A mechanochemical process to capture and separate carbon dioxide from natural gas using boron nitride nanosheets.

Addressing climate change is a critical and pressing matter that requires immediate attention to mitigate its severe repercussions. In order to enhance the capture and separation of carbon dioxide from natural gas and nitrogen gas, it is imperative to develop new capture materials and more efficient storage processes. In this study, we introduce an innovative environmentally friendly storage and separation technique. Through a controlled mechanochemical process, a substantial amount of carbon dioxide (103.6 wt%) was successfully captured within boron nitride. This process also excels at effectively isolating carbon dioxide from a gas mixture containing natural gas (CH4) or nitrogen due to its superior adsorption selectivity for CO2 over the other two gases. The stored carbon dioxide can be released upon heating, and this procedure can be repeated several times (minimum four times), indicating a game changing process in CO2 gas capture and separation technology with the advantages of green, low cost and efficiency.

Background concentrations and spatial distribution of PFAS in surface waters and sediments of the greater Melbourne area, Australia.

A survey of per- and polyfluoroalkyl substances (PFAS) was conducted in Melbourne, Australia to determine background concentrations in residential, industrial, municipal wastewater treatment plants, and rural land uses. Surface water and sediment samples collected from 65 sites with different catchment land uses were analysed for thirty-three PFAS. Twenty-two out of thirty-three targeted PFAS were detected, with at least one PFAS species was detected in 98% water samples and 8% sediment samples. One site was determined to have point-source pollution from an airport (surface water Σ33PFAS = 4261 ng/L) and was excluded from statistical analyses. The median Σ33PFAS concentration in surface water was 63.5 ng/L and the average was 78.6 ng/L (range < DL-526 ng/L). PFAS species with the highest median concentrations were PFBA (11.3 ng/L), PFHxA (9.2 ng/L), PFOA (8.3 ng/L), PFOS (8.0 ng/L), PFPeA (7.5 ng/L), PFHpA (3.2 ng/L), and PFHxS (2.9 ng/L). The average Σ4PFAS in sediments was 0.35 ng/g d.w. (range =

KADAM topical warm oxygen therapy device for diabetic foot ulcer-a novel approach.

Purpose: Diabetic foot ulcer (DFU) is a significant healthcare burden demanding prompt attention. In the past decade, newer technologies such as topical oxygen therapy have grown increasingly popular. The purpose of the study was to determine effect of KADAM-a topical warm oxygen therapy (TWOT) medical device in healing of DFU. Methods: The KADAM medical device developed by Yostra Labs Pvt Ltd, delivered pure oxygen between 93 ± 3% concentration at an optimal temperature range of 39-42º Celsius to DFU wound site. Results: A total of 40 diabetic foot ulcer individuals, aged over 18 years were included in the study. Individuals with the Grade 1 DFU were 34 (85%), grade 2 were 5 (12.5%) and grade 3 were 1 (2.5%). The changes in initial area and final area for the various diabetic foot ulcer grades were as follows: 0.32 [0.12, 0.96] (< 0.001) for grade 1 ulcer, 0.76 [0.54, 1.17] (P = 0.013) for grade 2 ulcer and 1.26 for grade 3 ulcer. The percentage reduction in wound size achieved for the grade 1 & 2 DFU were 100%, and grade 3 was 75%. Conclusion: Topical warm oxygen therapy serves as an adjunctive modality to facilitate diabetic foot ulcer healing in the clinical practice.

How do plants remember drought?

MAIN CONCLUSION: Plants develop both short-term and transgenerational memory of drought stress through epigenetic regulation of transcription for a better response to subsequent exposure. Recurrent spells of droughts are more common than a single drought, with intermittent moist recovery intervals. While the detrimental effects of the first drought on plant structure and physiology are unavoidable, if survived, plants can memorize the first drought to present a more robust response to the following droughts. This includes a partial stomatal opening in the watered recovery interval, higher levels of osmoprotectants and ABA, and attenuation of photosynthesis in the subsequent exposure. Short-term drought memory is regulated by ABA and other phytohormone signaling with transcriptional memory behavior in various genes. High levels of methylated histones are deposited at the drought-tolerance genes. During the recovery interval, the RNA polymerase is stalled to be activated by a pause-breaking factor in the subsequent drought. Drought leads to DNA demethylation near drought-response genes, with genetic control of the process. Progenies of the drought-exposed plants can better adapt to drought owing to the inheritance of particular methylation patterns. However, a prolonged watered recovery interval leads to loss of drought memory, mediated by certain demethylases and chromatin accessibility factors. Small RNAs act as critical regulators of drought memory by altering transcript levels of drought-responsive target genes. Further studies in the future will throw more light on the genetic control of drought memory and the interplay of genetic and epigenetic factors in its inheritance. Plants from extreme environments can give queues to understanding robust memory responses at the ecosystem level.

Altered patterns of abdominal muscle activation during forced exhalation following elective laparotomy: An experimental research.

BACKGROUND: Post-operative pulmonary complications are common after exploratory laparotomy. Good abdominal muscle functioning is essential for forced exhalation and effective coughing. However, the impact of a laparotomy on abdominal muscle activity remains uncertain. The study aimed to assess abdominal muscle activity during forced exhalation following elective laparotomy. MATERIALS AND METHODS: A was carried out on those undergoing (n = 30) their first elective laparotomy. Abdominal muscle activity, as percentage maximal voluntary contraction (%MVC), was assessed during forced exhalation using surface electromyography (EMG) for transverse abdominis (TrAb), external oblique (EO), and rectus abdominis (RA) pre-operatively and up to seven days post-operatively. Peak expiratory flow rate (PEFR) was assessed during the forced exhalation maneuver. Median %MVC was used to represent the trends and Z-scores to report the change from the baseline activity. Spearman's correlation was used for the correlation between %MVC and PEFR. RESULTS: Pre-operatively, we observed the %MVC of TrAb (75.58%) to be the highest followed by RA (66.28%) and EO (62.12%). Post-operatively, all the muscles demonstrated increased activity wherein EO (84.33%) was most active on post-op day1, and for the rest of the days TrAb was the most active. However, as observed from Z-scores of all the three muscles the activity of EO was raised significantly from the baseline. No correlation was observed between %MVC and PEFR. CONCLUSION: TrAb is the most active muscle that contributes to forced exhalation. Following an elective laparotomy, TrAb is no longer the most active muscle, rather it is the EO that primarily contributes to forced exhalation. This should be considered while providing post-operative respiratory care. However, more research is required in this area to better understand the role of expiratory muscle training for those undergoing elective laparotomies.

Multicentered prospective investigator initiated study to evaluate the clinical outcomes with extracorporeal cytokine adsorption device (CytoSorb®) in patients with sepsis and septic shock.

BACKGROUND: Sepsis is a severe clinical syndrome related to the host response to infection. The severity of infections is due to an activation cascade that will lead to an auto amplifying cytokine production: The cytokine storm. Hemoadsorption by CytoSorb® therapy is a new technology that helps to address the cytokine storm and to regain control over various inflammatory conditions. AIM: To evaluate prospectively CytoSorb® therapy used as an adjunctive therapy along with standard of care in septic patients admitted to intensive care unit (ICU). METHODS: This was a prospective, real time, investigator initiated, observational multicenter study conducted in patients admitted to the ICU with sepsis and septic shock. The improvement of mean arterial pressure and reduction of vasopressor needs were evaluated as primary outcome. The change in laboratory parameters, sepsis scores [acute physiology and chronic health evaluation (APACHE II) and sequential organ failure assessment (SOFA)] and vital parameters were considered as secondary outcome. The outcomes were also evaluated in the survivor and non-survivor group. Descriptive statistics were used; a P value < 0.05 was considered to be statistically significant. RESULTS: Overall, 45 patients aged ≥ 18 and ≤ 80 years were included; the majority were men (n = 31; 69.0%), with mean age 47.16 ± 14.11 years. Post CytoSorb® therapy, 26 patients survived and 3 patients were lost to follow-up. In the survivor group, the percentage dose reduction in vasopressor was norepinephrine (51.4%), epinephrine (69.4%) and vasopressin (13.9%). A reduction in interleukin-6 levels (52.3%) was observed in the survivor group. Platelet count improved to 30.1% (P = 0.2938), and total lung capacity count significantly reduced by 33% (P < 0.0001). Serum creatinine and serum lactate were reduced by 33.3% (P = 0.0190) and 39.4% (P = 0.0120), respectively. The mean APACHE II score was 25.46 ± 2.91 and SOFA scores was 12.90 ± 4.02 before initiation of CytoSorb® therapy, and they were reduced significantly post therapy (APACHE II 20.1 ± 2.47; P < 0.0001 and SOFA 9.04 ± 3.00; P = 0.0003) in the survivor group. The predicted mortality in our patient population before CytoSorb® therapy was 56.5%, and it was reduced to 48.8% (actual mortality) after CytoSorb® therapy. We reported 75% survival rate in patients given treatment in < 24 h of ICU admission and 68% survival rates in patients given treatment within 24-48 h of ICU admission. In the survivor group, the average number of days spent in the ICU was 4.44 ± 1.66 d; while in the non-survivor group, the average number of days spent in ICU was 8.5 ± 15.9 d. CytoSorb® therapy was safe and well tolerated with no adverse events reported. CONCLUSION: CytoSorb® might be an effective adjuvant therapy in stabilizing sepsis and septic shock patients. However, it is advisable to start the therapy at an early stage (preferably within 24 h after onset of septic shock).

Incidence, Risk Factors and Clinical Outcomes of Patients with Hypermucoviscoid Klebsiella in a Tertiary Intensive Care Unit.

BACKGROUND AND OBJECTIVES: Hypermucoviscoid Klebsiella(hvKP), a dreaded variant of Klebsiella, so far, fewer cases were reported from the community. This study was designed to evaluate the incidence of hvKP isolates, risk factors for hvKP infections, antibiotic sensitivity pattern and clinical outcome including morbidity and mortality. PATIENTS AND SETTING: Patients who have got admitted under medical intensive care unit (MICU) and had positive culture of Klebsiella infections. MATERIALS AND METHODS: This study was conducted at department of MICU at a tertiary care hospital between January 2018 and December 2018. A standardized proforma was prepared and data was collected, which includes basic demographics of the patients, co-morbidities, clinical details and mortality. This study was approved by the Institutional Review Board and Ethics Committee. RESULTS: A total of 165 patients (males, 123; 74.5%) had Klebsiella pneumoniae infection during the study period, out of whom 32 was hvKP (19.4%). The mean age was 53.1 ± 16.8 years. Among the 32 hvKP patients, 22 (68.8%) were hospital acquired infection (HAI) and 10 were (31.2%) community acquired infection. The overall mortality rate of hvKP infection was 56.2% (18/32). The incidence of mortality rate was similar in patients having pan-drug sensitive and in patients with extreme drug-resistance (61.9% vs. 66.7%; P = 0.831). HAI is significantly associated with multi drug resistance of hvKP (odds ratio [OR], 7.917; P < 0.05) and diabetes is associated with increased risk of hvKP related mortality (OR, 5.250; P = 0.054). CONCLUSIONS: Our study results showed, increased incidence of HAI with hvKP predominantly associated with pneumonia and increase in trend of drug resistance with two cases being pan resistant. More number of studies are required to evaluate the existing antibiotics strategy and steps to curb the spread of this dreaded infection.

Influence of disease duration and socioeconomic factors on the prevalence of infection and hospitalization in rheumatoid arthritis: KRAC study.

AIM: The use of healthcare resources by rheumatoid arthritis (RA) patients can be related to the presence of disease, comorbid conditions, use of steroids, and the combined use of immunosuppressants. This study evaluated the risk factors associated with infection and hospitalization in RA. METHODS: This multicenter, cross-sectional study enrolled 3247 RA subjects fulfilling the 2010 American College of Rheumatology/European League Against Rheumatism criteria to examine the prevalence of hospitalization and episodes of documentable non-tubercular infections as a part of the "Karnataka rheumatoid arthritis comorbidity" study (KRAC). The study included 2081 subjects and 1166 were excluded due to incomplete data. Demographic, clinical and treatment variables were collected, and the events related to infections and hospitalization were extracted from the medical records. Comparative analysis and multivariate logistic regression were performed. RESULTS: Around 22% of the subjects had hospitalizations and 2.9% had infections. Infections were pertaining to dental (1.3%), urinary tract (1.6%) and candidiasis (0.2%). Skin- and soft tissue-related infections were found in 1.8% and 0.3% of patients, respectively. Increased need of hospitalization in RA patients was associated with advanced age (≥60 years), lower education, family income, and longer duration of RA. Presence of comorbidity, usage of three or more disease-modifying anti-rheumatic drugs (DMARDs) and family income influenced the likelihood of infection. Dental infections were less likely in working subjects and more likely in patients with increased disease duration, higher family income, comorbidities and those between the age group 40-59 years. Urinary tract infection was associated with DMARD usage. CONCLUSION: Patient-specific risk factors should be considered to improve treatment strategies and to reduce the risk of infection and hospitalization in RA patients.

Incidence of infection other than tuberculosis in patients with autoimmune rheumatic diseases treated with bDMARDs: a real-time clinical experience from India.

Biologic disease-modifying anti-rheumatic drugs (bDMARD) have transformed the treatment paradigm of chronic autoimmune rheumatic diseases (ARDs), but they are often associated with adverse drug reactions. The present study evaluated the frequency, characteristics and type of infections, other than tuberculosis (TB), in ARD patients receiving bDMARDs. The multicentre, cross-sectional, retrospective, observational study was conducted across 12 centers in Karnataka, India, between January to August 2016. The study included patients receiving bDMARD therapy for various ARDs. Outcome variables considered were any infection, minor infections and major infections, other than TB. Clinical variables were compared between infection and no infection group, and the increase in the likelihood of infection with respect to various clinical variables was assessed. The study involved 209 subjects with a median (range) age of 41 (16-84) years and male to female ratio of 0.97:1. A total of 29 (13.88%) subjects developed infection following bDMARD therapy, out of whom a majority had minor infection (n = 26). The likelihood of developing any infection was noted to be more in subjects receiving anti-TNF (golimumab, P = 0.03) and those on three or more conventional synthetic (cs) DMARDs (P < 0.01). Infection risk was higher in patients with systemic lupus erythematosus (P = 0.04), other connective tissue disease (P < 0.01) and in patients with comorbidities (P = 0.13). The risk of infection was associated with the use of anti-TNF therapy and more than three csDMARDs, co morbidities and Adds such as systemic lupus erythematosus and connective tissue disease.

Application of Topical Oxygen Therapy in Healing Dynamics of Diabetic Foot Ulcers - A Systematic Review.

BACKGROUND: Individuals with diabetes may develop diabetic foot ulcers due to diabetic peripheral neuropathy. Multiple factors influence the ulcer healing process; oxygen helps in facilitating the different stages of wound healing. OBJECTIVE: The objective of this systematic review was to analyze the different levels of evidence available in the application of topical oxygen therapy, warm oxygen therapy, or other modes of topical oxygen delivery in the healing dynamics of diabetic foot ulcers. METHODS: Databases searched included Pubmed/Medline, Science Direct, Web of Science, Scopus, Cochrane, and CINAHL. The eligibility criteria of studies included participants ≥18 years with chronic non-healing diabetic foot ulcer (duration ≥3 months) receiving warm oxygen or topical oxygen therapy (TOT), and other modes of topical oxygen administration, which were compared with standard care group. Randomized and non-randomized studies were included. The primary outcome measure assessed was the rate of wound healing or wound closure. RESULTS: The review included 5 studies which used different modes of topical oxygen administration. The healing trajectory of the wounds was completely achieved in low-grade ulcers (grade 1), whereas all high-grade ulcers (grades 2, 3, and above) showed either 100% or 50% healing with a reduction in ulcer size and ulcer tissue depth. CONCLUSION: Topical oxygen therapy facilitates wound healing dynamics among individuals with chronic diabetic foot ulcers.

Biologics and risk of tuberculosis in autoimmune rheumatic diseases: A real-world clinical experience from India.

AIM: Tuberculosis (TB) is one of the major adverse events of concern associated with the use of biologics for managing autoimmune inflammatory rheumatic diseases (AIRDs). The study presents the data on incidence of TB in relation to biologic used, screening test and TB prophylaxis in a real-world setting. METHODS: The cross-sectional, observational, retrospective study was conducted across 12 centres in Karnataka, India. The study included patients receiving biologics therapy for AIRDs, established based on the respective diagnostic criteria. The development of TB after receiving biologic therapy and other clinical variables and the predictability of the test performed for latent TB were evaluated. RESULTS: One hundred and ninety-five AIRDs patients with an average age of 41 years were initiated on biologic therapy. Twenty-one patients were latent TB positive and were given antitubercular prophylaxis, prior to biologics treatment. During follow-up, seven patients belonging to the negative test group (n = 174) developed TB. The negative predictive values noted for Mantoux test (n = 120) and quantiFERON TB gold test (n = 178) were 96.52% and 96.25%, respectively. Patients on anti-tumor necrosis factor were more likely to develop TB. Presence of comorbidities and steroid use increased the likelihood of developing TB by 1.5 and 4.6 times, respectively. CONCLUSION: Close monitoring of patients receiving biologics is essential for early identification of adverse events, especially in test negative patients. Prophylaxis can effectively reduce the risk of developing TB in patients positive for screening.

Authenticity and geographic origin of global honeys determined using carbon isotope ratios and trace elements.

Honey is the world's third most adulterated food. The addition of cane sugar or corn syrup and the mislabelling of geographic origin are common fraudulent practices in honey markets. This study examined 100 honey samples from Australia (mainland and Tasmania) along with 18 other countries covering Africa, Asia, Europe, North America and Oceania. Carbon isotopic analyses of honey and protein showed that 27% of commercial honey samples tested were of questionable authenticity. The remaining 69 authentic samples were subject to trace element analysis for geographic determination. One-way ANOVA analysis showed a statistical difference (p < 0.05) in trace element concentrations of honey from Australian regions and different continents. Principal component analysis (PCA) and canonical discriminant analysis (CDA) coupled with C5.0 classification modelling of honey carbon isotopes and trace element concentrations showed distinct clusters according to their geographic origin. The C5.0 model revealed trace elements Sr, P, Mn and K can be used to differentiate honey according to its geographic origin. The findings show the common and prevalent issues of honey authenticity and the mislabelling of its geographic origin can be identified using a combination of stable carbon isotopes and trace element concentrations.

Arthritis in sarcoidosis: A multicentric study from India.

INTRODUCTION: Ten to 15% of patients with sarcoidosis have associated arthritis. Chronic arthritis is fairly uncommon. There is a paucity of data on articular manifestations of the disease from India. METHODS: Case records of adult patients with sarcoidosis presenting to 11 rheumatology centers from 2005 to 2017 were retrospectively reviewed. Joint involvement was assessed clinically, classified as acute or chronic depending on duration of symptoms less or greater than 6 months, respectively. RESULTS: A total of 117 patients with sarcoid arthritis were reviewed. Forty-five patients were classified as having Lofgren's syndrome. The pattern of joint involvement revealed the ankle to be most commonly affected in both the groups. Shoulder, wrist, metacarpophalangeal, proximal interphalangeal joints of hands and knee joint involvement were significantly more common in chronic sarcoid arthritis. Peripheral lymphadenopathy and uveitis were significantly more frequent in chronic sarcoid arthritis. Forty out of 49 patients with acute arthritis followed up over a median of 1.8 years had achieved complete remission. Twelve out of 16 chronic sarcoid arthritis (median follow up 2.5 years) had achieved complete remission with 15, 12 and five patients on steroids, methotrexate and hydroxychloroquine, respectively. One patient with acute sarcoid arthritis with concomitant interstitial lung disease had died due to lung infection. CONCLUSION: Acute oligoarthritis was the commonest presentation with the ankle being the most commonly affected joint. Upper limb joint (predominantly distal) and knee involvement were more common as reported in our largest series worldwide of chronic sarcoid arthritis in adults. Hilar adenopathy and erythema nodosum were common extra-articular features in both acute and chronic sarcoid arthritis. A limitation of the study was the retrospective nature of the analysis.

Factors influencing remission in rheumatoid arthritis patients: results from Karnataka rheumatoid arthritis comorbidity (KRAC) study.

AIM: To study the prevalence of remission in rheumatoid arthritis (RA) patients and the influence of different factors like literacy, socioeconomic status, presence of comorbidity and treatment strategy in achieving remission. METHODS: The study involved 1990 RA patients who were recruited for the Karnataka Rheumatoid arthritis comorbidity (KRAC) study. Based on the factors evaluated, the study participants were classified as follows: age, < 30 years, 30-39 years, 40-49 years, 50-59 years and ≥ 60 years; educational status, illiterate/no formal education, high school or less, graduate, post-graduate and doctorate; family income (₹ per annum), < 50 000, 50-100 000, 100-500 000, and > 500 000; duration of illness prior (DOIP): ≤ 6 months, 6-24 months, 24-120 months and > 120 months. Joint counts were performed by a rheumatologist or trained joint assessor. To assess the treatment outcome, the disease activity score was calculated using the Disease activity Score of 28 joints - erythrocyte sedimentation rate (DAS 28-3 ESR). RESULTS: As per the DAS 28-3 ESR score, around 20% (n = 397) of the study subjects achieved remission. The corresponding mean ± SD of DAS 28-3 ESR noted for remission and non-remission groups were 2.13 ± 0.42 and 4.32 ± 1.28. The majority of the patients were treated with double disease-modifying anti-rheumatic drugs (DMARDs) (60.7%). The likelihood of remission was found to be more in patients who reported DOIP ≤ 6 months. Furthermore, the chances of remission reduced with increase in patient's age and the highest remission rate was noted for 30-39 years age group (59%), followed by 40-49 years (35.4%) and 50-59 years (19.7%). CONCLUSION: The prevalence of remission noted was around 20%. Early treatment, escalating dose of DMARDs, and patient counseling are important contributing factors for attaining remission.

Identifying Sources of Environmental Contamination in European Honey Bees (Apis mellifera) Using Trace Elements and Lead Isotopic Compositions.

Trace element concentrations (As, Mn, Pb, and Zn) and Pb isotopic compositions were analyzed in honey bees, wax, and honey along with co-located soil and dust samples from Sydney metropolitan and Broken Hill, Australia. Compared with the other trace elements, Pearson correlations show that Pb concentrations in soil and dust had the strongest relationship to corresponding values in honey bees and their products. Dust Pb was not only highly correlated to corresponding soil values (r = 0.806, p = 0.005), it was the strongest predictor of Pb concentrations in honey bees, wax, and honey (p = 0.001, 0.007, 0.017, respectively). Lead isotopic compositions (206Pb/207Pb and 208Pb/207Pb) showed that honey bees and their products from Broken Hill were nearly identical (95-98%) to the composition of the local ore body. Samples of honey bees and their products collected from background sites adjacent to national parks in Sydney had Pb isotopic compositions (206Pb/207Pb = 1.138-1.159, 208Pb/207Pb = 2.417-2.435) corresponding to local geogenic values (206Pb/207Pb = 1.123-1.176, 208Pb/207Pb = 2.413-2.500). By contrast, honey bees and their products from Sydney metropolitan (206Pb/207Pb = 1.081-1.126, 208Pb/207Pb = 2.352-2.408) were similar to aerosols measured during the period of leaded petrol use (206Pb/207Pb = 1.067-1.148, 208Pb/207Pb = 2.341-2.410). These measurements show Pb concentrations and its isotopic compositions of honey bees, and their products can be used to trace both legacy and contemporary environmental contamination, particularly where sources are well documented. Moreover, this study demonstrates that legacy Pb emissions continue to be remobilized in dust, contaminating both food and ecological systems.

Post Incisional Hernia Meshplasty Vesicocutaneous Fistula - A Rare Complication.

Laparoscopic meshplasty is gold standard in hernia surgery. Mesh migration into bowel/bladder has been documented after laparoscopic repair, though migration into bowel is more common than bladder. Only 12 cases of migration into bladder have been described post inguinal meshplasty. We report the 1st case of mesh migration into bladder post Incisional hernia meshplasty, presenting as vesicocutaneous fistula. The objectives of this report are highlighting important points enabling earlier diagnosis, treatment. We would also like to suggest important preventive measures during meshplasty which we believe will go a long way in avoiding this important complication, thus immensely benefiting patients.

Spontaneous Bladder Rupture Masquerading as Pseudo-diverticulum.

Spontaneous bladder rupture is rare. Presentation is non-specific and in absence of history of trauma, radiation, inflammatory conditions and other leading causes, there is considerable diagnostic delay. Absence of clear cut diagnostic signs leads to increased morbidity and mortality. In many patients, omentum seals perforation, giving diverticular appearance in Cystogram. The objective of this case report is to highlight important specific diagnostic points in history and radiology which will help in clear, early diagnosis and treatment causing immense benefit to the patient. We would also like to highlight a specific radiological point to distinguish true from pseudo-diverticulum.

Methotrexate-induced pancytopenia: a case series of 46 patients.

AIM: Methotrexate (MTX) has the potential to cause serious adverse reactions and even mortality. We analyzed the predisposing factors and outcome in patients with MTX-induced pancytopenia admitted into our unit from 1996 to 2015. METHODS: Patients were identified by departmental database search. Pancytopenia was defined as white blood cell count (WBC) < 3500 cells/mm3 , hemoglobin (Hb) < 11 g/dL and platelet count < 150 000 cells/mm3 . Severe pancytopenia was defined as WBC < 2000 cells/mm3 , Hb < 10 g/dL and platelet count < 50 000 cells/mm3 . RESULTS: Forty-six patients were included in the study (female = 35). Twenty-four had been under the care of either primary care physicians or orthopedic surgeons and presented to us with pancytopenia. Sixteen patients had severe pancytopenia. Disease distribution was as follows: rheumatoid arthritis 33, psoriasis eight, systemic sclerosis two and others three. The median dose of MTX was 10 mg/week and median duration of treatment was 11 months. The median cumulative dose was 750 mg. Symptoms at presentation included: oral mucositis (n = 37); fever (n = 24); diarrhea (n = 12), bleeding gums (n = 5) and purpura (n = 3). The potential risk factors were: hypoalbuminemia (n = 23), renal insufficiency (n = 14), dosing errors (n = 13) and non-supplementation of folates (n = 7). Thirteen patients died. WBC at admission was found to determine survival (P < 0.05). CONCLUSION: In patients on MTX, oral mucositis and fever can herald pancytopenia. MTX-induced pancytopenia is associated with high mortality. WBC at admission is the most important prognostic factor. There is need for increased awareness among physicians to minimize prescribing errors. A national guideline on monitoring of patients on MTX is desirable.

Reduced incidence of extra-articular manifestations of RA through effective disease control: Karnataka Rheumatoid Arthritis Comorbidity (KRAC) study.

AIM: To estimate the prevalence of extra-articular manifestations (EAM) in rheumatoid arthritis (RA) patients and the impact of demographic, clinical and treatment factors. METHOD: The study was carried out as a part of 'Karnataka Rheumatoid arthritis comorbidity (KRAC) study' conducted at 14 centers across Karnataka, India between September 2014 and July 2015. The data were collected by trained clinical research associates using a structured pro forma, under the supervision of the consulting rheumatologists. Based on the factors evaluated, the study participants were classified as follows: age, < 30 years, 30-39 years, 40-49 years, 50-59 years and ≥ 60 years; and duration of illness prior to visiting rheumatologist (DOIP), ≤ 6 months, > 6 months-2 years, 2-10 years and > 10 years. The Disease Activity Score of 28 joints-3 (erythrocyte sedimentation rate) score was calculated for each patient by three variable methods. RESULTS: The total number of patients considered for the study after exclusion was 1716. The subjects had a mean (SD) age of 48.1 (12.71) years, the male-to-female ratio was 1 : 5, and median (range) of duration of RA was 48 (0.5-484) months. The prevalence of EAM noted was around 13%. EAM were more likely during the first 2 years of the disease (odds ratio [OR]: 1.465; P = 0.047) and increased with longer DOIP. The incidence was less in patients with low disease activity (OR: 0.657) and worse with the presence of deformities (OR: 2.1). CONCLUSION: The study corroborates the current concept of effective disease control to reduce the incidence/likelihood of EAM in RA patients.