Long-term effectiveness of transforaminal anterolateral approach CT-guided cervical epidural steroid injections for cervical radiculopathy treatment

AIM

To evaluate the long-term clinical effectiveness of computed tomography (CT)-guided transforaminal cervical epidural steroid injection using an anterolateral approach for the treatment of cervical radiculopathy (CR) using well-established robust clinical scoring systems for neck pain and neck disability. Despite its widespread use, evidence to support the long-term benefit of routine cervical epidural steroid injection is currently very limited.

MATERIALS AND METHODS

This study included 113 patients with magnetic resonance imaging (MRI)-confirmed CR who underwent a steroid injection at a single cervical level via a unilateral transforaminal anterolateral approach. Pain was assessed quantitatively at pre-injection, 15 minutes post-injection, 1 month, 3 months, and at 1 year. Neck disability was assessed using the Oswestry Neck Disability Index (NDI) at pre-injection, 1 month, 3 months, and 1 year time points.

RESULTS

Eighty patients completed the study. Sixty per cent reported reduced neck pain (mean pain reduction, 55%), which was clinically significant in 45% cases. Furthermore, 66% reported an improvement in neck disability (mean improvement, 51%), which was clinically significant for 56% patients. Clinically significant good outcomes in both neck pain and neck disability were evident from as early as 1-month, and importantly, were independent both of pre-treatment CR characteristics (including severity of pre-injection neck pain or disability) and of findings on pre-injection MRI imaging.

CONCLUSION

Transforaminal anterolateral approach CT-guided epidural steroid injection resulted in a clinically significant long-term improvement in both neck pain and disability for half of the present cohort of patients with unilateral single-level CR. This improvement was independent of the severity of the initial symptoms and pre-injection MRI findings.

Ethnomedicinal uses of plants for various diseases in the remote areas of Changa Manga Forest, Pakistan

Abstract This study aims at reporting the indigenous knowledge of the medicinal flora from the inhabitants of surroundings of the World’s largest artificial planted forest “Changa Manga”, Pakistan. Data were collected by direct interviews and group meetings from 81 inhabitants including 32 local healers having information regarding the use of indigenous medicinal plants over a period of one year. Different statistical tools were applied to analyze the data including Frequency citation (FC), Relative frequency citation (RFC), Use Value, Factor of informants consensus and fidelity level. This study reported 73 plant species belonging to 37 plant families and 46 genera. The majority of plant species belong to compositae family. The most commonly used medicinal plants were P. hysterophorus L., P. dactylifera L., S. indicum L, P. harmala L., P. emblica L., and A. indica A.Juss. The greatest number of species was used to cure gastrointestinal disorders. The highest fidelity level (68.18%) was of E. helioscopia to cure gastrointestinal disorders. Maximum fresh uses (17) were reported by C. dactylon (L.) Pars. While the highest number of species reporting fresh uses in similar number was 13. In this study, five novel plants are being reported for the first time in Pakistan for their ethnomedicinal worth. Our data reflect unique usage of the medicinal plants in the study area. The statistical tools used in the study proved useful in pointing the most important and disease category specific plants. High use value plant and the new reported medicinal plants might prove an important source of the isolation of pharmacologically active compounds.

Independent risk factors for COVID-19-associated coagulopathy

OBJECTIVE

Past three years since the beginning of the outbreak, we have obtained satisfactory data on COVID-19. However, data on risk factors of COVID-19-associated coagulopathy (CAC) are extremely limited. Prediction of CAC might be a game changer since it is related to poor prognosis. Seeking independent risk factors for CAC was the main aim of the study.

PATIENTS AND METHODS

510 hospitalized COVID-19 patients were retrospectively screened. Forty-eight of them were excluded due to irrelevant D-dimer or ferritin elevation. The remaining patients were stratified into three groups as overt coagulopathy, significant pulmonary microthrombosis, and patients without coagulopathy. The overt coagulopathy group included cases with macrothrombosis or disseminated intravascular coagulation (DIC). The significant pulmonary microthrombosis group covered the cases that had clinical deterioration with simultaneous marked D-dimer elevation. The group of patients without coagulopathy included the asymptomatic patients with normal or elevated D-dimer levels.

RESULTS

Overt coagulopathy developed in 3.2% and significant pulmonary microthrombosis in 10.1% of the patients. In the multivariate analysis, not receiving low molecular weight heparin (LMWH) (p=0.002), a level of D-dimer >15,000 U/ml (p=0.013) were associated with overt coagulopathy. In addition, levels of initial LDH >480 IU/L (p=0.022) and initial ferritin >1,000 ng/ml (p=0.036) were associated with significant pulmonary microthrombosis. Not receiving LMWH (p=0.001) was also associated with significant pulmonary microthrombosis, when multivariate analysis was performed by the parameters with a p-value <0.1 in the univariate analysis. Furthermore, all cases with DIC had Gram-negative bacterial sepsis.

CONCLUSIONS

Not receiving LMWH, high levels of D-dimer, initial LDH, and initial ferritin are independent risk factors for CAC. DIC does not appear to develop based on COVID-19.

Burden and distribution of dengue infection in Pakistan (2000-19): a review

The goal of this study is to review the overall prevalence, burden, and distribution of the dengue disease in Pakistan from 2000 to 2019. Literature was searched using different search engines like Google scholar, PubMed, etc. providing the keywords "Dengue disease/infection, Dengue virus, DENV, DF/DHF/ DSS Pakistan". All the published research papers/reports on the dengue virus over the period 2000 to 2019 were studied and selected data were summarized using MS Excel for windows such as total cases, age wise, gender, DENV serotype distribution, total DHF, and DSS patients. The literature providing insufficient data was excluded. The total number of cases reported during 2000-19 were 201,269. The maximum number of cases during the mentioned literature survey period was reported in Khyber Pakhtunkhwa (KP) (23.3%) followed by Punjab (3.8%) and Sindh (1.9%). The majority of dengue-infected cases were reported as Dengue fever (74.4%) followed by DHF (24.1%) and DSS (1.5%). Overall the deaths during the mentioned literature survey were 1082, of which the maximum mortalities were reported from KP (N=248) followed by Punjab (N=220). DENV remains a major public health problem in Pakistan and seems to remain endemic for a long time. The total prevalence of dengue infection is increased accordingly with time from 2000 to 2019. Moreover, all the four serotypes exist in Pakistan with increased mortalities.

AB0748 Anti-Fibrotic Therapy in Progressive Pulmonary Fibrosis Associated with Sytemic Sclerosis: Characteristics of SSc-İAH Patients Receiving Nintedanib and Advers Events during Treatment

Background

Nintedanib, an intracellular inhibitor of tyrosine kinases, has been recently approved for interstitial lung disease associated with systemic sclerosis (SSc-ILD). Nintedanib has shown antifibrotic and antiinflammtory effects in animal models of fibrosing ILDs.

Objectives

We aimed to evaluate clinical charcteristics of progressive SSc-ILD patients receiving anti-fibrotic therapy who were resistant to standart immunosuppressives (ISs) and adverse events during treatment period in this cohort.

Methods

Fifteen patients fulfilling ACR/EULAR (2013) classification criteria for SSc and receiving nintedanib for progressive ILD despite standart ISs included into this retrespective analysis.

Results

Demographics and clinical characteristics of SSc patients were summarised in Table 1. Median age, duration of Raynaud’s and duration of non-Raynaud symptom were 49 (35-72), 8 (1-30) and 4 years (1-21), respectively. ILD was evident median 2 years (0.5-20) after onset of Raynaud’s and 1 years (0.5-11) after onset of non-Raynaud symptom. Before pulmonary involvement, 7 patients received methotrexate and 1 patient cyclophosphamide (CYC) for diffuse cutaneous involvement. After evident ILD, 6 patients received CYC, 5 patients mycophenolate mofetil (MMF) and 4 patients azathioprine as first ISs for SSc-ILD. Median FVC(%) and DLCO(%) were 56 (39-67) and 44 (20-67) before antifibrotic therapy. Thirteen patients (%92,8) received ≥2 ISs before nintedanib. Duration of evident ILD to onset of antifibrotic therapy was median 5.5 years (2-11). Nintedanib was prescribed concomitantly with MMF in 8 or rituksimab-MMF in 6 patients. Median follow-up of antifibrotic treatment period was 7 months (2-18). Advers events during nintedanib were summarised in Table 2. One patient was deceased due to small cell lung cancer at 9.month of nintedanib.

Table 1.

Characteristics of SSc-ILD Patients Receiving Nintedanib

n (%)Females12 (80)Clinical CharacteristicsDiffuse Cutaneous SSc13 (86.7)Limited Cutaneous SSc2 (13.3)Synovitis3 (20)Digital ulsers8 (53.3)Pulmonary arterial pressure >30 mmHg (echo)5 (30)Gastrointestinal involvement10 (76.9)SerologyANA13(86.7)Anti-Scl7010 (66.7)ImmunosuppressivesCYC8 (53.3)MMF14 (93.3)AZA7 (46.7)MTX6 (40)RTX6 (40)Low dose steroids15 (100)Table 2.

Advers Events during Nintedanib Treatment in SSc-ILD patients

SSc-ILD (n=15)Any advers events n(%)8 (53.3) Diarrhoea5 (30) Nausea/ vomiting1 (6.7) Abdominal pain3 (20) Weight decreased3 (20) Yorgunluk2 (13.3) Cough3 (20) Infections (pneumonia)3 (20) Liver test abnormalities4 (26.7) Malignancy1 (7.1) Dose reduction and reescalation7 (46.7) Dose interruption2 (13.3)

Conclusion

Nintedanib was prescribed in progressive SSc-ILD patients who had predominatly diffuse cutaneous involvement, anti-SCL70 positivity and exposed to multiple standart ISs. Duration of ISs were higher than 5 years before antifibrotic therapy. Gastrointestinal (GI) advers events were frequent during nintedanib requiring dose reduction in half of the patients. Nintetanib can be used in progressive SSc-ILD patients considering some difficulties in such a disease with GI involvement. Efficacy analysis of the antifibrotic therapy needs further studies including long term follow-up.

Disclosure of Interests

None declared

AB1082 FREQUENCY AND SEVERITY OF COVID-19 IN PATIENTS WITH VARIOUS RHEUMATIC DISEASES TREATED REGULARLY WITH COLCHICINE OR HYDROXYCHLOROQUINE

Background

Several anti-inflammatory drugs which were targeted different mechanisms and investigated for both prevention and treatment for COVID-19.

Objectives

The current study aimed to investigate whether patients regularly using colchicine or hydroxychloroquine (HCQ) have an advantage of protection from COVID-19 or developing less severe disease.

Methods

Patients who were taking colchicine or HCQ regularly for a rheumatic disease including Familial Mediterranean Fever, Behçet’s syndrome, Systemic Lupus Erythematosus, Rheumatoid Arthritis and Sjogren’s syndrome as well as their healthy household contacts as the control group were included into the study. The clinical data regarding COVID-19 were collected using a standard form, and serum samples were analyzed for anti-SARS-COV-2 nucleocapsid IgG. Patients treated with any biologic or immunosuppressive treatments were not included into the study.

Results

A total of 635 regular colchicine users with their 643 household contacts and 317 regular HCQ users with their 333 household contacts were analyzed. Anti-SARS-Cov2 IgG was positive in 43 (6.8%) regular colchicine users and 35 (5.4%) household contacts (OR=1.3; 95% CI:0.8-2; p=0.3) (Table 1). COVID-19 related symptoms were described by 29 (67.4%) of the patients and 17 (48.6%) household contacts (OR=2.2; 95% CI:0.9-5.5; p=0.09), and hospital admission was observed in five (11.6%) and one (2.9%) of these subjects (OR=4.5; 95% CI:0.5-40.2; p=0.1), respectively (Figure 1). Seropositive subjects were observed in 22 (6.9%) regular HCQ users and 24 (7.2%) household contacts (OR=1.1; CI:0.6-1.9; p=0.8) (Table 1). COVID-19-related symptoms occurred in 16 (72.7%) of the 22 patients and 12 (50%) of 24 household contacts (OR=2.7; 95% CI:0.8-9.1; p=0.1). Three patients (13.6%) were admitted to hospital, while one household contact (4.2%) was hospitalized (OR=3.6; 95% CI:0.3- 37.8; p=0.2) (Figure 1). Disease-specific analyses disclosed that there was no significant difference in terms of COVID-19 frequency and severity between a particular disease subset and household contacts (Table 1). Univariate logistic regression analysis showed no effect of age and gender on the SARS-CoV-2 seroprevalence rate among regular colchicine or HCQ users and household contacts (p=0.2 and p=0.7, respectively for colchicine users versus contacts, p=0.7 and p=0.3, respectively for HCQ users versus contacts).

Figure 1.

Severity of COVID-19 in regular colchicine or HCQ users and these patients’ household contacts

Table 1.

Disease specific outcomes of the entire cohort

VariableFMF (n=373)FMF HHC* (n=386)PBehcet Patients (n=262)Behcet HHC (N=257)PSLE Patients (N=197)SLE HH (n=221)pRA Patients (n=79)RA HH (n=73)PSjögren patients (N=41)Sjögren HH (N=39)pAge, mean ± SD years36.4 ± 13.236.3 ± 16.10.942.9 ± 11.438.1 ± 15.20.00144.2 ± 12.639.4 ± 170.00253.9 ± 10.340.3 ± 16.60.00157.1 ± 11.246.2 ± 16.10.001Gender, n (%) Female249 (66.8)173 (44.8)0.001160 (61.1)118 (45.9)0.001184 (93.4)75 (33.9)0.00173 (61.1)20 (27.4)0.00141 (100)10 (25.1)0.001Positive antibody to SARS-COV-2, n (%)25 (6.7)23 (5.9)0.618 (6.9)12 (4.7)0.314 (7.1)19 (8.6)0.64 (5.1)2 (2.7)0.54 (9.8)3 (7.7)0.9Symptomatic COVID-19 in seropositive cases, n (%)18 (72)10 (43.4)0.0411 (61.1)7 (58.3)0.611 (78.6)9 (47.3)0.073 (75)0 (0)0.42 (50)3 (100)0.4Hospital admission in seropositive cases, n (%)1 (3.8)0 (0)-4 (22.2)1 (8.3)0.32 (14.3)0 (0)0.21 (25)0 (0)-1 (25)1 (33.3)0.3Mean colchicine dose, mg/day ± SD1.5 ± 0.4--1.4 ±0.4-----------Mean duration of colchicine usage, years ± SD11.3 ± 8.3--10.4 ± 7.7-----------Mean HCQ dose, mg/day ± SD------263.6 ± 95.1--255 ± 90.8--273.7 ± 132.5--Mean duration of HCQ usage, years ± SD------10.1 ± 6.6--7.3 ± 5.2--9 ± 6.3--

HCQ hydroxychloroquine, FMF familial mediterranean fever, HHC household contacts, RA rheumatoid arthritis, SLE systemic lupus erythematosus

Conclusion

Being on a regular treatment of colchicine or HCQ was not resulted in the prevention of COVID-19 or amelioration of its manifestations.

Disclosure of Interests

None declared

Frequency and Predictors of Acute Kidney Injury in Patients With Acute Coronary Syndrome in a Tertiary Care Hospital: A Retrospective Study

Introduction

Acute kidney injury (AKI) is a complex condition marked by rapid deterioration of renal function (within hours or days), with clinical symptoms ranging from a minor rise in serum creatinine to anuric renal failure needing renal replacement therapy. AKI is one of the complications of acute coronary syndrome (ACS). This study aims to determine the frequency of AKI among patients with ACS and identify its predictors.

Method

This study is a retrospective observational study conducted at the Dow University of Health Sciences, a tertiary care hospital located in Karachi, Pakistan. This study was conducted from January 2020 to June 2021. All patients aged 18-75 years admitted with ACS and admitted for more than 48 hours were included in the study. A pre-set questionnaire was used to collect data from the hospital management information system (HMIS).

Results

The frequency of AKI among patients with ACS was 24.18%. The factors associated with AKI among patients with ACS on multivariable logistic regression included the age of patients (odds ratio (OR) = 1.04, p-value = 0.018), having diabetes mellitus (OR = 2.33, p-value = 0.031), admission Killip ≥ II (OR = 2.12, p-value = 0.041), previous history of myocardial infarction (MI) (OR = 3.64, p-value = 0.001), baseline glomerular filtration rate (GFR) (OR = 0.94, p-value = 0.001), in-hospital ejection fraction (EF) (OR = 0.93, p-value = 0.001), and serum creatinine at admission (OR = 1.02, p-value = 0.001).

Conclusion

Age, comorbidities including diabetes mellitus and previous history of MI, admission Killip ≥ II, baseline GFR, in-hospital EF, and serum creatinine level at admission are significant independent predictors of AKI in patients with ACS.

AB0331 PULMONARY INVOLVEMENT IN A SINGLE CENTER COHORT OF PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

The prevalence of SLE pulmonary involvement varies depending on several factors, including diagnostic methods [1].

Objectives:

We aimed to determine the frequency of involvement with different diagnostic methods in a single center cohort.

Methods:

300 SLE patients were included. Chest x-ray (CXR), lung spirometry, carbonmonoxide diffusion test (DLCOc) and echocardiography were performed. High resolution thorax computed tomography (HRCT) was done for a definite diagnosis of interstitial lung disease (ILD) whilst diagram electromyography (EMG), ultrasonography (USG) and magnetic resonance imaging (MR) were utilized to diagnose shrinking lung syndrome (SLS).

Results:

The mean age and follow-up time were 43 and 11,5 years respectively. Of 300 patients, 16% had ILD, 6,7% had pulmonary hypertension (PHT), 3% had SLS, 0,3% had pulmonary infarction. At the start of the study, patients’ records showed that 4% had ILD, 5% PHT, 0,3% SLS and 0,3% pulmonary infarction. The median age, mean duration of disease and follow-up time were significantly higher and longer in patients with ILD compared to patients without (p<0.05). Forced expiratory volume (FEV1), forced vital capacity (FVC), DLCOc and total lung capacity (TLC) were significantly lower in patients with ILD and with SLS (p<0,001). Patients with ILD had significantly higher frequency of arthritis, serositis, Raynaud myositis and anti-Scl70 positivity. Avascular necrosis, diabetes and malignancy were significantly more frequent in those patients. All patients with suspected SLS undergone diagram EMG, USG and MR. Out of 10 suspected cases, in 6 EMG, in 5 USG and in 9 MR was compatible with SLS diagnosis. 5 patients had 3 of the diagnostic methods positive to diagnose SLS. Muscle atrophy and weakness, avascular necrosis were more frequent in this group of patients (p<0.05). There were more patients treated with mycophenolate mofetil (MMF) and cyclophosphamide in the SLS group whilst more with MMF in the ILD group. Significantly higher frequency of patients had stopped using hydroxychloroquine (HCQ) in the ILD group (p=0,04).

Conclusion:

Interstitial lung disease is common in patients with SLE and considerable number of patients have SLS [2]. Spirometry, DLCOc and CXR are simple but valuable to diagnose pulmonary involvement in SLE patients. Diaphragm MR, USG and EMG are complementary methods for definite diagnosis in SLS [2]. Considering the significant difference of prevalence between the start and the end of the study, one of the possibbilities is the underrecognition of SLE pulmonary disease due to its being part of a multisystemic presentation. Higher usage of immunosuppressives in these patients may support a multisystemic active disease. Although drug effect is another concern, it is hard to establish a causal relationship due to the study’s cross-sectional design. HCQ may have a role in ILD prevention.

References:

[1]Keane MP, Lynch JP. Pleuropulmonary manifestations of systemic lupus erythematosus. Thorax 2000;55:159-166.

[2]Singh R, Huang W, Menon Y, Espinoza LR. Shrinking lung syndrome in systemic lupus erythematosus and Sjogren’s syndrome. J Clin Rheumatol. 2002 Dec;8(6):340-5.

Table 1.

Spirometry; DLCO; diaphragm EMG, USG and MRI results of patients with SLS.

Patient/Age/Sex1/44/F2/57/F3/39/F4/38/M5/23/F6/60/F7/58/F8/37/F9/66/F10/28/FFEV1 (%)47655963676271537039FVC (%)56735962797072556237DLCO (%)45504465535547656245TLC (%)61716566786454636245USG deep inspiration (L)4,704,742,593,013,063,065,734,172,121,59USG deep inspiration (R)3,721,982,262,242,772,174,672,834,622,49USG diaphragm thickness (L)4,823,002,482,842,551,592,093,181,621,44USG diaphragm thickness R(R)1,231,041,841,802,191,311,791,972,081,63MR high sideRRRRRRRLLMR height difference4,926,192,872,641,672,451,730,950,78EMG resting AMP (R)0,20,30,60,50,60,40,10,80,90,7EMG resting LAT (R)76,47,166,786,154,7565,8EMG resting AMP (L)0,40,50,80,71,20,60,31,20,50,5EMG resting LAT (L)6,355,756,855,66,05664,355,26,15

Disclosure of Interests:

None declared

Novel coronavirus 2019 (COVID-19) pandemic outbreak: A comprehensive review of the current literature

Coronavirus disease 2019 (COVID-19) is a pandemic caused by the novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The spread of the virus was rapid and currently COVID-19 cases are present worldwide in 213 countries, area or territories. Researchers worldwide are working and sharing their contribution regarding epidemiology, prevention, treatment, clinical and diagnostic patterns of the COVID-19. Current review is another contribution to the current knowledge, presenting the data in organized and systematic format about the current pandemic of COVID-19. The epidemiological information presented in the paper is subject to change as new cases are diagnosed and status of active cases is updated on daily basis.

E. coli expression and immunological assessment of expressed recombinant Newcastle disease virus hemagglutinin-neuraminidase protein in chickens

Every year, the poultry industry experiences significant economic losses due to epidemics of Newcastle disease virus (NDV). Developing new vaccines by identifying and using the immunogenic hemagglutinin-neuraminidase (HN) protein can protect the poultry industry. In the present study, the full-length HN protein was expressed in Escherichia coli (E. coli) BL21 (DE3) cells, purified via affinity chromatography and detected via western blot analysis using His-specific antibodies. The purified HN protein was further evaluated in chickens to study the immune response against NDV. The successful production of HN-specific IgY proved the activity of the purified HN protein. IgY was present in the serum of immunized chickens. However, the immune response was higher in chickens immunized with purified HN protein along with complete and incomplete adjuvants than in chickens immunized with only the HN protein. Keywords: protein; Newcastle disease virus; poultry; infectious diseases; vaccines.

Novel coronavirus 2019 (COVID-19) pandemic outbreak: A comprehensive review of the current literature

Coronavirus disease 2019 (COVID-19) is a pandemic caused by the novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The spread of the virus was rapid and currently COVID-19 cases are present worldwide in 213 countries, area or territories. Researchers worldwide are working and sharing their contribution regarding epidemiology, prevention, treatment, clinical and diagnostic patterns of the COVID-19. Current review is another contribution to the current knowledge, presenting the data in organized and systematic format about the current pandemic of COVID-19. The epidemiological information presented in the paper is subject to change as new cases are diagnosed and status of active cases is updated on daily basis.

SAT0200 RISK FACTORS FOR ADVERSE PREGNANCY OUTCOMES IN SYSTEMIC LUPUS ERYTHEMATOSUS PATIENTS

Background:

Pregnancies of patients with systemic lupus erythematosus (SLE) can be risky both for the mother and the fetus because of disease activity and pregnancy complications.1

Objectives:

In this study, we evaluated the risk factors related to adverse pregnancy outcomes (APO) in our pregnant SLE cohort who were followed up by both Rheumatology and Obstetrics and Gynecology departments at our university.

Methods:

168 pregnancy data were analyzed from 136 patients who fulfilled ACR classification criteria for SLE. The course of pregnancies were monitored and fetal/neonatal outcomes were recorded. Unexplained fetal death after 12 weeks of gestation, neonatal death, preterm birth due to preeclampsia, eclampsia or HELLP and birth of small for gestational age (SGA) infant were defined as APO. Cumulative clinical, laboratory and serological findings, disease activity (SLEDAI-2K) and damage (SLICC/ACR), and conventional risk factors were compared between APO(+) and APO(-) groups.

Results:

The comparison of demographics, conventional risk factors and disease characteristics in APO(+) and APO(-) groups are summarized in Table-1. In APO(+) pregnancies, the duration of disease was longer (p <0.05) and the frequency of chronic hypertension was higher (p <0.05) compared to APO(-) pregnancies. Renal and neuropsychiatric (NP) involvement, thrombocytopenia, antiphospholipid syndrome (APS), lupus anticoagulant and anti-cardiolipin IgM positivity were significantly higher in APO(+) group. Mean SLEDAI-2K scores of three trimesters and postpartum 6 months were higher in APO(+) patients compared to APO(-) patients (2.2 ± 3.6 vs 1.2 ± 2.04, p <0.05; 4.9 ± 6.03 vs 2.7 ± 5.01, p = 0.02, respectively). Percentage of patients with damage at the beginning of pregnancy and the mean SLICC damage score were significantly higher in APO(+) group compared to APO(-) group (1.8 ± 2.1 vs 0.8 ± 1.3, p <0.05). In APO(+) group, damage was significantly higher in neuropsychiatric, renal and cardiovascular and locomotor systems (p <0.05).

Conclusion:

Although an important proportion of SLE pregnancies result in live birth, active disease, especially renal and NP involvement, and presence of damage at the beginning of pregnancy increase the risk of maternal and fetal complications. Furthermore, the presence of APS or antiphospholipid antibody positivity are important risk factors for obstetric complications. In conclusion, pregnancy should be allowed after controlling the disease activity and patients should be closely monitored in coordination with Obstetrics and Gynecology clinics. In case of presence of damage, both the patient and the physician should be aware of a possible adverse pregnancy outcome.

References:

[1]Ann Intern Med. 2015 August 4; 163(3): 153–163. doi:10.7326/M14-2235.

Table 1.

Demographic data of APO (+) and APO (-) groups, comparison of conventional risk factors, cumulative clinical, serological and laboratory features

APO(-)(n=111)APO (+)(n=57)pAge35.1±6.734.9±5.9NSAge at conception30.6±5.628.9±4.2NSDisease duration (months)141.6±70166.9±87.9<0.05Chronic hypertension, n (%)6 (7)11 (19.6)<0.05Photosensitivity, n (%)86 (77.5)43 (75.4)NSMalar rash, n (%)66 (59.5)38 (66.7)NSOral ulcer, n (%)11 (9,9)6 (10.5)NSArthritis, n (%)77 (59.4)42 (73.7)NSSerositis, n (%)17 (15.3)13 (22.8)NSRenal, n (%)39 (35.1)30 (52.6)<0.05Hematologic, n (%)78 (70.3)40 (70.2)NSThrombocytopenia, n (%)37 (33.3)30 (52.6)<0.05AIHA, n (%)16 (14.4)14 (24.6)NSNeurologic, n (%)7 (6.3)9 (15.8)<0.05Anti-cardiolipin IgG, n(%)28 (25.2)18 (32.1)NSAnti-cardiolipin IgM, n (%)18 (16.2)18 (32.1)<0.05Lupus anticoagulant, n (%)26 (23.4)28 (49.1)<0.001Antiphospholipid syndrome, n (%)28 (25.2)30 (52.6)<0.001

(NS=not significant, APO=adverse pregnancy outcome, AIHA=autoimmune hemolytic anemia)

Disclosure of Interests: :

None declared

THU0369 EVALUATION OF DIFFERENT CLASSIFICATION CRITERIA IN SYSTEMIC SCLEROSIS IN A TURKISH COHORT: THE IMPORTANCE OF NON-SKIN MANIFESTATIONS, SEROLOGY AND CAPILLAROSCOPY

Background:

Proximal scleroderma is the major criterion in both 1980 and 2013 classification criteria for sytemic scleroris (SSc). ACR(1980) criteria included digital lesions and bibasiler fibrozis, nonetheless ACR/EULAR(2013) criteria based on a scoring system including digital lesions, telangiectasia, abnormal nailfold video-capillaroscopy(NVC), PAH, Raynaud’s and specific autoantibodies.

Objectives:

We aimed to implement both criteria in a Turkish SSc kohort to evaluate the contribution of non-skin manifestations, NVC and autoantibodies.

Methods:

A consecutive hundred and thirty-nine (125 females) SSc patients diagnosed and evaluated by the same experts (YY, MI) with relevant NVC records and at least 6 months follow-up were included into the study. Classificaiton criteria were used retrospectively using a preformed database.

Results:

Characteristics of the SSc patients were summarized in table-1. The mean age, duration of Raynaud’s and non-Raynaud symptoms were 47.1±11.9, 8.9±7.9 and 5.7±5.8 years, respectively. Diffuse and limited cutaneous disease were diagnosed in 62(44.6%) and 60(43.2%) patients respectively. Asclerodermic disease was present in 17(12.2%) patients. ANA, anti-centromere and anti-Scl70(+) positivity was 80.5%, 18.0% and 37.4%, respectively.

Twelve patients (8.6%) could not be classified as SSc by both criteria; 5 with Raynaud’s+specific antibodies (2 anti-centromere+, 2 anti-Scl70+), 4 with Raynaud’s+puffy hands+NC abnormalities, 2 with Raynaud’s+telangiectasia and a patient with Raynaud’s+sclerodactyly. Nineteen (13.7%) patients could not be classified as SSc according to ACR (1980) can be classsified according to ACR/EULAR (2013) (table-1 and -2).

The sensitivity for ACR/EULAR (2013) and ACR (1980) criteria were found to be 91,4% vs 75,5%; 98.4% vs 96.8% in diffuse cutaneous SSc, 98.3% vs 68.3% in limited cutaneous SSc and 47.1 vs 23.5% in asclerodermic SSc, respectively.

Table 1.

The sensitivity for ACR (1980) and ACR/EULAR (2013) classification criteriain SSc

ACR/EULAR (2013) +ACR/EULAR (2013)-totalACR (1980)+1080108ACR (1980)-191231total12712139Table 2.

SSc patients fulfilling ACR (1980) and/or ACR/EULAR (2013) criteria

ACR/EULAR (2013)ACR (1980)Classified n=127Not classified n=12+Prox scleroderma+87+Puffy hands294+Sclerodactyly+1121+Digital ulcers + +Pitting scars62 72+Telangiectasia862+Nailfold capillaroscopy974 Normal9 Early173 Active40 Late501+PAH12+Interstitial lung Disease +60+Raynaud’s12012+SSc- specific antibodies795

Conclusion:

The sensitivity of ACR/EULAR (2013) criteria was shown to be higher than ACR (1980) criteria in our Turkish SSc cohort with established cases. Although in diffuse cutaneous subgroup, the sensitivity was >%96 for both criteria, in limited cutaneous subgroup, the sensitivity was preserved for ACR/EULAR(2013) while apparently decreased for ACR(1980) criteria (<%70). The sensitivity for both of the two sets were lowest in the asclerodermic group. In SSc patients with limited or no skin involvement, non-skin manifestations, NVC findings and spcific serology should be carefully sought. Some of these patients could not be classified by the current criteria.

Disclosure of Interests:

None declared

THU0349 THE RELATIONSHIP BETWEEN DISEASE ACTIVITY AND SEVERITY IN SYSTEMIC SCLEROSIS: A PROSPECTIVE ANALYSIS OF 278 PATIENTS

Background:

Evaluating disease activity and severity in systemic sclerosis (SSc) is crucial to define the patients who are candidate for treatment options.

Objectives:

We aimed to investigate the relationship between disease activity and severity in SSc in a large cohort.

Methods:

This is a cross-sectional prospective analysis of 278 (253 females) patients fulfilling ACR/EULAR (2013) classification criteria for SSc. Disease activity and severity were calculated seperately for cutaneous subsets (EscSG and Medsger). The patients were grouped as inactive if EscSG score=0, mildly active if EscSG score>0<3, active if EscSG score≥3.

Results:

The mean age, duration of Raynaud’s and non-Raynaud features were 48.5±13.1, 12.1±9.8 and 8.3±7.5 years respectively. Characteristics of the SSc patients were summarized in table-1.

Ninety-three (34%) and 151(54%) patients were evaluated as having active and mildly active disease. Only 34(12%) patients had inactive disease. The patients with diffuse cutaneous involvement (dcSSc) who were active had higher modified Rodnan Skin score(mRSS) and severity scores of general, skin and joint-tendon involvements; the patients who had mildly active disease also had higher scores of mRSS and severity scores of skin compared to those with inactive disease (table-2).The patients with limited cutaneous involvement (lcSSc) who were assessed as having active disease had higher mRSS and higher severity scores of general, skin, peripheral vascular, lung, joint-tendon and gastrointestinal involvements; the patients who had mildly active disease also had higher scores of mRSS and severity scores of skin, lung, joint-tendon and gastrointestinal involvements compared to those with inactive disease (table-2).

Conclusion:

One third of our cohort was found to have active disease despite treatment and only 12% had inactive disease. Skin involvement and severity of different organs were shown to be higher in patients with active disease in both cutaneous subsets, together with severity of lung, peripheral vascular and gastrointestinal involvements in active lcSSc. LcSSc and dcSSc patients who had mildly active disease also had severe disease similar to those with active patients. Disease activity and severity should be assessed as separate measurements to highlight the course of the disease and may guide to the management of patients with SSc.

Disclosure of Interests:

None declared

FRI0160 THE CORRELATION BETWEEN PREGNANCY, DISEASE ACTIVITY AND ADVERSE PREGNANCY OUTCOMES IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

Patients with systemic lupus erythematosus (SLE) can present with acute disease flares/exacerbations during pregnancy and postpartum period.1These flares can cause adverse pregnancy outcomes (APO).

Objectives:

In this study, our pregnant SLE cohort, which was under medical surveillance of both our Rheumatology and Gynecology and Obstetrics departments was analyzed. We intended to determine the effects of pregnancy on disease activity and the correlation between disease flares and adverse pregnancy outcomes.

Methods:

168 pregnancy data involving 136 patients with SLE meeting the ACR criteria were examined. Cumulative clinical, laboratory and serological parameters were described and disease activity and flares were calculated using SLEDAI-2K disease activity index during preconceptional six month period, during all trimesters of pregnancy, and during postpartum six month period. Patients with low lupus disease activity scores (LLDAS) during each of these periods were identified. Fetal/neonatal death, premature birth due to preeclampsia, eclampsia or HELLP syndrome, neonates small for gestational age were determined as adverse pregnancy outcomes. Relationship of APO with disease activity was studied and patients with APO were compared to patients without APO.

Results:

Mean SLEDAI-2K scores was 1.3±2.2 (0-16) during preconceptional six month period, 1.3±2.6 (0-16) during conception period, 1.7±3.2 (0-22) during first trimester, 1.4±2.7 (0-16) during second trimester, 1.5±3.3 (0-20) during third trimester and 3.5±5.4 (0-26) during postpartum six month period. Mean postpartum six month period SLEDAI-2K score was higher compared to the mean pregnancy SLEDAI-2K score (p<0.05). LLDAS was sustained in 79% of all pregnancies. 19% of pregnancies resulted in flares. 42% of these flares were severe and 58% were mild or moderate. 49% of severe flares occurred during the postpartum six month period and this percentage was significantly higher compared to each trimester (p<0.05). Most of the flares during pregnancy and postpartum period had mucocutaneous (37%), renal(35%) and hematological(25%) involvement.

APO was observed in 34% of pregnancies (n=57). APO (+) group was characterized by significantly longer disease duration and higher disease activity in all periods compared to APO (-) group (142±70 vs 170±88 months, p<0.05). In APO (-) group, the proportion of patients with severe disease activity during all pregnancy periods and postpartum period was significantly low (%18 vs 35, p<0.05), while the proportion of patients with sustained LLDAS was much higher (%88 vs 70).

Conclusion:

Postpartum six-month period appears to have the highest risk for disease flares during SLE pregnancies. Disease activity during pregnancy increases the risk of APO. Patients with sustained LLDAS have significantly lower APO rates. In order to achieve a positive pregnancy outcome and lower maternal morbidity, regular follow up of patients during pregnancy and postpartum period by Rheumatology and Gynecology and Obstetrics Departments is necessary.

References:

[1]Eudy AM, et al. Ann Rheum Dis 2018;0:1–6. doi:10.1136/annrheumdis-2017-212535

Disclosure of Interests:

None declared

SAT0346 THE EFFICACY AND SAFETY OF RITUXIMAB IN 27 CASES OF TREATMENT RESISTANT SYSTEMIC SCLEROSIS WITH SEVERE DISEASE ASSESSED BY ACTIVITY SCORES

Background:

Treatment options for systemic sclerosis (SSc) remain limited especially in severe skin, lung and musculoskeletal involvements. B-cell targeted therapy with anti-CD20 Rituximab (RTX), is widely available, reports from case series are encouraging as a a rescue therapy and might have an improving effect on organ involvement in SSc.

Objectives:

We aimed to retrospectively analyze the efficacy and safety of rituximab (RTX) courses in patients with severe systemic sclerosis who were refractory to standard immunosuppressive treatment.

Methods:

Twenty-seven SSc patients fulfilling ACR/EULAR classification criteria (2013) who received RTX treatment due to acive disease despite treatment with immunosuppresives were analyzed. Disease activity was evaluated by using EScSG/EUSTAR activity scores prior to and after RTX treatment. Disease severity was also assessed at baseline by Medsger’s index.

Results:

The demographics and characteristics of SSc patients were as follows: the median age of 50 (30-70), duration of Raynaud’s 10 (3-26) and non-Raynaud symptom 8.5 (3-18) years and summarised in table 1. RTX was given as a single cycle (2 infusions of 1000 mg) in 12 cases, 2 cyles in 5 cases, ≥3 cyles in 10 cases. DMARDs were prescribed in 19 (73%) patients (14 MMF, 5 MTX) concomitantly with RTX. The main RTX indications were skin and lung involvement (n=9), skin and arthritis (n=6), skin(n=5), lung (n=3), myositis (n=2), cardiac involvement (n=1) and digital vasculopathy (n=1). Medsger severity score was 7.39±3.091(3-13) at baseline.

Table 1.

Prevelance of Characteristics of SSc Patients

n(%)female/male25 /2diffuse/limited cutaneous SSc22 (81.5) / 5 (19,2)Clinical Characteristicssynovitis / flexion contractures12(44,4) / 10 (37,1)tendon friction rubs / myositis7 (26,9) / 4 (15,4)renal crisis1 (3,8)GI involvement19 (69,2)lung involvement16 (61,5)SerologyANA23 (85,2)Anti-Scl70 / Anti-sentromer16(61,5) / 1(3,8)Anti-Ro6 (22,2)Previous ImmunosuppressivesCYC / MMFAZA / MTX Low dose steroids19 (73,1) / 19 (73,1) 12 (46,2) / 16 (61,5) 27 (100)

Disease activity and severity scores prior to and after RTX were summarised table 2. Disease activity scores were improved after RTX in patients who had a median follow-up period of 1 year (0,5-5 years). After RTX treatment, according to EscSG /EUSTAR scores 13 (%46.2) and 10 (%34.6) patients out of 26 were assessed as inactive.

Table 2.

Disease activity scores prior to and after RTX treatment

Prior to RTX (n=26)After RTX (n=18)median Δ Change (n=18)EscSG activity score4,89±1,82 (2,0-9,0)2,37±1,10 (0,50-4,50)-2,00 (P<0,001)EUSTAR activity score4,57±2,68(1,0-10,0)2,30±2,15 (0,0-7,25)-2,00 (P=0,002)

There were severe infecions in 4 patients (Pneumonia in 2, infected digital ulcers in 2) and an episode of sinusitis in one during treatment period. One patient was deceased because of pneumonia and sepsis after the first cycle of RTX.

Conclusion:

In our SSc cohort, RTX treatment was used in severe patients, who had predominantly diffuse cutaneous disease with lung and joint involvements, severe vasculopathy and anti-Scl-70 positivity. Concomitant DMARDs were used in three-forth of the patients in addition to RTX cycles. Disease activity scores that assessed retrospectively were shown to be improved after RTX and 37-48% of the cases were assessed as inactive by using activity scores. Serious infections like pneumonia and infected digital ulcers were observed in 14,8% of cases during the follow-up. The addition of RTX treatment can be effective in selected patients with active disease despite immunosuppressive therapy.

Disclosure of Interests:

None declared

Serum and urine TNF-like weak inducer of apoptosis, monocyte chemoattractant protein-1 and neutrophil gelatinase-associated lipocalin as biomarkers of disease activity in patients with systemic lupus erythematosus

OBJECTIVES

TNF-like weak inducer of apoptosis (TWEAK), monocyte chemoattractant protein-1 (MCP-1) and neutrophil gelatinase-associated lipocalin (NGAL) are proinflammatory cytokines/chemokines that are considered as potential biomarkers reflecting disease activity in systemic lupus erythematosus (SLE). In this study, we aimed to investigate the association of serum (s) and urine (u) levels of TWEAK, MCP-1 and NGAL with disease activity in both renal and extra-renal SLE.

METHODS

Thirty active patients with SLE (15 renal and 15 extra-renal) were recruited. Thirty-one inactive patients with SLE (16 renal and 15 extra-renal), 14 patients with ANCA-associated vasculitis (AAV) all of whom had active renal involvement and 20 healthy volunteers were selected as control groups. Serum and urine levels of TWEAK, MCP-1 and NGAL were tested using ELISA.

RESULTS

Serum and urine levels of TWEAK and NGAL were significantly higher in the active SLE group compared to the inactive SLE group (sTWEAK p = 0.005; uTWEAK p = 0.026; sNGAL p < 0.001; uNGAL p = 0.002), whilst no significant differences regarding serum and urine MCP-1 levels were observed (p = 0.189 and p = 0.106, respectively). uTWEAK (p = 0.237), sMCP-1 (p = 0.141), uMCP-1 (p = 0.206), sNGAL (p = 0.419) and uNGAL (p = 0.443) levels did not differ between patients with active renal and extra-renal SLE. Serum TWEAK was higher in patients with active renal SLE (p = 0.006). There were no differences between active renal SLE and active renal AAV. Levels of all biomarkers were correlated with the SLE Disease Activity Index.

CONCLUSION

sTWEAK, uTWEAK, sNGAL and uNGAL are biomarkers showing disease activity in SLE. However, our results implicate that these biomarkers may not be specific for SLE, and can be elevated in patients with active renal involvement of AAV.

Incidence and Recurrence of Allergic Fungal Sinusitis at Tertiary Care Facility

To assess the incidence and recurrence of patients of allergic fungal sinusitis after administration of topical steroids for 24 months this is a cross-section study. Total 90 patients diagnosed with nasal pathology were enrolled from January 2011 to December 2015 at Liaquat National Hospital, various sign and symptoms were tabulated. Patients clinical, radiological and histopathological reports were analyzed. Post operative steroid dose and recurrence rate was noted. Post stratification, Chi-square test and Fisher's exact test was applied to see the association between CT Scan and endoscopic findings and recurrence considering P value ≤ 0.05 as significant. Total 90 patients of either sex aged between 12 and 63 years fulfilled the inclusion criteria and were enrolled in the study. The results showed that among all study patients, 53(58.9%) were male and 37(41.1%) were female. Common presenting symptoms included nasal obstruction, nasal discharge & headache followed by proptosis. From 90 cases, 73(81.2%) had chronic rhinosinusitis and 17(18.9%) cases had Aspergillus. Postoperatively patients were given topical steroids and recurrence was seen in twelve (17.8%). All were aspergillus positive. The incidence of AFRS is (17) 18.9% of CRS which is slightly higher as reported in previous literature. Endoscopic finding may differ from CT scan finding. Patients presented with CRS should receive steroids for at least 2 years to prevent recurrence.

Risk of Multiple Sclerosis in Epstein-Barr Virus Infection

Multiple sclerosis (MS) is a chronic neuro-inflammatory, immune-mediated disorder of the central nervous system; however, less is known about its cause. It causes neurological disability in young adults, more commonly in women. Several risk factors including environmental, genetics, and infections have been identified, which contribute to the abnormal immune response. Viruses belonging to the Herpes family have been indicated as a potential risk for MS; their biological mechanisms are not known but several possibilities have been discussed. Epstein-Barr virus (EBV) is the leading and most common virus associated with MS. It is a potential oncogenic virus that hosts the B lymphocytes and has been associated with numerous cancers such as Burkitt's lymphoma, Hodgkin's lymphoma, and nasopharyngeal carcinoma. The risk of MS is low in patients who are EBV negative but increases by several folds in individuals who have a history of infectious mononucleosis (IM). Several ecological studies, co-occurring pathologies, and experimental laboratory-based research provide evidence to support the relationship between EBV and MS.

Effect of Extender Supplemented with Boron on Post-Thaw Motility, Viability, DNA Damage and Fertilization Ability of Cryopreserved Brown Trout (Salmo trutta macrostigma) Spermatozoa

BACKGROUND

Boron has been considered as an essential nutrient for decreasing lipid peroxidation and improving antioxidant mechanism in different animal species. On the other hand, its effect on quality or DNA damage following cryopreservation process in fish sperm is still unclear.

OBJECTIVE

Experiments were designed to analyse the effect of an ionic based extender supplemented with boron on post-thawed motility, viability, fertility and DNA integrity of cryopreserved brown trout (Salmo trutta macrostigma) sperm.

MATERIALS AND METHODS

Sperm samples were cryopreserved with the ionic extender containing different boron concentrations (0.1, 0.2, 0.3 and 0.4 mM) using a controlled freezer at two different freezing rates (FR-I: 10°C min^-1 from +4°C to -40°C and FR-II: 15°C min^-1 from +4°C to -40°C). Sperm motility, viability, fertilization, eyeing and DNA fragmentations were determined in post-thawed samples.

RESULTS

Freezing rate-I provided significantly higher fertilization and eyeing rates compared to freezing rate-II (p<0.05). Higher post-thaw motility (62.8±1.4%) and fertilization (75.2±0.9%) rates were obtained with the 0.4 mM boron concentration at freezing rate-I.

CONCLUSION

Supplementation of the extender with boron increased fertilization and eyeing rates and also decreased DNA damages at both freezing rates.

Clinical characteristics and prognostic factors of scleral rupture due to blunt ocular trauma

PurposeTo describe and identify ocular and wound characteristics, and prognostic factors associated with final visual acuity (VA) in patients with scleral rupture due to blunt ocular trauma.MethodsThe medical records of 61 patients with globe rupture due to blunt ocular trauma who underwent primary repair were reviewed retrospectively. The data recorded included demographic characteristics, initial and final VA, ocular signs, wound characteristics, and surgeries. Initial VA, ocular signs, wound characteristics, and surgeries were analyzed to determine the association with the final VA.ResultsForty three women and 18 men with a mean age of 43.6±23.5 years were included in the study. The locations of scleral wounds were mostly in the superonasal quadrant (41.0%) and zone 2 (75.4%). In eyes with hyphema (P=0.009), vitreous hemorrhage (P=0.001), and retinal detachment (P=0.004), final VA was statistically worse than eyes without these signs. A moderate positive correlation was found between the initial and final VA (P<0.001). Final VA was statistically worse in eyes with horizontal midline wounds than in eyes with vertical midline wounds (P=0.002). A moderate negative correlation was found between scleral wound length and final VA (P<0.001). Patients who underwent cataract surgery had statistically better final VA (P=0.002).ConclusionsScleral rupture was detected mostly in females, superonasal quadrant and zone 2. Poor final VA was significantly associated with poor initial VA, longer wound length, horizontal midline wound, presence of hyphema, vitreous hemorrhage and retinal detachment at presentation, and cataract surgery not performed during follow-up period. Scleral ruptures have different demographic, ocular and wound characteristics than other open globe injuries.

Tuberculosis and other opportunistic infections in tofacitinib-treated patients with rheumatoid arthritis

OBJECTIVES

To evaluate the risk of opportunistic infections (OIs) in patients with rheumatoid arthritis (RA) treated with tofacitinib.

METHODS

Phase II, III and long-term extension clinical trial data (April 2013 data-cut) from the tofacitinib RA programme were reviewed. OIs defined a priori included mycobacterial and fungal infections, multidermatomal herpes zoster and other viral infections associated with immunosuppression. For OIs, we calculated crude incidence rates (IRs; per 100 patient-years (95% CI)); for tuberculosis (TB) specifically, we calculated rates stratified by patient enrolment region according to background TB IR (per 100 patient-years): low (≤0.01), medium (>0.01 to ≤0.05) and high (>0.05).

RESULTS

We identified 60 OIs among 5671 subjects; all occurred among tofacitinib-treated patients. TB (crude IR 0.21, 95% CI of (0.14 to 0.30)) was the most common OI (n=26); median time between drug start and diagnosis was 64 weeks (range 15-161 weeks). Twenty-one cases (81%) occurred in countries with high background TB IR, and the rate varied with regional background TB IR: low 0.02 (0.003 to 0.15), medium 0.08 (0.03 to 0.21) and high 0.75 (0.49 to 1.15). In Phase III studies, 263 patients diagnosed with latent TB infection were treated with isoniazid and tofacitinib concurrently; none developed TB. For OIs other than TB, 34 events were reported (crude IR 0.25 (95% CI 0.18 to 0.36)).

CONCLUSIONS

Within the global tofacitinib RA development programme, TB was the most common OI reported but was rare in regions of low and medium TB incidence. Patients who screen positive for latent TB can be treated with isoniazid during tofacitinib therapy.