Course Of Steroids Research Articles

P050 Rapidly worsening subcutaneous oedema in a young boy: a case of juvenile dermatomyositis

Abstract Background/Aims Juvenile onset dermatomyositis (JDM) is a rare disease with an incidence of 2-4 per million. The presentation includes skin manifestations of heliotrope rash, Gottron's papules, nail fold changes, bilateral peri-orbital or upper eyelid edema and focal mild facial swelling with muscle weakness. Widespread and generalized subcutaneous oedema is a rare presentation in JDM. Methods A 4-year-old previously healthy boy presented to a tertiary care hospital in Sri Lanka with generalized rash involving the face, limbs and trunk for seven days associated with facial puffiness and hair loss. He also complained of generalized myalgia and irritability and refused to walk. He did not have dysphagia, dysphonia or shortness of breath. He had a prodromal febrile illness two weeks back that had been treated as a viral fever. He had evidence of palatal ulcers, chelitis, malar rash, erythema of eyelids, eyelid swelling and necrotic vasculitic lesions in peripheries. He had tenderness over his thighs with muscle power being MRC grade 3/5 in the proximal muscles of his lower limbs. Arm and neck flexors’ power was normal. Results His ESR was raised at 35 mm/hour and CRP was normal. His CPK was 2726 U/l, AST was raised at 931 U/l, ALT was 511 U/l and albumin was 33 g/l. His ANA, dsDNA and ENA panel was negative. A myositis immunoblot could not be done due to financial constraints. An EMG showed evidence of myositis in his proximal muscles. He fulfilled the criteria for juvenile dermatomyositis based on Bohan and Peter’s criteria. He was treated with high dose steroids, dexamethasone 2 mg 6 hourly. While receiving steroids he deteriorated with worsening subcutaneous oedema of face and neck with high fever spikes. The oedema progressed to involve his whole body. His muscle power deteriorated with involvement of his arms. A venogram ruled out any obstructive venous disease. A CT CAP ruled out any underlying malignancy. His 2D echo revealed normal heart function. He was converted to IV Methylprednisolone 30 mg/kg and was started on plasmapharesis. He improved after the 3rd cycle and was started on cyclophosphamide infusions. He received six cyclophosphamide pulses with a tapering course of steroids. He remains controlled in his disease with no new muscle weakness or skin manifestations. However, he remains steroid dependent and is awaiting treatment with Rituximab. Conclusion Subcutaneous oedema in JDM is attributed to a vasculopathy. This is associated with severe rapidly progresssive disease with high mortality and requires aggressive immunosuppression. As seen in our patient disease is resistant to conventional treatment. Early recognition leads to better outcomes in these patients. Disclosure S. Janagan: None. W.A.E. Udeshika: None. P.M. Samarasinghe: None. J.D. Jagoda: None.

P056 Rheumatology haematology interface: an unusual case of aortitis

Abstract Background/Aims In rheumatological practice it in not unusual to see patients with haematological involvement. We would like to present a very rare diagnosis of Erdheim-Chester disease presenting as retroperitoneal fibrosis and large vessel vasculitis who failed to respond to conventional treatments with steroids and methotrexate. Methods A 71-year-old man presented to haematology with retroperitoneal mass. This was investigated with CT thorax, abdomen and pelvis and a biopsy was performed which was negative for haematological malignancies. However, CT scan picked up thickening of aorta and a PET scan was performed subsequently confirming widespread aortitis and peri-renal mass thought to be consistent with retroperitoneal fibrosis. The patient was started on reducing course of oral steroids with a working diagnosis of retroperitoneal fibrosis with large vessel vasculitis. Results Subsequent staining for IGG-4 was negative and biopsy was not typical with IgG4 cells. The patient was started on high doses of oral steroids by haematologist with Methotrexate started subsequently by rheumatologist due to persistent changes on PET scan, high inflammatory markers and worsening of patient with generalised malaise, weight loss and fatigue. The patient failed to respond to uptitrated doses of methotrexate and was discussed with a specialist unit for consideration of anti-IL6 tocilizumab to control his large vessel vasculitis. On discussion of imaging in MDT, unusual appearance with sparing of ureters, splaying of peri-nephric fat, lack of IgG4 cells pointed towards an alternative diagnosis. Conclusion The patient was subsequently discussed in the national adult histiocytosis meeting with national and international haematologists. The clinical presentation, radiological appearance was thought to be classic of Erdheim-Chester disease, a rare form of adult onset histiocytosis. After further discussions with specialist centre the patient has been commenced on trametinib, a MEK inhibitor treatment (cell tissue negative for BRAF mutation). The patient has recently developed heart failure and has undergone right heart catheter which has found extremely rare pulmonary artery vasculitis too. Disclosure S. Raghuvanshi: None. B. Tarar: None. A. Shaaban: None.

Comparison of respiratory distress syndrome amongst preterm twins (28-34 Weeks) born within and after two weeks of completion of single antenatal corticosteroid course: A bidirectional cohort study.

BackgroundThe literature on neonatal outcomes in preterm twins delivered before 34 weeks but within and after 14 days of a single initial steroid course is limited.Material and methodsThis bidirectional (226 prospective and 42 retrospectives) cohort study was performed at a tertiary care teaching hospital in South India. We compared the respiratory distress syndrome and neonatal death amongst preterm twins from 28 to 34 weeks born < 14 days (Group A, n=268) and after 14 days (Group B, n=268) of completion of a single course of antenatal steroids. We used multivariable regression analysis (log-binomial model) to adjust for confounding variables. We generated a propensity-matched score with probit regression to analyse outcomes (respiratory distress and neonatal deaths).ResultsThe two groups had significant differences in the distribution of birthweight, gestation period and mode of delivery. On adjusted analysis, the period of gestation below 33 weeks and weight below 1.5 kg had the maximum influence on respiratory and other morbidities, and weight less than 1 kg on neonatal death. [adjusted relative risk (ARR) 26.06, (95%CI=2.37-285.5), p=0.008]. On propensity scoring after matching all these variables, we found an [ARR of 2.0 (95% CI: 1.03-3.88), P=0.017] for neonatal death after 14 days of steroid injection. The ARR for respiratory distress syndrome was 1.13 in those born after 14 days of steroids, though it did not reach statistical significance.ConclusionOn propensity scoring, the steroid-delivery interval more than 14 days was associated with a significantly increased risk (ARR of 2) of neonatal death.

The role of dermatoscopy and reflectance confocal microscopy in the assessment of relapsing secondary cutaneous follicular B-cell lymphoma

A 72-year-old man presented with several infiltrated painless patches and nodules (5-15 mm) on his scalp, without lymphadenopathy. The patient reported that he previously had similar erythematous-to-purple lesions and had been treated with a 2-week course of topical steroid, reporting a partial response (Fig 1).

Using mTOR Inhibitor Nanoimmunotherapy to Induce Cardiac Allograft Tolerance in Non-Human Primates

<h3>Purpose</h3> Though tolerance to kidney allografts has been consistently achieved using a mixed chimerism model, cardiac allografts remain resistant to tolerance induction. Lipoprotein-based nanobiologics loaded with a mammalian target of rapamycin inhibiting prodrug (mTOR inhibiting nanobiologics, mTORi-NBs) inhibit trained immunity and promote graft infiltrating M2-macrophages that provide a favorable local immunologic milieu for tolerance induction. In this study, we evaluate the ability of mTORi-NBs to induce tolerance in a cardiac allograft model in NHPs. <h3>Methods</h3> Six NHPs underwent simultaneous heterotopic heart and bone marrow transplantation for mixed chimerism induction. Group A (n=3) was conditioned with 3 Gy total body irradiation (TBI), 7 Gy thymic irradiation (TI), ATGAM, anti-CD40L monoclonal antibody on days 0, 2, 5,7, 9, and 12 post-bone marrow transplant (pBMTx), and cyclosporine until day 28 pBMTx. Group B recipients (n=3) underwent the same conditioning regimen with the addition of mTORi-NBs at a dose of 0.15 mg/kg on days 2, 5, 12, 19, and 26 pBMTx. Group B donors were also treated with a single dose of mTORi-NBs two days before transplant. <h3>Results</h3> In group A, all allografts had end stage rejection by day 175 pBMTx with a mean duration of lymphocyte chimerism of 74 days. The first recipient in group B developed durable full chimerism and mild graft versus host disease (GVHD) which resolved after a course of steroids and cyclosporine. After resolution of his GVHD, his graft continued beating strongly with no evidence of rejection through day 239 pBMTx. The second and third recipients received half dose (1.5 Gy) TBI and both allografts are contracting strongly at days 271 and 26 pBMTx, though the second recipient had some evidence of rejection at day 212 pBMTx. Currently, the mean duration of lymphocyte chimerism in Group B is 149 days. <h3>Conclusion</h3> Preliminary studies suggest that adding mTORi-NB nanoimmunotherapy to a mixed chimerism protocol prolongs both donor lymphocyte chimerism and heart graft survival in NHPs even when reducing pre-operative TBI.

Systemic sarcoidosis presenting as nasolacrimal duct obstruction – A rare presentation

Lacrimal sac sarcoidosis is rare and reported in 7.7% of the cases of systemic sarcoidosis. Nasolacrimal duct obstruction, as the initial presentation of sarcoidosis, is very rare. A 50-year-old woman presented to us with complaints of watering and discharge from the right eye for the past 3 months. On examination, she was found to have a right-sided nasolacrimal duct obstruction and underwent external dacryocystorhinostomy (DCR). Intraoperatively, a biopsy was done because of the abnormally thickened sac wall. The histopathology examination was suggestive of granulomatous inflammation. After ruling out tuberculosis and fungal infection with the appropriate investigation, a diagnosis of pulmonary sarcoidosis with lacrimal sac involvement was made because of the mediastinal lymphadenopathy on computed tomography. She was treated with a course of oral steroids along with immunosuppressants for 3 months. There was no evidence of recurrence at 8 months of follow-up.

Persistent hypoglycemia in the setting of metastatic malignant insulinoma to the liver treated with chemoembolization and bland embolization

We are describing a patient with malignant insulinoma and unusual clinical and pathological features. The patient presented late in the course of the disease with history of abdominal pain and was found to have large tumor of the pancreas and metastasis to the liver. Also, he presented with acute diarrhea which is not a feature of Insulinoma. During the hospital stay the patient had sever hypoglycemia with very inappropriately high to the low blood glucose levels of Insulin, C- peptide and Proinsulin. On biopsy of the tumor it was found to be neuroendocrine tumor, but staining’s for Insulin were negative. The patient was treated with surgical resection of the distal pancreas when the insulinoma was located, splenectomy, cholecystectomy and appendectomy. Also, chemoembolization and embolization of the metastatic tumors of the liver were done and patient’s hypoglycemia was treated with Diazoxide and short course of Steroids and Octreotide. We underscore the need of combined clinical, laboratory, radiological and pathological approach while diagnosing malignant Insulinoma.

Abnormal Newborn Screen During a Pandemic.

Abnormal Newborn Screen During a Pandemic.

Letter to the editor: Liver transplantation following severe acute respiratory syndrome‐coronavirus‐2 vaccination–induced liver failure

Several case reports have described development of liver injury following severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) vaccination in Hepatology.[1, 2] These cases showed autoimmune hepatitis (AIH) features, and all cases responded well to corticosteroid therapy. Herein, we present a patient who underwent liver transplantation due to fulminant liver failure following vaccination with the BioNTech vaccine. A 53-year-old previously healthy man received a first dose of BioNTech vaccine on the June 5, 2021. Ten days after vaccination, he developed mild abdominal pain, erythematous skin eruption, and pruritus. Initial laboratory findings were alanine aminotransferase (ALT) 333 (upper limit of normal [ULN] 55 U/L), aspartate aminotransferase (AST) 168 (ULN 34 U/L), alkaline phosphatase 102 (ULN 150 U/L), and total bilirubin 0.8 (ULN 1.2 mg/dl). The patient’s symptoms were considered to be a hypersensitivity reaction. Oral antihistaminic therapy and topical steroids did not lead to clinical improvement. On day 18 after vaccination, prednisolone 32 mg/day for 10 days followed by 16 mg/day for 20 days was commenced. One week into the steroid course, symptoms significantly improved, and aminotransferases decreased (Figure 1). The patient was reluctant to receive a second vaccine dose for fear of additional side effects but had travel plans and needed a full vaccination chart. He, therefore, scheduled a second Pfizer-BioNTech vaccine dose 6 weeks after the first dose. Following the second vaccination, similar symptoms reoccurred after a few days. The dose of prednisolone was increased to 32 mg/day, gradually tapered, and discontinued in mid-August 2021. One month after, he developed abdominal pain, myalgia, fatigue, and jaundice. The symptoms and laboratory findings did not improve over 10 days, and he was referred to a tertiary liver transplant center. At admission, ALT was 485, AST was 629, total bilirubin was 6.6 mg/dl, and the international normalized ratio was 1.36. Serum IgG levels were 28.3 (7.0–16.4 g/L). Viral serology was negative for hepatitis A–E, Epstein-Barr virus, cytomegalovirus, and herpes simplex virus. Antinuclear antibodies, smooth muscle actin, antimitochondrial antibodies, anti–liver–kidney microsome 1, liver cytosolic antigen 1, and anti–soluble liver antigen were all negative; and ceruloplasmin was normal. The liver biopsy showed portal inflammation with interface activity and significant lobular necroinflammatory activity, hepatocellular rosette formation and emperipolesis that are typical components of AIH. Treatment with prednisolone (40 mg/day, i.v.) and plasma exchange did not improve the liver function. The patient developed HE and underwent living donor liver transplantation. One month after liver transplantation, he was alive with significantly improved laboratory findings. We presented a report of severe outcome of liver injury that developed after SARS-CoV-2 vaccination. We are aware that it is difficult to establish a definitive causality between SARS-CoV-2 vaccine and hepatitis. However, our case demonstrates strong evidence of vaccine-induced immune-mediated liver injury. The patient developed liver injury after a first dose of Pfizer-BioNTech vaccine which on reexposure led to severe liver injury. Our case, along with other reports, suggests that AIH-like hepatitis may develop after SARS-CoV-2 vaccination. Early diagnosis and effective management seem to be very important in this emerging condition. Nothing to report. Cumali Efe, Murat Harputluoğlu, and Sezai Yilmaz conceptualized the study. Cumali Efe, Murat Harputluoğlu, and Neşe Karadağ Soylu collected and analyzed data. All authors approved the final version of the manuscript. All data that support the findings of this study are presented in the text.

Uveal lymphoid hyperplasia: treatment with combination antibiotics and steroids

Background/aimsUveal lymphoid hyperplasia (formerly benign reactive hyperplasia of the choroid) spans histopatholological characteristics ranging from reactive hyperplasia to low-grade lymphoid neoplasm. There is strong evidence that other low-grade lymphoid neoplasms,...

Changing Tocolytic Exposures among Neonatal Intensive Care Unit Admitted Preterm Infants.

Since 2010, the American College of Obstetrics and Gynecology have released three committee opinions to recommend and reaffirm the utility of magnesium sulfate for neuroprotection and later for tocolysis to achieve antenatal steroid course completion in preterm labor. We sought to determine changes in antenatal magnesium sulfate exposure and other tocolytic agents for pregnancies resulting in neonatal intensive care unit (NICU)-admitted preterm infants. Using the Pediatrix Clinical Data Warehouse, we evaluated all inborn infants delivered between 22 and 33 weeks' gestation and admitted to the intensive care units from 2009 to 2018. We classified patients based on antenatal exposure to tocolytic medications: calcium channel blockers (nifedipine and amlodipine), betamimetics (terbutaline, theophylline, and ritodrine), prostaglandin inhibitors (indomethacin), and magnesium sulfate. A total of 229,781 patients met inclusion criteria. During the study period, magnesium sulfate exposure increased from 27.6 to 57.7% of births while betamimetic exposure decreased from 10.2 to 5.2%. Increasing magnesium sulfate exposure over time was seen at all gestational ages examined and magnesium exposure was most common between 23 and 31 weeks' gestation. By 2017 to 2018, 70.5% of 24 to 29 weeks' gestation NICU infants received exposure to at least one tocolytic agent while this remained at 53.7% of 32 to 33 weeks' NICU admitted infants. Antenatal steroid exposure increased from 74.8 to 87.4% during the study period. For NICU-admitted preterm infants, prenatal exposure patterns to tocolytic agents has shifted since 2009 with prenatal magnesium sulfate exposure increasing significantly. Antenatal steroid exposure has risen concurrently. Exposure to tocolytic agents is the highest among preterm infants born between 24 and 29 weeks' gestation. · Exposure to magnesium sulfate significantly increased from 2009 to 2018 for NICU admitted infants.. · Concurrently, the use of other tocolytics decreased significantly.. · The use of antenatal steroids has been rising over time..

Acute disseminated encephalomyelitis with bilateral optic neuritis following ChAdOx1 COVID-19 vaccination

BackgroundAcute disseminated encephalomyelitis (ADEM) is a rare immune-mediated inflammatory demyelinating disease of the central nervous system. We report a case of ADEM presenting with bilateral optic neuritis temporally associated with the ChAdOx1 vaccine against SARS-COVID19 virus.Case presentationA 36-year-old female presented with bilateral optic neuritis following her first dose of the ChAdOx1 vaccine. Initial MRI Brain showed evidence of demyelination within the subcortical white matter, with no radiological involvement of the optic nerves. Visual evoked potentials were consistent with bilateral optic neuritis which was confirmed radiologically on follow up MRI. She was treated with intravenous steroids with improvement both in symptoms and radiological appearance. A pseudo-relapse occurred which was treated with a further course of intravenous steroids followed by an oral taper. The clinical, radiological and serological results were most consistent with diagnosis of ADEM.ConclusionsADEM is an exceedingly rare complication of ChAdOx1 vaccine despite millions of doses. While it is imperative clinicians remain aware of neurological complications of vaccines, the importance of vaccination to control a pandemic should not be undermined.

P498 Sources of excess steroid prescriptions and clinical adverse outcomes associated with steroid excess: The Leeds Steroids study

Abstract Background This retrospective study aims to determine steroid prescription practice across primary and secondary care, quantify the proportion of primary care prescriptions communicated to secondary care, and assess outcomes associated with excessive steroid use. Methods The study cohort consists of all patients attending IBD clinics under Leeds Teaching Hospitals from 1/1/2016 to 31/12/2017 with linked primary care records. Data were extracted from the hospital’s electronic health record. Steroid excess was defined based on ECCO guidelines. Cases with excess were reviewed to determine if escalation was implemented, appropriateness of escalation, timeliness of that (within 6 weeks of steroid course) and whether steroid excess was unavoidable. Results 2246 patients were included in the study (Mage: 47.26 y; 47.6% male; 46.4% CD, 46.8% UC; 36.2% of CD patients on thiopurines, 26.3% on biologics; 78.8% of UC patients on 5-ASA, 21.4% thiopurines, 5.6% biologics). During the study period 32.9% of patients were exposed to steroids (77.4% of steroid prescriptions issued for IBD, 27.5% of prescriptions for IBD originating from primary care). Significantly more prescriptions from secondary care were of appropriate dose and duration compared to primary care (84.7% vs 40.7%, p&amp;lt;0.001). Secondary care was made aware within six weeks of steroid initiation in 60.3% of steroid courses prescribed by primary care. 49.5% of patients flared after being prescribed steroids from primary care, compared to 39.1% from secondary care, p=0.003. Steroid excess was observed in 14.5% of patients and was related to IBD in 76% of them. In patients with steroid excess due to their IBD; excess was acted upon in 82.8% of patients (77.5% had treatment escalation). Escalation was considered appropriate in 98.9% of patients however, it was timely in 62.4% of patients and steroid excess was unavoidable in 47.6%. Patients with steroid excess due to IBD had significantly more hospital admissions for IBD (p&amp;lt;0.001), hospital admissions for infections (p=0.036) and more antibiotic courses prescribed by GP (p=0.023) compared to patients without steroid excess. Conclusion Steroid prescribing for IBD flares originating from primary care is common however, steroid dose and duration are frequently inappropriate, and more than one third of courses are not communicated to secondary care in a timely manner. A significantly higher amount of patients flare again after being prescribed steroids by primary care. Finally, over 50% of steroid excess is potentially avoidable and steroid excess is related to negative consequences such as IBD admissions, admissions for infections and antibiotic prescriptions.

P671 Occurrence and clinical impact of eosinophilic esophagitis in a large cohort of children with Inflammatory Bowel Disease

Abstract Background Scarce data have investigated the association between pediatric Inflammatory bowel disease (IBD) and Eosinophilic esophagitis (EoE). We, therefore, aimed to describe the epidemiology and a possible peculiar phenotype and natural history of such association. Methods Case-control study based on the Italian Society for Pediatric Gastroenterology (SIGENP) national registry. All children with a concomitant diagnosis of IBD and EoE were included. Overall prevalence and incidence in 2 periods, 2009–2015 and 2016–2021, were calculated. Cases were matched with IBD only and EoE only patients in a 1:3 ratio. Phenotype and outcomes (courses of steroids, risk of complications, surgery, treatment escalation, and hospitalization) were compared between groups. Results Eleven patient (age 11,27 ± 2,83, Male 91%) with EoE-IBD out of 3090 patients with IBD only were identified, resulting in a prevalence of 0,35% and an incidence of 0,18% for the period 2009–2015 and 0,45% for the period 2016–2021. Treatment escalation rates were significantly higher in patients with IBD compared to EoE-IBD at 12 and 24-month follow-up (0 vs 30%, p = 0.04 and 9% Vs 45,5%, p = 0.03, respectively). Patients with IBD only were at a significantly higher risk of hospitalization than both EoE-IBD and EoE only patients (Log Rank p &amp;lt; 0.001). We found no significant differences in major outcomes related to the EoE course in EoE-IBD patients compared to EoE patients. Conclusion Overall, the incidence and prevalence of EoE in children with IBD are low, although the incidence seems to be rising in the six years. Having an EoE appears to be associated with a milder IBD disease course while having an IBD doesn’t seem to affect the natural history of EoE. More data are needed to better define the phenotype of such condition.

P674 Predictors of response to biologics in Crohn’s Diseases: A population-based study from the epi-IIRN

Abstract Background Approximately one third of patients with inflammatory bowel disease (IBD) fail to response to anti TNF drugs, and another 25–50% loses response within one year. Identifying prognostic factors of therapeutic failure, may facilitate balancing the risks and benefits of this therapy. In this population-based study, we aimed to explore predictors of therapeutic failure of biologics in Crohn’s disease (CD). Methods We retrieved data from two of four Health Maintenance Organizations in Israel, covering 38% of the population as part of the validated epi-IIRN IBD cohort. We included an inception cohort of CD patients, diagnosed since 2005 who were commenced on biologics. Those who underwent CD-related surgery within 90 days from diagnosis were excluded. The primary outcome was therapeutic failure (i.e. discontinuation of treatment or need for surgery or &amp;gt;1 short steroid courses). The secondary outcome was primary non-response (PNR; i.e. therapeutic failure within 4 months of initiation). Predictors were sought through Cox proportional hazard model. Results A total of 2,805 patients were included (923 [33%] pediatric-onset, 1,882 [67%] adults) with a median follow-up of 7.5 years (IQR 4.4–11.5). The probability of of PNR was 11% and of therapeutic failure 29%, 52% and 62%, after one, three and five years after commencing biologics, respectively. Female sex (HR 1.2 [95%CI 1.1–1.4]), intestinal surgery prior to biologic treatment (HR 1.5 [95%CI 1.1–1.8]) and number of flares prior to biologic treatment (HR 1.1 [95%CI 1.1–1.2]) were associated with therapeutic failure. PNR was associated with intestinal surgery (HR 2.0 [95%CI 1.3–2.9]) and steroid use (HR 1.7 [95%CI 1.3–2.2]). Laboratory blood work, including CRP, ESR, albumin, hemoglobin, leukocytes and platelets, at diagnosis (HR 0.8 [95%CI 0.4–1.5]) and at initiation of biologics (HR 1.1 [95%CI 0.6–1.9]) did not predict therapeutic failure in the multivariable model. Conclusion Half of CD patients failed to response to biologic treatment within three years. Disease severity prior to biologic treatment, reflected by intestinal surgeries, number of flares and steroid use, predicted therapeutic failure. These results emphasize the importance of timely introduction of intensified treatment in patients at risk.

P423 Azathioprine still remains the first step-up therapy in patients with Inflammatory Bowel Disease in low-middle income countries

Abstract Background Inflammatory bowel disease (IBD) including Ulcerative Colitis (UC) and Crohn’s Disease (CD) is characterized by remitting/relapsing course. A proportion of patients with UC, and almost all patients with CD require long-term immunosuppression to maintain endoscopic and clinical remission and prevent disease progression. The present study aimed to evaluate the long-term efficacy of thiopurines, their predictors, and the effect of the early use of thiopurines on disease outcomes in patients with IBD. Methods A retrospective cohort analysis of patients with IBD following up in IBD clinic at AIIMS, New Delhi, India from, 2004–2020. Efficacy was defined as a state of not requiring hospitalization, anti-TNF agents, surgery, and only minimum (≤, 1 steroid course in, 2 years) steroid requirement during follow-up. Early and late thiopurine initiation was defined as commencement of thiopurines ≤2 and &amp;gt;2 years of disease onset, respectively. Results Of, 1264 consecutive patients on thiopurines (both, 6-MP and azathioprine), 988 (UC:720, CD:268) were considered for efficacy analysis (males-60.8%, mean age at disease onset-31.69±12.34 years and thiopurine initiation-35±13.14 years). Time to event analysis showed a median efficacy rate of, 79%, 72% and, 68%, 61% at, 5 and, 10 years in UC and CD patients respectively after thiopurine initiation. On multivariate analysis, only the male sex was found to be a significant predictor of relapse (HR:, 1.49, 95% CI:, 1.021–2.194; P=0.039) in UC and Ileal involvement (HR:, 0.391, 95% CI:, 0.176–0.86; P=, 0.021) and steroid-dependent disease (HR:, 0.429, 95% CI:, 0.186–0.965; P=, 0.041) were associated with decreased risk of relapse and presence of any adverse event was associated with increased risk of relapse (HR:, 2.37, 95%CI:, 1.39–4.05; P=0.008). Kaplan Meier survival analysis showed no difference between the efficacy of early and late thiopurine groups, both in UC (Log-rank test P = 0.72) and CD (Log-rank test P = 0.76). Figure, 1: Kaplan Meier curve showing relapse-free survival on thiopurine in ulcerative colitis and Crohn’s disease. Figure, 2: Kaplan Meier survival analysis comparing relapse-free survival in early vs late thiopurine initiation group in UC (Log-rank test P = 0.72). Figure, 3: Kaplan Meier survival analysis comparing relapse-free survival in early vs late thiopurine initiation group in CD (Log-rank test P-value:, 0.764). Conclusion Thiopurines still remains a viable long-term option for maintenance of remission in patients with IBD, especially in resource-limited countries. Their use can be further enhanced by optimizing their therapy and regular monitoring for adverse events.

P682 Predictors of response to biologics in Ulcerative Colitis: A population-based study from the epi-IIRN

Abstract Background Identifying prognostic factors of therapeutic failure, may facilitate balancing the risks and benefits of biologic treatment. In this population-based study, we aimed to explore predictors of therapeutic failure of biologics in Ulcerative Colitis (UC). Methods We retrieved data from two of four Health Maintenance Organizations in Israel, covering 38% of the population and part of the validated epi-IIRN IBD cohort. We included an inception cohort of UC patients, diagnosed since 2005, who were commenced on biologics. Those who underwent colectomy within 90 days from diagnosis were excluded. The primary outcome was therapeutic failure (i.e. discontinuation of treatment or need for colectomy or &amp;gt;1 short steroid courses). The secondary outcome was primary non-response (PNR; i.e. therapeutic failure within 4 months of initiation). Predictors were sought through Cox proportional hazard model. Results A total of 910 patients were included (246 [27%] pediatric-onset, 664 [73%] adults) with a median follow-up of 7.9 years (IQR 4.9–12.0). The probability of PNR was 16% and of therapeutic failure 35%, 55% and 63% after one, three and five years after commencing biologics, respectively. Older age at diagnosis (HR 1.01 [95%CI 1.005–1.01]), number of flares prior to initiation of biologics (HR 1.1 [95%CI 1.05–1.2]) and steroid use prior to biologics (HR 1.3 [95%CI 1.1–1.6]) were associated with therapeutic failure. PNR was associated with use of steroids prior to initiation of biologics (HR 2.1 [95%CI 1.4–3.3]). Laboratory blood work, including CRP, ESR, albumin, leukocytes, hemoglobin and platelets did not predict therapeutic failure, whether at diagnosis (HR 1.1 [95%CI 0.6–2.0]) or at initiation of biologics (HR 1.2 [95%CI 0.7–2.1]). Conclusion One third of UC patients failed to response to biologic treatment within one year. Older age at diagnosis and disease severity prior to biologic treatment, reflected by number of flares and steroid use, predicted therapeutic failure.

The Long-Term Effects of 12-Week Intranasal Steroid Therapy on Adenoid Size, Its Mucus Coverage and Otitis Media with Effusion: A Cohort Study in Preschool Children.

Background: The purpose of this study is to analyse the long-term effects of a 12-week course of topical steroids on adenoid size and its mucus using endoscopy and on middle ear effusion measured by tympanometry. Methods: The study presents an endoscopic choanal assessment of the change in adenoid size (adenoid to choanae ratio, A/C ratio) and its mucus coverage in 165 children with Grade II and III adenoid hypertrophy three to six months after finishing a 12-week course of intranasal steroid treatment with mometasone furoate. Additionally, tympanometry was performed to measure middle ear effusion. Changes in the tympanograms were analysed. Results: The mean A/C ratio before treatment was 65.73%. Three to six months after finishing a 12-week course of intranasal steroid treatment, the mean A/C ratio decreased to 65.52%, although the change was not statistically significant (p = 0.743). There was no change in adenoid mucus according to the MASNA scale before and three to six months after the end of the steroid treatment (p = 0.894). Long-term observations of tympanograms before and three to six months after the end of the treatment did not show improvement (p = 0.428). Conclusions: The results indicate that there was no effect of topical steroids on adenoid size, its mucus and otitis media with effusion (OME) three to six months after finishing a 12-week course of treatment. In the light of performed study, decision of adenoidectomy and tympanostomy should not be procrastinated.

Papulopustular rash following Moderna COVID-19 (mRNA-1273) vaccine: A case report

Coronavirus disease-2019 (COVID-19) has affected countries around the world. The introduction of COVID-19 vaccines has proved the most effective arsenal in the fight against the disease. However, with the vaccination of billions of people, data on vaccine-induced adverse reactions are also emerging. We report a 32-year-old woman who manifested papulopustular rash 7 days after receiving Moderna COVID-19 (mRNA-1273) vaccine. The patient responded to a short course of systemic steroids and antihistamines. Awareness regarding the possible adverse events that can be anticipated after the COVID-19 vaccination may help the healthcare professionals to offer prompt and effective care to the affected.

Severe preeclampsia in a non-proteinuric patient

We present a 57year old now Para 2+0 lady who conceived through assisted reproductive technology and subsequently presented to us at 12weeks of gestation for antenatal care. Her antenatal period was uneventful until the 32nd week of gestation when she suddenly developed hypertension without any proteinuria. On admission, renal and liver function tests were found to be grossly deranged. She was stabilized with anti-hypertensives and given a course of steroids for fetal lung maturity. She subsequently had an emergency lower segment caesarean section at 33 weeks of gestation and was delivered of a live male baby weighing 1.8 kilograms. A high index of suspicion for pre-eclampsia is very important in the management of patients with hypertension in pregnancy, even in the absence of proteinuria.