Steroid Usage Research Articles

Medication use among lung cancer patients before and after initiating immune checkpoint inhibitors: A population study.

e21119 Background: Polypharmacy is an independent prognostic factor in older patients with lung cancer treated with immune checkpoint inhibitors (ICIs). Previous studies have shown that steroids, opioids, proton pump inhibitors, fluoroquinolone are associated with worsening overall survivals for lung cancer patients. The prevalence of drug use among lung cancer patients using ICIs is understudied. Methods: The study population consisted of older adults (aged 65 years or older) diagnosed with lung cancer from January 1, 2011, to December 31, 2016, in the Surveillance, Epidemiology, and End Results–Medicare linked database. Patients with a diagnosis of lung cancer and a claims record showing nivolumab plus ipilimumab combination therapy or anti–PD-1 therapy (ie, pembrolizumab or nivolumab) as their ICI prescribed were included in the analyses. Index date was defined as the date of first dose of ICIs. We examined medication usage within 90 days prior and after index date. Drug categories were classified, by mechanism of action from Lexicomp®, using Medicare Part D Drug event generic name. Descriptive analysis was used to show the percentage of concurrent drug usage for each drug category. McNemar test was used to compare the drug use prevalence before and after index day. Results: There are 669 patients in the study (male [48.56%], 65–74-year-old [67.10%]). Usage of steroids (89.09%), opioids (87.89%) was high before ICIs. Significant decreases were observed between before and after the index day for most prescribed drug categories, including anti-psychotics (-62.94%, p < .0001). But the use of thyroid products (35.83%, p < .0001) increased in usage after starting ICIs. Conclusions: To our knowledge, this is the first population-based study to quantify concurrent medication use amongst lung cancer patients undergoing immunotherapy. This study suggests the polypharmacy decreased significantly after initiation of ICIs. Future studies are required to investigate the reasons for the changes in medication use and increased utilization of thyroid products.[Table: see text]

A Narrative Review of the Pathophysiology of Mucormycosis Infection Among COVID-19 Patients in India: Epidemiology and Clinical Implications

Background and Objective: During the second COVID-19 wave in India (April to May 2021), mucormycosis has affected the ‘recovering’ and the ‘recovered but vulnerable’ COVID-19 patients across the country. This review synthesizes information on the risk factors and pathophysiology of mucor infection among COVID-19 patients, which in turn supplements existing information from public health and clinical sciences. The study objective includes analyzing the morbidity of mucor infection and its pathophysiological mechanism, during India’s second wave of the COVID-19 pandemic. Methods: We conducted a systematic literature search of PubMed and Google Scholar databases, using the following text terms: ‘COVID-19,’ ‘SARS-CoV-2,’ ‘mucormycosis,’ and ‘zygomycosis.’ We identified 24 citations and 16 other published literature which described mucormycosis in association with COVID-19. The relevant literature was analyzed for findings on the risk factors of mucor infection and its outcome among individuals with COVID-19. Results: The risk factors for mucor infection include diabetes mellitus, immunosuppression (for example, the administration of steroids/monoclonal antibodies/broad-spectrum antibiotics), prolonged stay in the intensive care unit, co-morbidities such as malignancy or post-transplantation, and prophylactic therapy with voriconazole (generic anti-fungal). The second wave of COVID-19 in India was more severe due to the increased occurrence of systemic inflammation and coagulopathy, which can cause direct damage to the blood vessels resulting in injuries to organs such as the liver, kidney, and heart. Conclusion and Implications for Translation: The increased incidence of mucormycosis during the second wave of the COVID-19 pandemic in India (April to May 2021) was due to a combination of immunocompromising effects of corticosteroids, microangiopathy of diabetes, and peripheral microthrombi among COVID-19 patients. The indiscriminate usage of steroids for treating COVID-19 disease seems to be the likely cause, including the use of immunomodulatory drugs such as interleukin 6 inhibitors like tocilizumab (TCZ) for patients with severe COVID-19. Clinical practices should adopt a judicious approach towards the prescription of steroids and monitoring blood sugar for all COVID-19 patients admitted to the hospital as well as those isolated at home (even during the post-recovery period). The high mortality rate of mucor infection demands appropriate primary prevention measures, as well as early diagnosis and treatment modalities for improving patient survival. Copyright © 2022 Ramani et al. Published by Global Health and Education Projects, Inc. This is an open-access article distributed under the terms of the Creative Commons Attribution License CC BY 4.0.

Patients with transplantation have reduced mortality in bacteraemia: Analysis of data from a randomised trial

ObjectivesInfection remains a major complication of organ transplantation. Paradoxically, epidemiological studies suggest better survival from serious infection. We analysed the relationship between organ transplantation and short -term mortality of patients with bloodstream infection. MethodsData on transplantation status was extracted from a large prospective, multi-centre clinical trial in bloodstream infection. Logistic regression for 28-day mortality was performed on the whole cohort and a propensity-matched cohort (3:1). Infective pathogen, focus of infection, and clinical variables were included in the model. Mediation analysis was performed on clinical variables to explore causation. Results4,178 participants were included in the full cohort, with 868 in the matched cohort, of which 217 received an organ transplant. Haematopoietic stem cell transplants (HSCT) were the most common transplant (n = 99), followed by kidney (n = 70). The most common pathogens were staphylococci and Enterobacterales. Transplantation status was associated with a reduced mortality in both the whole (Odds Ratio, OR 0.53; 95% CI 0.28, 0.77) and matched (OR 0.55, 95% CI 0.34, 0.90) cohort, while steroid use was robustly associated with increased mortality OR 4.4 (95% CI 3.12, 6.20) in the whole cohort and OR 5.24 (95% CI 2.79, 9.84) in the matched cohort. There was no interaction between steroid use and transplant status, so transplant patients on steroids generally had increased mortality relative to those without either. ConclusionsOrgan transplantation is associated with a near halving of short term mortality in bloodstream infection, including a cohort matched for comorbidities, infective pathogen and focus. Steroid usage is associated with increased mortality regardless of transplant status. Understanding the mechanism and causation of this mortality benefit should be a focus of future research.

Mucormycosis – A prosthodontists perspective

Mucormycosis, an opportunistic fungal infection commonly associated with diabetes, is now intermittent as a result of co-infection with COVID-19 and steroid use, affecting the nose and paranasal sinuses of the head and neck region, with high mortality and morbidity. It is also more common in diabetic ketoacidosis, neutropenia, cancer, organ transplantation, and/or high serum iron levels, burns, acquired immunodeficiency syndrome, indiscriminate usage of steroids, lymphoma, leukemia, poor metabolic status etc. The most common treatment protocol for such conditions is aggressive surgical debridement, which includes resection of involved maxillofacial structures such as the maxilla, orbit, and/or nose.Rehabilitation of such large maxillofacial defects is a Prosthodontic challenge, with many problems encountered such as lack of retention due to dislodging forces exerted by scarred postsurgical soft tissues, lack of bony base, lost structures of the posterior palatal seal area, multiple defect sites, and compromised medical status due to comorbidities, which also affects the defect's healing rate.For patients to survive, early diagnosis and treatment are frequently required. The clinical manifestations, etiopathogenesis, and management of the dreaded fungal infection known as mucormycosis in the head and neck region will be reviewed in this paper.

Strategy to small intestine obstruction caused by Crohn’s disease on the basis of transnasal ileus tube insertion

BackgroundPrevious studies reported that transnasal ileus tube was a new and useful method for rapid relief of small intestinal obstruction. However, no study reported the impacts of the transnasal ileus tube for Crohn’s disease combined with intestinal obstruction. We aimed to describe the strategy to the small intestine obstruction caused by Crohn’s disease on the basis of transnasal ileus tube insertion.MethodsFrom November 2019 to November 2021, the data of 6 hospitalized patients with CD, diagnosed and conservatively treated in The Second Hospital of Nanjing, were not relived and retrospectively collected. After the insertion of transnasal ileus tube, demographic information, clinical features and treatment data were extracted from medical records.ResultsSix Crohn’s disease patients with intestinal obstruction were included. Half of them were male. The patients aged from 29 to 70 years. Five patients had chronic intestinal obstruction more than one year. Three patients had intestinal surgery history. One patient had colonic abdominal fistula and anastomotic fistula, when she took intermittent usage of sulfsalazine and steroid. On admission, all the patients had abdominal pain, distention and mass. Five patients had anemia, low albumin and cholinesterase. All CDAI scores were more than 400. Compared to 19 patients with incomplete intestinal obstruction improved by nasogastric decompression tube, 6 patients with intestinal obstruction catheter had significant difference in time for relieving abdominal pain and distension (p = 0.003), time for alleviating abnormal mass (p ≤ 0.01), drainage volume (p = 0.004), and preoperative CDAI score (p = 0.001). Compared with X-ray image before insertion, complete remission of obstruction of 5 patients were observed in intestinal cavity after insertion. After 1–2 months nutrition, all the patients had small intestine resection and ileostomy, half of them underwent colectomy and fistula repair, and 4 patients were performed enterolysis at the same time, the residual small intestine length ranging from 250 to 400 cm. 1 patient had permanent ileostomy;1 patient had abdominal infection after operation. The typical manifestations of acute and chronic inflammation, transmural inflammation, pseudopolyps and serous fiber hyperplasia could be seen in pathological findings of patients 1 to 5. All the patients continued enteral nutrition after surgery. Four patients were treated with infliximab or vedolizumab.ConclusionThe current intestinal obstruction catheter which is used to treat patients with Crohn's combined obstruction can afford quick clinical remission, longer nutrition time, and suitable preoperative CDAI score for operation, which is worthy of wildly being used.

Case report on topical steroids causing infantile iatrogenic cushing syndrome

Cushing Syndrome is characterised by raised levels of Glucocorticoids in free plasma. It is caused because of excess endogenous release of steroids or excess usage of exogenous steroids. The common form Cushing syndrome present in children is Iatrogenic Cushing syndrome. It is either due to excessive administration of parenteral or oral preparations of steroids which are used in treatment of pulmonary, renal, haematological and autoimmune diseases. Topical steroids rarely causes Cushing syndrome. In our case report, We will describe about a four month old girl child who developed Cushing syndrome ( Iatrogenic ) because of prolonged and excessive use of Topical preparations steroids Namely clobetasol for treatment of napkin ( diaper ) dermatitis.

Sensitivity of liquid-based cytology in the diagnosis of mucormycosis in COVID-19 treated patients.

BackgroundThe coronavirus disease 2019 (COVID‐19) infection caused by the novel severe acute respiratory syndrome corona virus 2 (SARS‐CoV‐2) is associated with a wide range of disease patterns, ranging from mild to life‐threatening pneumonia. COVID‐19 can be associated with a suppressed immune response and/or hyperinflammatory state due to a cytokine storm. Reduced immunity, combined with steroid usage to prevent a cytokine storm along with various pre‐existing comorbidities can prove to be fertile ground for various secondary bacterial and fungal infection, including mucormycosis. Diagnosis of Mucor is a challenging task given the high negativity rate of various detection methods. While histopathology is considered the gold standard, the acquisition of necessary tissue biopsy specimens requires invasive procedures and is time consuming.MethodIn this study five different methods of Mucor detection, namely conventional cytopathology, liquid‐based cytology (LBC, BD SurePath™), potassium hydroxide (KOH) preparation, culture, and histopathology were analysed. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for all five methods.ResultsLBC had values for sensitivity, specificity, PPV, and NPV of 72.4%, 100%, 100%, and 38.4%, respectively, closely matching histopathology in sensitivity (75.9%). The sensitivity of culture, conventional cytopathology, and KOH were very low compared to histopathology and LBC.ConclusionThis study showed that LBC, can be a rapid and effective alternative to histopathology in Mucor diagnosis.

Evaluation of early postoperative day 1 discharge after endoscopic endonasal pituitary adenoma resection.

While multiple studies have evaluated the length of stay after endonasal transsphenoidal surgery (ETS) for pituitary adenoma, the potential for early discharge on postoperative day 1 (POD 1) remains unclear. The authors compared patients discharged on POD 1 with patients discharged on POD > 1 to better characterize factors that facilitate early discharge after ETS. A retrospective chart review was performed for patients undergoing ETS for pituitary adenoma at a single tertiary care academic center from February 2005 to February 2020. Discharge on POD 1 was defined as a discharge within 24 hours of surgery. A total of 726 patients (mean age 55 years, 52% male) were identified, of whom 178 (24.5%) patients were discharged on POD 1. These patients were more likely to have pituitary incidentaloma (p = 0.001), require dural substitutes and DuraSeal (p = 0.0001), have fewer intraoperative CSF leaks (p = 0.02), and have lower postoperative complication rates (p = 0.006) compared with patients discharged on POD > 1. POD 1 patients also showed higher rates of macroadenomas (96.1% vs 91.4%, p = 0.03) and lower rates of functional tumors (p = 0.02). POD > 1 patients were more likely to have readmission within 30 days (p = 0.002), readmission after 30 days (p = 0.0001), nasal synechiae on follow-up (p = 0.003), diabetes insipidus (DI; 1.7% vs 9.8%, p = 0.0001), postoperative hypocortisolism (21.8% vs 12.1%, p = 0.01), and postoperative steroid usage (44.6% vs 59.7%, p = 0.003). The number of patients discharged on POD 1 significantly increased during each subsequent time epoch: 2005-2010, 2011-2015, and 2016-2020 (p = 0.0001). On multivariate analysis, DI (OR 7.02, 95% CI 2.01-24.57; p = 0.002) and intraoperative leak (OR 2.02, 95% CI 1.25-3.28; p = 0.004) were associated with increased risk for POD > 1 discharge, while operation epoch (OR 0.46, 95% CI 0.3-0.71; p = 0.0001) was associated with POD 1 discharge. This study demonstrates that discharge on POD 1 after ETS for pituitary adenomas was safe and feasible and without increased risk of 30-day readmission. On multivariate analysis, surgical epoch was associated with decreased risk of prolonged length of stay, while factors associated with increased risk of prolonged length of stay included DI and intraoperative CSF leak. These findings may help in selecting patients who are deemed reasonable for safe, early discharge after pituitary adenoma resection.

P188 Baricitinib effectiveness after a previous inadequate response to an alternative JAK inhibitor: results from the Swiss rheumatoid arthritis register

Abstract Background/Aims Previous research has suggested that switching between b/tsDMARDs with different mode of action may be more effective than switching agents within the same mechanism of action. Limited data exists about the impact of an inadequate response to a previous JAK-inhibitor (JAKi) on subsequent JAKi effectiveness. Methods This is a nested study within the Swiss Clinical Quality Management (SCQM) registry of RA patients. All patients initiating baricitinib treatment courses (BARI) between 01-09-2017 and 01-06-2020, with at least one follow-up visit, were included. We compared the time to treatment discontinuation, as a measure of drug effectiveness, of BARI with a previous history of an inadequate response (IR) to tofacitinib (“BARI-post-TOFA”) or without (“BARI-initial”). Tofacitinib IR was defined as previous tofacitinib treatment discontinuation for adverse events or for ineffectiveness. Baseline characteristics were compared using t-tests or χ2. We used Kaplan-Meier curve to display crude time to discontinuation and a Cox model to estimate adjusted hazard ratio (HR). Cox model was adjusted for potential confounding factors: age, BMI, concomitant csDMARD, concomitant steroid usage, baseline CDAI, disease duration, smoking status, line of therapy, gender and seropositivity to RF/ACPA. Results Of the 273 included BARI, 72 were initiated in patients with a history of a previous tofacitinib IR (Table 1). No differences were found between the “BARI-post-TOFA” and the “BARI-initial” groups in terms of time-to-discontinuation, as demonstrated by both the unadjusted Kaplan-Meier survival analysis (Log-rank p = 0.44) and the fully adjusted Cox analysis (Hazard Ratio BARI-post-TOFA vs BARI-initial = 0.76 (95% IC [0.42 - 1.34]; p = 0.34). Other covariates significantly associated with drug maintenance were active smoking (p = 0.03) and CDAI score (p < 0.01). Conclusion In this preliminary analysis, a history of prior tofacitinib IR did not appear to significantly impact subsequent drug maintenance of baricitinib. Disclosure B.T.P. Gilbert: Other; Invited speaker for Lilly Symposium SGR Congress Lausanne (2021). D.S. Courvoisier: None. D. Mongin: None. K. Lauper: None. V.A. Guimaraes: Other; Clinical Research Scientist Immunology at Eli Lilly (Suisse) S.A. R.B. Mueller: None. A. Finckh: Grants/research support; Invited speaker and consultant for Eli Lilly. Has received research grant from Eli Lilly.

Postoperative outcomes after degenerative lumbar spine surgery in rheumatoid arthritis patients -a propensity score-matched analysis

BackgroundAlthough treatment options for rheumatoid arthritis (RA) have evolved significantly since the introduction of biologic agents, degenerative lumbar disease in RA patients remains a major challenge. Well-controlled comparisons between RA patients and their non-RA counterparts have not yet been reported. The objective of the present study was to compare postoperative outcomes of lumbar spine surgery between RA and non-RA patients by a retrospective propensity score-matched analysis.MethodsPatients who underwent primary posterior spine surgery for degenerative lumbar disease in our prospective multicenter study group between 2017 and 2020 were enrolled. Demographic data including age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) physical status classification, diabetes mellitus, smoking, steroid usage, number of spinal levels involved, and preoperative patient-reported outcome (PRO) scores (numerical rating scale [NRS] for back pain and leg pain, Short Form-12 physical component summary [PCS], EuroQOL 5-dimension [EQ-5D], and Oswestry Disability Index [ODI]) were used to calculate a propensity score for RA diagnosis. One-to-one matching was performed and 1-year postoperative outcomes were compared between groups.ResultsAmong the 4567 patients included, 90 had RA (2.0%). RA patients in our cohort were more likely to be female, with lower BMI, higher ASA grade and lower current smoking rate than non-RA patients. Preoperative NRS scores for leg pain, PCS, EQ-5D, and ODI were worse in RA patients. Propensity score matching generated 61 pairs of RA and non-RA patients who underwent posterior lumbar surgery. After background adjustment, RA patients reported worse postoperative PCS (28.4 vs. 37.2, p = 0.008) and EQ-5D (0.640 vs. 0.738, p = 0.03), although these differences were not significant between RA and non-RA patients not on steroids.ConclusionsRA patients showed worse postoperative quality of life outcomes after posterior surgery for degenerative lumbar disease, while steroid-independent RA cases showed equivalent outcomes to non-RA patients.

Doping with aromatase inhibitors and oestrogen receptor modulators in steroid users: Analysis of a forum to identify dosages, durations and adverse drug reactions

Some users of anabolic androgenic steroids (AAS) secretly consume aromatase inhibitors (AI) and selective oestrogen receptor modulators (SERM). Cyber-forums can be potential sources of information. Our aim was to determine the cycles used, and to identify the adverse drug reactions (ADRs) experienced, reported in a bodybuilding forum. We collected discussions on a French forum for AAS users (MESO-Rx®), from January 2013 to 2019 on concerning clomiphene, tamoxifen, anastrozole, exemestane and letrozole were collected. Characteristics of the users, duration of cures, treatments, dosages, point of purchase and occurrence of ADRs were analysed. Among the 1792 posts published on the forum, 845 concerned SERM and 571 concerned AI, i.e. 2180 drugs used (several cycles included concomitant consumption). Our population was exclusively male, with an average age of 28.2±6.3years, and had been practising weight training for 6.7±5.6years. The SERMs were mainly used to "revive the hypothalamohypophyseal axis" and the AIs to "fight against androgen aromatisation". The median treatment duration was 22 days for SERM, 70days for anastrozole, 84days for exemestane and 30days for letrozole, with a mean dose of 69mg/d for clomiphene, 22mg/d for tamoxifen, 0.4mg/d for anastrozole, 10mg/d for exemestane, 2mg/d for letrozole. The main way of obtaining these drugs was through the internet. 157 ADRs were identified: 95 for SERMs and 62 for AI. The most represented were acne, musculoskeletal, mood and reproductive disorders. Impaired quality of life (according to the patient) was described in 54% of the SERM posts and 26% of the AI posts. Patient narratives posted on forums can be a useful tool in the context of doping, to better understand practices, motivations and possibly to bring up pharmacovigilance signals.

Use of systemic steroids during pulmonary exacerbations in children and adolescent with Cystic fibrosis.

To determine the role of systemic steroids in cystic fibrosis patients and its effects on pulmonary exacerbation in children and adolescents. The retrospective cohort study was conducted at the Aga Khan University Hospital, Karachi, and comprised data from January 2015 to December 2019 of cystic fibrosis patients aged 3-18 years hospitalised with pulmonary exacerbations. The patients were divided into systemic steroid group A and non-systemic steroid group B. Patients in group A received parenteral steroids during acute exacerbation of cystic fibrosis in the first two weeks of admission, while those in group B did not receive systemic steroids. Length of hospital stay and number of days on oxygen support were compared between the groups. Data was analysed using SPSS 22. Of the 124 patient charts evaluated, 84(67.7%) were included; 40(47.6%) in group A and 44(52.4%) in group B. There were no significant differences between the groups related to age, age at diagnosis, weight, height, and pulmonary exacerbations (p>0.05). Group A had significantly fewer days on oxygen support compared to group B (p<0.001), but there was inter-group difference in mean length of hospital stay (p=0.53). Systemic steroid usage during hospitalisation for acute exacerbation of cystic fibrosis was associated with decreased duration of oxygen requirement with standard treatment.

Suicidal tendencies and psychiatric symptoms as consequence of anabolic androgenic steroid usage among athletes in District Rawalpindi.

To elucidate the possible association between suicidal tendencies and psychiatric symptoms associated with anabolic androgenic steroid usage among athletes. The cross-sectional study was conducted from December 2016 to July 2017 in Rawalpindi and Wah Canttonment, Pakistan, after approval from the International Islamic University, Islamabad, and comprised male athletes aged >18 years. Those using androgenic anabolic steroid formed group A, while the non-users were in group B. In addition to demographics, data was collected using Beck Scale for Suicidal Ideation and the Symptoms Checklist-90. Data was analysed using SPSS 22. Of the 60 subjects, there were 30 (50%) in each of the two groups. The majority were aged 24-26 years 41 (68.30%). Group A scored significantly higher compared to group B on suicidal ideation, had more interpersonal problems, depression, hostility, paranoia and psychoticism (p<0.05). Unemployment and low household income increased steroid usage (p<0.05). There was found to be a significant association of anabolic androgenic steroid use with suicidal tendencies and mental health issues.

Usage of Antihistamines and Topical Corticosteroids in the Management of Geographic Tongue

Geographic tongue (GT) is a benign inflammatory condition of the tongue with map-like areas of erythema. In symptomatic cases, pharmacotherapy is advised to improve quality of life and reduce chances of recurrence. Aim: The study aimed to compare the usage of antihistamines and topical corticosteroids in the management of symptomatic geographic tongue. Objective: The objective was to evaluate the most common drug used in symptomatic geographic tongue management and assess the association between patient gender and drugs given. Materials and Methods: The treatment data of patients (n = 88) was collected from Dental Information Archival System with data from June 2019 to February 2021. The usage of antihistamines and topical steroids was assessed over two weeks to relieve clinical symptoms. Results: The association between drug type, drug name, and reduction in the clinical symptoms after two weeks of the review was statistically significant, with an X2 value of 9.132 at a P value of 0.010 (p &lt; 0.05). The association between drug type, drug name, and gender was not statistically significant (p &gt; 0.05). 38.6% of cases were prescribed Diphenhydramine maleate syrup. It was followed by Betamethasone Mouthwash which was used for 31.8% of cases. Triamcinolone acetonide and Chlorpheniramine tablets were prescribed for 15.9%and 13.6%patients, respectively. Conclusion: Antihistamines should be the first drug type of choice in treating symptomatic GT. Topical steroids could be considered an adjunct or standalone second drug type of choice.

Interdisciplinary and Psychiatric Treatment of Anabolic Androgenic Steroids Users.

The prevalence of anabolic androgenic steroid (AAS; anabolic steroids) use in recreational sports is underestimated. Due to the influence of social media, an increase in AAS use in recreational sports and in the general population is to be expected. AAS use is associated with significant physical and mental health consequences, and the psychiatric consequences include the risk of developing addictive behaviour. The widespread stigmatization of AAS use also by professionals often undermines users' trust in physicians and drives them into the arms of so-called "gurus." The tightening of anti-doping practices in sports and an exclusively prohibitive stance have so far failed to convincingly curb the problem in recreational sports. Harm reduction strategies could help patients to get the help they need from primary care providers.

Plasma Interleukin-33 Cannot Predict Hip Osteonecrosis in Patients With Sickle Cell Disease: A Case-Control Study

BackgroundPlasma interleukin-33 (IL-33), a cytokine associated with inflammatory and autoimmune disease, has been described to be significantly raised in osteonecrosis of the femoral head (ONFH) and hence was recommended for use as a marker for ONFH. The concentration of plasma interleukin-33 level has not been estimated in any studies conducted in patients with sickle cell disease (SCD); hence, we investigated the levels of plasma interleukin-33 in patients with sickle cell disease with or without ONFH to assess whether it can be used as a marker for the early detection of ONFH in this disease also.MethodsForty-four consecutive patients with sickle cell disease with osteonecrosis of the femoral head and matched controls without ONFH were evaluated for plasma interleukin-33 levels by enzyme-linked immunosorbent assay (ELISA). All patients were confirmed for sickle cell disease using high-performance liquid chromatography (HPLC). ONFH was diagnosed in patients with sickle cell disease using clinical-radiological findings. Univariate and multivariate analyses were performed using the IL-33 level as the dependent variable.ResultsPlasma IL-33 levels were comparable in 44 patients with sickle cell disease with osteonecrosis of the femoral head as compared with 24 patients with sickle cell disease without ONFH (2.05 ± 4.57 pg/mL versus 1.50 ± 2.89 pg/mL, p-value = 0.590). There was no significant difference in IL-33 levels in different stages of avascular necrosis (AVN).ConclusionsPlasma interleukin-33 levels cannot act as a marker of ONFH as were being considered in idiopathic ONFH or ONFH caused by other causes such as trauma and chronic steroid or alcohol usage.

Physician education can minimize inappropriate steroid use in patients with inflammatory bowel disease: the ACTION study.

Epidemiological data on steroid use in South Korean patients with inflammatory bowel disease (IBD) are limited. We documented the steroid use patterns in these patients, and whether physician education on appropriate steroid use affected these patterns. ACTION was an observational cohort study conducted in adults (≥19 years) with IBD. A retrospective chart review was performed at baseline (cohort 1) and 1 year after physician training (cohort 2). Eligible cases with excessive or inappropriate steroid use were identified, along with any associated risk factors. Data were collected during May 2018-July 2019 from patients with Crohn's disease (CD) and ulcerative colitis (UC) in cohort 1 (n=1,685) and cohort 2 (n=1,649). At baseline, 155 patients (9.2%) had received steroids within the previous 12 months, 46 (29.7%) of whom had used steroids excessively, 16 (34.8%) of these having inappropriately used excessive steroids. Although steroid exposure was similar in cohort 1 (9.2%) and cohort 2 (9.7%), the latter comprised fewer excessive steroid users (20.0% vs. 29.7%). Severe disease was associated with excessive steroid use in cases with UC, but not with CD. Although, overall steroid use was relatively low in South Korean patients with IBD, one-third of steroid users used them excessively, and one-third among these used excessive steroids inappropriately. High disease activity was the main risk factor for excessive steroid use which may potentially be reduced by physician education, especially in cases with UC. Active screening to minimize excessive and inappropriate steroid use through physician education should be considered.

A Useful Blood Flow Restriction Training Risk Stratification for Exercise and Rehabilitation.

Blood flow restriction training (BFRT) is a modality with growing interest in the last decade and has been recognized as a critical tool in rehabilitation medicine, athletic and clinical populations. Besides its potential for positive benefits, BFRT has the capability to induce adverse responses. BFRT may evoke increased blood pressure, abnormal cardiovascular responses and impact vascular health. Furthermore, some important concerns with the use of BFRT exists for individuals with established cardiovascular disease (e.g., hypertension, diabetes mellitus, and chronic kidney disease patients). In addition, considering the potential risks of thrombosis promoted by BFRT in medically compromised populations, BFRT use warrants caution for patients that already display impaired blood coagulability, loss of antithrombotic mechanisms in the vessel wall, and stasis caused by immobility (e.g., COVID-19 patients, diabetes mellitus, hypertension, chronic kidney disease, cardiovascular disease, orthopedic post-surgery, anabolic steroid and ergogenic substance users, rheumatoid arthritis, and pregnant/postpartum women). To avoid untoward outcomes and ensure that BFRT is properly used, efficacy endpoints such as a questionnaire for risk stratification involving a review of the patient’s medical history, signs, and symptoms indicative of underlying pathology is strongly advised. Here we present a model for BFRT pre-participation screening to theoretically reduce risk by excluding people with comorbidities or medically complex histories that could unnecessarily heighten intra- and/or post-exercise occurrence of adverse events. We propose this risk stratification tool as a framework to allow clinicians to use their knowledge, skills and expertise to assess and manage any risks related to the delivery of an appropriate BFRT exercise program. The questionnaires for risk stratification are adapted to guide clinicians for the referral, assessment, and suggestion of other modalities/approaches if/when necessary. Finally, the risk stratification might serve as a guideline for clinical protocols and future randomized controlled trial studies.

Abstract 79: Adrenal insufficiency in the elderly population

Background: In India the proportion of geriatric population is steadily rising. The symptoms of adrenal insufficiency (AI) may overlap with aging. This study aims to describe the profile of AI in the elderly.Aims and Objectives: To describe the demographic profile, clinical features and laboratory parameters in elderly individuals with biochemically proven adrenal insufficiency and to identify the indications for prolonged steroid therapy in subjects with tertiary AI.Results: 50 adults aged > 60 years were enrolled for the study, this included 29 males (58%), 21 females (42%), with a mean age of 69.27. The symptomatology of the patients were, abdominal pain (14/7:p<0.05), anorexia (60/30:p<0.05), joint pains (66/33:p<0.05) dizziness (18/9), lack of energy (80/40), myalgia (44/22), fatigue (83/43), in terms of signs proximal myopathy was found to be more in males (p< 0.05). In this study 72% of the population had history of steroid usage, most commonly for joint pains.Conclusions: Steroid usage was a common cause for AI in the geriatric population. AI in the elderly can present with vague symptoms. A high index of suspicion is indispensable to test and diagnose this, the carers and HCWs should be cautioned about the ill effects of unprescribed and prolonged steroid medication.

Abstract 77: BMD, TBS and HSA in chronic glucocorticoid users attending a tertiary centre in Southern India

Background: Glucocorticoids (GC) are used for various chronic medical conditions and is one of the most abused drugs in India. Despite widespread GC use, there is lack of knowledge among physicians regarding assessment and management of glucocorticoid induced osteoporosis (GIO). This study was performed to assess bone mineral density (BMD), trabecular bone score (TBS) and hip structural analysis (HSA) in chronic steroid users.Methods: Observational study done from 2013-2020. Details of patients were obtained through archived medical records. Bone biochemical parameters and densitometric variables that included bone mineral density (BMD), trabecular bone score (TBS) and hip structural analysis (HSA) were assessed by a DXA scan.Results: A total of 74 subjects (56 females, 45/56 postmenopausal) with a mean (SD) age and BMI of 49.5 (12.5) years, 29.0 (6.9) kg/m2 were studied. Vitamin D deficiency was present in 33/74 (44.6%) of subjects. 15 subjects (20.3%) had sustained fragility fractures. At baseline, the prevalence of osteoporosis at NOF and lumbar spine was 24/74 (32.4%) and 34/74 (45.9%) respectively. Degraded trabecular microarchitecture as defined by a TBS <1.200 was present in 32/74 (43.2%) of the subjects. Among those with normal BMD at the lumbar spine, 13/40 (32.5%) had a low TBS. Buckling ratio (BR) at the narrow (NN) neck > 10 was seen in 57/74 (77%) of subjects. Among subjects with normal BMD at the femoral neck, 33/50 (66%) had a BR at NN >10, which indicates high fracture risk.Conclusion: GIO continues to be prevalent among steroid users. TBS and HSA may confer additional benefit regarding bone health, not conveyed by conventional BMD assessment in chronic glucocorticoid users.