Duration Of Corticosteroid Therapy Research Articles

Opioid Use and Outcomes in Patients Hospitalized With Acute Severe Ulcerative Colitis.

Opioid use has not been shown to improve hospitalized inflammatory bowel disease patient pain scores and may prolong the length of stay (LOS). Additional clinical implications of opioid use, particularly high amounts, in the hospital setting have not yet been explored. We sought to determine how high opioid use impacts clinical outcomes in acute severe ulcerative colitis (ASUC). In this single-center study, we identified all patients hospitalized with ASUC who received intravenous corticosteroids from July 1, 2014 to December 31, 2021. Clinical outcomes including opioid exposure, cumulative intravenous corticosteroid dose, biologic rescue therapy initiation date, colectomy rate, opioid prescription at discharge, LOS, and hospitalization cost were collected. High opioid use was defined as ≥40 oral morphine equivalents (OMEs) per day. A univariable logistic regression was performed to evaluate the association of high opioid use with ASUC outcomes. 185 eligible hospitalizations for ASUC were evaluated. 75 patients (41%) received opioids during hospitalization, and 20 patients (11%) received ≥40 OMEs/day. High opioid use was associated with a median 3-day delay in biologic rescue therapy initiation when compared with low/no opioid use (P = .02). 70% of patients with high opioid use received an opioid prescription at discharge compared with 10% of those with low/no use (P < .001). Opioid use was not associated with LOS, duration of corticosteroid therapy, colectomy rate, or hospitalization cost. Among ASUC hospitalizations, high opioid use was associated with delayed biologic rescue therapy initiation and higher rates of opioid prescriptions at discharge.

#1347 Development and validation of a nomogram for predicting complete kidney function recovery after drug-induced acute interstitial nephritis

Abstract Background and Aims Drug-induced acute interstitial nephritis (DI-AIN) represents a common cause of acute kidney injury. Early withdrawal of the culprit drug along with corticosteroid therapy (CS) remains the mainstay of treatment. Despite this, up to 50% of patients may not fully recover kidney function after DI-AIN. The aims of this study were to develop and externally validate a predictive nomogram to assess the probability of complete recovery (CR) of kidney function at 6 months after treatment. Method Multicenter, retrospective, observational study in 13 nephrology departments belonging to the GLOSEN group. Patients with biopsy proven DI-AIN treated with CS between 1996-2023 were included. Other potential causes of AIN such as infections or systemic diseases were carefully ruled out. Dataset was randomly divided into training group (n = 164) and validation group (n = 60). The least absolute shrinkage and selection operator (LASSO) regression was used to screen the main predictors of CR (serum creatinine value &amp;lt;25% of the last value before DI-AIN), and used to build the nomogram. Accuracy of the nomogram was assessed by discrimination and risk calibration, in the training and validation sets. Results The study group comprised 224 patients with DI-AIN, of whom: 51 (31%) in the training group and 19 (32%) in the validation set, achieved CR at 6 months after treatment with CS. Median age was 70 (IQR 57–76), and 115 (51%) were males. The clinical characteristics were well balanced between the training and validation data sets. The selected variables by LASSO were age (under/above 65 years), gender, degree of interstitial fibrosis and time to CS initiation (under/above 7 days). Based on multivariable logistic regression model, a nomogram was developed for assessing the probability of CR (Fig. 1). The area under the curve (AUC) of the nomogram was 0.809 (95% CI 0.721–0.880) indicating a good discriminative power. Bootstrap self- sampling was performed 1000 times for validation of the nomogram model. The AUC was 0.837 (95 % CI: 0.705–0.931), indicating good predictive stability. Calibration plot revealed that the predicted outcomes aligned well with the observations. Decision curve analysis (DCA), and clinical impact curve analysis (CICA) suggested that the model had clinical benefit. Conclusion We constructed and validated a practical nomogram with good discrimination and calibration, to predict the probability of CR of kidney function at 6 months in DI-AIN treated with corticosteroids. This clinical tool can provide clinicians with an estimate of kidney prognosis and can potentially assist them in titrating the intensity and duration of corticosteroid therapy.

Sepsis and Adrenal Insufficiency.

In sepsis, dysregulation of the hypothalamic-pituitary-adrenal axis, alterations in cortisol metabolism, and tissue resistance to glucocorticoids can all result in relative adrenal insufficiency or critical illness-related corticosteroid insufficiency (CIRCI). The symptoms and signs of CIRCI during sepsis are nonspecific, generally including decreased mental status, unexplained fever, or hypotension refractory to fluids, and the requirement of vasopressor therapy to maintain adequate blood pressure. While we have been aware of this syndrome for over a decade, it remains a poorly understood condition, challenging to diagnose, and associated with significantly diverging practices among clinicians, particularly regarding the optimal dosing and duration of corticosteroid therapy. The existing literature on corticosteroid use in patients with sepsis and septic shock is vast with dozens of randomized controlled trials conducted across the past 4 decades. These studies have universally demonstrated reduced duration of shock, though the effects of corticosteroids on mortality have been inconsistent, and their use has been associated with adverse effects including hyperglycemia, neuromuscular weakness, and an increased risk of infection. In this article, we aim to provide a thorough, evidence-based, and practical review of the current recommendations for the diagnosis and management of patients with sepsis who develop CIRCI, explore the controversies surrounding this topic, and highlight what lies on the horizon as new evidence continues to shape our practice.

Risk of Coronavirus Disease 2019-Associated Pulmonary Aspergillosis Based on Corticosteroid Duration in Intensive Care Patients.

Coronavirus disease 2019 (COVID-19)-associated pulmonary aspergillosis (CAPA) is a potential complication in critically ill COVID-19 patients. Corticosteroids are standard of care for hospitalized COVID-19 patients but carry an increased risk of secondary infections including CAPA. The objective of this study was to evaluate if duration of corticosteroid therapy ≤10 days versus >10 days affects the risk of developing CAPA. This was a retrospective cohort study of adult patients with severe COVID-19 pneumonia requiring mechanical ventilation who received at least 3 days of corticosteroid treatment. Incidence of CAPA and secondary outcomes were compared using appropriate bivariable analyses. Steroid duration was evaluated as an independent predictor in a logistic regression model. A total of 278 patients were included (n = 169 for ≤10 days' steroid duration; n = 109 for >10 days). CAPA developed in 20 of 278 (7.2%) patients. Patients treated with >10 days of corticosteroid therapy had significantly higher incidence of CAPA (11.9% vs 4.1%; P = .0156), and steroid duration >10 days was independently associated with CAPA (odds ratio, 3.17 [95% confidence interval, 1.02-9.83]). Secondary outcomes including inpatient mortality (77.1% vs 43.2%; P < .0001), mechanical ventilation-free days at 28 days (0 vs 1.5; P < .0001), and secondary infections (44.9% vs 28.4% P = .0220) were worse in the >10 days cohort. Corticosteroid treatment >10 days in critically ill COVID-19 patients is associated with an increased risk of CAPA. Patients may require corticosteroids for reasons beyond COVID-19 and clinicians should be cognizant of risk of CAPA with prolonged courses.

264. COVID-19 Associated Pulmonary Aspergillosis in Intensive Care Patients Based on Duration of Corticosteroid Administration

Abstract Background Coronavirus disease 2019 (COVID-19) associated pulmonary aspergillosis (CAPA) has emerged as a complication in critically ill COVID-19 patients. Corticosteroids are standard of care for COVID-19 patients. Prolonged corticosteroids have been associated with an increased risk of CAPA, but duration of use associated with this risk remains unknown. The objective of this study was to evaluate if the duration of corticosteroid therapy ≤ 10 days vs &amp;gt; 10 days affects the risk of developing CAPA. Methods This single-center, retrospective, cohort study included patients ≥ 18 years old admitted to University Hospital between March 2020 and December 2021, diagnosed with severe COVID-19 pneumonia requiring mechanical ventilation, and who received at least 3 days of corticosteroid treatment. CAPA was defined according to 2020 European Confederation of Medical Mycology and the International Society for Human and Animal Mycology consensus guideline. Baseline characteristics, CAPA, and secondary outcomes were compared using appropriate bivariable analyses. Steroid duration was evaluated as an independent predictor of CAPA in a logistic regression model. Results Final analysis included 278 patients (n=169 ≤ 10 days steroid duration; n=109 &amp;gt; 10 day steroid duration). Baseline characteristics were similar between groups, with the exception of acute kidney injury and solid organ transplantation. Median duration of steroids was 6 days in the ≤ 10 day group vs 18 days in the &amp;gt; 10 day group. In total, 20/278 (7.2%) patients developed CAPA. Patients treated with &amp;gt; 10 days of corticosteroid therapy had significantly higher incidence of CAPA (12% vs 4.1%; p = 0.0156) and duration was independently associated with CAPA (OR 3.25, 95% CI 1.03-10.24). Secondary outcomes including inpatient mortality (43.2% vs 77.1%; p &amp;lt; 0.0001), mechanical ventilation free days at 28 (1.5 vs 0; p &amp;lt; 0.0001) and secondary infections (28.4% vs 44.9% p = 0.0220) were all significantly worse for &amp;gt; 10 day corticosteroid cohort. Conclusion Duration of corticosteroid treatment &amp;gt; 10 days in critically ill patients is associated with an increased risk of CAPA. Though patients may require corticosteroids for non-COVID-19 indications, clinicians should attempt to limit prolonged courses of corticosteroids in COVID-19 patients. Disclosures All Authors: No reported disclosures.

S114 Assessment of Corticosteroid Use as a Marker of Quality-of-Care in the Management of Inflammatory Bowel Disease

Background: Despite the development of new therapeutic strategies, corticosteroids still play a role in the induction of Inflammatory Bowel Disease (IBD) remission. However, often these drugs are misused. Methods: Descriptive, retrospective observational study of patients with IBD under follow-up in the Inflammatory Bowel Disease Program of Clínica Universidad de los Andes (Chile) during the period of January 2021-August 2022. The objectives were to assess the dose and duration of corticosteroid therapy, and the subsequent change in treatment in patients with IBD. The statistical analysis, descriptive and association statistics x2 with P< 0.05 were used. Results: Four hundred and thirty-two IBD patients were included, 63% of them women, with a median age of 42 years (14-94), 66% with ulcerative colitis (UC). Sixty-six percent of patients have received corticosteroids during the course of their disease (range 1-9 times) for a median of 12 weeks (2-48 weeks), prednisone being the most frequently used corticosteroid (53%). Seventy-seven percent of patients have received treatment for >3 months or in supratherapeutic doses (more than 1 mg/Kg, range 40-60 mg of prednisone). There was a change in treatment in 82% of these patients. During the Program’s follow-up, 10% have received corticosteroids (71% prednisone, 29% budesonide) with no differences according to IBD type, gender, age or type of treatment. No patient has received corticosteroids for >3 months or in supratherapeutic doses in our Inflammatory Bowel Disease Program. Two percent developed corticosteroid dependency and in 90% there was a change of treatment. Conclusion(s): This study validates the assessment of the use of corticosteroids as a marker of quality of care in IBD. The management of these patients through a specialized program could reduce the excessive use of corticosteroids.

Co-infection and ICU-acquired infection in COVID-19 ICU patients: a secondary analysis of the UNITE-COVID data set

BackgroundThe COVID-19 pandemic presented major challenges for critical care facilities worldwide. Infections which develop alongside or subsequent to viral pneumonitis are a challenge under sporadic and pandemic conditions; however, data have suggested that patterns of these differ between COVID-19 and other viral pneumonitides. This secondary analysis aimed to explore patterns of co-infection and intensive care unit-acquired infections (ICU-AI) and the relationship to use of corticosteroids in a large, international cohort of critically ill COVID-19 patients.MethodsThis is a multicenter, international, observational study, including adult patients with PCR-confirmed COVID-19 diagnosis admitted to ICUs at the peak of wave one of COVID-19 (February 15th to May 15th, 2020). Data collected included investigator-assessed co-infection at ICU admission, infection acquired in ICU, infection with multi-drug resistant organisms (MDRO) and antibiotic use. Frequencies were compared by Pearson’s Chi-squared and continuous variables by Mann–Whitney U test. Propensity score matching for variables associated with ICU-acquired infection was undertaken using R library MatchIT using the “full” matching method.ResultsData were available from 4994 patients. Bacterial co-infection at admission was detected in 716 patients (14%), whilst 85% of patients received antibiotics at that stage. ICU-AI developed in 2715 (54%). The most common ICU-AI was bacterial pneumonia (44% of infections), whilst 9% of patients developed fungal pneumonia; 25% of infections involved MDRO. Patients developing infections in ICU had greater antimicrobial exposure than those without such infections. Incident density (ICU-AI per 1000 ICU days) was in considerable excess of reports from pre-pandemic surveillance. Corticosteroid use was heterogenous between ICUs. In univariate analysis, 58% of patients receiving corticosteroids and 43% of those not receiving steroids developed ICU-AI. Adjusting for potential confounders in the propensity-matched cohort, 71% of patients receiving corticosteroids developed ICU-AI vs 52% of those not receiving corticosteroids. Duration of corticosteroid therapy was also associated with development of ICU-AI and infection with an MDRO.ConclusionsIn patients with severe COVID-19 in the first wave, co-infection at admission to ICU was relatively rare but antibiotic use was in substantial excess to that indication. ICU-AI were common and were significantly associated with use of corticosteroids.Trial registration ClinicalTrials.gov: NCT04836065 (retrospectively registered April 8th 2021).Graphical abstract

Assessing recovery of adrenal function in glucocorticoid-treated patients: Our strategy for screening and management

BackgroundLong-term glucocorticoid (GC) use is the most frequent cause of adrenal insufficiency through suppression of the hypothalamic-pituitary-adrenal axis. There are no guidelines for predicting adrenal insufficiency (AI) and minimizing its risk. MethodsThis is a prospective observational study carried out in the Endocrinology-Diabetology and Nutrition department between 2014 and 2021. All patients had received GC therapy for longer than 3 weeks before switching to hydrocortisone substitution, for various indications. These patients were admitted to our department for stimulation tests. We assessed the prevalence of AI, predicting factors, screening and management. ResultsIn our study the GC-induced AI was found in 49% of patients. We found a strong correlation between the basal morning serum cortisol, body mass index and the peak cortisol level after stimulation tests, while no correlation was found between adrenal function and age, sex, indication of GC therapy, duration of corticosteroid therapy, cumulative dose and daily dose. Patients with GC induced AI took a mean of 12 ± 12,18 months to recover. Adrenal function recovery rate was higher in patients tested by short Synacthen than in those tested by Insulin Hypoglycemia. ConclusionsWe demonstrated the positive correlation between serum cortisol peak levels after stimulation and body mass index. The study supports that basal cortisol level, the duration of corticoid cessation and the type of stimulation test can predict the response of cortisol to stimulation tests.

Factors Affecting the Statural Growth Retardation in Children using Steroids in Idiopathic Nephrotic Syndrome

Background and Aim: Idiopathic nephrotic syndrome or nephrosis causes massive protein leakage in the urine. Its treatment requires steroids (prednisone, methylprednisolone), often for a prolonged period, notably in case of steroid-dependence or steroid-resistance. In children, long-term use of steroids can lead to several side effects such as statural growth retardation/ stunting. This study evaluated the frequency of stunting in idiopathic nephrotic syndrome in children on steroids and identified the associated factors. &#x0D; Material and Methods: This was a retrospective, descriptive cohort study carried out in children aged 0 to 16 years treated at the paediatric nephrology unit of Aristide Le Dantec Hospital in Dakar, between 1 December 2017 and 31 May 2020. All records of nephrotic children treated in outpatient or inpatient setting were included. These children had to be on corticosteroid therapy for at least 30 months and have a height taken regularly during follow-up consultations.&#x0D; Results: Of 259 children followed for idiopathic nephrotic syndrome, 93 were included in the study. The median age was 96.5 months and the sex ratio was 1.9. The mean height of the children at the beginning of the follow-up was -0.26 DS, at the end it was -0.88 DS. At the beginning of the follow-up, 8 children had already stunting. At 12 months follow-up, 72 children (77.4%) had a decrease in z-score; and at 30 months, there were 7 more children (84.9%) who had a decrease in z-score. Methylprednisolone boluses were given to 17 children (18.3%). Calcium supplementation was done in 91 children (97.8%). Vitamin D supplementation was given to 91 children (97.8%). The mean number of relapses was 1.8. Factors associated with stunting were number of relapses ≤3 (p=0.03), duration of corticosteroid therapy &gt;6 months (p&lt;0.0001) and cumulative doses of prednisone &gt;100 mg/kg (p=0.04).&#x0D; Conclusion: In prolonged nephrotic syndrome in children, corticosteroids can cause stunting.

Central serous chorioretinopathy in uveitis patients after corticosteroid therapy: a report of 6 cases

Purpose. To report central serous chorioretinopathy (CSCR) in uveitis patients.Material and methods. A retrospective chart review of uveitis patients seen in a time frame of 20 years at the Centre for Ophthalmic Specialised Care, Lausanne, Switzerland. The ophthalmic and systemic features are presented.Results. Out of 1793 uveitis patients followed at the Centre for Ophthalmic Specialised Care, 6 patients (0.3%) developed CSСR following corticosteroid therapy due to uveitis. The mean age of patients was 40 ± 13.4 years, disease incidence was not associated with gender. In all 6 patients’ clinical disease was unilateral but subclinical signs were present in all fellow eyes. The mean duration of corticosteroid therapy before CSCR had occurred was 4.95 ± 4.0 months. The mean best-corrected visual acuity at the moment of CSCR was 0.6 ± 0.26 and 0.8 ± 0.17 after discontinuation of corticosteroids. Neurosensory retinal detachment and pigment epithelium detachment were observed in 3 eyes, respectively. During fluorescein angiography (FA), focal dye leakage and areas of alteration of RPE were observed in 6 out of 10 eyes. Diffuse hyperfluorescence of choroidal vessels observed by ICGA was detected in all eyes.Conclusion. Central serous chorioretinopathy should be suspected when functional and morphological deterioration occurs in uveitis patients receiving corticosteroid therapy with no signs of inflammation reactivation. This complication is extremely rare but serious condition which needs a prompt tapering and discontinuing of corticosteroids.

Corticosteroids in the Management of Infectious Keratitis: A Concise Review

Microbial keratitis is devastating corneal morbidity with a variable spectrum of clinical manifestations depending on the infective etiology. Irrespective of the varied presentation delayed treatment can lead to severe visual impairment resulting from corneal ulceration, possible perforation, and subsequent scarring. Corticosteroids with a potent anti-inflammatory activity reduce host inflammation, thus minimizing resultant scarring while improving ocular symptoms. These potential effects of corticosteroids have been applied widely to treat various corneal diseases ranging from vernal keratoconjunctivitis to dry eye disease. However, antimicrobial therapy remains the mainstay of treatment in microbial keratitis, whereas the use of adjunctive topical corticosteroid therapy remains a matter of debate. Understandably, the use of topical corticosteroids is a double-edged sword with pros and cons in the treatment of microbial keratitis. Herein we review the rationale for and against the use and safety of topical corticosteroids in the treatment of infective keratitis. Important considerations, including type, dose, efficacy, the timing of initiation of corticosteroids, use of concomitant antimicrobial agents, and duration of corticosteroid therapy while prescribing corticosteroids for microbial keratitis, have been discussed. This review intends to provide new insights into the therapeutic utility of steroids as adjunctive treatment of corneal ulcer.

MO215DEPRESSIVE DISORDER IN LUPIC PATIENTS WITH LUPUS NEPHRITIS: DATA FROM A POPULATION OF 67 PATIENTS WITH BIOPSY PROVEN LUPUS NEPHRITIS

Abstract Background and Aims Systemic lupus erythematosus is a multi-organ, multi-systemic autoimmune disease with significant burden on generally young patients. Renal involvement is relatively frequent, recent studies cite a prevalence of 15-60% of patients, and 25% develop end-stage renal disease after 10 years of disease onset. We studied the incidence of depressive disorders in a population of 67 patients with biopsy proven lupus nephritis. Data about depression in patients with renal involvement of lupus is still scarce. We identified variables associated with the development of depressive disorders in lupus patients. Method We concluded a single center transversal study to assess the incidence of depressive disorder in patients with biopsy proven lupus nephritis. We used the self-report Beck Depression/ Anxiety Inventory (BDI/ BAI), 1961/ 1990, translated in Romanian and validated in the Romanian population to diagnose depression. We also wanted to identify risk factors associated with depression in such patients. We used EpiInfo for the statistical analysis and data was extracted from medical records. Results We included in the study patients diagnosed with systemic lupus erythematosus, and had renal biopsy between January 2008 – December 2018. Patients were followe-up until May 2020. Beck Depression/Anxiety Inventory was administered a single time during the follow-up visit between (March 2019 – May 2020). In our study group, 58 patients were female (86.5%). Median age at diagnosis of lupus disease was 29 years (min 10 years, max 62 years). Median duration of the disease until the self-assessment inventory was 10 years (min 1.5 years, max 30 years). Median duration of corticosteroid treatment was 10.1 years (min 1.58 years, max 29). 1 patient had class I, 2 had class II, 12 had class III, 32 had class IV, 12 had class V, 1 had class VI, 1 had classes III+V, 1 had classes IV+V of lupus nephritis (ISN classification of lupus nephritis). 13 patients had normal scores of the Beck Inventory (0-9 points), 7 had mild depression (10 - 15 points), 37 had moderate depression (16- 23 points), 10 had severe depression (24-63 points). We identified female gender (p=0.009), duration of corticosteroid therapy (p=0.036), duration of the lupic disease (p=0.036) to be independently associated with depression development. Other variables, such as creatinine levels at the moment of the assessment, duration of maintenance therapy with mycofenolate mofetil or azathioprine, proteinuria, inflammatory markers were not associated significantly with depression. Conclusion We identified clinical variables associated with depression development in patients with lupus nephritis. The study brings data useful for the clinician, helping doctors focus on the variables that predict depression in lupus patients and making screening for depressive disorders more focused on the patients with risk factors.

Outcomes of immune checkpoint inhibitor-mediated colitis: Multicenter cohort study.

2643 Background: Immune checkpoint inhibitor (ICI)-mediated colitis (IMC) is a common and serious adverse event. Although small series have described the clinical presentation of IMC, large multicenter series that integrate clinical, endoscopic, and histologic findings are lacking. Methods: We retrospectively assessed patients who received ICI and had endoscopically confirmed IMC from 2010 to 2019. IMC was graded based on the CTCAE version 5.0 criteria. Multivariate logistic regression analyses were conducted to assess factors associated with recurrence of IMC symptoms and long duration of corticosteroids use (&gt; 70 days). Results: 675 patients were included. 387 patients were males (57%). Median age was 63 years. Melanoma was the most common cancer type (327; 48%). Most (365; 54%) patients received CTLA-4 inhibitor ICI, as monotherapy or in combination with PD-(L)1. Median time from ICI therapy to IMC was 62 days. IMC was grade 2 in 335 (50%) patients, Grade 3 in 181 (27%), and grade 4 in 16 (3%). 155 (23%) patients had mucosal ulceration on endoscopy, 91 of them had severe features (deep, large, or multiple ulcers); 336 (50%) patients had non-ulcerative inflammation. The rest had normal endoscopic findings with histologic inflammation. Most patients were admitted to the hospital for management of IMC (405; 60%) and 16 (3%) needed ICU-level of care. Treatment included corticosteroids in 577 (85%) patients (median duration 52 days), TNF inhibitor in 245 (36%), and vedolizumab in 90 (13%). 202 (32%) patients had recurrent IMC after resolution of symptoms. On multivariate logistic regression, factors associated with IMC recurrence and long (&gt; 70 days) duration of corticosteroid therapy were grade of IMC ( p = 0.049), treatment with infliximab or vedolizumab ( p = 0.044), presence of mucosal ulceration ( p = 0.034 ), or features of active histologic inflammation ( p = 0.076). Of note, patients with mucosal ulceration received infliximab or vedolizumab more frequently ( p &lt; 0.001). For patients with grade 2 IMC, mucosal inflammation on endoscopy and delay in performing endoscopy with time from IMC onset to endoscopy more than a month were associated with IMC recurrence and longer duration of corticosteroid use ( p = 0.029 and p &lt; 0.001, respectively). 16 (3%) patients had colonic perforation, 7 of them underwent surgical resection. No IMC-related death occurred. Conclusions: IMC is a clinically significant adverse event that can lead to premature termination of ICI therapy with high rates of hospital admission. Rarely, it results in colonic perforation requiring surgical intervention and ICU admission. Our data suggest that there is a utility of endoscopic and histologic evaluation in the prediction of worse outcomes from IMC. This finding is particularly important for grade 2 IMC as current guidelines do not recommend endoscopic evaluation for this group.

Post-Transplant Lymphoproliferative Disorder in Lung Transplantation: A Single-Center Experience in Japan

<h3>Purpose</h3> Post-transplant lymphoproliferative disorder (PTLD) affects 3-9% of lung transplant (LTx) recipients, with a mortality range of 20-50%. Despite this high morbidity and mortality, few large studies on Asian population are reported, therefore, we lack fixed consensus regarding specific predictive risk factors in LTx recipients. This study was aimed at uncovering the risk factors of PTLD and evaluating the treatment strategy and outcome of Japanese PTLD cases. <h3>Methods</h3> We retrospectively reviewed 195 patients (re-transplantation cases were excluded) who underwent LTx at our hospital between October 1998 and February 2020. <h3>Results</h3> Seven PTLD patients (3.6%) were identified. The indication for LTx in PTLD group was 2 (28.6%), 3 (42.8%), 2 (28.6%) patients for idiopathic pulmonary fibrosis, other interstitial pneumonia including connective tissue disease, lung disease after hematopoietic stem cell transplantation, respectively. The proportion of indication was significantly different from those in non-PTLD patients (p=0.046). All PTLD patients had taken corticosteroid at the time of LTx (p<0.01), and the duration of corticosteroid therapy was significantly longer in the PTLD group (p<0.01). Overall survival after LTx was also significantly worse in the PTLD group (p=0.027). Among 7 PTLD patients, 3 patients died within 1 year after the onset of PLTD, resulting from viral and fungal infection with or without PTLD progression. Remaining 4 patients lived longer than 30 months; however, 3 out of 4 patients developed chronic lung allograft dysfunction (CLAD) after the treatment of PTLD. <h3>Conclusion</h3> Long-term preoperative corticosteroid therapy can be a risk factor of PTLD after LTx. Regardless of the state of PTLD, opportunistic infection was a lethal complication and should be desperately prevented. CLAD may occur at a higher rate after treatment of PTLD, therefore, close monitoring and adjustment of immunosuppressants are needed.

Neuropathies of leprosy

Neuropathies form an integral part of the symptomatology of leprosy. Neuropathies of leprosy take various forms and shapes. At one end is the cutaneous nerve involvement adjacent to the anaesthetic skin patch and the other is of symmetrical pansensory neuropathy and the devastating sensory ataxia of leprous ganglionits. Lepra reactions add to the spectrum. Hosts immunological status largely decides the clinical manifestations seen in nerves and skin. A wide array of diagnostic techniques like ultrasonography, magnetic resonance neurography, serological markers, molecular tests, skin biopsy and in selected cases, the nerve biopsy with special stains and electron microscopy are obtainable to help the clinical diagnosis. The unsuspecting clinician, lack of community awareness and limited availability of diagnostic tests are important adverse factors in the total outcome. Multi drug therapy is efficacious and corticosteroids reduce the impact of nerve damage in leprosy. The efficacy, dose and duration of corticosteroid therapy are presently inexact and other immune suppressants like azathioprine are being evaluated. Chronic disabilities and residual deficits require attention of multiple specialties. In the coming time, focus on prevention could lead to favourable results.This review will discuss the classification systems, common and uncommon clinical features, diagnostic armamentarium and therapeutic and preventive aspects of neuropathies of leprosy.

Trabecular and cortical bone involvement in rheumatoid arthritis by DXA and DXA-based 3D modelling.

To evaluate cortical and trabecular bone involvement of the hip in RA patients by dual-energy X-ray absorptiometry (DXA) and 3D analysis. The secondary end-point was to evaluate bone involvement in patients treated with classic (c-DMARD) or biological (b-DMARD) disease-modifying antirheumatic drug therapies and the effect of the duration of the disease and corticosteroid therapy on 3D parameters. A cross-sectional study of 105 RA patients and 100 subjects as a control group (CG) matched by age, sex, and BMI was carried out. BMD was measured by DXA of the bilateral femoral neck (FN) and total hip (TH). The 3D analyses including trabecular and cortical BMD were performed on hip scans with the 3D-Shaper software. FN and TH BMD and trabecular and cortical vBMD were significantly lower in RA patients. The c-DMARD (n = 75) group showed significantly lower trabecular and cortical vBMD than the CG. Despite the lower values, the b-DMARD group (n = 30) showed no significant differences in most parameters compared with the CG. The trabecular and cortical 3D parameters were significantly lower in the group with an RA disease duration of 1 to 5years than in the CG, and the trabecular vBMD was significantly lower in the group with a duration of corticosteroid therapy of 1 to 5years than in the CG, while no significant differences were found by standard DXA in the same period. RA patients had a higher risk of developing low BMD or osteoporosis than controls. RA patients receiving c-DMARD therapy showed significantly lower BMD than controls, while no significant differences in most parameters were found between RA patients receiving b-DMARDs and controls. 3D-DXA allowed us to find changes in trabecular and cortical bone compartments in RA patients.

Corticosteroid therapy for severe COVID-19 pneumonia: optimal dose and duration of administration.

Severe COVID-19 is associated with a hyperinflammatory state, and corticosteroid therapy may be effective. We review the recent literature and discuss the appropriate dose and duration of corticosteroid therapy. Low-dose corticosteroid therapy is often used to treat COVID-19. However, several doses of methylprednisolone (or prednisolone) have been attempted, ranging from about 40 mg/day to 2 mg/kg/day. Doses may need to be adjusted depending on severity. Corticosteroid therapy is generally administered for a short period over several days. However, COVID-19-induced respiratory failure is often prolonged, so longer administration may be considered. Careful monitoring for complications due to corticosteroid therapy is vital.

Duration of topical steroid application after photorefractive keratectomy with mitomycin C.

Contradictory results of postoperative steroid application in photorefractive keratectomy (PRK) led to a meta-analysis of the existing data to achieve a definite conclusion on the optimum dosage and duration of corticosteroid therapy after PRK. The overall pooled unstandardized mean difference (PUMD) of the corneal haze score was -0.20 (95% CI, -0.29 to -0.12). In subgroup analysis, the PUMD of the corneal haze score was statistically significant in 2 subgroups, -0.57 (-0.85 to -0.30) for 3 to 6 months postoperatively and -0.13 (-0.23 to -0.04) for ≤ 3 months postoperatively. Analysis of the PUMD of postoperative spherical equivalent in participants with low to moderate myopia (≥-6.00 D) and high myopia (<-6.00 D) showed positive effects of steroids on prevention of myopia regression. In conclusion, long-term topical steroid application after PRK seems unnecessary in low and moderate myopia. New randomized clinical trials using current technologies are recommended for postoperative treatments.

Duration of corticosteroid use and long‐term outcomes after adult heart transplantation: A contemporary analysis of the International Society for Heart and Lung Transplantation Registry

Long-term corticosteroid (CS) maintenance remains an effective option for immunosuppression following heart transplantation. We used the International Society for Heart and Lung Transplantation Registry to examine characteristics and long-term survival among heart transplant recipients with different duration of CS therapy. Primary adult heart recipients transplanted between 2000 and 2008 who survived at least 5years were categorized into three groups according to CS use: early withdrawal (≤2years) (EARLY D/C), late withdrawal (between 2 and 5years) (LATE D/C), or long-term use (>5years) (LONG-TERM). Recipient and donor characteristics, post-transplant morbidities, and mortality were compared among groups. Kaplan-Meier was used to estimate survival up to 10years post-transplant. The study cohort included 8161 recipients (2043 in EARLY D/C; 2031 in LATE D/C; and 4087 in LONG-TERM). LONG-TERM use of CS decreased over time, from 60% in 2000 to 43% in 2008, while EARLY D/C increased from 19% to 33%, respectively. Survival at 10years after transplant was lower among the LONG-TERM group (73% vs EARLY D/C 82% vs LATE D/C 80%; P<0.0001). In this large multinational cohort, the practice of long-term CS maintenance was associated with lower long-term survival compared with shorter CS use.

SUPPORTING THERAPY IN EOSINOPHILIC ESOPHAGITIS: WHY, WHOM, HOW?

Aim. To demonstrate peculiarities of clinic features, difficulties of diagnostics and treatment of eosinophilic esophagitis using a clinic case.Materials and methods. The investigation of the clinic case in young woman with eosinophilic esophagitis is presented. The diagnosis was established 6 years after the manifestation of the disease on the stage of complications developed (esophageal stricture). A complex examination included endoscopy, morphologic methods and consultations with adjacent specialists (llergologist, ENT). Drug therapy was carried out by system and topical corticosteroids according to recommendations of Russian gastroenterological association from 2013.Results. The right diagnosis was established by the assessment of the clinic feature of dysphagia with revealing of mucosal eosinophilic infiltration during histological study of esophageal mucosal biopsies. The elimination diet and corticosteroid therapy improved the clinic course of the disease considerably. However, there were no signs of morphological changes of esophageal wall recovery. As a result, the patient needed to be treated and managed constantly. Based on the literature data the authors described variations of natural history of the disease, discussed the approaches to supporting therapy, and revealed group selection criteria of the patients most of all needed to anti-relapsing therapy.Conclusion. Eosinophilic esophagitis is a chronic immune-antigendependent inflammatory disease of the esophagus with insufficiently investigated etiopathogenesis. A number of questions concerning this disease need to be studied (clinical course, possibility of long-lasted remission and self-recovery, duration of corticosteroid therapy, etc).