Flare Ups Research Articles

2348 A Rare Case of Biktarvy-Induced HBV Flare

INTRODUCTION: Exacerbation of chronic hepatitis B virus (HBV) is defined as an acute rise in alanine aminotransferase (ALT) more than five times the upper limit of normal. Flare-ups of chronic HBV and human immunodeficiency virus (HIV) coinfection receiving antiretroviral therapy is seldom due to discontinuation or initiation of emtricitabine treatment. Here, we present a rare case of reinitiation of Biktarvy causing HBV flare. CASE DESCRIPTION/METHODS: A 53-year-old male presented to the emergency department from infectious disease clinic for worsening transaminitis, nausea and right upper quadrant (RUQ) pain for two days. Patient did not report any alcohol, supplement or acetaminophen use. Past medical history is significant for HIV and chronic HBV. He had been non-adherent to Biktarvy (bictegravir, emtricitabine, tenofovir alafenamide) for months and was restarted on the medication three weeks prior to presentation. His vitals were within normal limits. Physical examination revealed RUQ tenderness. Complete blood count showed platelet count of 137K. Coagulation study, basic metabolic panel, lipase were within normal limits. HBV Viral load: 7,126,237, HIV Viral load: undetectable, aspartate aminotransferase (AST): 599, ALT: >680. Hepatitis panel showed immunity to Hepatitis A, Hepatitis C: negative, HBV surface antigen: positive, HBV core IgM: positive and no seroconversion of Hep Be antigen to antibody. All viral serologies, HIV, HBV status and transaminases listed in Tables 1 and 2 from former and current admission. Autoimmune and hereditary conditions work up done during current admission were negative (Table 3). RUQ ultrasound was unremarkable. Patient was seen in clinic two weeks later and reported adherence with Biktarvy. Liver enzymes continued to trend down and his symptoms of nausea and RUQ pain subsided. DISCUSSION: Emtricitabine is one of the components of HIV regimen of Biktarvy. Treatment flares due to emtricitabine arise only in 5-10% of patients and are usually asymptomatic. Our patient had symptomatic hepatotoxicity after restarting Biktarvy over the span of three weeks. Hepatotoxicity could be due to the variations of viral replication activating immune responses. Even though the flare ups of chronic HBV can be due to initiation of emtricitabine, it is recommended to continue the agent and monitor for down trending pattern of aminotransferases which was depicted in our case.

Engaging Patients and Caregivers in Research for Pediatric Inflammatory Bowel Disease: Top 10 Research Priorities.

Including individuals with lived experience in pediatric inflammatory bowel disease (IBD) is essential to establishing a research agenda that is mutually impactful to both those treating and those experiencing the disease. Using the James Lind Alliance approach to research priority setting, a 10-member steering committee composed of current and former pediatric patients with IBD, caregivers, and clinicians was formed. A national survey, disseminated across Canada, elicited uncertainties which were divided into unanswered and answered research questions. Subsequently a research prioritization survey was disseminated where respondents ranked their top 20 research uncertainties. A final prioritization meeting was held to agree upon the top 10 uncertainties. From 1209 research questions submitted by 363 participants, the list was reduced to 105 indicative questions that were within scope and deemed unanswered in the literature. Via the national research prioritization survey, this list was further reduced. The top 10 uncertainties identified at the final research consensus meeting, with 21 participants from all stakeholder groups, included "What are the causes of IBD?," "Can IBD be prevented?," "What role does diet have in the management of pediatric IBD?." Other questions concerned flare ups, biomarkers, optimal patient education, long-term effects of medication and early-diagnosis, role of psychological support, and optimal approach to diagnosis. This research adds a unique perspective by deriving a list of pediatric IBD research uncertainties important by patients and caregivers and clinicians.

426 Type I interferon-driven pathogenic angiogenesis initiated by antimicrobial killing of B.oleronius during flare ups of rosacea

Rosacea is a common inflammatory skin disorder characterised by recurrent flare-ups and neoangiogenesis, eventually culminating in persistent erythema. Cathelicidin antimicrobial peptides and their upstream activating protease Kallikrein 5 (KLK5) have been implicated in rosacea, yet the pathogenic mechanisms that lead to flare-ups remain elusive. In gene expression analyses, we find selective overexpression of type I interferon (IFN) specifically during acute flare-ups of disease. Using an established in vivo model of rosacea, we find that IFN expression in situ, critically dependent on plasmacytoid dendritic cells (pDCs), drives a predominant TH17/22 profile, similar to the signature found in our patient cohort. Transgenic mice overexpressing KLK5 in the skin recapitulate the cathelicidin-pDC-IFN-TH17/22 axis, in support of a consistent overarching pathway. Finally, we find that IFN cooperates with IL22 to promote survival and proliferation of vascular endothelial cells, and in the sprouting of dermal microvasculature in vivo. Furthermore, B.oleronius, a bacterium that is linked to severity in rosacea, is exquisitely sensitive to killing by cathelicidins leading to potent activation of pDCs to produce IFN in vitro and in vivo. Taken together, proteolytic activation of cathelicidins, along with skin microbes lead to rapid pDC activation and IFN production during flare-ups of rosacea. The latter plays a critical role in inducing a predominant TH17/22 profile promoting pathogenic angiogenesis. Our study identifies a pathogenic KLK5-cathelicidin-pDC-IFN-IL22 axis in rosacea and mechanistically links B.oleronius to the induction of characteristic rosacea skin lesions, providing novel actionable targets for treatment along this pathway.

Efficacy of 0.1% tacrolimus in long-term management of erosive lichen planus

Objectives This study documented the response of erosive oral lichen planus (OLP) to exclusive treatment with 0.1% topical tacrolimus over a 12-month period or until the patient became unresponsive to therapy. Materials and methods A retrospective cohort design was used to acquire data on 12 patients with recalcitrant OLP that were prescribed 0.1% tacrolimus. These patients were prescribed 0.1% tacrolimus after failing to respond to conventional corticosteroid therapy. Information about their response to medication initially and on flare ups were included in this study. Results The sample consisted of nine women and three men. All patients were given 0.1% tacrolimus to be applied 3 times a day. Two patients did not respond to the treatment at all, 4 patients showed partial response to tacrolimus treatment. Six patients showed complete initial response to treatment. Conclusion 50% of our patients showed a suboptimal response to 0.1% tacrolimus use for erosive OLP, thus, suggesting that in some cases 0.1% tacrolimus may be an ineffective option for managing erosive OLP.

MON-047 Monoclonal antibodies: Saviour of the gut vs an agent of kidney injury!

We present an interesting and unique case where a monoclonal antibody given to treat Crohn's disease, has been linked with fibrillary glomerulonephritis. A 39 year old caucasian British woman was referred for her deteriorating renal function in August 2016. She had a rise in creatinine from 109µmol/L (reference range 45-84µmol/L) to 188µmol/L in six months. Patient had a past medical history of Crohn’s disease diagnosed six years previously. Her treatment included courses of Mesalazine, Azathioprine (on and off for two years), Mercaptopurine, and corticosteroids (on and off during flare ups of crohn's). She was started on Adalimumab in April 2016 and a rapid decline in renal function was noted over the following four months. This is a retrospective case study and was picked up by the author when he followed up the patient in the renal outpatient clinic. The case was found unique and interesting as there is not much literature about Adalimumab as a cause for kidney injury and fibrillary glomerulonephritis. Patient's clinical notes, local electronic clinical data and slides/reports from histopathology department were requested and used to write this case report. Systemic examination of the patient was unremarkable and blood pressure was normal (120/70 mmHg). Peripheral pulses were intact with no bruits. Urinalysis showed 3+ blood with no protein (urine Albumin: Creatinine ratio 1.4mg/mmol, reference range <3mg/mmol). C3, C4 and immunoglobulins were in the normal range. Autoimmune screen including anti-nuclear antibodies (ANA) and anti-neutrophilic cytoplasmic antibodies (ANCA) were negative. There was no paraprotein band on serum electrophoresis, and urine free light chains were negative. A renal ultrasound showed normal sized kidneys with no obstruction or scarring. In the absence of a clear cause for her declining renal function, a renal biopsy was performed. This revealed significant interstitial fibrosis (Figure 1A). On electron microscopy there was evidence of fibrillary casts (Figure 1B) with ischaemic collapse of glomeruli and some foot process fusion.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The biopsy findings were compatible with tubulointerstitial nephritis with fibrillary glomerulonephritis (GN). This was though to be secondary to Adalimumab as kidney function declined four months after starting it and got better after discontinuation of Adalimumab. This is evident from the improvement of her serum creatinine value as depicted in the graph below (Figure 2). Fibrillary GN occurs in 1% of renal biopsies and pathogenesis of fibrillary GN remains unknown; no clinical findings are specific.

PB2334 AUTOLOGOUS STEM CELL TRANSPLANT IN ADULT MULTIPLE SCLEROSIS PATIENTS: A STUDY FROM NORTH INDIA

Background: Autologous Stem Cell Transplant (ASCT) has been shown to provide long periods of progression free survival in Multiple Sclerosis (MS). Over the past many years many groups have done the procedure in various groups of patients with different types of MS and using different conditioning regimens. Aims: This is an observational study to demonstrate safety of ASCT in MS patients at a transplant centre in North India using a lymphoablative regimen. Methods: The study was conducted from January 2017 and December 2018. MS patients who were either referred by a neurologist or who came of their own volition were evaluated. Kurtzke Expanded Disability Status Scale (EDSS) score was calculated and those with a score of >7 were excluded. Patients <18 years were excluded. Informed written consent was taken. Mobilization was done with G-CSF (10 μg/kg/day) with prednisolone (1 mg/kg/day) to prevent disease flare-up. A minimum of 2 × 106 CD34 cells/kg were collected. Conditioning regimen consisted of Rabbit ATG 0.5 mg/kg on day -6 followed by 1 mg/kg on day -5 to -2 and Cyclophosphamide 50 mg/kg on day-5 to -2. Rituximab 375 mg/m2 was given on day-7 and day+30 to prevent EBV reactivation and disease relapse. Antibiotic prophylaxis was given with levofloxacin, fluconazole and valacyclovir. Any persistent change in the EDSS score ≥0.5 was considered significant. Results: A total of 34 patients were included in this study. Ten patients had positive urine cultures prior to transplant and were treated before starting any chemotherapy.Majority (73%) of the patients were women (25/34). There was one patient of PPMS, sixteen of RRMS, and remaining were SPMS(50%). The median EDSS score was 5.5. The median age of the study population was 32 years. Mobilization was easily achieved with G-CSF with no disease flare ups. The median CD34 cell harvest was 5.71 × 106 cells/kg. All patients developed febrile neutropenia which was managed as per department policy. There was no mortality during peri transplant up to day+100. One patient of SPMS died following intracerebral bleed on day +120 unrelated to transplant complications. Subjective symptoms improved in majority (30/34) patients. EDSS score improved in 11/34 patients (8/11 with RRMS) with disease progression in 3/34 patients at a median follow up duration of 562 days. Five out of nine RRMS patients with active disease on MRI had a response. Summary/Conclusion: The study shows that ASCT can be done safely for patients with relatively high EDSS scores with additional precautions for screening for infections. RRMS patients with active disease on MRI show the most improvement. SPMS patients may not show significant improvement in the short term.

Asthma vs. PM2.5: A Bridge Between Health and Environmental Surveillance.

Asthma vs. PM2.5: A Bridge Between Health and Environmental Surveillance.

Development of a Novel Staging Model for Affective Disorders Using Partial Least Squares Bootstrapping: Effects of Lipid-Associated Antioxidant Defenses and Neuro-Oxidative Stress.

Although, staging models gained momentum to stage define affective disorders, no attempts were made to construct mathematical staging models using clinical and biomarker data in patients with major depression and bipolar disorder. The aims of this study were to use clinical and biomarker data to construct statistically derived staging models, which are associated with early lifetime traumata (ELTs), affective phenomenology, and biomarkers. In the current study, 172 subjects participated, 105 with affective disorders (both bipolar and unipolar) and 67 controls. Staging scores were computed by extracting latent vectors (LVs) from clinical data including ELTs, recurring flare ups and suicidal behaviors, outcome data such as disabilities and health-related quality of life (HR-QoL), and paraoxonase (PON)1 actvities and nitro-oxidative stress biomarkers. Recurrence of episodes and suicidal behaviors could reliably be combined into a LV with adequate composite reliability (the "recurrence LV"), which was associated with female sex, the combined effects of multiple ELTs, disabilities, HR-QoL, and impairments in cognitive tests. All those factors could be combined into a reliable "ELT-staging LV" which was significantly associated with nitro-oxidative stress biomarkers. A reliable LV could be extracted from serum PON1 activities, recurrent flare ups, disabilities, and HR-QoL. Our ELT-staging index scores the severity of a relevant affective dimension, shared by both major depression and bipolar disorder, namely the trajectory from ELTs, a relapsing course, and suicidal behaviors to progressive disabilities. Patients were classified into three stages, namely an early stage, a relapse-regression stage, and a suicidal-regression stage. Lowered lipid-associated antioxidant defenses may be a drug target to prevent the transition from the early to the later regression stages.

A fragile normality – illness experiences of working-age individuals with osteoarthritis in knees or hips

Objective: Examine how individuals manage to live a life with osteoarthritis in the knee or hip.Methods: Focus group interviews were held with ten female and two male patients aged 45–65 years, who had participated in a vocational rehabilitation programme one to five years’ earlier. The interviews were analysed using thematic analysis.Results: Participants’ experiences are described in three themes: (1) Having “a changed and unreliable body” refers to a persistent presence of symptoms and an occasional, unpredictable flare up of symptoms involving sudden loss of movement control; (2) patients living with “(un) manageable life situations” downscale their daily activities to maintain a normal life; however, their flare-ups are unmanageable and cause significant life disruption; and (3) patients “strive to maintain an independent self” by doing their best to continue living as before without receiving any help. For the patients, continuing to participate in working life signifies an independent life that is on equal terms with others.Conclusions: The participants of this study adjusted and managed their daily activities to continue to live a normal life in accord with cultural norms. However, unpredictable flare ups and loss of control made their otherwise normal life somewhat fragile.Implications for rehabilitation•Osteoarthritis is a common disease which is often considered relatively stable, controllable and manageable.•This sample study highlights the participants uncertainty related to unpredictable variability in symptoms.•Appropriate management strategies for bad days need to be developed especially for those struggling at work.

The Jbel Saghro Au(–Ag, Cu) and Ag–Hg Metallogenetic Province: Product of a Long-Lived Ediacaran Tectono-Magmatic Evolution in the Moroccan Anti-Atlas

The Jbel Saghro is interpreted as part of a long-lived silicic large igneous province. The area comprises two lithostructural complexes. The Lower Complex consists of folded metagreywackes and N070–090°E dextral shear zones, which roughly results from a NW–SE to NNW–SSE shortening direction related to a D1 transpressive tectonic stage. D1 is also combined with syntectonic plutons emplaced between ca. 615 and 575 Ma. The Upper Complex is defined by ash-flow caldera emplacements, thick and widespread ignimbrites, lavas and volcaniclastic sedimentary rocks with related intrusives that were emplaced in three main magmatic flare ups at ca. 575, 565 and 555 Ma. It lies unconformably on the Lower Complex units and was affected by a D2 trantensive tectonic stage. Between 550 and 540 Ma, the magmatic activity became slightly alkaline and of lower extent. Ore deposits show specific features, but remain controlled by the same structural setting: a NNW–SSE shortening direction related to both D1 and D2 stages. Porphyry Au(–Cu–Mo) and intrusion-related gold deposits were emplaced in an earlier stage between 580 and 565 Ma. Intermediate sulfidation epithermal deposits may have been emplaced during lull periods after the second and (or) the third flare-ups (560–550 Ma). Low sulfidation epithermal deposits were emplaced late during the felsic alkaline magmatic stage (550–520 Ma). The D2 stage, therefore, provided extensional structures that enabled fluid circulations and magmatic-hydrothermal ore forming processes.

Safe Start of Ibrutinib in Patients with Chronic Lymphocytic Leukemia and Uncontrolled Autoimmune Hemolytic Anemia

It is estimated that 4-10% of patients with chronic lymphocytic leukemia (CLL) will develop autoimmune hemolytic anemia (AIHA) over the course of their disease. Ibrutinib has proven to be effective in treatment of relapsed, refractory, 17p deleted, and treatment naïve CLL. The effect of ibrutinib on AIHA in the context of CLL has not been established since patients with active hemolysis were excluded from major trials. In this abstract, we present a case series of patients that were actively hemolyzing at the start of ibrutinib therapy and in which their AIHA achieved prolonged response.Patient characteristics and laboratory data are shown in Table. Five patients (3 women, 2 men), median age 61 years (range 57 to 78), with CLL and active, uncontrolled AIHA at the time of ibrutinib initiation were identified. Uncontrolled AIHA was defined as anemia with evidence of hemolysis (at least two of the following: increased reticulocyte count, elevated lactate dehydrogenase, elevated indirect bilirubin, and reduced haptoglobin and a positive direct antiglobulin test (DAT)). Patients had a median hemoglobin of 70 g/L (range 69-96) prior to start of ibrutinib and 3 of them required transfusion support for symptomatic anemia. All patients were receiving prednisone for management of AIHA at the time of ibrutinib initiation and had been on it for a median of 10 days (range 9 - 25) without AIHA resolution. 1 patient received intravenous immunoglobulin concurrently. All patients had received at least one line of therapy for CLL in the past and 3 had experienced previous AIHA responsive to steroids. AIHA in 2 patients was related to previous fludarabine exposure but had responded to a prednisone tapering schedule and were off steroids by the time of the new AIHA flare. Median hemoglobin of 130 g/L (range 113-149) was reached at time of AIHA response.All 5 patients tolerated 420mg oral daily of ibrutinib therapy and AIHA was controlled in a median of 6.5 weeks (range 6-10). Discontinuation of steroids was achieved in all patients at a median of 10 weeks (range 6-17) without evidence of further hemolysis. All patients except one are receiving ongoing follow up and have been followed up for a median of 130 weeks (range 15-150) since ibrutinib start. Patients have not shown evidence of AIHA relapse and continue off AIHA treatment (prednisone). One patient required discontinuation of ibrutinib 6 months after starting due to neutropenia but there was no evidence of AIHA relapse in follow up. The patient has passed away from unrelated GI bleed 2 years after the initial AIHA event.This is the largest case series to our knowledge on the safe start of ibrutinib in CLL complicated by active AIHA. Hemolysis in all patients responded to a short prednisone taper with ibrutinib concurrently and obtained a sustained response at follow up without any flare ups or further AIHA treatment use. These cases suggest that it is safe to start ibrutinib during uncontrolled, active hemolysis in contrast to 2 previous case reports that suggested causal relationship between ibrutinib and onset of severe CLL-associated AIHA (Rider et al, 2015; Hodskins et al, 2014). As previously reported, AIHA occurrence or relapse once ibrutinib has been started is rare (Rogers et al, 2016). DisclosuresNo relevant conflicts of interest to declare.

Rectal Adenocarcinoma in Crohnʼs Disease: A Case Report

This is a case of a 21 year old male patient who underwent total colectomy and a colostomy for a long standing and extensive Crohns disease who developed rectal adenocarcinoma and eventually expired. In Crohn's disease, cancer risk data is limited. If colorectal cancer does develop, however, the prognosis is recognized to be poor with reduced survival.This 21 year old male presented to our clinic in 2007 at age 13 who was diagnosed with Crohn disease at age 7.His medical history is remarkable with 4 to 5 blood transfusions for anemia, growth hormone deficiency, hypogonadism, vitamin D deficiency and a stable pituitary microadenoma. He was managed with numerous courses of steroids, antimetabolites such as infliximab, certolizumab and 5ASA.His Colonoscopy in 2008 revealed complete loss of vascularity and large pseudo polyps, biopsy was consistent with markedly active chronic colitis with crypt distortion in the colon, marked acute ileitis and acute chronic inflammation in the stomach supporting the diagnosis of Crohn disease .Despite aggressive medical management, his symptoms continued to progress and was hesitant to have an ileostomy over the years .In august 2014 he has failed all medications and was placed on Entyvio.He was having flare ups and recurrent pelvic and abdominal abscess with partial bowel obstruction, perforation of the ileum likely contributed to the abscess and impending fistula. His routine colonoscopy procedure was not successful as there was a large rectal mass which was consistent with malignancy and the biopsy of the rectal mass showed a poorly differentiated infiltrating adenocarcinoma .So, he had diagnostic laparoscopy converted to exploratory laparotomy, extensive lysis of abdomen and pelvic adhesions, drainage of pelvic and abdominal abscesses, ileocectomy and colostomy, eventually deteriorated and expired with rectal adenocarcinoma.Colorectal cancer represents the major cause for excess morbidity and mortality by malignant disease in ulcerative colitis as well as in Crohn's disease. Younger patients with long-standing Crohn's disease should be considered for colonic surveillance to permit earlier diagnosis and treatment of potential colorectal carcinoma. Cancer risk begins to be significant 8 years after the onset of pancolitis (involvement of entire large intestine), or 12-15 years after the onset of left-sided colitis. Colonoscopy every 1 to 2 years with biopsies for dysplasia.3062_A Figure 1. a large rectal mass3062_B Figure 2. Showing large pseudopolyps

The Non-Avoidant Pacing Scale: Development and Preliminary Validation

Despite widespread use as a chronic pain management strategy, pacing has been linked with higher levels of pain and disability. A recent meta-analysis found a positive correlation between existing measures of pacing and avoidance, which may partially account for these poorer outcomes. A measure was developed to differentiate pacing from avoidance by emphasizing non–pain-contingent pacing behaviors and nonavoidance of pain. A sample of 283 adults with chronic pain completed the Non-Avoidant Pacing Scale (NAPS) and existing measures of pacing, avoidance, pain, and physical and psychological functioning. Exploratory factor analysis of 10 items (subsample 1, n = 141) suggested two 4-item factors: planned pacing behaviors and pacing through flare ups. Confirmatory factor analysis of 8 items (subsample 2, n = 142) revealed satisfactory fit (goodness-of-fit index .947, comparative fit index .964). The pattern of correlations between each factor and avoidance and key outcomes suggests that the NAPS total scale (ɑ = .819) captures key pacing behaviors and differentiates pacing from avoidance. Unlike existing measures, the NAPS was not positively correlated with avoidance and was associated with better psychological functioning across affective and cognitive domains. The NAPS allows researchers and clinicians to assess the role of pacing in chronic pain management without artefactual overlap with avoidance. PerspectiveThe NAPS assesses activity pacing in chronic pain without artefactual overlap with avoidance. Associations were found between more frequent pacing, as measured by the NAPS, and better psychological functioning. Clearly differentiating pacing from avoidance allows for accurate assessment of the role of pacing in chronic pain management.

General practitioners' views on the influence of cost on the prescribing of asthma preventer medicines: a qualitative study.

Objective Out-of-pocket costs strongly affect patient adherence with medicines. For asthma, guidelines recommend that most patients should be prescribed regular low-dose inhaled corticosteroids (ICS) alone, but in Australia most are prescribed combination ICS-long-acting β2-agonists (LABA), which cost more to patients and government. The present qualitative study among general practitioners (GPs) explored the acceptability, and likely effect on prescribing, of lower patient copayments for ICS alone. Methods Semistructured telephone interviews were conducted with 15 GPs from the greater Sydney area; the interviews were transcribed and thematically analysed. Results GPs reported that their main criteria for selecting medicines were appropriateness and effectiveness. They did not usually discuss costs with patients, had low awareness of out-of-pocket costs and considered that these were seldom prohibitive for asthma patients. GPs strongly believed that patient care should not be compromised to reduce cost to government. They favoured ICS-LABA combinations over ICS alone because they perceived that ICS-LABA combinations enhanced adherence and reduced costs for patients. GPs did not consider that lower patient copayments for ICS alone would affect their prescribing. Conclusion The results suggest that financial incentives, such as lower patient copayments, would be unlikely to encourage GPs to preferentially prescribe ICS alone, unless accompanied by other strategies, including evidence for clinical effectiveness. GPs should be encouraged to discuss cost barriers to treatment with patients when considering treatment choices. What is known about the topic? Australian guidelines recommend that most patients with asthma should be treated with low-dose ICS alone to minimise symptom burden and risk of flare ups. However, most patients in Australian general practice are instead prescribed combination ICS-LABA preventers, which are indicated if asthma remains uncontrolled despite treatment with ICS alone. It is not known whether GPs are aware that the combination preventers have a higher patient copayment and a higher cost to government. What does this paper add? This qualitative study found that GPs favoured combination ICS-LABA inhalers over ICS alone because they perceived ICS-LABA combinations to have greater effectiveness and promote patient adherence. This aligned with GPs' views that their primary responsibility was patient care rather than generating cost savings for government. However, it emerged that GPs rarely discussed medicine costs with patients, had low knowledge of medicine costs to patients and the health system and reported that patients rarely volunteered cost concerns. GPs believed that lower patient copayments for asthma preventer medicines would have little effect on their prescribing practices. What are the implications for practitioners? This study suggests that, when considering asthma treatment choices, GPs should empathically explore with the patient whether cost-related medication underuse is an issue, and should be aware of the option of lower out-of-pocket costs with guideline-recommended ICS alone treatment. Policy makers must be aware that differential patient copayments for ICS preventer medicines are unlikely to act as an incentive for GPs to preferentially prescribe ICS alone preventers, unless the position of these preventers in guidelines and evidence for their clinical effectiveness are also reiterated.

Outcomes of immunosuppressors and biologic drugs in inflammatory bowel diseases: a real life experience

Treatments and therapeutic approaches in IBD are constantly evolving. The newly emerged biologic treatments are one such evolving approach, with much ongoing studies to determine the outcomes safety and side effects, in comparison to the older immunosuppressive treatment regimens. In this research, a retrospective analysis was conducted on 112 patients with IBD, retrieved from a single center in Lebanon, in aim of evaluating the outcomes of biologic, immunosuppressive, or combination of both drug classes, over one another, in the treatment of patients with IBD in the real life experience. Patient treated with Azathioprine were 58%, patients receiving Infliximab were 13%, 20% received Adalimumab, and only 8.9% of patients received a combination of Azathioprine and Adalimumab. Overall Response rates to treatment were high (92.9%), while non-responders were 7.1%. As for flare up rates, it was observed that 32.1% of patients had flare ups during treatment, while the majority (61.6%) did not. Less flare up and side effect rates were noted among patients treated with biologic treatment. In addition, the results showed that biologic drugs are superior in achieving a higher response rate compared to immunosuppressive treatment. This result was significant to the 95% confidence interval.

A Glance on Nail Involvement by Pemphigus Vulgaris

Nail involvement by pemphigus vulgaris is uncommon and has been associated with the severity of disease. Paronychia, onychomadesis, Beau's lines, nail hemorrhages, cross riding, discoloration, hyperkeratosis, pitting, pterygium, onychodystrophy, onycholysis, onychorrhexis, onychoschizia and trachyonychia have been reported. These nail disorders may appear before, concomitantly or after the typical manifestations of pemphigus flare ups. Two adult patients presenting with nail disorders associated with pemphigus vulgaris are herein commented. Case studies might contribute to enhance the awareness about these nail disturbances very scarcely reported.

\u201cI just know\u201d: exploring self-knowledge in chronic obstructive pulmonary disease

The importance of lay knowledge in health care settings, particularly in relation to long-term conditions, has received increasing attention over the past few decades. However, there remains some way to go before patients’ experiential or self-knowledge forms part of current clinical decision making and care provision. Chronic obstructive pulmonary disease (COPD) is a chronic respiratory condition which affects people on a daily basis. People living with this condition develop experiential knowledge about their symptoms and are, arguably, best placed to assess these and treat any acute worsening of their condition accordingly. Here we explore how people with COPD articulate their knowledge and make sense of it within the context of their everyday lives. We re-analysed data from a qualitative interview-based study with 44 participants living with moderate to severe COPD using a grounded theory approach. We found that participants focused their attention on symptoms and sensations of the chest while developing an embodied self-awareness that allowed them to assess whether they were experiencing an acute worsening of their condition. Participants appeared confident in using this self-knowledge to distinguish such acute flare ups from the daily variability of their condition, described as good days and bad days. We suggest that people with COPD are very attuned to their bodies despite the vagueness and sometimes seemingly unrelated nature of their symptoms and signs. We argue that self-knowledge should be acknowledged as valid and meaningful by both patients and clinicians. This is particularly important because of the clinical uncertainty about the precise onset and presentation of acute exacerbations in COPD.

Same old peristomal dermatitis, but what's causing it?

Introduction Prevalence of peristomal dermatoses ranges between 6-80% 1 and more commonly affects patients with urostomies and ileostomies, than with colostomies. Most common causes include irritant contact dermatitis from urine/faeces, mechanical dermatitis, chronic papillomatous dermatitis, seborrheic dermatitis and allergic contact dermatitis. We report an unusual case of allergic contact dermatitis to printing ink on stoma bag which has not knowingly been reported before. Case description A 66-year-old male, presented with a pruritic rash under colostomy bag, not responding to topical emollients and steroids. Examination findings were of an eczematous rash with no obvious leak at stoma site or from bag. He was not on any medication such as Nicorandil which might be contributing to peristomal dermatitis/ulceration. Provisional diagnoses were allergic contact dermatitis and irritant contact dermatitis. First patch test for standard european battery was negative. Histopathology had shown eczematoid spongiotic dermatitis, consistent with allergic/irritant contact dermatitis. He was treated with several emollients, topical Trimovate®, Betnovate® and topical 0.1%Tacrolimus; however, it had made no significant difference even by occlusion with hydrocolloid dressing. Subsequently he was patch tested with colostomy bag tied on to forearm for a week. It was divided in five patches: 1.Inner sticky pad 2.Outer sticky pad 3.Bag 4.Printed area of bag and 5.Joined area of bag. Surprisingly he had shown strongly positive reaction only to number 4 but not to any other part of the bag. It was thought that he was allergic to that particular ink and not to bag itself as he did not show any reaction to un-branded part of the bag. He was advised to cover the printed under surface of the colostomy bag with Micropore® and to continue Hydromol® as barrier emollient and Mometasone furoate ointment for flare ups. His problem completely resolved with covering inked part of colostomy bag with Micropore® and he was discharged back to GP. Enquiry had been made to manufacturer regarding materials used in ink, as patch test for standard European battery were negative, however manufacturer of the colostomy bag had passed it on to the manufacturer of the ink and no further information had been received to this date. Conclusion Allergic contact dermatitis had been reported secondary to ostomy bag/pouch, sealing rings, strapping, deodorizers, adhesives, skin cleansers and topical emollients and ointments. Patch testing had always been the key investigation in these cases. Most reported cases had shown sensitivity to ‘epoxy resin' which is a component of stoma bag itself. Allergic contact dermatitis had also been reported to karaya gum seal ring 2 , colophony & benzyl peroxide 3 , tinuvin P® / 2-benzotriazol 4 , di-aminodiphenylmethane and rubber seal surrounding the bag 5 . Other cases had shown sensitivity to adhesive tapes, polyisobutylene (adhesive ring of ostomy bag), adhesive remover wipes, stomahesive paste®, dansac® soft paste, gantrez ES®, balsam of Peru, cinnamic aldehyde, geraniol, benzyl alcohol, isoeugenol, propylene glycol and DOR ostomy deodorant® 6 . However, so far we had not noted any case report showing sensitivity to printing ink on colostomy bag. It is unfortunate that we are still unable to get the information on components of ink however, in suspected cases it would be worth covering the printed under surface of colostomy bag to overcome possible allergic contact dermatitis. Recommending manufacturers of stoma care products to avoid printing on the surface in contact with the skin would also be another feasible alternative. Take-home message 1.Allergic contact dermatitis is one of the common causes of peristomal dermatitis. 2.Patch test is important if allergic/irritant contact dermatitis is suspected. 3.Stoma bag can be used directly for patch testing if commercially available patch tests batteries do not show any positive result. 4.Although quite rare, patients can develop sensitivity to printing ink on stoma bag and covering printed surface can be considered if clinically suspected.

What constitutes back pain flare? A cross sectional survey of individuals with low back pain

Background and purposeLow back pain (LBP) is a lifelong problem for many. In acute episodes, or as a persistent condition, LBP is fluctuating in nature, with pain and other features of the condition varying in intensity and duration over time. Symptom flares (also known as flare ups) contribute to this variation and can have a great impact on the lives of those who have LBP. An important goal of treatments for, and research on, LBP is arguably to decrease symptom flare in both frequency and severity. However, this goal is problematic with little research, and no consensus, on how to define LBP flare. In particular, patients’ understandings of LBP flare have received limited attention in the literature. To appropriately address this issue, we sought to understand how flares are conceptualized by individuals with LBP. MethodsWe used an inductive, predominantly qualitative methodology, conducting an online survey with 130 individuals who self-reported experiencing LBP. The survey investigated participants’ views on LBP flare including its meaning, features and symptoms, and whether ‘flare’ and ‘pain increase’ were synonymous. Qualitative analysis of responses involved thematic and content analysis with descriptive statistics used for the quantitative component. ResultsOur data analysis found that participants identified many aspects of a flare to be important. Qualitative analyses highlighted a number of themes including that LBP flare was conceptualized as: (1) an increase in pain and other uncomfortable sensations such as paraesthesia or muscle tension, (2) an increase in the area, quality and/or duration of symptoms, (3) a reduction in physical, cognitive and/or social functioning, and (4) negative psychological and/or emotional factors. Flare was also discussed as a change that was difficult to settle. When participants considered whether ‘flare’ and ‘pain increase’ were synonymous, responses were evenly divided between ‘no’ (47%) and ‘yes’ (46%) with remaining participants ‘unsure’. ConclusionsThe key finding was that many people with LBP do not consider their condition to be flared simply on the basis of a pain increase. In general, other features were required to also change. Results highlighted that a narrow focus on pain is unlikely to differentiate minor pain events from a flare. These findings are important as they contrast with most commonly used definitions of a flare that focus predominantly on pain increase. ImplicationsOur findings have implications for understanding the trajectory of LBP over time. Understandings derived from perspectives of individuals with LBP highlight that defining flare in LBP is complex. In order to provide person-centred care, individual context and experiences should be taken into account. Therefore, understandings of LBP flare require consideration of factors beyond simply an increase in pain. A comprehensive, person-centred understanding of flare that includes a number of features beyond simply an increase in pain intensity is likely to be useful to better identify flares in research settings, assisting endeavours to understand and reduce LBP. Similarly, in clinical settings a nuanced conceptualisation of flare is likely to help health professionals communicate understandings of flare when working with individuals to manage their LBP.

Role of footwear allergens in juvenile plantar dermatosis

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Juvenile plantar dermatosis (JPD) is characterized by shiny dry fissured dermatitis of the plantar surface of the foot, affecting children aged 3-14years. The most accepted theory is that JPD is a frictional contact dermatitis of the forefoot in which atopics are more prone to develop. Allergic contact dermatitis remains a close differential diagnosis; it can aggravate the predisposing JPD. In this background we carried out a study among children aged fourteen years and below with clinically diagnosed JPD to know the age and sex profile, aggravating factors and clinical features in this part of the country&lt;span lang="EN-IN"&gt;.&lt;/span&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; All children aged 14 years and below with JPD attending our outpatient department from November 2006 to November 2007 were included in this study. Using a preset proforma, data regarding age and sex, information on any relation to footwear, past history of allergic disorders in person or family members was collected. All the 40 patients were patch tested using the footwear allergen series in petrolatum base. Patch test unit was removed after 48hours and the results were interpreted using criteria laid down by International Contact Dermatitis Group (ICDRG). The data was analyzed and made an attempt to understand the role of footwear allergy in JPD.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; 22 girls and 18 boys attended our OPD with JPD between the age group of 4-14 years. 52.5% were using footwear made of plastic; 25%used leather; 12.5% rubber footwear. Patients presented with erythema and glazed appearance of foot along with fissuring. The areas of involvement were distal soles and toes in 70%, distal sole alone in 7.5% and distal sole and dorsum of toes in 22.5% of patients. Personal history of atopy was documented in 15% of patients and family history of atopy was present in 20% of cases. 20% of patients complained of exacerbation with footwear. Of the 40 patients who underwent patch testing, 10% only showed &lt;span lang="EN-IN"&gt;positive patch test reaction mainly to potassium dichromate (5%). &lt;/span&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; JPD is not an uncommon disease and it predominantly affects school going children. Seasonal variation was associated with aggravation of disease. Specific footwear was identified to cause flare ups in a significant percentage of study population (20%) and this was proven by patch test results in half of them. Though nearly one fifth of the affected had an atopic diathesis in person or family, the present data suggests that JPD is not exclusive to atopics. A large sized study is required to &lt;span lang="EN-IN"&gt;evaluate the role of footwear in JPD.&lt;/span&gt;&lt;/p&gt;