Analysis of Germin-like protein genes family in Vitis vinifera (VvGLPs) using various in silico approaches

Abstract Germin-like proteins (GLPs) play an important role against various stresses. Vitis vinifera L. genome contains 7 GLPs; many of them are functionally unexplored. However, the computational analysis may provide important new insight into their function. Currently, physicochemical properties, subcellular localization, domain architectures, 3D structures, N-glycosylation & phosphorylation sites, and phylogeney of the VvGLPs were investigated using the latest computational tools. Their functions were predicted using the Search tool for the retrieval of interacting genes/proteins (STRING) and Blast2Go servers. Most of the VvGLPs were extracellular (43%) in nature but also showed periplasmic (29%), plasma membrane (14%), and mitochondrial- or chloroplast-specific (14%) expression. The functional analysis predicted unique enzymatic activities for these proteins including terpene synthase, isoprenoid synthase, lipoxygenase, phosphate permease, receptor kinase, and hydrolases generally mediated by Mn+ cation. VvGLPs showed similarity in the overall structure, shape, and position of the cupin domain. Functionally, VvGLPs control and regulate the production of secondary metabolites to cope with various stresses. Phylogenetically VvGLP1, -3, -4, -5, and VvGLP7 showed greater similarity due to duplication while VvGLP2 and VvGLP6 revealed a distant relationship. Promoter analysis revealed the presence of diverse cis-regulatory elements among which CAAT box, MYB, MYC, unnamed-4 were common to all of them. The analysis will help to utilize VvGLPs and their promoters in future food programs by developing resistant cultivars against various biotic (Erysiphe necator and in Powdery Mildew etc.) and abiotic (Salt, drought, heat, dehydration, etc.) stresses.

General public awareness, knowledge and attitude toward COVID-19 infection and prevention: a cross-sectional study from Pakistan

Background: The aim of this study is to evaluate the knowledge, perceptions, and attitude of the public in Pakistan (using social media) towards COVID-19. Methods: A cross-sectional study was conducted amongst 1120 individuals nationwide. A self-developed, pre-tested questionnaire was used that comprised of sections covering demographic characteristics, medical history, hygiene awareness, COVID-19-related knowledge, and learning attitude. Descriptive statistics were used for frequencies, percentages, averages and standard deviations. Inferential statistics were done using the Student's t-test and ANOVA. Results: The average age of participants was 31 years (range 18-60 years). In total 56 individuals (5%) had completed primary or secondary school education; 448 (40%) were employed (working from home) and 60% were jobless due to the COVID-19 crisis. Almost all the study subjects (1030 (92%)) were washing their hands multiple times a day. A total of 83% had awareness regarding quarantine time, 82% used face masks whenever they left their homes, 98% were aware of the origin of the disease, and 70% had knowledge regarding the most common symptoms of COVID-19. Conclusion: It can be concluded from the current study that female participants had higher level of education, and more awareness regarding the coronavirus. The majority of the participants followed proper hand washing regimes and washed their faces. Further knowledge and awareness should be promoted.

General public awareness, knowledge and attitude toward COVID-19 infection and prevention: a cross-sectional study from Pakistan

Background: The aim of this study is to evaluate the knowledge, perceptions, and attitude of the public in Pakistan (using social media) towards COVID-19. Methods: A cross-sectional study was conducted amongst 1120 individuals nationwide. A self-developed, pre-tested questionnaire was used that comprised of sections covering demographic characteristics, medical history, hygiene awareness, COVID-19-related knowledge, and learning attitude. Descriptive statistics were used for frequencies, percentages, averages and standard deviations. Inferential statistics were done using the Student's t-test and ANOVA. Results: The average age of participants was 31 years (range 18-60 years). In total 56 individuals (5%) had completed primary or secondary school education; 448 (40%) were employed (working from home) and 60% were jobless due to the COVID-19 crisis. Almost all the study subjects (1030 (92%)) were washing their hands multiple times a day. A total of 83% had awareness regarding quarantine time, 82% used face masks whenever they left their homes, 98% were aware of the origin of the disease, and 70% had knowledge regarding the most common symptoms of COVID-19. Conclusion: It can be concluded from the current study that female participants had higher level of education, and more awareness regarding the coronavirus. The majority of the participants followed proper hand washing regimes and washed their faces. Further knowledge and awareness should be promoted.

AB0761 Are we treating-to-target in spondyloarthritis (SpA)? A cross sectional analysis from the Asia Pacific League of Associations for Rheumatology (APLAR) SpA Registry

Background

Data on the extent of treat-to-target (T2T) recommendations application in SpA patients across Asia Pacific region is lacking. APLAR SpA Registry aimed to assess the utility of T2T on long term clinical outcomes, and to improve disease management and inform health care policy.

Objectives

To provide a snapshot of the registry including demographics, disease activity and medication use.

Methods

Patients fulfill the CASPAR 2006 for psoriatic arthritis (PsA) and 2009 ASAS criteria for axial spondylitis (AxSpA) were recruited. This cross sectional analysis included the first 188 patients recruited across 7 Asia Pacific regions (Hong Kong, Singapore, Korea, Thailand, India, Qatar & Pakistan).

Results

83 patients PsA and 115 AxSpA patients were included. They had moderate inflammation (DAPSA: 19.61±14.29, ASDAS: 2.32±1.07). Majority of PsA patients received conventional synthetic disease-modifying drug (csDMARDs, 81%) with relatively low prevalence of biologic DMARDs (bDMARDs) (24%). Most AxSpA patients used NSAIDs (79%) while nearly half of them received bDMARDs (49%). Other details listed in Table 1. Prevalence of bDMARDs use in our registry was lower than that from the USA (Corrona PsA Registry, 59%), Turkey & Canada (PsArt-ID, 40%) and the Netherlands AxSpA registry (56%) (1-3). Regarding T2T, 28% and 44% of PsA patient achieved minimal disease activity (MDA) and Disease Activity in Psoriatic Arthritis low disease activity (DAPSA LDA) respectively. The proportion of patients achieving target in other cohorts were 46% for MDA (PsArt-ID) and 46% for DAPSA LDA (Corrona) (1, 2). 37% and 47% of AxSpA patient achieved Bath Ankylosing Spondylitis Disease Activity Index (BASDAI)<4 and Ankylosing Spondylitis Disease Activity Score (ASDAS) LDA. Proportion of patients achieving ASDAS LDA were similar to the Netherlands registry for patients with ASDAS LDA or BASDAI<4 (Figure 1A)(3). Patient on bDMARD were more likely to achieve treatment target (Figure 1B). There were no significant difference between socio-economic status and disease features between bDMARD user and non-user.

Table 1.

Demographics, clinical features and disease activity of patients

PsA (n=83)AxSpA (n=115)Age50.012.836.512.4Male n, %4251%8583%Asian n, %83100%10196%Disease duration, years7.17.35.27.6Any sacroiliitis n, %10299%HLA B27, positive n, %9189%Duration of early morning stiffness, min30392529Tender joint count7901Swollen joint count3400No. of dactylitis digit1100PASI4.05.0SPRACC1201BASDAI2.82.0ESR, mm/h31262016CRP, mg/L10151127HAQ-DI0.610.610.390.51DAPSA19.6114.29ASDAS CRP2.321.07

Data given in mean SD unless stated

. No. of case from Hong Kong 40; Singapore 46; Korea 24; Thailand 20, India 15; Qatar 10; Pakistan 33; HLA - human leucucyte antigen; PASI - psoriasis area and severity index; SPRACC - Spondyloarthritis Research Consortium of Canada Enthesitis Index; BASDAI - Bath Ankylosing Spondylitis Disease Activity Index; ESR - erythrocyte sedimentation rate; CRP - C-reactive protein; HAQ-DI - Health assessment questionnaire disability index; DAPSA - Disease activity in Psoriatic Arthritis; ASDAS - Ankylosing Spondylitis Disease Activity Score

Figure 1.

(A) Achievement of LDA in APLAR SpA registry and other registry and (B) use of bDMARDs among patients in APLAR SpA registry with or without achieving LDA

Conclusion

Patient using bDMARDs were more likely to achieve treatment target. We expect that when T2T is widely applied, better outcomes will be reported in future.

References

[1]Bakirci, S., et al. (2019). “What are the main barriers to achieve minimal disease activity in psoriatic arthritis in real life?” Clin Exp Rheumatol37(5): 808-812.

[2]Beckers, E., et al. (2021). “Treat-to-target in axial spondyloarthritis: an observational study in daily practice.” Rheumatology (Oxford).

[3]Ogdie, A., et al. (2021). “Effect of Multidomain Disease Presentations on Patients With Psoriatic Arthritis in the Corrona Psoriatic Arthritis/Spondyloarthritis Registry.” J Rheumatol48(5): 698-706.

Disclosure of Interests

Isaac T. Cheng: None declared, Ho SO: None declared, Ying Ying Leung Speakers bureau: received honorarium/ speaker fee from AbbVie, DKSH, Janssen, Novartis and Pfizer., Praveena Chiowchanwisawakit: None declared, Stanley Angkodjojo Speakers bureau: Boehringer Ingelheim Singapore in Nov 2021, Consultant of: Abbvie (Singapore), DKSH (Singapore) in 2021, Muhammad Ahmed Saeed: None declared, Kichul Shin: None declared, Mohit Goyal: None declared, Muhammad Haroon: None declared, Mohammed Hammoudeh Speakers bureau: Have you been paid as a speaker for (pharmaceutical) companies, Grant/research support from: participated in drug companies sponsored trials, Nallasivan Subramanian: None declared, Ho Yin Chung: None declared, James Cheng-Chung Wei: None declared, Mitsumasa Kishimoto Consultant of: MK received consulting fees and/or speaker fees from AbbVie, Amgen, Asahi-Kasei Pharma, Astellas, Ayumi Pharma, BMS, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Gilead, Janssen, Kyowa Kirin, Novartis, Ono Pharma, Pfizer, Tanabe-Mitsubishi, and UCB Pharma., Lai-Shan Tam Consultant of: has acted as a consultant for Janssen, Pfizer, Sanofi, AbbVie, Boehringer Ingelheim, and Lilly, Grant/research support from: has received grant/research support from Amgen, Boehringer Ingelheim, Janssen, GSK, Novartis, and Pfizer

POS0208 STRESS AT HOME IS COMMON AND HAS SIGNIFICANT ASSOCIATION WITH MARITAL STATUS, HIGHER DISEASE ACTIVITY, COMORBIDITIES, AND WORSE QUALITY OF LIFE AMONG PATIENTS WITH RHEUMATOID ARTHRITIS: SINGLE CENTRE RESULTS FROM THE PRIME REGISTRY COHORT

Background

In chronic inflammatory diseases like rheumatoid arthritis (RA), psychological stress is widely recognised as an important risk factor to negatively affect the disease course. Perceived stress can potentially induce the disease exacerbation, but on the other hand, the disease itself might produce significant stress to patients thus the vicious circle is formed and maintained.

Objectives

We aimed to examine the prevalence of mental/emotional stress at home and its associations among patients with Rheumatoid arthritis. We addressed this question using real-world data from the PRIME registry.

Methods

This was a cross-sectional study conducted using data collected at the time of patient enrolment in the PRIME registry. The PRIME Registry is a large, independent, prospective, observational cohort initiated in October 2019 that comprises patients diagnosed with RA, SLE, PsA or AS by a rheumatologist, and is being actively followed up. IRB approval and informed consent was obtained. We assessed the data for RA patients. The clinical variables studied were gender, age, smoking habits, body mass index, education status, marital status, disease duration, comorbidities (using Charlson Comorbidity Index). Education status was stratified by whether participants completed secondary (high) school education. The SF-12 Physical Component Score (PCS-12) and Mental Component Score (MCS-12) was also measured. Evaluation of disease activity and severity was made as per internationally agreed definitions, such as: swollen joint counts, tender joint counts, deformed joint counts, and DAS-28. All participants were directly inquired at the interview during the time of patient enrolment about the presence or otherwise of mental/emotional stress at home, and to rate it from 1-3 (mild, moderate, severe). For better understanding and ease of statistical analysis, dichotomous variable was made with moderate-to-severe stress patients were categorised into one group and none-to-mild stress patients into second group.

Results

The data from consecutive 1016 RA patients (mean age 40.8±13 years, 78.6% female, disease duration of 65±67 months) was reviewed. Forty-nine percent of patients accepted to have moderate-severe stress at home. Female gender (p=0.003), low education status (p=0.050), being unmarried (p=0.051), and MCS, PCS, CCI (p<0.001) were associated with moderate-severe stress. However, no statistical association of age and disease duration was noted. On univariate analysis, significant association of moderate-severe stress at home was noted with deformed joint counts (p=0.003), higher DAS-28 scores (p<0.001), low education status (p=0.02) and being married (p<0.001). Weak statistical association of age (p=0.30), disease duration (p=0.12), low education status (p=0.14), female gender (p=0.24) was noted. On multiple logistic regression analysis, a significant association of moderate-severe stress at home was observed with higher DAS-28 scores (OR 2.38, CI 2.00-2.84, p<0.001), MCS-12 (OR 0.65, CI 0.61-0.69, p<0.001), comorbidities-CCI (OR 1.41, CI 1.15-1.74, p=0.001) and being unmarried (OR 0.55, CI 0.36-0.83, p=0.005). The final regression model resulted in a statistically significant improved association/prediction of worse moderate-severe stress at home (R square=71%). Following variables were included in multiple stepwise regression analysis: age, disease duration, gender, education status, marital status, comorbidities index, major trauma/stress in last one year, DAS-28, MCS-12 and PCS-12 scores.

Conclusion

Nearly half of the cohort was noted to have moderate-severe level of stress at home, and is associated with important adverse clinical outcomes. These findings demonstrate an important need for integration of rheumatologic, social workers and mental health services

Disclosure of Interests

Muhammad Haroon Speakers bureau: Novartis, Abbvie, Pfizer, Roche, Grant/research support from: Abbvie, Sadia Asif: None declared, Saadat Ullah: None declared, Farzana Hashmi: None declared, Saba Javed: None declared

POS0574 FEMALE GENDER AND STRESS ARE MAIN DETERMINANTS OF NON-ADHERENCE AND NEGATIVE ILLNESS PERCEPTION AMONG PATIENTS WITH RHEUMATOID ARTHRITIS: SINGLE CENTRE RESULTS FROM THE PRIME REGISTRY COHORT

Background

Adherence to medications among patients with RA is traditionally considered to be low. Little is known about the indicators and the outcomes of patients having good adherence to medications among Pakistani RA patients.

Objectives

We aimed to assess the level of non-adherence and its associations with clinical indicators and outcomes using validated measures in a large consecutive Pakistani RA population. Moreover, we measured illness perception using additional validated tools to help us better understand this concept.

Methods

This was a cross-sectional study conducted using data collected at the time of patient enrolment in the PRIME registry. IRB approval and informed consent was obtained. The clinical variables studied were gender, age, smoking habits, body mass index, education status, marital status, disease duration, Charlson Comorbidity Index. Education status was stratified by whether participants completed secondary (high) school education. Evaluation of disease activity and severity was made as per internationally agreed definitions. To measure adherence, the instrument used in the study was the Urdu version of the General Medication Adherence Scale (GMAS), which has been validated for RA patients. Brief Illness Perception Questionnaire (BIPQ) is the simplified version of the Illness Perception Questionnaire (IPQ). BIPQ is a nine-item scale designed to rapidly assess the cognitive and emotional representations of illness. To facilitate interpretation of results in daily clinical practice and to identify patients with the most negative illness perception, we dichotomized the BIPQ scores using the 75th interquartile range score as cutoff, as previously done.

Results

The data of consecutive 320 RA patients enrolled in PRIME registry (mean age 37.4±13.4 years, 74% female, disease duration of 73±68 months, 30% rural residents, 32.5% had low education status of ≤primary school, and 35% of the cohort was employed) was reviewed. Thirty six percent of the cohort (n=116) was noted to have non adherence. On multiple logistic regression analysis, a significant association of moderate-severe stress (OR 1.85, CI 1.04-3.2, p=0.03), DAS-28 scores (OR 1.83, CI 1.52-2.21, p<0.001), HAQ scores (OR 1.77, CI 1.07-2.92, p=0.02), deformed joint counts (OR 1.30, CI 1.15-1.46, p<0.001). We further examined the concept of non-adherence among our cohort across three domains or components of GMAS questionnaire individually. Firstly, on multivariate regression analysis showed that non-adherence due to patient behavior had significant association with male gender (OR 0.48, p=0.01), unemployment (OR 1.82, p=0.02), stress (OR 2.17, p=0.001), DAS-28 (OR 1.15, p=0.050), worse HAQ scores (OR 1.83, p=0.005). Secondly, multivariate regression analysis showed that non-adherence due to comorbidity and pill burden was associated with age of onset of arthritis (OR 1.02, p=0.006), DAS-28 (OR 1.18, p=0.03), and HAQ (OR 1.81, p=0.008). Thirdly, multivariate regression analysis showed that cost-related non-adherence had no significant association with patient related demographics and traits, but was noted to have significant association with worse DAS-28 and HAQ scores. The mean total BIPQ score of the cohort was 62±8.8. Twenty six percent of the cohort (n=86) was noted to have the most negative illness perception (BIPQ score of >68). On multiple logistic regression analysis, a significant protective association of male gender (OR 0.24, CI 0.11-0.53, p<0.001) and age of onset of arthritis (OR 0.96, CI 0.94-0.99, p=0.01), along with significant association of worse HAQ scores (OR 3.7, CI 2.2-6.1, p<0.001) was noted with the most negative illness perception.

Conclusion

Non-adherence is common and its main determinants were female gender and stress, along with associated adverse clinical outcomes. Gender-based discrimination in low socioeconomic states along with associated stress is a plausible explanation.

Disclosure of Interests

Farzana Hashmi: None declared, Muhammad Haroon Speakers bureau: Novartis, Roche, Abbvie, Pfizer, Grant/research support from: Abbvie, Pfizer, Sadia Asif: None declared, Saadat Ullah: None declared, Saba Javed: None declared.

Fluid shear stress-induced mechanotransduction in myoblasts: Does it depend on the glycocalyx?

Muscle stem cells (MuSCs) are involved in muscle maintenance and regeneration. Mechanically loaded MuSCs within their native niche undergo tensile and shear deformations, but how MuSCs sense mechanical stimuli and translate these into biochemical signals regulating function and fate is still poorly understood. We aimed to investigate whether the glycocalyx is involved in the MuSC mechanoresponse, and whether MuSC morphology affects mechanical loading-induced pressure, shear stress, and fluid velocity distribution. FSS-induced deformation of active proliferating MuSCs (myoblasts) with intact or degraded glycocalyx was assessed by live-cell imaging. Glycocalyx-degradation did not significantly affect nitric oxide production, but reduced FSS-induced myoblast deformation and modulated gene expression. Finite-element analysis revealed that the distribution of FSS-induced pressure, shear stress, and fluid velocity on myoblasts was non-uniform, and the magnitude depended on myoblast morphology and apex-height. In conclusion, our results suggest that the glycocalyx does not play a role in NO production in myoblasts but might impact mechanotransduction and gene expression, which needs further investigation. Future studies will unravel the underlying mechanism by which the glycocalyx affects FSS-induced myoblast deformation, which might be related to increased drag forces. Moreover, MuSCs with varying apex-height experience different levels of FSS-induced pressure, shear stress, and fluid velocity, suggesting differential responsiveness to fluid shear forces.

Reduced growth rate of aged muscle stem cells is associated with impaired mechanosensitivity

Aging-associated muscle wasting and impaired regeneration are caused by deficiencies in muscle stem cell (MuSC) number and function. We postulated that aged MuSCs are intrinsically impaired in their responsiveness to omnipresent mechanical cues through alterations in MuSC morphology, mechanical properties, and number of integrins, culminating in impaired proliferative capacity. Here we show that aged MuSCs exhibited significantly lower growth rate and reduced integrin-α7 expression as well as lower number of phospho-paxillin clusters than young MuSCs. Moreover, aged MuSCs were less firmly attached to matrigel-coated glass substrates compared to young MuSCs, as 43% of the cells detached in response to pulsating fluid shear stress (1 Pa). YAP nuclear localization was 59% higher than in young MuSCs, yet YAP target genes Cyr61 and Ctgf were substantially downregulated. When subjected to pulsating fluid shear stress, aged MuSCs exhibited reduced upregulation of proliferation-related genes. Together these results indicate that aged MuSCs exhibit impaired mechanosensitivity and growth potential, accompanied by altered morphology and mechanical properties as well as reduced integrin-α7 expression. Aging-associated impaired muscle regenerative capacity and muscle wasting is likely due to aging-induced intrinsic MuSC alterations and dysfunctional mechanosensitivity.

Comparison of Chemical and Mechanical Prophylaxis of Venous Thromboembolism in Non-surgical Mechanically Ventilated Patients

To compare the efficacy of mechanical and chemical prophylaxis in non-surgically mechanically ventilated patients in terms of reduction in mortality and length of hospital stay.

A total of 200 patients admitted to intensive care units (ICUs) were recruited retrospectively. Half participants received mechanical prophylaxis and half received chemical prophylaxis. Patients with medical diseases with age 18 years or above, both genders, Pakistani nationals, receiving mechanical ventilation for more than 48 hours or receiving subcutaneous low molecular weight (LMW) heparin or subcutaneous unfractionated heparin were included. Cases who undergone surgery and were then admitted to ICU, those who received both mechanical and chemical therapies, and patients who received anticoagulant treatment before admission to ICU were excluded from the study. The patient’s age, gender, length of stay in ICU, and mortality were recorded in each group. Chi-square test was used to compare categorical data and Student t-test for continuous variables.

The mean age was 55.51±8.37 years. The males were 108(54%) and females were 92(46%). The mortality rate was higher in the mechanical prophylaxis group (49%) than chemical (31%) statistically significantly (P=0.014). Similarly, the length of hospital stay was also higher in the mechanical prophylaxis group (7.27±0.897 days) than chemical (6.67±1.045) statistically (P<0.001).

Chemical prophylaxis can reduce mortality and length of hospital stay more effectively than mechanical prophylaxis in ICUs admitted patients.

Imaging considerations for thermal and radiotherapy ablation of primary and metastatic renal cell carcinoma

Ablative (percutaneous and stereotactic) thermal and radiotherapy procedures for management of both primary and metastatic renal cell carcinoma are increasing in popularity in clinical practice. Data suggest comparable efficacy with lower cost and morbidity compared to nephrectomy. Ablative therapies may be used alone or in conjunction with surgery or chemotherapy for treatment of primary tumor and metastatic disease. Imaging plays a crucial role in pre-treatment selection and planning of ablation, intra-procedural guidance, evaluation for complications, short- and long-term post-procedural surveillance of disease, and treatment response. Treatment response and disease recurrence may differ considerably after ablation, particularly for stereotactic radiotherapy, when compared to conventional surgical and chemotherapies. This article reviews the current and emerging role of imaging for ablative therapy of renal cell carcinoma.

1172 Maggot Debridement Therapy (MDT) In Treating Group A Streptococcus Necrotizing Fasciitis of The Lower Limb as A Part of Multimodal Therapy

Background

Medical-grade maggots have been commercially available recently and today there is a resurge interest in MDT. They are approved for debridement of wounds with necrotic tissue, including pressure ulcers, venous ulcers. However, for necrotising fasciitis, it has been used with precaution due to the complexity of the disease. In our practice, Maggot debridement therapy (MDT) has been proven to be very effective in the treatment of gram-positive bacterial infections. Worldwide, Case reports on the results of 15 patients with necrotizing fasciitis treated with MDT have been reported. However, in current practice, Maggot Debridement therapy has not been widely applied.

Case presentation

A 63-year-old lady admitted to a general surgery ward with uncomplicated cellulitis of the right leg. After 2 days, the patient then was diagnosed with Necrotising fasciitis which was treated with wound debridement. Postoperative histopathology specimen confirmed necrotizing fasciitis V.A.C. VERAFLO™ Therapy was used postoperatively followed by two more debridement sessions. To reduce the need for further surgical debridement Maggot Debridement Therapy was started. Over the next 3 weeks, six sessions of Maggot Debridement therapy were applied to the infected area. Skin grafting then was performed 3 months later. The patient then discharged home with regular surgical fellow up.

Conclusions

NF is a complex disease, associated with high morbidity and mortality. Multimodal therapies are essential to achieve aggressive yet conservative wound debridement with preservation of viable tissue. This case report showed that MDT is a feasible, safe, cost-effective option that to be added to the other treatment modalities

Fully automated detection of prostate transition zone tumors on T2-weighted and apparent diffusion coefficient (ADC) map MR images using U-Net ensemble

PURPOSE

Accurate detection of transition zone (TZ) prostate cancer (PCa) on magnetic resonance imaging (MRI) remains challenging using clinical subjective assessment due to overlap between PCa and benign prostatic hyperplasia (BPH). The objective of this paper is to describe a deep-learning-based framework for fully automated detection of PCa in the TZ using T2-weighted (T2W) and apparent diffusion coefficient (ADC) map MR images.

METHOD

This was a single-center IRB-approved cross-sectional study of men undergoing 3T MRI on two systems. The dataset consisted of 196 patients (103 with and 93 without clinically significant [Grade Group 2 or higher] TZ PCa) to train and test our proposed methodology, with an additional 168 patients with peripheral zone PCa used only for training. We proposed an ensemble of classifiers in which multiple U-Net-based models are designed for prediction of TZ PCa location on ADC map MR images, with initial automated segmentation of the prostate to guide detection. We compared accuracy of ADC alone to T2W and combined ADC+T2W MRI for input images, and investigated improvements using ensembles over their constituent models with different methods of diversity in individual models by hyperparameter configuration, loss function and model architecture.

RESULTS

Our developed algorithm reported sensitivity and precision of 0.829 and 0.617 in 56 test cases containing 31 instances of TZ PCa and in 25 patients without clinically significant TZ tumors. Patient-wise classification accuracy had an area under receiver operator characteristic curve (AUROC) of 0.974. Single U-Net models using ADC alone (sensitivity 0.829, precision 0.534) outperformed assessment using T2W (sensitivity 0.086, precision 0.081) and assessment using combined ADC+T2W (sensitivity 0.687, precision 0.489). While the ensemble of U-Nets with varying hyperparameters demonstrated the highest performance, all ensembles improved PCa detection compared to individual models, with sensitivities and precisions close to the collective best of constituent models.

CONCLUSION

We describe a deep-learning-based method for fully automated TZ PCa detection using ADC map MR images that outperformed assessment by T2W and ADC+T2W.

Comparison of 5 Rectal Preparation Strategies for Prostate MRI and Impact on Image Quality

PURPOSE

To compare 5 different rectal preparation strategies for prostate MRI.

METHODS

This 5-arm quality-assurance study evaluated 56 patients per arm (280 patients) including: no preparation, clear-fluids diet (CFD) beginning at 00:00 hours on the day of MRI, Fleet®-enema, enema + CFD, enema + CFD + IV-antispasmodic agent. The study was powered to 0.80 with alpha-error of 0.05. Three blinded radiologists independently evaluated T2-Weighted (T2W) and Diffusion Weighed Imaging (DWI) for: rectal diameter (maximal AP diameter), rectal content (stool, fluid, gas), rectal motion, T2W/DWI image quality, T2W image sharpness and DWI susceptibility artifact using 5-point Likert scales. Overall comparisons were performed using analysis of variance (ANOVA) and Kruskal-Wallis, with pair-wise comparisons using paired t-tests and Wilcoxon sign-rank tests.

RESULTS

Rectal diameter and amount of gas were lower in enema compared to non-enema groups (p < 0.001), with smallest diameter and least gas in the enema + CFD + IV-antispasmodic group (p = 0.022-<0.001). T2W image quality and sharpness were highest in the enema + CFD groups (p < 0.001) with no difference comparing enema + CFD with/without IV-antispasmodic (p = 0.064, 0.084). Motion artifact was least in enema + CFD + IV-antispasmodic group compared to all other groups (p < 0.001), followed by the enema + CFD group (p = 0.008-<0.001). DWI image quality was highest (p < 0.001) and DWI susceptibility artifact lowest (p < 0.001) in the enema + CFD groups (p < 0.001) and did not differ comparing enema + CFD with/without anti-spasmodic (p = 0.058-0.202).

CONCLUSIONS

Use of enema + clear-fluids diet before prostate MRI yields the highest T2W and DWI image quality with the least DWI artifact. IV-antispasmodic use reduces motion on T2W but does not improve image quality on T2W or DWI, or lessen DWI artifact compared to enema + clear-fluids diet.

Evaluation of methanolic crude extract of Linum usitatissimum for the removal of biofilm in diabetic foot isolates

Linum usitatissimum L is a widely used traditionally for multiple ailments. The present research was carried out to explore the antimicrobial, and anti-biofilm activity of crude extract of Linum usitatissimum L (Lu. Cr). Phytochemical and proximate analyses were performed. The bandages of diabetic foot patients were collected from the various hospitals. The bandages were cultured to isolate the bacterial strains present on it. The disc diffusion method was used to identify the antimicrobial potential whereas the minimum inhibitory concentration of the Lu.Cr were also determined. Proximate analysis confirms moisture content 8.33%, ash content 4.33%, crude protein 21.20%, crude fat 49.2% and crude fiber 5.63%. It was revealed that Gram-positive bacteria are most prevalent among all study groups. Lu.Cr possess significant bactericidal potential against S. aureus among all other microbes. Owing to this potential, linseed coated bandages can be used alternatively for the treatment of diabetic foot.

Utility of Quantitative T2-Mapping Compared to Conventional and Advanced Diffusion Weighted Imaging Techniques for Multiparametric Prostate MRI in Men with Hip Prosthesis

BACKGROUND

Diffusion weighted imaging (DWI) is fundamental for prostate cancer (PCa) detection with MRI; however, limited by susceptibility artifact from hip prosthesis.

PURPOSE

To evaluate image quality and ability to detect PCa with quantitative T2-mapping and DWI in men with hip prosthesis undergoing prostate MRI.

STUDY TYPE

Prospective, cross-sectional study.

POPULATION

Thirty consecutive men with hip replacement (18 unilateral, 12 bilateral) undergoing prostate MRI from 2019 to 2021.

FIELD STRENGTH/SEQUENCE

3-T; multiparametric MRI (T2W, DCE-MRI, echo-planar [EPI]-DWI), T2-mapping (Carr-Purcell-Meiboom-Gill), FOCUS-EPI-DWI, PROPELLER-DWI.

ASSESSMENT

Five blinded radiologists independently evaluated MRI image quality using a 5-point Likert scale. PI-RADS v2.1 scores were applied in four interpretation strategies: 1) T2W-FSE+DCE-MRI+EPI-DWI, 2) T2W-FSE+DCE-MRI+EPI-DWI+FOCUS-EPI-DWI, 3) T2W-FSE+DCE-MRI+EPI-DWI+PROPELLER-DWI, 4) T2W-FSE+DCE-MRI+EPI-DWI+T2-maps. Five-point confidence scores were recorded.

STATISTICAL ANALYSIS

ANOVA, Kruskal-Wallis with pair-wise comparisons by Wilcoxon sign-rank, and paired t-tests, P < 0.05 was considered significant. Cohen's Kappa (k) for PI-RADSv2.1 scoring and proportion of correctly classified lesions tabulated for pathology-confirmed cases with 95% confidence intervals (CIs).

RESULTS

For all radiologists, T2-map image quality was significantly higher than EPI-DWI, FOCUS-EPI-DWI, and PROPELLER-DWI and similar (P = 0.146-0.706) or significantly better (for two readers) than T2W-FSE and DCE-MRI. PI-RADS v2.1 agreement improved comparing strategy A (k = 0.46) to strategy B (k = 0.58) to strategy C (k = 0.58) and was highest with strategy D which included T2-maps (k = 1.00). Radiologists' confidence was significantly highest with strategy D. Strategies B and C had similar confidence (P = 0.051-0.063) both significantly outperforming strategy A. Twelve men with 17 lesions had pathology confirmed diagnoses (13 PCa, 4 benign). Strategy D had the highest proportion of correctly classified lesions (76.5-82.4%) with overlapping 95% confidence intervals.

DATA CONCLUSION

T2-mapping may be a valuable adjunct to prostate MRI in men with hip replacement resulting in improved image quality, higher reader confidence, interobserver agreement, and accuracy in PI-RADS scoring.

LEVEL OF EVIDENCE

1 TECHNICAL EFFICACY STAGE: 2.

AB0093 CLINICAL AND SEROLOGICAL CHARACTERISTICS OF SYSTEMIC SCLEROSIS: EXPERIENCE FROM A TERTIARY CARE CENTER IN PAKISTAN

Background:

Systemic sclerosis (SS) is less studied Connective tissue disease in our population. It is characterized by different manifestations which if left undiagnosed and untreated lead to serious complications. The hallmark of this disease is fibrosis of various organs including skin and also involving pulmonary, gastrointestinal and cardiovascular system. We aim to evaluate the clinical and serological characteristics of SS in our population. In addition, we evaluated the prevalence of Fibromyalgia and Depression in patients with SS.

Objectives:

We aimed to determine Clinical and Serological Characteristics of Systemic Sclerosis visiting our department of Rheumatology, Fatima Memorial hospital, Lahore.

Methods:

It is a cross-sectional study of 38 patients visiting outdoor and indoor in Rheumatology department of Fatima Memorial Hospital from September 2019 to January 2020. All systemic sclerosis patients with age 16 years or above were included in this study. After taking informed consent, we filled the performas to record all the required information. We evaluated the clinical, serological and radiological features of Systemic Sclerosis.

Results:

A total of 38 patients were included in the study with mean age was 34.47 ± 1.53 years. Female gender comprised of 32(84.2%), with male to female ratio of 1:5.3. Thirty-four (89.5%) had developed Raynaud phenomenon and sclerodactyly was found in 34(89.5%), digital ulcers in 25 (65.8%), and tendon friction rub in 12 (31.6%) patients. Skin tightness proximal to elbow was present in 9 (23.7%). Microstomia (decreased mouth opening) was present in 32(84.2%) patients. Twenty-eight (73.7%) patients had arthritis.Respiratory symptoms comprised of shortness of breath in 36(94.7%), palpitation in 24 (63.2%) and chest pain in 7(18.4%). Gastrointestinal (GI) symptoms comprised of regurgitation in 31 (81.5%) and dysphagia in 14 (36.8%). Interstitial lung disease was present in 30 (78.9%) patients, with higher prevalence in diffuse scleroderma (100%) than in limited scleroderma (70%) (p=0.01). Pulmonary hypertension was present in 18 patients, with significantly higher prevalence in diffuse disease (57.1%), that was secondary to interstitial lung disease and in limited disease it was found in (11.8%) (p<0.01). Thirty (78.9%) patients were found to have restricted disease on pulmonary function tests.

Obstetric history showed a higher prevalence of primary infertility in at least 6 (15.8%) patients, with significantly higher prevalence in limited systemic sclerosis disease as compared to diffuse disease (23.5% vs 9.5%, and p=0.05). Fibromyalgia diagnosed as per ACR criteria was present in 7 (18.4%) patients, and depression assessed by Hospital Anxiety and depression (HADS) score was present in 10 (26.3%) patients.

Anti nucleic acid antibody (ANA) was found positive in 30 (78.9%) patients. Anti Scl-70 antibodies were in 24 (63.2%) patients, with significant association with diffuse disease (85% vs 35.3% and p<0.01), while anti centromere antibodies were present in 20 (52.6%) patients; significantly higher in limited disease (94.2% vs 19.0%, and p<0.01).

Conclusion:

Scleroderma is a very important, autoimmune multisystem disease. It has female preponderence. Raynaud phenomenon is the most initial clinical feature followed by other manifestations of variable course and disease severity. Interstitial lung disease and pulmonary hypertension were the most important complication found in our patients which has poor prognosis. So, It is imperative to early diagnose and treat the disease manifesations to prevent future complications.

Keywords:

Scleroderma, Systemic sclerosis.

Disclosure of interest:

Sadia Asif: None declared, Muhammad Haroon: None declared, Dr Asadullah Khan: None declared, Dr. Muhammad Faiq: None declareDOI: 10.1136/annrheumdis-2021-eular.1635

The Spectrum of Clinical Characteristics and Complications of Tetanus: A Retrospective Cross-Sectional Study From a Developing Nation

Introduction While tetanus has largely been eradicated with the advent of the tetanus vaccine, its prevalence in Pakistan remains alarmingly high due to insufficient uptake of the vaccination program. The clinical presentations that the disease elicits range from mere opisthotonos to more sinister complications, including respiratory failure and death, often posing an insurmountable challenge for hospitals. Methods A retrospective cross-sectional study was conducted and analyzed the medical charts of 43 patients with a confirmed diagnosis of tetanus infection. The charts were perused for the patients' demographics, clinical characteristics, and disease outcomes. The prevalence of various clinical symptoms and complications were reported in terms of frequencies and percentages. Results The mean age of the patients hovered at 29.53 ± 16.53 years, with a range of 12 to 65 years. Of those affected, 83.7% were males while 16.3% were females. Notably, none of the infected patients had a prior history of vaccination against tetanus. Trismus was noted to be the most prevalent clinical manifestation and was found in 90.70% of the patients while paraesthesia at the site of infection, found in 6.98%, was the least prevalent. The overall mortality was noted to hover at 46.5%. Conclusion While tetanus has largely been eradicated, its prevalence in Pakistan remains alarmingly high. The complications noted in the study have implications for the country's public health system and aims to better inform the current state of the national vaccination program.

POS0310 EXPOSURE TO MAJOR PSYCHOLOGICAL TRAUMA OR STRESS IN THE PRECEDING ONE YEAR SIGNIFICANTLY CONTRIBUTES TO POOR DISEASE CONTROL IN PATIENTS WITH RHEUMATOID ARTHRITIS: SINGLE CENTRE RESULTS FROM THE PRIME REGISTRY COHORT

Background:

Stress response is considered to involve the activation of both the hypothalamus-pituitary-adrenal axis and the autonomic nervous system, along with its communication with the immune system. Because many rheumatic diseases are characterized by immune-mediated joint inflammation, stressful events might contribute to the aetiology, maintenance and exacerbation of rheumatic diseases.

Objectives:

We aimed to examine whether real-life major stressful events lead to poor disease control among patients with Rheumatoid arthritis (RA). We addressed this question using real-world data from the PRIME registry.

Methods:

This was a cross-sectional study conducted using data collected at the time of patient enrolment in the PRIME registry. The PRIME Registry is a large, independent, prospective, observational cohort initiated in October 2019 that comprises patients diagnosed with RA, SLE, PsA or AS by a rheumatologist, and is being actively followed up. IRB approval and informed consent was obtained. We assessed the registry data for RA patients. The clinical variables studied were gender, age, smoking habits, body mass index, education status, marital status, disease duration, comorbidities (using Charlson Comorbidity Index). Education status was stratified by whether participants completed secondary (high) school education. Evaluation of disease activity and severity was made as per internationally agreed definitions, such as: swollen joint counts (SJC), tender joint counts (TJC), deformed joint counts, and DAS-28. Major psychological trauma or stress was defined if the patient has experienced any of the following in the past year: a) major personal injury or illness; b) death/major illness of a close relative; c) marital separation/divorce; d) loss of job; e) major financial loss; f) mass casualty incident loss.

Results:

The data of consecutive 507 RA patients (mean age 42.3±12.6 years, 73.6% female, disease duration of 80±22 months) was reviewed. Thirty-six percent of the cohort reported to have major psychological stress and trauma in the preceding one year. No statistical association of age, gender, and marital status was noted, but statistical association of low education status (p=0.042), longer disease duration (p=0.044), higher DAS-28 values (p<0.001) and other markers of RA disease activity (SJC, TJC, ESR, patient global health) was found. On multiple logistic regression analysis, a significant association of major psychological stress and trauma in the preceding one year was noted with active disease (DAS-28; OR 1.67, CI 1.17-2.4, p=0.005). Following variables were included in the full regression model, disease duration, gender, age, marital status, education status, and DAS-28 value (also used models with SJC, TJC, deformed joint counts, ESR, patient global health, but the results remained unchanged).

Conclusion:

Major psychological stress and trauma in the preceding one year is associated with high disease activity among patients with RA. Therapies that focus on stress management may be important adjuncts to traditional pharmacotherapy in the treatment of inflammatory rheumatic diseases.

Disclosure of Interests:

Muhammad Haroon Speakers bureau: Roche, Novartis, Grant/research support from: Abbvie, Pfizer, Sadia Asif: None declared, Shabnam Batool: None declared, Farzana Hashmi: None declared, Saadat Ullah: None declared, Arfa Ashraf: None declared, Hafiza Javeria Shaheen: None declared

POS0663 SAFETY AND EFFICACY OF COMBINING METHOTREXATE AND LEFLUNOMIDE AMONG PATIENTS WITH INFLAMMATORY ARTHROPATHIES: FINDINGS FROM THE PRIME REGISTRY

Background:

Currently, conventional synthetic DMARDs (csDMARDs) are the most commonly prescribed drugs as first-line treatment for peripheral arthritis. In resource-constrained settings where biologic agents are not widely available, there are limited therapeutic options for patients with rheumatoid arthritis (RA) and seronegative inflammatory arthropathies refractory to other csDMARD therapies. Hence, in our practice, we are inclined to use combination of potent DMARDs after MTX failure, prior to considering biologic therapies. We believe that combination of DMARDs, especially combining MTX and Leflunomide (LEF) provides a potent and valuable low-cost treatment option. Efficacy of MTX and LEF is very well established, but there have been lot of concern as regards their combination use due to potential risk of hepatotoxicity.

Objectives:

We aimed to review our inflammatory arthropathies cohort data especially examining the safety, efficacy and drug retention of the combination usage of MTX and Leflunomide. We addressed this question using real-world data from the PRIME registry.

Methods:

This was a cross-sectional study conducted using data collected at the time of patient enrolment in the PRIME registry. The PRIME Registry is a large, independent, prospective, observational cohort initiated in October 2019 that comprises patients diagnosed with RA, SLE, PsA or AS by a rheumatologist, and is being actively followed up. IRB approval and informed consent was obtained. A number of clinical variables were recorded. Detailed history was gathered from every patient regarding their present and past medications usage. Questions were asked directly about the usage or otherwise of all available DMARDs and biologics. The duration of usage, any adverse events, or the reasons for discontinuation were recorded. Evaluation of disease activity and severity was made as per internationally agreed definitions.

Results:

The data of 766 inflammatory arthritis patients (RA=663, PsA=103) was reviewed. Among them, 241 patients (RA=196, PsA=45) were using combination therapy of MTX and LEF (combo MTX+LEF) with mean age 42.3±6 years; 42% male]. These patients had failed MTX or LEF monotherapy. Among these 241 patients, 49 patients were also on concomitant hydroxychloroquine therapy. It was noted that median drug retention of combo MTX+LEF therapy has been 9.5 months (IQR 6-16). Regarding any adverse events of combo MTX+LEF therapy, hepatotoxicity (ALT ≤3 times the upper limit of normal) was noted among 15 (6.2%) patients, hepatotoxicity (ALT ≥3 times the upper limit of normal) was noted among 8 (3.3%) patients, and troublesome gastrointestinal upset (nausea, or vomiting, or diarrhoea) in 3 (1.2%). Overall, only 13 (5.4%) patients had to discontinue this combo MTX+LEF therapy due to adverse events. Disease activity among combo MTX+LEF users was as follows: 64% (n=29) of PsA patients had achieved MDA; 42% (n=83) of RA cohort were in DAS28 remission, 46% (n=91) of RA patients were having DAS low disease activity.

Conclusion:

Combination of MTX and LEF was well tolerated and had good drug retention time, with 94.6% of patients having ongoing treatment to date. In low-income countries, where bDMARD availability is limited, financial arguments significantly influence decision making process, and our data provides initial evidence that MTX and LEF combination therapy could be an effective treatment option.

Disclosure of Interests:

Muhammad Haroon Speakers bureau: Roche, Novartis, Grant/research support from: Abbvie, Pfizer, Arfa Ashraf: None declared, Hafiza Javeria Shaheen: None declared, Sadia Asif: None declared, Shabnam Batool: None declared, Farzana Hashmi: None declared, Saadat Ullah: None declared

AB0581 NAIL PSORIASIS AMONG PATIENTS WITH PSORIATIC ARTHRITIS IS MORE ASSOCIATED WITH THE SEVERITY OF SKIN PSORIASIS THAN WITH FEATURES OF SEVERE ARTHRITIS

Background:

Nail disease is an important feature of psoriasis arthritis (PsA), and has been recognised as one of the 6 important clinical domains by GRAPPA. Little is known about how patients with PsA and nail disease compare to patients without nail disease. Nail disease has been found to associate with severe PsA.

Objectives:

The objective of this study was to examine the association of nail disease with patient demographics and features of active psoriasis and PsA.

Methods:

For this cross-sectional study, data from 3 PsA cohorts was studied (St Vincent’s University Hospital Dublin, Ireland; University Hospital Kerry, Ireland; and Fatima Memorial Hospital Lahore, Pakistan). Following informed consent, patients underwent detailed skin and rheumatologic assessments including disease activity measures. Since a large number of patients were in clinical remission at the time of assessment, we made 2 documentations of reversible clinical variables (e.g., current skin scores (PASI), current nail disease, current tender and swollen joint counts, current enthesitis, current dactylitis) at the time of study entry and, through extensive medical record review, we identified patient’s maximum skin and joints disease activity scores ever documented, e.g., maximum skin scores (PASI max), TJC max, SJC max, nail disease ever, dactylitis ever, enthesitis ever. Nail disease was stratified by the presence or absence of nail psoriasis.

Results:

Data on 476 PsA patients was assessed (age 53.8±10.8, PsA duration 13.9±10 years, BMI 29±5; current PASI 2.5±3.2, current TJC 1.8±2.6 years, current SJC 1.4±2.2 years; 37% of the cohort had enthesitis ever, 46% had dactylitis ever, 30.7% had current dactylitis, and 28% with current enthesitis). 63.4% (n=302) of the cohort ever had nail disease, and 45.4% (n=216) had current nail disease at the time of assessment. On univariate analysis, significant or marginally significant statistical association of current nail disease was noted with current PASI (p<0.001), enthesitis ever (p=0.004), current enthesitis (p=0.11), dactylitis ever (p=0.027), current dactylitis (p=0.07), MDA not achieved (p<0.001), current SJC (p=0.08), and current TJC (p=0.32); however, no statistical association was noted with age, gender, disease duration, smoking status, low education status.The following variables were included in multiple stepwise regression analysis: current PASI, current enthesitis, current dactylitis, current TJC, current SJC, MDA not achieved, and low education status; a significant association of current nail disease was noted with current PASI (OR 2.2, CI 1.83-2.54, p<0.001) with a borderline association of current dactylitis (OR 1.6, CI 0.94-2.58, p=0.083). When we used nail disease ever as a dependent variable in the multiple regression model using covariates of PASI max, TJC max, SJC max, dactylitis ever, enthesitis ever, MDA not achieved and low education status, a significant association of nail disease ever was noted with PASI max (OR 1.09, CI 1.01-1.17, p=0.01), TJC max (OR 1.08, CI 1.02-1.14, p=0.005) and borderline association with dactylitis ever (OR 1.74, CI 0.96-3.15, p=0.067)

Conclusion:

The presence of nail disease among patients with PsA is significantly associated with severity of skin psoriasis with only borderline associations with measures of active musculoskeletal involvement.

Disclosure of Interests:

Muhammad Haroon Speakers bureau: Roche, Novartis, Grant/research support from: Abbvie, Pfizer, shehla farrukh: None declared., Shabnam Batool: None declared., Sadia Asif: None declared., Oliver FitzGerald Speakers bureau: Abbvie, Janssen, Pfizer, Consultant of: BMS, Celgene, Eli Lilly, Janssen, Pfizer, Grant/research support from: Abbvie, BMS, Eli Lilly, Novartis, Pfizer.

POS0589 PREVALENCE AND SEVERITY OF STRESS AT HOME AMONG PATIENTS WITH RHEUMATOID ARTHRITIS: SINGLE CENTRE RESULTS FROM THE PRIME REGISTRY COHORT

Background:

In chronic inflammatory diseases like rheumatoid arthritis (RA), psychological stress is widely recognised as an important risk factor to negatively affect the disease course. Stress activates the hypothalamic-pituitary adrenal axis and the autonomic nervous system, which associate with the release of neurotransmitters (i.e. norepinephrine), hormones (i.e. cortisol) and activation of immune cells. Perceived stress can potentially induce the disease exacerbation, but on the other hand, the disease itself might produce significant stress to patients thus the vicious circle is formed and maintained.

Objectives:

We aimed to examine the prevalence of mental/emotional stress at home and its associations among patients with Rheumatoid arthritis. We addressed this question using real-world data from the PRIME registry.

Methods:

This was a cross-sectional study conducted using data collected at the time of patient enrolment in the PRIME registry. The PRIME Registry is a large, independent, prospective, observational cohort initiated in October 2019 that comprises patients diagnosed with RA, SLE, PsA or AS by a rheumatologist, and is being actively followed up. IRB approval and informed consent was obtained. We assessed the data for RA patients. The clinical variables studied were gender, age, smoking habits, body mass index, education status, marital status, disease duration, comorbidities (using Charlson Comorbidity Index). Education status was stratified by whether participants completed secondary (high) school education. Evaluation of disease activity and severity was made as per internationally agreed definitions, such as: swollen joint counts, tender joint counts, deformed joint counts, and DAS-28. All participants were directly inquired at the interview during the time of patient enrolment about the presence or otherwise of mental/emotional stress at home, and to rate it from 1-3 (mild, moderate, severe). For better understanding and ease of statistical analysis, dichotomous variable was made with moderate-to-severe stress patients were categorised into one group and none-to-mild stress patients into second group.

Results:

The data of consecutive 507 RA patients (mean age 42.3±12.6 years, 73.6% female, disease duration of 80±22 months) was reviewed. Forty-eight percent of patients accepted to have moderate-severe stress at home (moderate stress=29.9%, severe stress=18.3%). On univariate analysis, significant association of moderate-severe stress at home was noted with deformed joint counts (p=0.036), higher DAS-28 scores (p<0.001), and being married (p=0.001). Weak statistical association of age (p=0.11), disease duration (p=0.13), low education status (p=0.14), female gender (p=0.24) was noted. On multiple logistic regression analysis, a significant association of moderate-severe stress at home was observed with higher DAS-28 scores (OR 1.76, CI 1.29-2.41, p<0.001) and deformed joint counts (OR 1.15, CI 1.00-1.31, p=0.040). Following variables were included in multiple stepwise regression analysis: age, disease duration, low education status, married, Das-28 scores, and deformed joint counts. However, when gender was included in the regression analysis, a significant association of moderate-severe stress at home was observed with female gender (OR 3.99, CI 1.47-10.83, p=0.007), higher DAS-28 scores (OR 1.8, CI 1.31-2.51, p<0.001), with marginal association with deformed joint counts (OR 1.13, CI 0.99-1.30, p=0.061).

Conclusion:

Stress at home is common among patients with RA, and nearly half of the cohort was noted to have moderate-severe level of stress at home. Ongoing stress at home has significant association with higher RA disease activity and deformities suggesting a bidirectional relationship. These findings demonstrate an important need for integration of rheumatologic, social workers and mental health services

Disclosure of Interests:

Muhammad Haroon Speakers bureau: Roche, Novartis, Grant/research support from: Abbvie, Pfizer, Farzana Hashmi: None declared, Saadat Ullah: None declared, Arfa Ashraf: None declared, Hafiza Javeria Shaheen: None declared, Sadia Asif: None declared, Shabnam Batool: None declared

Pulsating fluid flow affects pre-osteoblast behavior and osteogenic differentiation through production of soluble factors

Bone mass increases after error-loading, even in the absence of osteocytes. Loaded osteoblasts may produce a combination of growth factors affecting adjacent osteoblast differentiation. We hypothesized that osteoblasts respond to a single load in the short-term (minutes) by changing F-actin stress fiber distribution, in the intermediate-term (hours) by signaling molecule production, and in the long-term (days) by differentiation. Furthermore, growth factors produced during and after mechanical loading by pulsating fluid flow (PFF) will affect osteogenic differentiation. MC3T3-E1 pre-osteoblasts were either/not stimulated by 60 min PFF (amplitude, 1.0 Pa; frequency, 1 Hz; peak shear stress rate, 6.5 Pa/s) followed by 0-6 h, or 21/28 days of post-incubation without PFF. Computational analysis revealed that PFF immediately changed distribution and magnitude of fluid dynamics over an adherent pre-osteoblast inside a parallel-plate flow chamber (immediate impact). Within 60 min, PFF increased nitric oxide production (5.3-fold), altered actin distribution, but did not affect cell pseudopodia length and cell orientation (initial downstream impact). PFF transiently stimulated Fgf2, Runx2, Ocn, Dmp1, and Col1⍺1 gene expression between 0 and 6 h after PFF cessation. PFF did not affect alkaline phosphatase nor collagen production after 21 days, but altered mineralization after 28 days. In conclusion, a single bout of PFF with indirect associated release of biochemical factors, stimulates osteoblast differentiation in the long-term, which may explain enhanced bone formation resulting from mechanical stimuli.

AB0533 COMBINATION OF METHOTREXATE AND LEFLUNOMIDE IS SAFE AND HAS GOOD DRUG RETENTION AMONG PATIENTS WITH PSORIATIC ARTHRITIS

Background:

Among patients with psoriatic arthritis (PsA), there remains a considerable confusion regarding the effectiveness of conventional synthetic DMARDs (csDMARDs), especially methotrexate (MTX). The availability of biologic DMARDs and targeted synthetic DMARDs have revolutionised the management of psoriatic disease; however, it comes with a significant cost burden. We believe that combination of DMARDs, especially combining MTX and Leflunomide (LEF) provides a valuable low-cost treatment option for patients with PsA after failure of MTX monotherapy. Hence, in our practice, we are inclined to use combination of potent DMARDs after MTX failure, prior to considering biologic therapies. Little is known about the combination use of LEF and MTX in PsA, especially in the context of drug retention time and tolerability.

Objectives:

We aimed to review our PsA cohort data especially examining the drug retention of first-line csDMARD monotherapy and combination csDMARDs.

Methods:

In our centre, MTX is a preferred first line csDMARD, unless contraindicated, and patients are followed up with a protocol on 4-6 weekly basis unless complete remission is achieved. MTX if needed is escalated to the maximum tolerated dose (up to 25mg/week), and if PsA is still active then preferably LEF is added (usual starting dose for add-on therapy is 10mg a day and if needed escalated to 20mg a day, without any loading dose). Other csDMARDs, such as sulphasalazine are used, if needed. For this study, after written-informed consent, only those adult patients were included who had a follow up of at least 6 months with our rheumatology services, and were fulfilling CASPAR criteria. Moreover, only patients who were DMARD-naïve (no prior DMARD therapy for any cause, including psoriasis), and initiated DMARD as monotherapy after 1 April 2018 were included. If any patient had already been on any DMARDs prior to attending our rheumatology services was excluded.

Results:

A total of 81 PsA patients [mean age 45.6±6 years; 52% male; mean PsA disease duration=9±4 years; 35% with dactylitis, 42% with enthesitis, 17% with sacroiliitis, median current PASI=2.6, median number of swollen joints=8.0, median number of tender joints= 11.0] fulfilled the inclusion and exclusion criteria. As regards first-line csDMARD monotherapy, 88% (n=71) of patients were commenced on MTX. In total, 79% (n=56 out of 71) of patients who were started on MTX as their first-line csDMARD therapy failed this monotherapy during follow-up (51=ineffective, 5=intolerance). After a median follow-up of 22 months, MTX median drug retention among all MTX monotherapy users (n=71) was only 7 months (IQR 5-7); and among MTX failures (n=56), MTX monotherapy median drug retention was 6.0 months (IQR 4-8). Eighty percent (n=45 out of 56) of the MTX monotherapy failure cohort was started on combination therapy of MTX and LEF (combo MTX+LEF); among them, only 7 patients needed escalation of therapy to bDMARDs, and the rest are still using combo MTX+LEF. It was noted that to date median drug retention time of combo MTX+LEF has been 8 months (IQR 7-11), and 84% (n=38 out of 45) of these patients are still using this combo therapy. Significantly more patients managed to continue the combo MTX+LEF therapy compared to MTX monotherapy (84% vs. 21%, p<0.001)

Conclusion:

Among csDMARD naïve PsA patients, 79% of patients failed MTX monotherapy with median drug retention time of only 6 months. Combination of MTX and LEF was well tolerated and had good drug retention time, with 84% of patients having ongoing treatment to date. Our data provides initial evidence that MTX and LEF combination therapy could be an effective treatment option for PsA

Disclosure of Interests:

Muhammad Haroon Speakers bureau: Roche, Novartis, Grant/research support from: Abbvie, Pfizer, Shabnam Batool: None declared., Sadia Asif: None declared., Farzana Hashmi: None declared., Saadat Ullah: None declared.

Fournier gangrene: pictorial review

Fournier gangrene is an emergency condition that is associated with a high mortality rate. It is defined as a rapidly progressing infective necrotizing fasciitis of the perineal, perianal, and genital regions. Early diagnosis, broad-spectrum antibiotic coverage, and adequate surgical debridement are crucial and lead to better prognosis and patient survival. There is increasing utilization of computed tomography (CT) in the initial evaluation of Fournier gangrene. CT can confirm the diagnosis in equivocal cases, determine the source of infection, and evaluate the disease extent. In this pictorial review, we discuss the pathogenesis of Fournier gangrene and display the imaging spectrum with an emphasis on CT findings, including asymmetrical fascial thickening, soft tissue stranding, soft tissue gas, collection, and abscess formation. The infection originating from colorectal pathology, the affected anatomy, and the involvement of the abdominal wall are important predictors of mortality. The familiarity of the varied imaging appearance of Fournier gangrene is necessary to provide an accurate diagnosis, and evaluation of disease extent is crucial for optimal surgical debridement.

Multidetector Computed Tomography in Traumatic and Nontraumatic Aortic Emergencies: Emphasis on Acute Aortic Syndromes

Aortic emergencies comprise of a list of conditions which are uncommon but are potentially fatal. Prognosis is usually determined by emergent diagnosis and treatment and hence radiology plays a key role in patient management. In this article, we aim to review the various causes of aortic emergencies and the relevant imaging findings placing special emphasis on acute aortic syndromes.

Molecular epidemiology of Shigella flexneri isolated from pediatrics in a diarrhea-endemic area of Khyber Pakhtunkhwa, Pakistan

Shigella flexneri is considered as an important causative agent of Shigellosis causing diarrhea in the countries with a low socioeconomic status. No study has been carried out on the molecular prevalence of S. flexneri in Khyber Pakhtunkhwa, Pakistan. So this study was designed to evaluate the molecular prevalence of S. flexneri and their associated risk factors. A total of 2014 diarrheal stool samples were collected from January 2016 to May 2017 from pediatrics patients of Khyber Pakhtunkhwa followed by identification of S. flexneri through biochemical, serological, and molecular methods. The overall prevalence of Shigella species was found to be 7.9% (n = 160). The predominant Shigella specie was S. flexneri (n = 155, 96.8%) followed by S. boydii (n = 5, 3.1%). Interestingly, no sample was found positive for S. sonnei and S. dysenteriae. The majority of Shigellosis cases occurred from June to September. Potential risk factors related with Shigellosis were unhygienic latrine usage, bad hand washing, and consumption of unhygienic food and water, and pipe leakage in the sewage system. In this study, we have observed a high number of Shigellosis cases especially those caused by S. flexneri. It is suggested that effective health awareness programs should be organized by the regional health authorities to minimize the magnitude of pediatrics Shigellosis.

RGD-functionalized supported lipid bilayers modulate pre-osteoblast adherence and promote osteogenic differentiation

Biomaterial integration into bone requires optimal surface conditions to promote osteoprogenitor behavior, which is affected by integrin-binding via arginine-glycine-aspartate (RGD). RGD-functionalized supported lipid bilayers (SLBs) might be interesting as biomaterial coating in bone regeneration, because they allow integration of proteins, for example, growth factors, cytokines, and/or antibacterial agents. Since it is unknown whether and how they affect osteoprogenitor adhesion and differentiation, the aim was to investigate adhesion, focal adhesion formation, morphology, proliferation, and osteogenic potential of pre-osteoblasts cultured on RGD-functionalized SLBs compared to unfunctionalized SLBs and poly-l-lysine (PLL). After 17 hr, pre-osteoblast density on SLBs without or with RGD was similar, but lower than on PLL. Cell surface area, elongation, and number and size of phospho-paxillin clusters were also similar. Cells on SLBs without or with RGD were smaller, more elongated, and had less and smaller phospho-paxillin clusters than on PLL. OPN expression was increased on SLBs with RGD compared to PLL. Moreover, after 1 week, COL1a1 expression was increased on SLBs without or with RGD. In conclusion, pre-osteoblast adhesion and enhanced differentiation were realized for the first time on RGD-functionalized SLBs, pointing to a new horizon in the management of bone regeneration using biomaterials. Together with SLBs nonfouling nature and the possibility of adjusting SLB fluidity and peptide content make SLBs highly promising as substrate to develop innovative biomimetic coatings for biomaterials in bone regeneration.

---Mechanosensitivity of aged muscle stem cells

During aging, skeletal muscle tissue progressively declines in mass, strength, and regenerative capacity. Decreased muscle stem cell (MuSC) number and impaired function might underlie the aging-related muscle wasting and impaired regenerative capacity. As yet, the search for factors that regulate MuSC fate and function has revealed several biochemical factors within the MuSC niche that may be responsible for the decline in MuSC regenerative capacity. This decline cannot be explained by environmental factors solely, as the MuSC potential to regenerate muscle tissue is not reversed by changing the biochemical MuSC niche composition. Here we discuss the likeliness that during physical exercise, MuSCs within their niche are subjected to mechanical loads, in particular pressure and shear stress, as well as associated deformations. We postulate that these physical cues are involved in the activation and differentiation of MuSCs as these cells contain several transmembrane sensor proteins that have been shown to be mechanosensitive in other cell types, that is, endothelial cells and osteoprogenitors. We will specifically address age-related changes in mechanosensing in MuSCs and their niche. Insight in the physical cues applied to the MuSCs in vivo, and how these cues affect MuSC fate and function, helps to develop new therapeutic interventions to counterbalance age-related muscle loss. This requires an approach combining two- and three-dimensional live cell imaging of MuSCs within contracting muscle tissue, mathematical finite element modeling, and cell biology. © 2017 The Authors. Journal of Orthopaedic Research® Published by Wiley Periodicals, Inc. on behalf of the Orthopaedic Research Society. J Orthop Res 36:632-641, 2018.

Epididymal Cystic Lymphangioma Presenting as Scrotal Swelling in a Post Surgery Case of Carcinoma Rectum- A Case Report

Cystic lymphangiomas are usually congenital malformations of draining lymphatic channels with most common sites including neck, axilla, mediastinum and retroperitoneum. Occurrence of lymphangiomas in scrotum or inguinal region is a rare entity and epididymal origin of these lesions is even more infrequent. We herein report a case of epididymal lymphangioma detected on USG, which developed after surgical abdominal lymph nodal dissection in an adult patient of carcinoma rectum presenting as painless scrotal swelling.

High frequency of methicillin-resistant Staphylococcus aureus in Peshawar Region of Pakistan

Staphylococcus aureus is an increasing problem in clinical practice because of reduced susceptibility to available antibiotics. The objective of the study was to determine the frequency of Methicillin-resistant S. aureus (MRSA) in Peshawar, Pakistan. Clinical isolates of S. aureus were subjected to determination of antibiotic resistance, MICs and inducible clindamycin resistance (ICR). Out of total 280 S. aureus isolates, the frequency of MRSA was 36.1 % (n = 101). MRSA infection was found higher among the age group 50-59 years (60.71 %, OR 3.09), followed by 20-29 years (47.5 %, OR 1.74). Frequency of MRSA in female and male was 39.8 and 34 % respectively. MRSA was more frequent in blood specimens (48.7 %, OR 2.14). The frequency of community and hospital acquired MRSA was 42 and 34.8 % respectively. MRSA showed high resistance (100 %) to penicillin and cefoxitin followed by erythromycin (99 %). While MRSA exhibited 100 % susceptibility to vancomycin and linezolid. We have also found 7 vancomycin intermediate sensitive S. aureus (VISA) isolates. ICR was observed in 15.84 % (n = 16) of MRSA isolates. It is concluded that MRSA is potential threat to public health in Peshawar. Vancomycin and linezolid could be prescribed as a drug of choice in treating MRSA associated infections. In addition, ICR should be routinely checked to avoid clindamycin treatment failure.

Molecular prevalence and antibiotics resistance pattern of class A bla CTX-M-1 and bla TEM-1 beta lactamases in uropathogenic Escherichia coli isolates from Pakistan

BACKGROUND/AIM

Extended spectrum beta lactamase (ESBL) production among E. coli is one of the principal mechanisms that augment resistance to antibiotics. In the current study the molecular detection of class A beta lactamases among uropathogenic Escherichia coli was evaluated.

MATERIALS AND METHODS

A total of 355 urine samples were collected from a tertiary care hospital in Peshawar. The ESBL production among E. coli isolates was detected by using the disc synergy diffusion method. Moreover, the molecular detection of bla TEM-1 and bla CTX-M-1 ESBLs, the antibiotic resistance pattern, and the minimum inhibitory concentrations (MICs) were also documented.

RESULTS

Among the 355 urine samples, 157 isolates were E. coli, and 23.56% of the isolates were ESBL E. coli. Among phenotypic ESBL producers, bla CTX-M-1 and bla TEM-1 were found in 59.45% and 40.54% of the isolates, respectively. A high resistance rate was observed against aztreonam (97.29%), while the lowest resistance was observed against imipenem (2.7%). The MICs of ESBLs E. coli for ceftriaxone, ciprofloxacin, and gentamicin was >512 µg/mL, 4 µg/mL to 128 µg/mL, and 1 µg/mL to 14 µg/mL respectively.

CONCLUSION

The present study showed that bla CTX-M-1 ESBL production is more prevalent in our clinical E. coli isolates. More often the ESBLs were resistant to commonly used antibiotics.

Ferritin Is a Marker of Inflammation rather than Iron Deficiency in Overweight and Obese People

Background. In clinical practice, serum ferritin is used as a screening tool to detect iron deficiency. However, its reliability in obesity has been questioned. Objectives. To investigate the role of ferritin in overweight and obese people, either as a marker of inflammation or iron deficiency. Methods. On the basis of body mass index (BMI), 150 participants were divided into three equal groups: A: BMI 18.5-25 kg/m², B: BMI 25-30 kg/m², and C: BMI > 30 kg/m². Serum iron, total iron binding capacity (TIBC), transferrin saturation, ferritin, C-reactive protein, and hemoglobin (Hb) were measured for each participant and analyzed through SPSS version 16. One-way ANOVA and Pearson's correlation tests were applied. Results. Ferritin was the highest in group C (M = 163.48 ± 2.23, P < 0.001) and the lowest in group A, (M = 152.78 ± 1.81, P < 0.001). Contrarily to ferritin, transferrin was the lowest in group C, (M = 30.65 ± 1.39, P < 0.001) and the highest in group A, (M = 38.66 ± 2.14, P < 0.001). Ferritin had a strong positive correlation with both BMI (r = 0.86, P < 0.001) and CRP (r = 0.87, P < 0.001) and strong negative correlation with Hb, iron, TIBC, and transferrin saturation (P < 0.001). Conclusion. Ferritin is a marker of inflammation rather than iron status in overweight and obese people. Complete iron profile including transferrin, rather than serum ferritin alone, can truly predict iron deficiency in such people.

Trigeminal hypoplasia due to vertebrobasilar dolichoectasia: A new entity

The term "vertebrobasilar dolichoectasia" refers to anomalous dilatation of the intracranial arteries associated with elongation or tortuosity of the affected vessels. The etiology of the disease is unknown and is usually detected incidentally. The predominant clinical manifestations arise due to the mass effect of the dilated vessels and may include cranial nerve compression, extrinsic aqueductal compression, motor and sensory disturbances. Trigeminal hypoplasia is a very uncommon condition, usually described in association with Goldenhar-Gorlin syndrome and has not yet been attributed to vertebrobasilar dolichoectasia. The current case report highlights this rare association of trigeminal nerve hypoplasia and vertebrobasilar dolichoectasia, leading to hemifacial and corneal anesthesia.