived, while another patient with plasmapheresis with subsequent cyclophosphamide and IVIG survived. All 3 patient receiving Rituximab and 4 patient receiving Cyclophosphamide alone survived

PC0060: Our patients with primary sjogren's: Does our social structure help despite severe symptoms?

S Pandya, R Solanki, A Parmar, M Bavaliya, N Patel, R Sharma, A Sanap, S Chikani, P Srivastava, R Shah, A Shukla, V Sharma, T Parikh; Vedanta Institute of Medical Science, Ahmedabad, Gujarat, India

Objective: To analyse demographic and laboratory characteristics of patients presenting to outpatient private clinics and their HRQOL

Materials and Methods: We collected data prospectively from 12 private clinics of the city in paper proformas which also had a QOL questionnaire inclusive of both physical and psychosocial aspects. Study duration was one month (June 15th to July 15th, 2019). The baseline data was analysed using descriptive statistics.

Results: Total 59, Please see table. On the QOL-PSS Questionnaire, 1. More patients had physical discomfort than psychosocial problems and 2. except for the questions 'my family understands me' and 'I have a good feeling about my body' where the majority were very positive, the rest were equivocal about their replies.

Conclusion: While the demography matched from patients elsewhere, more patients had physical pain/discomfort than being negative on the psychosocial aspects. Does living in joint families give greater social security to our patients and hence a less negative feeling – will need to be explored by further studies.

Table 1 Click here to view

PC0061: Palindromic rheumatism, agonizing but remitting variant!

S Pandya, P Shenoy, R Solanki, T Parikh; Vedanta Institute of Medical Science, Ahmedabad, Gujarat, India

Objective: To analyse demography of patients of PR, their response to therapy and comparison with another group.

Materials and Methods: Study Period: Feb '16 to July '19. Retrospective analysis (descriptive) of data – demographic, laboratory and response to therapy. Remission was defined as no attack of pain or swelling over 6 months. We also compared our data to that from another group from South India

Results: Please see table. While 87% of our patients were CCP positive, 71% were Rheumatoid factor positive.85% of our patients were in remission at a mean of 11.7 months' follow up.Compared to the other group, our patients presented earlier.

Conclusion: Although the severity of pain was more in PR, most patients achieved remission on cDMARDs. More data is needed on whether HCQ alone should be enough in managing these patients.

[TAG:2]PC0062: Comparison of HRCT and mantoux test in patients with quantiferon TB gold positive for screening of latent tuberculosis infection in patients with systemic inflammatory rheumatic diseases prior to treatment with biological disease-modifying antirheumatic drugs[/TAG:2]

Vidya K Bangar, John Mathew, Debashish Danda, Ashish, Ruchika, Ashwin, Arvind, Shivraj; Christian Medical College, Vellore, Tamil Nadu, India

Introduction: Comparison of HRCT and Mantoux test in patients with Quantiferon TB gold positive for screening of latent tuberculosis infection (LTBI) in patients with systemic inflammatory rheumatic diseases (SIRDs) prior to treatment with biological disease-modifying antirheumatic drugs (bDMARDs).

Aim: To compare HRCT and Mantoux test in patients with Quantiferon TB gold positive for LTBI in patients with SIRDs for treatment with bDMARDs.

Materials and Methods: The study included patients admitted in ward for last 8 months for bDMARD treatment and who had Quantiferon TB gold positive . They were analysed for HRCT and Mantoux test. These patients were given TB prophylaxis before initiating bDMARDs . They were followed and monitored for any features of tuberculosis flare.

Results: We found 20 patients with Quantiferon TB gold positive. It was found that 5(25%) were positive for Mantoux (>10mm) and 15(75%) were negative for same. 5 (25%) out of 20 had HRCT evidence of infection and 15 (75%) patients had normal HRCT. 2 (10%) patients had all 3 test positive. 2(10%) had both Mantoux and Quatiferon TB gold positive and HRCT Normal. 3(15%) had HRCT and Quantiferon TB gold positive with Mantoux negative. They were followed and monitored for any features of tuberculosis flare, none of them develop tuberculosis.

Conclusion: In our patients screened for latent TB by Quantiferon TB gold , Mantoux test and HRCT, Quantiferon TB gold was the most sensitive test.

PC0063: Assessment of quality of life in patients of axial spondyloarthritis using asqol questionnaire and its correlation with disease activity and functional indices

S Bhatt, N Pachera, V Vasdev, Ramakant, A Kumar; AHRR, Delhi, India

Background: The Ankylosing Spondylitis Quality of Life (ASQOL) questionnaire is an AS-specific measure of QOL designed for monitoring patients and evaluating treatment effects of new pharmaceutical products. There is paucity of studies assessing ASQOL in Indian population and various factors associated with poor QOL.

Objectives: In this study, we aimed to assess the QOL in AS patients using this tool and its correlation with disease activity and functional indices. Secondarily, we also studied the factors associated with poor QOL

Methods: 102 consecutive patients attending Rheumatology clinic at the institute fulfilling the latest ASAS criteria for AS were enrolled. Those having any other comorbidities that affect QOL were excluded. Recruited subjects were provided with the ASQOL questionnaire to self-assess the effect of disease on their QOL. Simultaneously, disease activity and functional status were assessed using BASDAI, BASFI, BASMI and ASDAS scores. Subjects were followed up at 1 month and 6 months and scores calculated. Association was studied between age and sex, duration of study, HLA B27 status and the ASQOL.

Results: Mean ASQOL score at baseline was 9.6 ± 4.4 and declined significantly during follow-up (6.04 ± 3.6 and 5.39 ± 3.4 respectively). ASQOL scores positively correlated with BASDAI, BASFI, ASDAS and BASMI scores. A significant positive correlation was also observed between age, duration of disease and ASQOL scores at various time intervals. HLA-B27 status did not affect QOL or any other disease activity indices significantly in our study.

Conclusion: ASQOL is an objective measure of QOL and varied significantly at different time intervals probably in relation to the effect of treatment. QOL was also adversely affected by age of the subjects and the duration of the disease as reflected by higher ASQOL scores. High disease activity and poor functional status was also associated with poor QOL.

PC0064: Comparison of sulfasalazine versus leflunomide based combination therapies in patients with psoriatic arthritis failing methotrexate monotherapy: A randomized controlled trial

Manoj Kumar, K C Shanoj, Laxmisha Chandrashekar, K T Harichandra Kumar, M B Adarsh, K G Chengappa, V S Negi; Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Background: Evidence regarding efficacy of various conventional disease-modifying anti-rheumatic drugs among psoriatic arthritis (PsA) patients are scarce particularly among those with inadequate response to methotrexate (MTX).

Objective: The study compared the efficacy of Sulfasalazine (SSZ) and Leflunomide (LEF) based combination therapies in terms of achievement of psoriatic arthritis response criteria (PsARC) response among the patients with PsA who had persistent active disease despite maximum tolerable dose of MTX.

Methodology: In this 12 weeks, assessor-blinded randomized controlled trial, patients with predominant peripheral polyarthritis who failed to achieve minimal disease activity (MDA) with maximum tolerable doses of methotrexate, were randomized to receive: sulfasalazine (2 gm per day) and methotrexate combination (24 patients); or leflunomide (20 mg per day) and methotrexate combination (25 patients). Primary outcome measure was proportion of patients achieving PsARC response and secondary outcome measures were proportions of patients achieving ACR20, ACR50, MDA, and DAPSA remission response.

Results: Forty-nine patients were enrolled after screening 188 patients. Baseline characteristics were comparable in both the treatment arms. At 12 weeks, PsARC response was achieved by 100% and 84% of patients treated with MTX and SSZ versus MTX and LEF respectively (P = 0.11). MDA was achieved by 75% and 60% of the patients treated with MTX and SSZ versus MTX and LEF respectively (P = 0.26). DAPSA remission response was achieved by 58% and 40% patients treated with MTX and SSZ versus MTX and LEF respectively (P = 0.19) [Figure 1] LEF was discontinued in one patient due to rise in creatinine. No other serious adverse effects were noted.

Conclusion: Both the combination therapies are efficacious and safe among the South Indian patients with polyarticular psoriatic arthritis and inadequate response to methotrexate monotherapy. There was a trend (non-significant) toward better response with sulfasalazine and methotrexate combination suggesting need of large scale.

Figure 1: CONSORT flow diagram and treatment reasponses among two treatment arms. ACR-American college of rheumatology; DAPSA-Disease activity in psoriatic arthritis; ITT-Intention to treat; LEF-Leflunomide; MDAMinimal disease activity; MTX-Methotrea Click here to view

PC0065: Smartphone application based management in rheumatoid arthritis: SMART- RA study, one year experience

Ashit Syngle, Nidhi Garg, Kanchan Chauhan; Healing Touch City Clinic and Fortis Hospital Mohali, Chitkara University, Rajpura, Punjab, India

Background: Compliance in RA remains critical to treatment outcomes but poses challenges in day-to-day care. In technology driven era, with more people having access to smart phones, opportunities exist for use of phone-based technologies.

Objective: Investigate impact of smart-phone application (HealthCius) on inflammatory disease activity and QOL in RA over one year.

Methods: 75 consecutive RA patients recruited. Subjects randomized into 2 groups. First, having access to smart-phone were assigned to intervention group using Healthcius application (n=45) and second, the control group not using application (n=30). Patients in two groups received standard treatment for RA. To patients, app was their individual treatment plan. It helped them comply by providing an easy to refer checklist, reminders, alerts and visual dashboard of their progress through the day. The app served as the doctor's virtual assistant inside the patient's smart phone. For the doctor, it was a live dashboard of all patients and their real time compliance levels. Outcome measures included ESR, CRP, DAS28 and HAQ-DI at baseline and 1 year.

Results: The two groups did not differ significantly for baseline characteristics. There was significant difference between control and intervention group for DAS28 (p <0.05), ESR (p≤0.05), CRP (p≤0.05) and HAQ-DI (p≤0.5) after 1 year in favor of smart phone application. Analysis within the groups revealed significant improvement in DAS28 (p<0.05), ESR (p=0.01), CRP (p=0.001) and HAQ-DI (p=0.01) in the application group as compared to control group. Impact of DMARDs usage was also evaluated at the end of the study and it was found that average drug usage of DMARDs was less in intervention group.

Conclusion: Greater improvement in inflammatory disease activity and QOL in smart phone application assisted RA patients suggesting that smart phone technology can be used to leverage health benefits in RA.

PC0066: Demographic profile of patients presenting with vasculitides (especially AAVs) from western India

Dhaiwat Shukla, Prashant Chotalia, Puja Srivastava, Rutviz Mistry, Sapan Pandya; Smt NHL MMC, Ahmedabad, Gujarat, India

Objective: To study the demographic and clinical profile of patents presenting with vasculitides (AAVs).

Materials and Methods: Retrospective analysis of the patients presenting with vasculitides (especially AAVs) during the period Oct 2017 to Oct 2019 at one tertiary care government centre(i.e. VSGH) and one private OPD(i.e. Vedanta) was done.Informed consent was taken.

Results: Total 107 patients have been included in the study. Mean age was 41.38+-15.35. Of them, 26(24.30%) had large vessel vasculitis (Takayasu arteritis), 11(5.34%)had medium vessel vasculitis(polyarteritis nodosa) rest had various forms of small vessel vasculitides. Mean BVAS of the patients was 17.68+-11.26.Subgroup analysis:-patients of AAV (ANCA associated vasculitides)

Conclusion: Of vasculitides presenting to the OPDs, maximal were AAVs. Distribution of these and their demographic and clinical features matched those from another study from North India. More data with follow up is needed to compare outcomes across different zones of India.

Table 1 Click here to view

PC0067: A retrospective analysis of disease outcome at 6 months in patients of RA managed at a municipal tertiary care centre: An observational study

Authors: Affiliation:

Objective: To study outcome in patients of RA at 6 months of starting their treatment, and to decide the factors influencing remission

Methodology: All patients fulfilling ACR 2010 criteria attending Rheumatology OPD in a tertiary care hospital in the Western part India from December 2015 to August 2019 have been included. Patients taking oral steroids at any point of time during study period have been excluded. Their baseline data, including demographic data and disease activity were analysed. At 6 months follow up their disease outcome measures were reanalyzed. Patients in remission at 6 months ( DAS28 <=2.6) were compared to those who were not.

Results: Total 256 patients with mean duration of illness 5.47+-5.96 years and a mean age was 47.25+-12.34. Their baseline DAS28 ESR was 4.18+-2.57. Mean HAQ at baseline was 1.1+-1.0.

Conclusion: At 6 months of follow up, about 2/3rds achieved EULAR remission with DMARDs and no cortiocosteroids. Males, those with higher baseline DAS 28 ESR and seropositive patients were more likely to achieve remission. More data with longer follow up would be useful to validate the judicious use of DMARDs WITHOUT corticosteroids in our settings.

Table 1: Validation of 2019 European League Against Rheumatism/American College of Rheumatology classification criteria in 303 systemic lupus erythematosus patients Click here to view

PC0068: A study on efficacy of adalimumab biosimilar in patients of spondyloarthritis

H Raghavendra, T N Tamilselvam, S Balameena, R Ramesh, S Mythili, S Karthikeyan, N Balakrishnan; Department of Rheumatology, Madras Medical College and RGGGH, Chennai, tamil Nadu, India

Aim: To study the efficacy of adalimumab biosimilar in bDMARD naïve patients and compare it with infliximab response in an age matched group of SpA patients.

Materials and Methods: Patients admitted in Institute of rheumatology, Madras medical college with newly diagnosed SpA(Axial) as per ASAS definition were included in the study. 20 patients were given Inj. Adalimumab biosimilar 40 mg sc every fortnightly for a total of 12 weeks . Their baseline ASDAS, BASDAI, BASFI were calculated and followed after 12 weeks of therapy. The response was compared with age-matched control group of 20 patients who had received Infliximab for the above indication.

Inclusion Criteria:

1. Patients above the age of 16 years.
2. Known case of AS diagnosed as per ASAS definition.
3. Patients who are HLA-B27 positive.
4. BASDAI>4, ASDAS> 2.1, CRP>6mg/L.

Exclusion Criteria:

1. Spondyloarthritis associated with psoriasis, IBD, Reactive arthritis.
2. HLA-B27 negative patients.
3. Active tuberculosis, HBV or HCV infection.
4. Inactive or low disease activity according to ASDAS-CRP scoring.

Primary Outcome: ASAS 20 response at 12 weeks.

Results: A total of 20 patients received Inj Adalimumab biosimilar as bDMARD along with NSAIDs . 30%(6) patients achieved ASAS 20 response at the end of 12 weeks whereas 80%(16) of patients in the infliximab group had achieved this response after the bolus doses. Patients in infliximab group had a greater improvement in outcome scores when compared to adalimumab biosimilar.

Conclusion: Adalimumab biosimilar was less efficacious in patients with AS when compared to infliximab bio-originator however, the patients who had response had good improvement in BASDAI and BASFI scores.

PC0069: Validation of 2019 Eular/Acr classification criteria for systemic lupus erythematosus in a south Indian cohort

B Harikrishnan, Suma Balan, Jyothi Srikanth, C B Mithun; Department of Clinical Immunology and Rheumatology, AIMS, Amrita ViswaVidyapeedham, Kochi, Kerala, India

Background: New 2019 EULAR/ACR classification criteria for SLE have been recently published. Validation studies for the new criteria were done in other parts of the world.

Objective: To compare the real world performance of 2019 EULAR/ACR classification criteria when applied to a known cohort of SLE cases in Kerala.

Methods: We retrospectively reviewed the electronic medical record of 30,541 patients who visited the Rheumatology department of AIMS, Kochi, a tertiary care center, from January 2014 to June 2019. 347 patients diagnosed with SLE by qualified experienced rheumatologists were included in the study. 44 patients were later excluded as they had overlap syndrome. Thus, there were 303 SLE patients (107 juvenile SLE and 196 adult SLE). From the 30,541 patients, another 303 patients(107 juvenile and 196 adult), who attended the rheumatology department on first week of each month, from 2014 January to 2019 June and diagnosed with other autoimmune diseases, were selected as controls. They were selected regardless of their specific clinical or immunologic manifestations. Patients were excluded if the diagnosis was uncertain. Each patient was evaluated to see if he or she satisfied the 1997, 2012, and 2019 criteria.

Results:

Conclusion: The new 2019 EULAR/ACR criteria attained better sensitivity, PPV, NPV and accuracy when compared to ACR 1997 and SLICC 2012 criteria; and better and almost same specificity as compared to SLICC 2012 and ACR 1997 criteria, respectively.

Click here to view

PC0070: Clinical characteristics of patients with isolated AntiDFS 70 antibody positivity

B S Vishnu, S Rajesh¹, Department of Family Medicine, Kerala Institute of Medical Sciences,¹Kerala Institute of Medical Sciences, Thiruvananthapuram, Kerala, India

Dense fine speckled (DFS) pattern is the most frequent pattern in high titre ANA-positive healthy persons is associated with anti-DFS70 antibody. There is negative association between anti-DFS70 antibodies and systemic autoimmune rheumatic disease, especially if no concomitant ANA associated rheumatic diseases (AARD)-specific autoantibodies are found. Published cohorts revealed association with various conditions like alopecia, asthma, atopic dermatitis, behcet's disease, celiac disease, chronic fatigue syndrome etc. We assessed the isolated Anti DFS positive patients to look into the clinical characteristics. 91.6 % of female patients predominated the group with equal proportion in less than 30yrs and 30 – 50 yrs group of 45.8% each. Fibromyalgia was the most common clinical feature accounting for 37.5 % among these patients. 12.5 % of patients with clinical features suggestive of undifferentiated connective disease had Anti DFS antibody positivity. Other system involvement was of predominant dermatological involvement seen as psoriasis, bullous pemphigoid and erythema dyschromicum perstans. Single organ autoimmune disease was another group with Anti NMDA encephalitis and autoimmune thyroiditis accounting for same. Other inflammatory spectrum included idiopathic uveitis and inflammatory bowel disease.

References

1. Mahler M, Parker T, Peebles CL, Andrade LE, Swart A, Carbone Y, et al. Anti-DFS70/LEDGF antibodies are more prevalent in healthy individuals compared to patients with systemic autoimmune rheumatic diseases. J Rheumatol 2012;39:2104-10.
2. Mahler M, Hanly JG, Fritzler MJ. Importance of the dense fine speckled pattern on HEp-2 cells and anti-DFS70 antibodies for the diagnosis of systemic autoimmune diseases. Autoimmun Rev 2012;11:642-5.
3. Miyara M, Albesa R, Charuel JL, El Amri M, Fritzler MJ, Ghillani-Dalbin P, et al. Clinical phenotypes of patients with anti-DFS70/LEDGF antibodies in a routine ANA referral cohort. Clin Dev Immunol 2013;2013:703759.

PC0071: A study on atherogenicity in systemic lupus erythematosus and its relationship with disease activity

Sujatha Narayanan, T N Tamilselvam, R Ramesh, S Mythili, S Karthikeyan , M Sabarinath, S Balakrishnan, S Nikhila, Archana Singh; Department of Rheumatology, Madras Medical College, Chennai, Tamil Nadu, India

Background: Cardiovascular disease is one of the major causes of morbidity and mortality in patients with systemic lupus erythematosus (SLE). The increased cardiovascular risk is both due to increased prevalence of classical risk factors and inflammation due to SLE per se. We wanted to study how much the risk is increased among SLE patients compared to healthy controls and among patients with active SLE(SLEDAI ≥4) and those in remission, by estimating the Atherogenic index of plasma(logarithmic value of triglycerides by HDL cholesterol), a value shown to correlate with cardiovascular risk in various studies.

Objectives: 1. Estimate the Atherogenic Index of Plasma(AIP) in SLE patients and comparison with healthy controls.2. Comparison of AIP among patients with active SLE and those in remission.

Methods: This cross-sectional observational study included newly diagnosed SLE patients. Data was collected from a total of 72 SLE patients, 72 non SLE controls. Disease activity was measured by SELENA-SLEDAI. SLE patients with Metabolic Syndrome(MetS) were excluded in the data analysis comparing patients with active SLE and those in remission. Data analysis was done using Wilcoxon signed rank test and Mann-Whitney U test.

Results: AIP was significantly increased among SLE patients when compared to general population (p value<0.0001) and significantly increased among SLE patients with MetS when compared with those without MetS (p value <0.01).However, there was no significant difference in AIP values between patients with active SLE and those in remission (p value>0.05)

Conclusion: The study Results: reiterate the fact that both metabolic syndrome and SLE contribute independently to the increased cardiovascular risk seen in SLE as measured by AIP. However, there was no alteration in atherogenicity in SLE patients with relation to disease activity. This emphasizes the importance of careful monitoring for cardiovascular risk in SLE even in remission.

PC0072: Neutrophil to lymphocyte ratio and platelet to lymphocyte ratio as activity markers in rheumatoid arthritis: A cross sectional study from Rajasthan, India

Parag Vijayvergia, Gopal Krishana Bohra, Abhishek Purohit, Kamala Kant Shukla, Kuldeep Singh; All India Institute of Medical Sciences, Jodhpur, Rajasthan, India

Introduction: Rheumatoid arthritis (RA) is an inflammatory disease with a prevalence of 1%.Disease severity is assessed by the Disease Activity Score of 28 joints (DAS-28) system. Recent studies suggest that NLR and PLR correlate with disease severity and other inflammatory markers suggesting a potential role for novel but inexpensive activity markers.

Objective: To assess correlation of NLR and PLR with CRP, ESR and explore the relationship with DAS 28 score.

Methodology: Patients diagnosed with RA using ACR/EULAR 2010 criteria were included. Patients with any other co-morbidities including diabetes, hypertension, cardiovascular diseases and other connective tissue diseases were excluded. DAS 28 ESR score was calculated and inflammatory markers and complete blood count were performed.

Results: Sixty-eight patients of RA were screened and 54 included. Fifty were females, 4 patients were early RA while others had established disease. All patients were on methotrexate with 25% on additional DMARDs. Five patients were on prednisolone at the time of assessment. 78% patients had active disease with DAS 28 ESR >3.2. A weak positive correlation was observed between PLR and Hs CRP levels(r = O.31, p= 0.02). No correlation was observed between NLR and PLR with disease activity or with ESR.

Discussion: In contrast to previous reports, NLR or PLR were not associated with disease activity. We have excluded any comorbidity which might affect NLR and PLR. Steroid use was <5% in our patients. These make our observations fairly robust.

Conclusion: Though NLR and PLR levels are reported to be higher in RA patients, they do not appear to reflect disease activity.

PC0073: Clinical and laboratory features in the first inception cohort of SLE in India: The data of first 466 patients

Avinash Jain, Murugavangini Egambaram¹, Asma Chougule², Janany Parathasarthy³, Parmeshar Sindhu⁴, Sindhura Gajula⁵, V S Negi¹, K G Chengappa¹, Ramnath Misra, Vineeta Shobha², Benzeeta Pinto², Ashish Jacob Mathew³, Parasar Ghosh⁶, Manish Rathi⁴, Liza Rajasekhar⁵, Ranjan Gupta⁷, Bidyut Das⁸, Saumya Ranjan Tripathi⁸, Amita Aggarwal

SGPGI, Lucknow, Uttar Pradesh,¹JIPMER, Puducherry,²St. John's Medical College, Bengaluru, Karnataka,³CMC, Vellore, Tamil Nadu,⁶IPGMER, Kolkata, West Bengal,⁴PGI, Chandigarh,⁵NIMS, Hyderabad, Telangana,⁷AIIMS, Delhi,⁸SCB, Cuttack, Odisha, India

Introduction: SLE is a multisystem disease with varying clinical manifestations and multiple autoantibodies. To date, all series of SLE from India have been retrospective. Thus, we prospectively studied clinical features at presentation in an inception cohort. Further, we studied if there were difference(s) in clinical or laboratory(lab) features of patients presenting early (within 6 months of symptoms) or late.

Methods: Indian SLE inception cohort for research (INSPIRE) is a multi-institutional cohort in which patients, satisfying SLICC criteria and disease duration ≤ 3 years, presenting to nine institutions after Aug 31, 2018 were enrolled. All demographic, clinical and lab data were collected in a standardized case report form and entered on web-based database.

Results: Among 466 patients, 426 were females. Most common clinical manifestations were mucocutaneous (87.1%) and fever (70.6%). Other manifestations included arthritis 309 (68.4%), serositis 110 (23.6%), renal 214 (45.9%), CNS 124 (26.6%), hematological 234 (50.2%), DVT (12.4 %) and ILD (8.5%).In mucocutaneous domain, most common was non-scarring alopecia (78.5%) followed by oral ulcers (57.7%), ACLE (55.1%), DLE (22.7%) and SCLE rash (15%). Among 214 patients with renal involvement, 87 out of 134 biopsied patients revealed proliferative nephritis. Mortality rate was 1.1 % with active disease in all.Lab abnormalities are highlighted in [Table 1]. ANA was negative in ten patients. High dsDNA and low complements were seen in 66.8% and 72.1% respectively. Most common antibodies after dsDNA were anti-smith and anti-Ro (37.1% and 35.4%) and 21.3% had anti-phospholipid antibodies.Patients presenting late more commonly had arthritis, hemolytic anemia and renal involvement but were less commonly febrile. Mean baseline SLEDAI did not differ but they had more patients with severe disease activity. Mortality rate was similar.

Conclusion: Mucocutaneous, constitutional features were most common in our cohort with higher renal involvement and severe disease activity in patients presenting late.

Table 1: Clinical, biochemical and scrological profile Click here to view

PC0074: Gender differences in psoriatic arthritis and relevance of age of onset of psoriasis

Taral Parikh, Sapan Pandya, Rakesh Solanki; Vedanta Institute of Rheumatic diseases, Ahmadabad, Gujarat, India

Background: Males with SpA have more axial disease, in females peripheral involvement is dominant.

Objective: As gender differences have not been studied well in PsA, we did this study.

Methods/Results: 180 patients, from 2012-2019, fulfilling the CASPAR criteria, analysed. Population was stratified by age of onset of psoriasis (cutoff 40 years).Male 117/ female 63. Mean age 43.07(±11.3), weight 70.8(±13.8), duration of psoriasis onset 7.9(±7.2), duration of PsA 3.5(±4.34), PASI; 3.4(±6.09), SJC 4.3(±4.5), TJC 6.2(±5.3), patient global assessment for psoriasis 3.4(±2.6), patient global assessment of PsA 6.6(±1.7). 16.5% -family history of psoriasis.Pattern: Axial+oligoarthritis 25(21%), axial+polyarthritis 21(17%), axial+distal 4(3.5%).Isolated: polyarthritis 32(27%), oligoarthritis 29(24%), axial 5(4%), 1 (0.8%)DIP.Enthesitis 1(7.5%), dactylitis 49(33.7%).

Conclusion: Males had more axial and oligoarticular involvement and females polyarticular involvement, even when stratified by age of onset. Females had higher joint counts and disease activity and males were more obese.

PC0075: Appearances are deceptive- behavioral patterns are different. Purpura of sjogren's syndrome versus henoch schonlein purpura- experience from a tertiary care centre

Rajeswari Sankaralingam, Ramu Ramasamy, Saranya Chinnadurai, Balaji Chilukuri, Vignesh Manthram, Shanmugesh Selvaraj, Aishwarya Ramachandran Department of Rheumatology, SRIHER, Chennai, Tamil Nadu, India

Background: Enigmatic among all vasculitides is the small vessel vasculitis – Purpura especially in Sjogren's Syndrome(SS) along with its closest mimic Henoch Schonlein Purpura(HSP).

Objective: To compare the Purpura of Sjogren's syndrome and HSP.

Methods: A prospective observational study was conducted by Department of Rheumatology, in a tertiary care centre between Jan 2018 to June 2019. The clinical, laboratory profiles and histopathology(HPE) of adult HSP and Sjogren's were studied.

Results: Total number of adult onset HSP was n=4, M:F was 2:2, mean age 39.25 years, mean duration of illness:13.5 days. All had palpable purpura, most common site was lower limbs(n=3), abdomen(n=1)and generalized(n=1). Other clinical features were polyarthralgia(n=2), polyarthritis(n=2), abdominal pain(n=2), vomiting(n=2)and hematuria(n=1). UGI scopy showed chronic gastritis(n=2) and erythematous ulcer in terminal ileum with proctitis(n=1). Investigations showed leukocytosis(n=4), mean ESR 37mm/hr, raised CRP(n=2), positive cryoglobulins(n=1)and reduced complements(n=1). HPE showed leucocytoclastic vasculitis(LCV)(n=4). Renal biopsy showed IgA deposits(n=1).Total number of Sjogren's patients was n=15, of whom 9 had recurrent palpable purpura. M:F was 0:9, Mean age was 43.11 years and mean disease duration 3.6 years. Most common sites were generalized(n=8) and localized(n=4) in lower limbs. Common striking clinical features were polyarthralgia(n=6), polyarthritis(n=1), sicca symptoms(n=9) and interstitial lung disease(n=2). Antibodies positive were RF(n=4), ANA(n=5), SSA & SSB(n=6), Low complements C3 & C4 (n=3) and elevated serum gammaglobulins(n=3)were seen. HPE showed varying Results, LCV(n=1), lymphocytic vasculitis(n=3) and anetoderma(n=1).

Conclusion: Both males and females were equally affected in HSP showing LCV in the HPE. Only females were affected in SS and were older. In SS, polyarthralgia was common and disease duration longer. All who had RF positivity had elevated acute phase reactants, severe purpura, hypergammaglobulinemia and mononuclear vasculitis. Cryoglobulin positivity –Is it a separate entity?

PC0076: Prevalence of articular and extra articular features of joint hypermobility in fibromyalgia

Pooja Belani, C B Mithun¹, Joe Thomas², Arun Tawari¹, Vishad Viswanath; Institute of Rheumatology and Immunology Sciences, Thiruvananthapuram,¹Department of Rheumatology, Amrita Institute of Medical Sciences and Research Centre,²Aster Medcity Hospital, Kochi, Kerala, India

Background: Fibromyalgia(FMS) and Joint hypermobility syndrome(JHS) are common causes of chronic pain syndrome with many overlapping features.

Objective: To study the prevalence of joint hypermobility and extra-articular features of JHS in patients with FMS.

Methods: A prospective cohort of FMS and JHS each were recruited from three tertiary rheumatology care facilities in Kerala from June2019 to August2019.Prevalence of Joint hypermobility and extraarticular manifestations of Joint Hypermobility were captured in the FMS cohort using a predesigned proforma and compared to those in the cohort with JHS.Patients satisfying ACR2010 criteria for FMS and Beighton score of ≥ 4/9 for BJHS were included in the respective group.Statistical analysis was done using SPSS 25.0.

Results: A total of 40 FMS patients and 74 JHS patients were recruited. Mean age was 39.9±11yrs in FMS vs 49.9 ±12.6yrs in JHS. Noteworthy,Beighton score ≥ 4/9 was present in 67%FMS patients while 36.5% of JHS patients fulfilled FMS criteria. Among the clinical features,dragging pain (77% vs 34%) and fatigue (95% and 77%), both p<0.005, were more common in FMS group,whereas myopia (54% vs 28%) and scoliosis((35% and 2.6%) were more frequent amongst JHS group,both p<0.001. 2 groups were comparable in terms of other features of JHS as varicose veins,joint crepitus,calf pain,foot abnormality and enthesopathy.Significantly,Beighton score negatively correlated with age in both the groups (-0.334 in FMS group and -0.49 in JHS, p<0.05).

Conclusion: Clinical features of JHS are common in FMS patients and could contribute substantially to the morbidity in FMS.Overlooking the features of Joint Hypermobility Syndrome,can lead to mislabeling as FMS. Importantly , there is a negative correlation between age and Beighton score. Therefore, at older age,diagnosis of JHS may require special attention to extraarticualar features of JHS rather than relying on Beighton score alone.

PC0077: Questionnaire based assessment of patients' beliefs, knowledge and perception about rheumatoid arthritis

Ranjan Gupta, Anju Mohan Renjith; Department of Rheumatology, All India Institute of Medical Sciences, New Delhi, India

Background: The long-term outcomes in rheumatic diseases not only depend upon the drugs but also on the patients' education, beliefs and their perception about their disease and other non-pharmacological interventions like exercise.

Objective: To assess the patients' beliefs, knowledge and perception about rheumatoid arthritis (RA) through a questionnaire

Methods: A questionnaire (Hindi Language) containing 28 multiple choice questions assessing the patients' knowledge about RA in 4 domains (a. etiology, disease process, signs & symptoms b. drug therapy & monitoring c. joint protection, exercise, coping and goal setting d. individual specific issues) related to the disease was prepared and applied to 300 consenting patients. All questions had an option of 'I don't know'. Epidemiological information was collected for all including their socio-economic and education status.

Results: There was a wide variation in the range of correct responses in different domains. Option 'I don't know' was exercised for total of 36.7% times in whole questionnaire. Only 33% patients knew that etiology for RA is unknown and 66% were aware that RA is not congenital. Only 19% patients are aware that it's not curable and 70% patients follow dietary restrictions for better relief. 25% patients are aware of the reasons for repeating liver and renal function tests and 55% believe that rheumatoid factor and anti-CCP antibodies are useful for treatment monitoring. Only 27% patients knew about DMARDs and 33% and 11% could correctly identify NSAIDs and steroids respectively. Almost 42% patients knew that regular exercises can prevent deformities but only 7% knew that they need to be done during active disease also. Only 7% patients are aware of using larger joints than smaller to preserve energy and prevent joint damage.

Conclusion: This study highlights the poor knowledge base of RA patients in a north Indian population and the need for effective educational programs.

PC0078: A prospective study on the relationship of USG findings, dental hygiene and antiCCP titres on joint erosions in rheumatoid arthritis

Debarup Das, Shaoli Ghosh, Koushik Basu; Medical College and Hospital, Kolkata, West Bengal, India

Background: We have tried to assess the correlation between the USG findings with the extent of joint damage in Rheumatoid arthritis patients to see whether it can be reliably used for monitoring in follow up and to seek any relationship of dental health status and anti-CCP titers with the erosive changes.

Objectives: 1. To assess the correlation of USG joint erosions with corresponding X Ray findings. 2. To assess the correlation of anti-CCP and dental hygiene with correspondingX-ray erosivefindings.

Methods: 50 Rheumatoid patients as per ACR/EULAR criteria, of disease duration < 2 years, attending our center selected randomly. Patients were clinically assessed for condition of their dental hygiene, and RF and anti-CCP titres, ESR & CRP values were assessed. High resolution Power Doppler (4-12 Hz) USG of joints was done to assess the joint erosions and digital X-rays obtained were analyzed to assess the joint erosion as per modified Van der Heijde(VDH) scoring system. Parameters were checked at presentation, and after 8 months. Changes in USG joint erosion scores at the end of the study were compared with that of X-ray erosions by correlation and regression analyses. Anti-CCP titres were compared with VDH scores at presentation, and at 8 months, and an Anova test was done to assess the effect of the condition of dental hygiene on VDH scores.

Results: We found a positive correlation between change in USG and X Ray erosions (correlation coefficient 0.66). Poor dental hygiene and higher anti-CCP titres were found to be associated with higher erosive changes, both at presentation and at the end of study period (p value 0.008).

Conclusion: USG was found to be a sensitive tool in assessing progression of erosive changes in rheumatoid. Dental health and antiCCP titres also showed a significant impact on joint erosions.

PC0079: Differences between adult and pediatric onset henoch-schonlein purpura from south India

Pranav R Chickermane, Vishnu S Chandran, Clint Sunny, Suma Balan, C B Mithun, Jyothi Srikanth; Department of Rheumatology and Clinical Immunology, Amrita Institute of Medical Sciences, Kochi, Kerala, India

Background: Henoch-Schonlein purpura (HSP) also known as IgA vasculitis, is an immune complex-mediated small vessel vasculitis. Predominantly a disease of childhood, it is considered to be rare and to have a more severe course in adults. There is paucity of data comparing the disease spectrum in children and adults.

Objectives: To investigate the differences in clinical manifestations and outcomes in pediatric and adult onset HSP.

Methods: The case records of a total of 149 patients fulfilling the new EULAR/ PRINTO/PRES criteria for HSP, who attended the Rheumatology OPD at a tertiary care hospital in south India over the last 6 years (2013-2018) were retrospectively analyzed. Pediatric onset HSP was defined by age at onset of HSP below 18 years. The clinical features, laboratory investigations and outcomes in the paediatric and adult onset HSP groups were compared. Outcome (complete recovery, relapse, persistent proteinuria and/or hematuria, or progression to chronic renal failure) at last visit was assessed in patients with a minimum follow up duration of 6 months.

Results: 78 patients with pediatric onset and 71 with adult onset HSP were seen during this period. During the disease course, children had a higher frequency of gastro-intestinal involvement (84.8% vs 45.1%, P< 0.01) compared to adults. Renal involvement was more common in adult onset than pediatric onset HSP (57.7% vs 39.2%, P <0.05) with 3 adult onset HSP patients progressing to chronic renal failure compared to one in the pediatric onset HSP group. Complete recovery was more common in children than adults (75.7% vs 41.2%, P<0.05).

Conclusions: We found statistically significant differences in clinical manifestations and outcomes between patients with pediatric and adult onset HSP. Gastro-intestinal involvement was more common in children than adults. Adults with HSP had more frequent renal involvement and worse renal outcomes than children.

PC0080: A study of serum procalcitonin levels in systemic onset juvenile idiopathic arthritis

Rajesh Kanumuri, Suma Balan; Department of Clinical Immunology and Rheumatology, Amrita Institute of Medical Sciences, Kochi, Kerala, India

Background: Patients with systemic onset Juvenile idiopathic arthritis (SOJIA) often present with clinical features similar to an infection. Differentiating the infection from a disease flare is a challenge to the clinician and there are very few studies in the literature about the role of procalcitonin in differentiating these two.

Objectives: 1. To determine the diagnostic role of serum procalcitonin in differentiating between infectious and non-infectious inflammation in febrile patients of SOJIA. 2. To determine the role of procalcitonin and CRP in differentiating the disease flare from macrophage activation syndrome(MAS).

Materials and Methods: Patients who are diagnosed with SOJIA (diagnosed by ILAR criteria) and presented with fever(≥38oC) between March 2018 to July 2019, were recruited and were stratified into three groups( Infection group, Disease flare, & Disease flare with MAS) based on their clinical profile. Respective Mean & Mode values are calculated and compared. ROC curve analysis was used to determine the respective cutoff values.

Results: Out of 43 hospital visits of 20 patients with SOJIA, 7 had infection, 15 had disease flare with MAS and 21 had disease flare without MAS. The median values of procalcitonin in infection & non-infectious groups were 1.72(IQR:15.01) 0.38(IQR:2.12). There was no statistical significance(Mann whitney U test was used, p value: 0.35). On the ROC curve, the cutoff value of procalcitonin to differentiate MAS group from disease flare alone group is 0.46ng/ml with a sensitivity and specificity of 80% and 81% respectively (p value:0.001). Likewise, the cutoff value of CRP is 93.6 mg/L with a sensitivity and specificity of 73.3 & 61.9% respectively (p Value: 0.049).

Conclusion: From our study we conclude that procalcitonin may not be helpful in differentiating the infectious from non-infectious inflammation in febrile patients of SOJIA. Those patients with MAS, even without any infection, procalcitonin levels can be elevated.

PC0081: Rituximab in patients with refractory myositis: A single center experience

Sharma Lucky, Natasha Negalur, J N Durga Rao Yadavalli, Tanna Dhaval, Dhiren Raval, Shounak Ghosh, Vinay Singal, Rajiva Gupta; Medanta-The Medicity Hospital, Gurgaon, Haryana, India

Background: Rituximab, a B cell depleting CD20 monoclonal antibody is being widely used in the management of refractory IIMs. B cells play an important role in the initiation and propagation of the immune response and are implicated in the pathogenesis of myositis.

Objective: Our objective was to assess the efficacy of Rituximab in patients with refractory myositis.

Methodology: We conducted a retrospective cohort study of 11 IIMs patients (5DM, 5PM, 1 Overlap) who attended Rheumatology and Clinical Immunology Clinic at Medanta, The Medicity between March 2017- 2019. All patients had refractory disease (inadequate response to at least two immunosuppressive agents along with concomitant glucocorticoid therapy unable to taper in 6 months) criteria. The patients received two infusions of rituximab (1 g each) at baseline, followed by repeated dose after 6 months. Baseline immunosuppressive therapy was maintained, and glucocorticoid dose was tapered according to clinical/laboratory parameters.

Results: 11 patients were included in the study.10 were female and 1 male patient. The mean disease duration was 2.2 +/- 1.21 years. The demographic, clinical and laboratory profile is shown in table I and II respectively. Almost 75% of the patients attained clinical and laboratory response after 1 yr. A significant reduction in median glucocorticoid dose was achieved at the end of one year (20mg vs 8.86mg per day). However, none of the patients were off steroid completely. No severe infection was noted during study period.

Conclusion: This study shows that rituximab is an effective therapy in refractory IIM patient. Though the MMT 8 score did not improve significantly, Rituximab therapy did help in reducing the dose of corticosteroid. However, a larger cohort with definite trial design is warranted.

PC0082: Jo1 versus non Jo1 myositis: Flip side of the same coin?

J N Durga Rao Yadavalli, Natasha Negalur, Wasim Kazi, Sharma Lucky, Rohit Bajaj, Kaustubh Telang, Shruti Bajad, Rajiva Gupta; Medanta-The Medicity Hospital, Gurgaon, Haryana, India

Background: IIM is a heterogeneous group of disorders with varied phenotypes and prognosis. Myositis specific antibodies have helped in sub classification and in both diagnosis, predicting the response to treatment and prognosis.

Objective: This study was aimed to study the differences in clinical features between Jo1 and Non-Jo1 subgroups.

Methods: This was a prospective observational study carried out at the department of Rheumatology and Clinical Immunology at Medanta Hospital, Gurgaon from August 2017 to July 2019. A Total of 89 consecutive patients who were diagnosed with IIM and fulfilling the Bohan and Peter criteria were included. These patients were divided into Jo1 and Non-Jo1 subgroups. Disease characteristics, lab features, treatment details were noted and analyzed.

Results: Total 25 pts(28%) out of 89 had MSA positivity. Among those Jo1 positivity was seen in 10(11.23%), PL-7 in 2(2.24%), PL-12 in 1(1.12%), SRP in 4(4.49%). Mean age was 35 +/- 8.37 and 42.64 +/- 15.85 years respectively in both groups. PM was seen in majority, about 70% in Jo1 and 50% in Non-Jo1 respectively, with Overlap Myositis in 2(25%) of Non-Jo1 group. Mechanics hands, Arthritis, Fever were seen more commonly in Jo1 as compared to Digital ulcers which were seen in Non-Jo1 group. ILD was seen in 7(70%) , 5(62.5%) respectively in both the groups. Ro was the predominant MAA observed in the study population. Median CPK (mg/dl) was 2994.5 in Jo1 and 604.5 in Non-Jo1 respectively. Non-Jo1 patients had less severe muscle disease.

Conclusion: Jo1 and Non-Jo1 subgroups have distinct phenotypes. Fever, Mechanics hands, Arthritis in Jo1 and Digital ulcers in Non-Jo1 were seen predominantly. Also, Non-Jo1 group had less severe muscle weakness and lower CPK values and association with Overlap Myositis.

PC0083: Wait for it to work: Building up right dose of duloxietine in fibromyalgia

Arun Tiwari, C B Mithun, Sandeep Surendran, V Shekhar; Amrita Institute of Medical Sciences, Kochi, Kerala, India

Background: Fibromyalgia is a prevalent chronic pain syndrome characterized by widespread pain and other unspecified somatic symptom. Duloxetine doses are to be increased gradually to maximum of 60 mg/day to attain maximum efficacy in fibromyalgia patients. Assessing efficacy at the doses lower then target doses can be misinterpreted as non-responders.

Objectives: To evaluate the efficacy and side effect profile of Duloxetine in fibromyalgia patients after 12 weeks of therapy.

Methods: The study was conducted under Department of Rheumatology, AIMS, Kochi. Patients enrolled in study, had visited rheumatology department from January 2018 to September 2019. It was a single centre, retrospective, crosses sectional study. Fibromyalgia patients who had good compliance to therapy and completed at least 3 follow ups at 12 weeks , were included in the study. Total 169 patients were finally included in the analysis after exclusions. The response to treatment was noted with difference in fibromyalgia revised questionnaire from baseline. Improvement in FIQR of >14 was consider as responder to Duloxetine.

Results: The response of treatment was noted on follow up visits after at least 2 months of treatment. Out of enrolled cases 102 were responders and 67 were non responders. Most common side effect noted in our patients was constipation (19) followed by dyslipidemia (18), gastritis /gastroesophageal reflux disease (GERD) symptoms (10), dry mouth (5), deranged liver function (4), giddiness (3), headache (1) and one patient had to discontinue duloxetine because of severe tiredness.

Conclusion: This study provides evidence that 12 weeks treatment with Duloxietine with gradual escalation dose upto 60 mg /day, in fibromyalgia patients improves fibromyalgia symptoms significantly. The relief is beyond pain improvement. The drug is well tolerated in fibromyalgia patients and the side effect profile is mild and it can be managed mostly with symptomatic treatment in appropriate doses.

PC0084: Juvenile lupus nephritis: Clinico-serologic presentation and outcomes compared to adults in a tertiary referral center

Anu Daber, Manoj Kumar, M B Adarsh, K G Chengappa, V S Negi; Jawaharlal Nehru Institute of Post Graduate Medical Education and Research, Puducherry, India

Background: Juvenile lupus nephritis presents with severe disease at onset and follows an aggressive disease course compared to adult-onset disease, with higher morbidity and irreversible renal damage.

Objective: 1.To study demographic, clinic-immunologic characteristics, renal activity, outcomes and cumulative renal and extra-renal damage in juvenile lupus nephritis.2.To compare renal response and cumulative renal and extra-renal damage with an adult population of similar disease severity at onset.

Methodology: The hospital records of children diagnosed with lupus nephritis below 18 years of age from 2009 to 2018 were reviewed. 211 juvenile l patients were screened and 31 patients with lupus nephritis having adequate records and regular follow up were included.59 adult patients with comparable renal disease at baseline were selected for comparison. The data collected included demography, clinical, serologic and renal biopsy parameters, therapy given, response at 12 months, renal and extra-renal damage.

Results: Both groups were comparable at onset of nephritis with regard to hypocomplementemia, SLEDAI scores, severity of proteinuria, histopathologic class of lupus nephritis and renal biopsy activity and chronicity indices. However, hematuria and high titre anti-dsDNA positivity was significantly higher in juvenile group. Anti-Sm, anti-Ku and anti-cardiolipin antibodies (IgG and IgM) were more commonly present in juvenile group. Both groups received similar treatment with IV cyclophosphamide for induction followed by azathioprine or MMF for maintenance. Renal response at 12 months was comparable between the groups. However, the juvenile group had a significantly higher percentage of patients with eGFR<50 ml/min at 12 months. The renal and extra-renal SDI scores at end of follow up were comparable between the groups.

Conclusion: Despite similar response to treatment among both groups, juvenile patients are predisposed to develop CKD stage 4 or 5 at end of 12 months with anti-phospholipid antibody positivity being an important confounding factor.

https://drive.google.com/file/d/1plQdr2ktlzSb-ScMJv7MFkpMZkK7Rafx/view?usp=sharing.

Figure 1: (a and b) Renal outcome at last follow up, (b) Extra-renal damage Click here to view

PC0085: Experience of biologics and small molecules in rheumatic disease in Gujarat

Sapan Pandya, Reena Sharma, Nishil Shah, Puja Srivastava, S S Chikani, Namisha Patel, Ripal Shah, Amruta Sanap, Himanshu Pathak, Manish Bavaliya, Alpana Parmar, Vishnu Sharma; Rheumatology Association of Gujarat, Gujarat, India

Background: Rheumatology Association of Gujarat (RAG) maintains a biologic registry of rheumatic diseases since 2017. This study aims to provide insight on the use of various biologics and small molecules used in various indications.

Methods: A registry was initiated in January 2017 and a common proforma was used to record data from 13 centers of patients on biologic in various rheumatologic conditions. The demographics, indication, duration of disease, co-morbidities were documented.

Results: The registry has 862 patients (454, 53.66% males) with a mean age of 41.51 ± 15.42 years and total duration of illness of 7.28 ± 6.18 years. The details of the baseline disease and frequency are shown in the chart. The table summarizes the relative use of biologics and small molecules, mortalities and cause of death associated with the use of the drugs. Out of 540 patients, 485(9.19%) patients had partial improvement/remission after starting biologic/small molecule. However, inflation of this percentage due to loss of followup of those who did not improve could not be ruled out.

Conclusion: Most common indication of biologic use is Rheumatoid Arthritis while the most commonly used biologic is Rituximab.Majority of the deaths were due to infections after starting biologics.

Figure 1: Frequency of use of biologic in various rheumatic diseases Click here to view

PC0086: Assessment of response of conventional synthetic disease-modifying anti-rheumatic drugs after withdrawal of abatacept on patients of rheumatoid arthritis with remission or low disease activity

A T Atal, S Kartik; Command Hospital, Pune, Maharashtra, India

Background: One biological Disease-Modifying Anti-Rheumatic Drug (bDMARD) Abatacept was withdrawn from Indian markets recently which necessitated a change in therapeutic strategy. Patients who had achieved remission or low disease activity were switched over to conventional synthetic DMARDs and followed up.

Objective: Assess the response to csDMARDs after withdrawal of Abatacept on patients of Rheumatoid Arthritis in remission/low disease activity.

Methods: This prospective study included patients of RA on Abatacept followed up at our Center from Jan 2018 to Jan 2019. Patients in remission or low disease activity(LDA) were switched to the csDMARD regime in optimised combinations and adequate doses as per existing guidelines.Clinical Disease Activity Index (CDAI )was documented at baseline, 3 and 6 months. Primary end-point was the maintenance of at least LDA as defined by a CDAI of 10.

Results: 19 patients( Males- 01, Females-18) were assessed for change of regime from Abatacept.1 patient with moderate disease activity was commenced on monthly subcutaneous Golimumab. She achieved LDA at 3 months and remission at 6 months. Of the remaining 18, 4(22%) were in remission and 14(78%) had LDA. In the remission group, at 3 months, all remained in remission, however, at 6 months, 3 were in remission and 1 in LDA. In the LDA group, 10 remained in LDA at 3 months while 4 progressed to moderate disease activity (MDA): 9 remained in LDA at 6 months and 5 patients had MDA. No patient defaulted and no one was lost to follow up. Of the 18 patients with LDA or remission at study onset, maintenance of at least LDA was achieved by 13 (72%)at 6 months follow up.

Conclusion: Majority of patients who have achieved remission or low disease activity with Abatacept can be continued on csDMARDs .