Combination Of Steroids Research Articles

돌발성 난청에서 발병 후 2주 이상 지연된 스테로이드 복합 치료의 이점

Objectives: We evaluated hearing recovery rates in sudden sensorineural hearing loss (SSNHL) according to a delay from onset to treatment. Materials and Methods: 281 subjects with SSNHL, who received steroid combination treatment as an initial treatment, were included in this study. We divided the patients into groups of the delay from onset to treatment: ≤48 hours, ≤7 days, ≤14 days, ≤21 days, ≤30 days, and 31–60 days groups. Results: Complete recovery (CR) rates were 21.2% in ≤48 hours group, 25.3% in ≤7 days group, and 7.9% in ≤14 days group. The CR was not found in groups with treatment delayed group after 14 days. The CR rate in ≤14 days group had 0.019-fold (95% CI: 0.051–0.769) decreased odds than the ≤48 hours group. Meaningful hearing recovery (MR) rates were 36.9%–47.1% in groups that received treatment within 14 days, and those of 17.7%–21.1% were observed in groups with a delay between 14 and 30 days. Of patients with treatment delays more than 31 days, hearing recovery of any type was not found. The MR rate in ≤30 days group had 0.234-folds decreased odds than ≤48 hours group (95% CI 0.061–0.906). Conclusions: Hearing recovery rates according to the delay of initial steroid treatment in SSNHL patients were identified. Clinicians can provide patients with information for hearing outcomes of delayed initiation of steroid treatment. Shared information facilitates better making decision with regard to their treatment plan. (J Clinical Otolaryngol 2021;32:212-220)

Toxocariasis-associated urinary system diseases: a systematic review of reported cases.

Toxocariasis is a neglected tropical disease caused by Toxocara canis and Toxocara cati. Toxocara species can involve many organs, such as the brain, heart and lungs, however, the urinary system involvement of toxocariasis is largely unknown. We performed a systematic review to identify cases infected with urinary tract toxocariasis. We identified seven cases that were eligible to be reviewed. Among the included citations, four studies reported bladder involvement and three reported kidney involvement. Fever, urinary, and abdominal presentations were amongst the most important clinical symptoms. Eosinophilic cystitis and nephrotic syndrome were the most common diagnoses.. The treatment regimen included a combination of anthelmintic drugs and steroids. In cases of urinary tract presentations accompanied by eosinophilia or histopathologic findings suggestive of parasitic infection, toxocariasis should be included in the list of differential diagnoses, especially in endemic areas.

Comparative evaluation of efficacy of muscle relaxant, vasodilator and combined intralesional steroid with hyalaronidase use in oral submucous fibrosis

Oral Sub Mucous Fibrosis (OSMF) is a disease , which predominately occurs in Indians and South East Asians. It is characterised by mucosal rigidity of varying intensity due to fibroelastic changes of the juxta-epithelial layer, resulting in a progressive inability to open mouth. The main concern in the condition is the management of trismus and burning sensation of oral mucosa. this study was conducted to compare various medical treatment protocol of OSMF, so as to arrive at definitive and effective protocol for the management of OSMF. 105 patients of OSMF attending the ENT OPD and satisfying the criteria for inclusion were enrolled for the study. The subjects were randomly divided into age sex matched into three study groups( Dexa with hyaluronidase , Oral vasodilator, Muscle relaxant) in which the relief in symptoms was noted. Lycopene was given in all patients. Group A, patients were given intralesional injection Dexamethasone with Hyaluronidase biweekly for five weeks and marked improvement was seen in cases of pain with spicy food 13 cases (76.47%), followed by decreased in mouth opening 9 cases (56.25%). In Group B, oral vasodilator Tablet Pentoxifylline 400 mg TDS was given and showed improvement in difficulty in protruding tongue in 9 cases (60%), pain with spicy food 8 cases (50%), decreased mouth opening 6 cases (37.5%), oral ulceration 3 cases (42.85%). In Group C with muscle relaxant Tablet Myosone 50 mg BD showed improvement pain with spicy food 8 cases (42.10%), decreased mouth opening 8 cases (42.10), difficulty in swallowing 3 cases (37.5%). As there is still paramount of controversy regarding the ethology of OSMF there is no definite treatment protocol. Patients which received intralesional dexamethasone and hyaluronidase along with oral lycopene showed better clinical and symptomatic improvement in comparison to others groups, which at present appears to the best option for OSMF.

Uveitis and Rheumatological Diseases

Uveitis is the most common ophthalmological disorder in the field of rheumatology, accounting for a significant proportion of visual morbidity, both locally and internationally. Causative factors can be divided into infectious and noninfectious etiologies. The diagnosis of uveitis is a major challenge due to heterogeneity in presentation. The disease course may be acute monophasic, recurrent, or chronic relapsing. Complications include posterior synechiae, secondary cataract, ocular hypertension or glaucoma, macular edema, retinal vascular occlusion, epiretinal membrane, and so on, and ultimately visual loss. Antimicrobial therapy is indicated for infection, whereas noninfectious uveitis warrants a combination of steroids, immunosuppressives, and anti-inflammatory agents. With the advancement of biologics, treatment strategies in chronic, noninfectious uveitis have had multiple breakthroughs, particularly in treatment-resistant cases. This article provides a review of the diagnostic approach to uveitis based on symptomatology and ophthalmological findings, and discussion of relevant treatment modalities and strategies.

Influence of Persistent Inflammation in Follow-Up Biopsies After Antibody-Mediated Rejection in Kidney Transplantation.

Background: Despite recent advances in immunosuppression treatment, antibody-mediated rejection (ABMR) remains the leading cause of kidney graft loss. Information about prognostic markers and the efficacy of treatment is scarce.Methods: Retrospective study with kidney recipients diagnosed an active ABMR from January 1, 2004 to December 31, 2019 to explore the influence of persistent inflammation in follow-up biopsies on graft survival after ABMR treatment.Results: About 116 patients were included. Active ABMR were treated with a combination of plasma exchange (PE), intravenous immunoglobulin (IVIg), rituximab, and steroids. At 6 months of treatment, 63 (54.3%) patients presented a stabilization or improvement in kidney-graft function. The effectiveness varied depending on the timepoint of the presentation between transplantation and rejection, which is lower for those with late ABMR (63 vs. 21% for early vs. late ABMR, respectively). Ninety patients (77%) underwent a control biopsy after ABMR treatment, from which 46 (51%) responded to the treatment. Microvascular inflammation (MVI) persisted in 64 (71%) biopsies, whereas tubulitis persisted in 17 (19%) biopsies. Death-censored graft survival at 1 year was significantly lower in patients with persistent MVI (86% vs. 95% without persistent MVI, P = 0.002), or with persistent tubulitis (44% vs. 66% without tubulitis, P = 0.02). In the Cox Regression analysis, the persistence of MVI [hazard ratio (HR), 4.50 (95%CI, 1.35–14.96), P = 0.01] and tubulitis [HR 2.88 95%CI (1.24–6.69), P = 0.01) in follow-up biopsies significantly increased the risk of graft failure.Conclusion: Persistent inflammation in follow-up biopsies after ABMR treatment was associated with an increased risk of graft loss, even without meeting Banff rejection criteria.Study Registration: Agencia Española de Medicamentos y Productos Sanitarios (AEMPS): 14566/RG 24161. Study code: UTRINM-2017-01.

NCMP-15. IMMUNE CHECKPOINT INHIBITOR ENCEPHALITIS: A RETROSPECTIVE COHORT STUDY

Abstract OBJECTIVE To review our institution’s experience with immune check point inhibitors (ICI) in patients with all cancer types and describe the incidence and outcomes of encephalitis associated with its use. METHODS We performed a single-center retrospective chart-review identifying patients who developed encephalitis within 12 weeks of treatment with an ICI. RESULTS Between 2011 to 2020 we identified 842 unique patients treated with an ICI with 32 patients (3.8%) developing encephalitis associated with treatment. The median time to diagnosis was 20 days post infusion (13-24 days IQR) and 3 infusions (2-4 IQR). No specific treatment was more significantly associated with encephalitis than the rest with the combination of ipilimumab and nivolumab (10 of 176, 5.68%) being the most common, and single agent nivolumab (9 of 222, 4.05%) and pembrolizumab (8 of 271, 2.95%) being slightly less frequent. By class PD-1 inhibitors were the most common treatment associated (n=18, 3.76%), however there was no one specific class more significantly associated with increased rates of encephalitis when comparing this to inhibitors of PD-L1 (n=2, 1.16%), CTLA-4 (n=2, 5.00%), or combination of PD-1/CTLA-4 (n=10, 6.02%) (p=0.26). Patients were treated with discontinuation of the therapy alone (n=7), high dose steroids alone (n=10), or a combination of high dose steroids, IVIG, or plasma exchange (n=15). The effects were typically reversible or non-disabling with the average 90-day ECOG score being 1.8. There were 8 patients (25%) who developed severe debility (n=4) or death (n=4). CONCLUSION Encephalitis is a rare complication associated with ICI therapies. Overall, there was no apparent specific drug or class more at risk of causing this complication. As ICI therapy is used more in practice, we will likely see a greater number of cases of ICI encephalitis and need to be aware of how it presents, diagnose, and treat appropriately to avoid permanent disability.

Efficacy and Safety of Ruxolitinib and Steroids for Treating Patients with Relapsed or Refractory Multiple Myeloma

IntroductionRuxolitinib (RUX) is an FDA-approved oral, selective inhibitor of Janus kinase (JAK) 1/2 for the treatment of patients with intermediate or high-risk myelofibrosis and polycythemia vera who have had an inadequate response to or are intolerant of hydroxyurea. Preclinical studies from our laboratory have demonstrated that RUX in combination with dexamethasone shows marked anti-myeloma effects both in vitro and in vivo. Specifically, RUX blocks expression of Mucin 1 whose function is linked to lenalidomide (LEN) resistance, downregulates PD-L1 and PD-L2 expression and reduces tumor stimulatory M2 macrophage polarization in multiple myeloma (MM) bone marrow. Recently published results from a Phase 1 trial for 28 heavily previously treated MM patients administered RUX, LEN and methylprednisolone (MP) demonstrated that the therapy was well tolerated and RUX overcame refractoriness to LEN and steroids (Berenson et al., Clin Cancer Res. 2020). The clinical benefit rate (CBR) and overall response rate (ORR) were 46% and 28%, respectively, and all 12 responding patients were refractory to LEN. We evaluated whether the combination of RUX and steroids without LEN was active for treating similar patients through treatment of a cohort within the current trial using this two-drug combination (NCT03110822).MethodsMM patients must have failed > 3 prior regimens and have been exposed to a proteasome inhibitor and LEN. Patients were treated orally (PO) with 15 mg RUX twice daily on days 1-28 of a 28-day cycle and 40 mg MP every other day. The treatment of this two-drug combination was continued until disease progression (PD). Once PD was confirmed, LEN at 10 mg PO daily on days 1-21 of a 28-day cycle was added to the regimen. Primary endpoints were safety, ORR and CBR.ResultsAs of July 15, 2021, 27 patients were enrolled. The median age was 64 years (range, 46-85), and 17 (63%) were male. Patients received a median of 4 (range, 3-11) prior treatments including LEN and steroid-containing regimens to which they were all refractory. Twenty-six patients have completed at least 1 full cycle of therapy; and, thus, were evaluable for efficacy.The ORR and CBR were 35% (n=9) and 39% (n=10), respectively. Notably, all 10 responding patients were refractory to LEN (i.e., progressed while on or within 8 weeks of last dosage). The remaining patients showed stable disease (n=12) or PD (n=4). The median follow-up was 13 months. The median progression-free survival was 4 months (range, 1-21). The median duration of response was 11 months (range, 1-20). Of 13 patients who progressed on the two-drug combination and had LEN added to their regimen, 6 patients responded (3 MR and 3 PR).Nine patients experienced SAEs including sepsis (12%), sepsis with neutropenic fever (4%), thrombocytopenia (4%), hyperglycemia (4%), neutropenia (4%), anemia (4%), acute heart failure (4%), rotator cuff tear (4%), osteomyelitis (4%), aspiration pneumonia (4%), pneumonia and pneumothorax (4%), and deep venous thrombosis (4%). Two patients died (one each from pneumonia and PD).ConclusionsThis ongoing Phase 1 trial is the first study demonstrating clinical activity of the two-drug combination of the JAK inhibitor RUX with steroids for MM patients. The treatment was well tolerated and shows promising efficacy for treating heavily previously treated MM patients. Because of this, additional studies are being conducted with higher doses of RUX in combination with MP for this patient population. DisclosuresVescio: Janssen: Speakers Bureau; Karyopharm: Speakers Bureau; GlaxoSnithKlein: Speakers Bureau; Amgen: Speakers Bureau. OffLabel Disclosure:Ruxolitinib is being investigated off-label to determine if it shows anti-myeloma activity in combination with steroids for relapsed/refractory myeloma patients.

Incidence of Pleural Effusion with Dasatinib and the Effect of Switching Therapy to Bosutinib in Patients with Chronic Phase CML

Incidence of Pleural Effusion with Dasatinib and the Effect of Switching Therapy to Bosutinib in Patients with Chronic Phase CML

A multicenter study of clinical and biochemical profiles, treatments, and short-term outcomes in children with multisystem inflammatory syndrome associated with SARS-CoV-2 infection from Western India

Background: Severe acute respiratory syndrome corona virus-2 (SARS-CoV-2) infection can lead to multisystem inflammatory syndrome in children (MIS-C). This study was conducted to study epidemiology, clinical profile, treatment strategies associated in children MIS-C in two cities in Western India. Subjects and Methods: This is a retrospective, observational study of children who fulfilled the criteria for MIS-C, admitted to eleven pediatric intensive care units (PICUs) in Western India during the first wave SARS-CoV-2 infection in India, between February 2020 and December 2020. Demographic and clinical data including laboratory parameters, treatment regimens, and outcomes were collected and analyzed. Results: Of the 234 children presenting with MIS-C, they were categorized into 3 clinical phenotypes: fever and hyperinflammation, Kawasaki disease (KD)-like, and shock with multisystem organ dysfunction syndrome (MODS). C-reactive protein, procalcitonin (PCT), D-dimer, and pro-B-type natriuretic peptide levels were elevated in all patients. Intravenous immunoglobulin (IVIG) was used in 128 (54.7%), corticosteroids in 214 (91.45%), tocilizumab in 1 (0.4%), and remdesivir in 4 (1.7%). 95 (40.5%) children required vasopressors and invasive mechanical ventilation was necessary in 26 (11.1%). Two hundred and twenty-nine patients were discharged home with median duration of PICU stay of 4 days and hospital stay of 7 days, and 5 (2.1%) patients died during treatment. Significant reduction in the duration of hospital stay was observed in those who received both steroid and IVIG (P < 0.05) and also in the shock ± MODS group (P < 0.05). Conclusions: Combination of steroid and IVIG for the treatment of MISC, especially with Shock and MODS reduce the duration of PICU stay than treated with steroid alone.

P5‐47: Safety and efficacy of remdesivir, baricitinib and high‐dose steroid combination therapy in patients hospitalized with COVID‐19

P5‐47: Safety and efficacy of remdesivir, baricitinib and high‐dose steroid combination therapy in patients hospitalized with COVID‐19

O02 Cancer, Covid and control of RA – a toxic combination?

Case report - IntroductionThis case highlights the dilemma of keeping rheumatoid arthritis disease under control in active cancer cases and establishing a consistent multidisciplinary dialogue during a pandemic and staffing crises.During chemotherapy and active cancer treatment, disease-modifying therapies (conventional and biologic) are often stopped. In some cases, the potential benefits versus risks of restarting usual therapies have to be balanced against risks of suppressing disease activity with high-dose steroids. Risks of infection (common and atypical) need to be considered.Case report - Case descriptionA is a 67-year-old female non-smoker diagnosed with seropositive rheumatoid arthritis (RF, anti –CCP positive) in 2008. Other conditions include type 2 diabetes, atrial fibrillation (on warfarin), hypothyroidism and obstructive sleep apnoea. Due to active disease, despite triple therapy (methotrexate, sulphasalazine and hydroxychloroquine), anti-TNF therapy (etanercept) commenced in 2009 with primary non-response. However, she responded well to B-cell therapy (rituximab) in conjunction with oral methotrexate (25mg weekly) receiving annual infusions from 2010 to 2016.In 2017, an elective sleeve gastrectomy procedure for high BMI was abandoned after peritoneal deposits of concern were noted. Histology and CT imaging were consistent with a primary peritoneal malignancy (Stage 3c low-grade serous adenocarcinoma). Treatment involved debulking surgery (total abdominal hysterectomy, bilateral salpinoophorectomy, omentectomy) and tamoxifen.Treatment for rheumatoid arthritis stalled during this period but as frequent steroids were required for active joint inflammation, in agreement with the oncologists, she had a rituximab cycle in 2018.Unfortunately, in 2019 she had signs of cancer progression (elevated tumour markers, CT imaging) and has subsequently started carboplatin chemotherapy. She has been unable to continue methotrexate or rituximab pending completion of the chemotherapy cycles (ongoing). However, her arthritis is now uncontrolled without increased steroids. Due to recurrent flares, her maintenance dose has been increased from 5mg to 7.5—10mg prednisolone daily until we can establish if it is safe and appropriate to recommence her usual arthritis regime.Even without disease-modifying therapy like methotrexate and rituximab, risk of infection (including atypical ones) is still significant with the combination of chemotherapy and steroids. Risk of progressive joint damage and adverse quality of life with active arthritis also needs to be considered. Staffing crises, exacerbated by COVID pandemic issues, have added to complexity of decision making and coordination of regular multidisciplinary discussions regarding treatment.Case report - DiscussionCancer is a known association in rheumatoid arthritis patients with a twofold higher risk of lymphoma compared to the general population. Whether condition or treatment affects risk remains unclear as immune dysregulation is relevant in both autoimmunity and cancer. Paraneoplastic, recent onset arthritis, chemotherapy- or immunotherapy-induced arthralgia/arthritis are also well documented. This case had a seropositive rheumatoid arthritis phenotype quite a few years prior to cancer diagnosis. Primary peritoneal cancer is uncommon, often presenting as in this case as an incidental finding. It is usually treated like ovarian cancerWhilst methotrexate has been implicated in lung cancer, melanoma and non-Hodgkin lymphoma, overall safety data suggest any risk is quite low (e.g., EBV-associated lymphoproliferative disorders usually resolve with drug discontinuation). It is also a known chemotherapeutic agent. Anti-TNF treatment algorithms generally exclude patients with recent cancer. Rituximab, originally developed as a cancer drug, is not thought to affect risk of cancer development or progression.Treatment with disease-modifying therapy (conventional and biologics) is often withheld in patients with active malignancy undergoing chemotherapy due to a theoretical risk of potentiated immunosuppression and toxicity, particularly cytopaenias. However, maintaining arthritis control with glucocorticoids also has short- and long-term risks. Combining chemotherapy agents like carboplatin with methotrexate has been used for urothelial carcinoma and can be well tolerated with close monitoring of haematological parameters.Thus, it could be argued this patient is at risk of infections whichever treatment approach is taken and regaining control of arthritis with recommencement of methotrexate and rituximab is much better for her quality of life.Regular multidisciplinary discussions are important to outline risks versus benefits of combined treatment. This may be difficult in practice during staffing crises. Covid risk in patients receiving rituximab and/or chemotherapy, timing and response to COVID vaccination are also important considerations.Case report - Key learning pointsPrimary peritoneal cancer is uncommon and can present as an incidental findingWhilst treatment for progressive cancer is important, withholding rheumatoid arthritis treatment can have a significant adverse impact on quality of lifeMorbidity and mortality risks of stopping treatment versus combined treatment (cancer therapy and disease-modifying therapy) ideally needs to be fully discussed and agreed with the patient and all care providers – lack of “named” providers, restructuring, redeployment, multi-specialty care and a global pandemic can make coordination of this difficult

Complex combined steroid mix of the female tract modulates human sperm

Human spermatozoa interact with a complex biochemical environment in the female reproductive tract en route to the site of fertilisation. Ovarian follicular fluid contributes to this complex milieu and is known to contain steroids such as progesterone, whose effects on sperm physiology have been widely characterised. We have previously reported that progesterone stimulates intracellular calcium concentration ([Ca2+]i) signalling and acrosome reaction in human spermatozoa. To characterise the effects of the unified complete follicular fluid steroid hormone complement on human spermatozoa, a comprehensive, data-based, ‘physiological standard’ steroid hormone balance of follicular fluid (shFF) was created from individual constituents. shFF induced a rapid biphasic [Ca2+]i elevation in human spermatozoa. Using population fluorimetry, we compared [Ca2+]i signal amplitude in cells exposed to serial applications of shFF (6 steps from 10-5X up to 1X shFF) with responses to the equivalent progesterone component alone (6 steps from 135 pM - 13.5μM). Threshold for the response to shFF was right-shifted (≈10-fold) compared to progesterone alone, but the maximum response to shFF was greatly enhanced. An acrosome reaction assay was used to assess functional effects of shFF-induced sperm calcium signalling. shFF as well as progesterone-treated spermatozoa showed a significant increase in % acrosome reaction (P < 0.01). All of this evidence suggests the modulation of progesterone-mediated responses by other follicular fluid steroids.

NON-CARDIOGENIC PULMONARY EDEMA FOLLOWING CARDIAC ABLATION: WILL THE REAL CULPRIT PLEASE STAND UP?

TOPIC: Diffuse Lung Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Non-cardiogenic pulmonary edema (NCPE) is an entity with a variety of etiologies and pathology that include alveolar damage due to direct toxicity or catecholamine surge. We present a case of non-cardiogenic pulmonary edema 48 hours following ablation for atrial fibrillation. CASE PRESENTATION: A 72-year-old woman with a history of atrial fibrillation, coronary artery disease with bypass grafting, and heart failure with preserved ejection fraction presented with sudden onset shortness of breath for a few hours. She had undergone cardiac ablation with pulmonary vein isolation and cavotricuspid isthmus line 2 days prior, with no periprocedural complications. She was tachypneic and hypoxic (oxygen saturation 51% on room air), with reduced breath sounds on auscultation but no peripheral edema or jugular venous distension. Laboratory workup was notable for leukocytosis, elevated N-terminal proBNP (9,853 pg/mL), elevated C-reactive protein (257 mg/L), with normal procalcitonin and negative viral panel, including SARS-CoV-2. Electrocardiography showed no acute abnormalities. Computed tomography (CT) of the chest did not show pulmonary embolism but demonstrated bilateral ground glass opacities. Oxygen was administered via high-flow nasal cannula, and diuresis was initiated in the inpatient setting. Echocardiography revealed mild left ventricular diastolic dysfunction, with left atrial enlargement and mild pulmonary hypertension (39 mm of Hg). Right heart catheterization demonstrated normal filling and pulmonary artery pressures (pulmonary capillary wedge pressure (PCWP) of 6 mm Hg and mean pulmonary artery pressure or 16 mm Hg). Systemic corticosteroids were empirically initiated for suspicion of an inflammatory etiology. The combination of steroids and diuresis produced symptomatic and radiographic improvement, and she was discharged with supplemental oxygen. Her oxygen was unable to be completely weaned off as of follow-up 6 weeks later. DISCUSSION: Catheter ablation for atrial fibrillation is a widely adopted rhythm control strategy with a favorable safety profile. NCPE appears to be an exceedingly rare complication of ablation, with only a few cases being reported in our literature review. The diagnosis of NCPE can be challenging to make, as it must be distinguished for cardiogenic edema. The lack of peripheral edema or jugular venous distension in our patient suggested the absence of cardiac etiology, but a right heart catheterization demonstrating normal PCWP definitively excluded it. Hypotheses for mechanisms for this reaction include a systemic inflammatory response syndrome, autoimmune reaction to ablation, and vagus nerve injury with consequent dysregulation of immunomodulation. Treatment is primarily supportive, including adequate ventilation, with consideration for diuresis and corticosteroids. CONCLUSIONS: NCPE is a rare adverse effect of ablation, and treatment is primarily supportive. REFERENCE #1: Weber R, Minners J, Restle C, et al. Pulmonary edema after extensive radiofrequency ablation for atrial fibrillation. J Cardiovasc Electrophysiol. 2008 Jul;19(7):748-52. DISCLOSURES: No relevant relationships by Dan Kazmierski, source=Web Response No relevant relationships by jacob miller, source=Web Response No relevant relationships by Pius Ochieng, source=Web Response No relevant relationships by NISHANT SHARMA, source=Web Response

022 Exploring the potential of the novel IFNγ aptamer TAGX-0003 as a treatment for alopeciaareata in pre-clinical models

Alopecia areata (AA) is an autoimmune hair loss disorder in which hair follicles (HFs) that have lost their protective immune privilege (IP) are attacked by an inflammatory cell infiltrate including key effector CD8+NKG2D+ cells rapidly turn into catagen. IFNγ is recognized as a key pathological cytokine in driving IP collapse and AA pathogenesis. While recently JAK inhibitors are used off- label, despite the possible long-term effect associated to their broad immunosuppressive activities, the combination of steroid and minoxidil is still considered to be the first line of treatment for AA.

Graves' orbitopathy

Graves' orbitopathy (GO) is an autoimmune orbital disease which is mostly associated with Graves' disease and requires good interdisciplinary cooperation. To minimize irreversible damages a stage-adapted anti-inflammatory therapy is of great importance. Discussion of the latest results of new findings of the pathogenesis, randomized controlled trials on anti-inflammatory treatments for Graves' orbitopathy and novel therapeutic concepts. In all patients with GO achieving euthyroidism, as well as cessation of smoking is very important to avoid prolongated diseases. Mild cases of GO can be treated with selenium supplementation and artificial tears. The moderate-to-severe, active form of GO requires primarily i. v. steroids in combination with orbital irradiation in case of impaired motility. In patients with insufficient therapeutic response after 6 weeks, treatment should be switched to other immunosuppressive agents. In severe sight-threatening cases even high-dose i. v. steroid treatments are often ineffective and bony orbital decompression is necessary. As latest research data have improved our understanding of the pathophysiology of GO, targeted therapies have been developed for GO. Teprotumumab, an IGF-1 receptor antibody, was shown effective in treating GO patients in a phase III trial and should soon be awarded approval for Europe. Inactive patients, who suffer from disturbing exophthalmos should be also treated with bony decompression before eye muscle or lid surgery. The current concept for Graves' orbitopathy is as follows: first anti-inflammatory therapy then surgical correction of the permanent defects. This might be modified in the future, due to the promising effects of targeted therapies.

Efficacy of Hyaluronic Acid Injections versus Steroid Injections on Painful Tendinopathies

Background: Tendinopathies are manifested by pain, swelling, and limited mobility functions.Corticosteroid injections have been a mainstay in the treatment of tendinopathy, and are widely used despite the controversy regarding their usefulness and safety.The peri-tendinous administration of hyaluronic acid (HA) has shown promising results in the management of tendinopathy. Objectives: The aim of the current study was to evaluate the efficacy of peri-tendinous injections of hyaluronic acid versus steroid injections on pain reduction in patients with painful tendinopathies. Patients and methods: A prospective study, including a total of 90 patients with tendinopathy who were recruited from the Rheumatology and Rehabilitation Outpatient Clinic at Sohag University Hospital. Demographic data including age, disease duration, and tendon affected were evaluated. Patients were divided into three groups, each group contained 30 patients. First group received peritendinous steroid injection, second group received peritendinous hyaluronic acid injection, and the third group received both peritendinous hyaluronic acid and steroid injections. Groups were compared using in visual analogue scale, tenderness and range of motion after one week, one month and after 3 months from injection. Results: Best improvement was seen in the group of combined hyaluronic acid and steroid; followed by the group of steroid injection alone, which showed early response better than hyaluronic acid alone. Conclusion: Local injection for tendinopathies by combined hyaluronic acid and steroid gives significantly better and more long standing effect compared to either hyaluronic acid or steroid alone. On the other hand, monotherapy showed non-significant difference between steroid and hyaluronic acid.

Analysis of Clinical, Pathological and Prognostic Features of Coexistent Membranous and IgA Nephropathy in a Series of 13 Patients at a Tertiary Care Hospital.

BackgroundMembranous nephropathy (MN) and immunoglobulin A nephropathy (IgAN) are although two different entities, yet can rarely coexist. There is not much data available on this coexistent disorder, specifically with regard to the treatment modality and outcome. Here, we analyse in detail, retrospectively, 13 cases of coexistent IgA and membranous nephropathy (IgA-MN).MethodsRenal biopsy data of 1084 diagnosed cases of either membranous or IgA nephropathy was obtained from March 2015 till March 2021. Out of 1084 patients, 19 diagnosed cases of the coexistent disorder were identified. Six out of 19 patients were excluded because of their unwillingness. From remaining 13 patients, data regarding clinical presentation, investigations, management and treatment response was collected from hospital database, files and via telephonic interview.ResultsThe overall prevalence noted was 1.75%. Among them, 53.8% were females and 46.2% were males. Their median age was 40 years (range: 14-71 years). On workup, mean serum albumin was 2.64 g/dl (range: 1.6-3.8 g/dl), mean proteinuria was 5.5 g/24 hours (range: 1.55-11.48 g/24 hours) and mean creatinine was 0.98 mg/dl (range: 0.5-2.8 mg/dl). Anti-phospholipase A2 receptor antibody positivity was only 14.2%. The renal biopsy of all patients showed thickening of the glomerular basement membrane with granular IgG deposits and mesangial expansion with granular IgA deposits. A total of 80% patients showed complete remission with steroids, calcineurin inhibitors (CNIs) and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARBs).ConclusionIgA-MN is probably a separate disorder that can only be confirmed on immunofluorescence microscopy. The response to the combination of steroids, CNIs and ACEi/ARBs is found to be the most effective; hence, this combination must often be used for the management of this coexistent disorder.

A Retrospective Study on Alopecia Areata in Children: Clinical Characteristics and Treatment Choices

Background: Although children are affected frequently with alopecia areata (AA), data are limited on clinical characteristics and treatment choices. Materials and Methods: We retrospectively reviewed the records of the pediatric dermatology department over a 12-year period to identify children with AA. Clinical data were collected. Results: Three hundred and sixty-four children with AA were identified, aged 1–12 years, 214 males and 150 females. The mean age of onset was 6.6 years (±3.3). The disease presented with patches on the scalp in the majority (90.7%), whereas only 6 children had alopecia totalis or universalis. The most commonly prescribed treatment was topical steroids (69.1%), followed by the combination of topical steroids and minoxidil 2% (14.3%). Oral steroids were prescribed in only 16 children. Follow-up at 3 months was available for only 70 children and the majority (84.3%) had some hair regrowth. Hair regrowth was unrelated to the number of plaques (p = 0.257), disease location (p = 0.302), and atopy (p = 0.999). Hair regrowth only correlated with the type of treatment (p = 0.003) with potent topical and intralesional steroids giving the best results. Conclusion: AA usually presents with a mild form in children, and potent topical steroids are the mainstay of treatment.

Long-term success treating inflammatory epiretinal neovascularization with immunomodulatory therapy.

This study aims to report the long-term outcomes of uveitis-associated optic disc and epiretinal neovascularization (NV) treated with immunomodulatory therapy alone. This is a retrospective, multi-center chart review conducted at Northwestern University (Chicago, IL) and San Raffaele Scientific Institute (Milan, Italy) from 2014 to 2021 of patients with optic disc and/or retinal neovascularization associated with uveitis. The data collected included age at the time of NV detection, gender, medications, and follow-up period. Imaging was reviewed if available. Eight eyes of six patients were identified. The mean age was 22years (range 10-52years); the median follow-up was 3years (range 6months to 7years). All eyes presented with active NV at the time of uveitis onset; 7 eyes were treatment-naïve. None had clinical or angiographic evidence of retinal ischemia. All patients received a variable combination of local steroids, systemic steroids, and systemic immunosuppression. Complete resolution of uveitic NV occurred in all eyes within a median of 8weeks (ranging 2-20weeks) from initiating treatment. No NV recurrence was noted. Immunomodulatory therapy alone may be successful in achieving long-term control of uveitis-associated NV, without the use of destructive measures.

849P Demographics of Langerhans cell histiocytosis patients who died during the 2010-2017

Langerhans cell histiocytosis (LCH) is a rare histiocytic neoplasm that originates from the dendritic cell and manifests as locally advanced disease or multisystem involvement. The overall 5-year survival rate of a person diagnosed with LCH is >90% (100% for patients with single-system disease and 91.7% for patients with multi-system disease). Management of single system or multisystem disease involves a combination of steroids and/or chemotherapy. Utilizing the NCDB, we aim to study the clinical and demographic characteristics of LCH patients who died during the period of 2010-2017.