Relapse after cessation of weekly tocilizumab for giant cell arteritis: a multicentre service evaluation in England.

OBJECTIVES: The National Health Service in England funds 12 months of weekly subcutaneous tocilizumab (qwTCZ) for patients with relapsing or refractory giant cell arteritis (GCA). During the COVID-19 pandemic, some patients were allowed longer treatment. We sought to describe what happened to patients after cessation of qwTCZ. METHODS: Multicentre service evaluation of relapse after stopping qwTCZ for GCA. The log-rank test was used to identify significant differences in time to relapse. RESULTS: 336 GCA patients were analysed from 40 centres, treated with qwTCZ for a median (interquartile range, IQR) of 12 (12-17) months. At time of stopping qwTCZ, median (IQR) prednisolone dose was 2 (0-5) mg/day. By 6, 12 and 24 months after stopping qwTCZ, 21.4%, 35.4% and 48.6% respectively had relapsed, requiring an increase in prednisolone dose to a median (IQR) of 20 (10-40) mg/day. 33.6% of relapsers had a major relapse as defined by EULAR. Time to relapse was shorter in those that had previously also relapsed during qwTCZ treatment (P = 0.0017); in those not in remission at qwTCZ cessation (P = 0.0036); and in those with large vessel involvement on imaging (P = 0.0296). Age ≥65, gender, GCA-related sight loss, qwTCZ treatment duration, TCZ taper, prednisolone dosing, and conventional synthetic DMARD use were not associated with time to relapse. CONCLUSION: Up to half our patients with GCA relapsed after stopping qwTCZ, often requiring a substantial increase in prednisolone dose. One third of relapsers had a major relapse. Extended use of TCZ or repeat treatment for relapse should be considered for these patients.

Comparative Assessment of ADA, IDRS, and FINDRISC in Predicting Prediabetes and Diabetes Mellitus in South Indian Population.

Introduction Diabetes risk-screening tools are validated and implemented across various countries. There is a need for improvement in these risk scores with suitable modifications so as to make them more sensitive, specific, and suitable to the local population. Objectives The aim of this study was to evaluate and compare the diagnostic accuracy and clinical utility of the Indian diabetes risk score (IDRS), the American diabetic association (ADA) risk score, and the Finnish Diabetes Risk Score in healthy subjects of South Indian origin in predicting the risk of diabetes and to correlate these risk scores with the blood glucose and hemoglobin A1c (HbA1c) levels in the study population. Materials and Methods A total of 160 subjects attending the master health checkup/outpatient department of a tertiary care hospital were included in the study. Each subject was asked to fill a questionnaire. Details obtained using the questionnaire were assessed as per the three diabetic risk scores. Fasting blood sugar/random blood sugar and HbA1c were estimated. Statistical Analysis Used Data analysis was done using SPSS 22/23. Pearson correlation was used to compare continuous variables, with p < 0.05 considered statistically significant. Sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, negative likelihood ratio, and Mitchell's clinical utility indices were calculated for each risk tool. Results We found the prevalence of diabetes to be 11.9%. ADA risk score was the only risk score that showed a statistically significant difference ( p -value = 0.05) between the low- and high-risk subjects. Conclusions ADA or IDRS risk scores can be used for screening diabetes in the South Indian population. We suggest that inclusion of the history of gestational diabetes and hypertension in the IDRS risk score might improve its sensitivity as a screening tool in our local population.

Agreement of Measurement between Arterial and Venous Electrolyte Levels in Neonates in a Tertiary Care Hospital.

Context Venous or arterial blood is used for the estimation of electrolytes in neonates in neonatal intensive care unit (NICU). In addition to the measurement of blood gases and bicarbonate in the arterial blood, arterial blood gas analysis also estimates electrolytes thus circumventing the need to collect a venous sample for electrolytes. The literature survey revealed studies comparing the electrolyte levels in arterial and venous blood in adults and older children, but to our knowledge none were found in neonates, hence the study. Aims The aim of the study is to compare the electrolytes in arterial and venous samples in neonates in a critical care set up and derive in-house prediction equation to correlate the arterial and venous electrolytes. Settings and Design Hospital-based, retrospective cross-sectional study done in critically ill neonates. Materials and Methods All the newborns (age ≤28 days) admitted in NICU from July 2016 to June 2018 were selected for the study and data collected with the help of Hospital Information System. Statistical Analysis MedCalc and NCSS 12 (trial version) software was used. Deming Regression and Bland Altman analysis were performed. Results A strong positive correlation between the arterial and venous blood electrolytes observed. An in-house prediction equation was derived for the venous electrolytes. Deming regression analysis showed that only potassium levels are statistically equivalent between the instruments and the sample type. Bland Altman Analysis between the arterial and venous electrolytes showed a mean difference which was well within the accepted Clinical Laboratory Improvement Amendment guidelines. Conclusion The electrolyte levels estimated by arterial blood in neonates can be used in an interchangeable manner only for potassium levels, whereas sodium and chloride estimation necessitates one to be cautious.

Effect of insulin resistance in assessing the clinical outcome of clinical and subclinical hypothyroid patients.

BACKGROUND: The effect of thyroid status on insulin sensitivity is of great interest but despite various studies there is conflicting data on this subject. Hypothyroidism has been associated with disorders of glucose and insulin metabolism involving defective insulin secretion in response to glucose, hyperinsulinemia, altered peripheral glucose disposal and insulin resistance. Thyroid dysfunction leads to alterations in glucose and lipid metabolism which is an important risk factor for cardiovascular diseases. The dyslipidemia and insulin resistance should be managed aggressively to reduce the impending risk. OBJECTIVES: The prime objectives of the study were as follows: 1. To compare and correlate insulin resistance levels with T3, T4, and TSH in hypothyroidism patients. 2. To compare and correlate lipid profile with T3, T4, and TSH in hypothyroidism patients with healthy controls. MATERIALS AND METHODS: Forty hypothyroidism patients and Forty healthy age and sex matched controls in the age group of 18 to 45 years were taken for the study. The venous blood samples collected were used for estimation of thyroid hormones, insulin, glucose and lipid profile. RESULTS AND DISCUSSION: There is significant increase in insulin, Homa-IR and glucose levels in hypothyroidism cases when compared to controls. Cholesterol, LDL, VLDL and triglycerides were significantly increased, whereas HDL was significantly decreased in hypothyroidism cases when compared with controls. Insulin was moderately correlated with cholesterol but there was no correlation with other lipid profile parameters in hypothyroidism patients. Homa-IR was significantly correlated with TSH in hypothyroidism cases when compared with controls. TSH was significantly correlated with cholesterol and LDL in hypothyroidism cases (both clinical and subclinical) when compared with controls. The present study helps to evaluate changes in insulin resistance and lipid risk factors. These factors should be managed aggressively to reduce the impending risk of cardiovascular diseases.

A Study of Autoimmune Polyglandular Syndrome (APS) in Patients with Type1 Diabetes Mellitus (T1DM) Followed Up at a Teritiary Care Hospital.

BACKGROUND: Type1 diabetes mellitus (T1DM) results from auto- immune destruction of insulin-producing ß cells and is characterized by the presence of insulitis and ß-cell autoantibodies. Up to one third of patients develop an autoimmune polyglandular syndrome (APS). Presence of other autoimmune disorders in patients with T1DM has been associated with increased morbidity and mortality. Hypoglycemia resulting from concurrent hypothyroidism or adrenal crisis can be dangerous; starting replacement therapy for hypothyroidism may result in adrenal crisis if background hypocortisolism is not recognized. Early detection of antibodies and latent organ-specific dysfunction is advocated to alert physicians to take appropriate action in order to prevent full-blown disease. AIMS: The objectives of this study were to assess the concurrence of various autoimmune disorders in patients with T1DM, to review the concept and detect the overt forms of Autoimmune Thyroid Disease (AITD), Addison's Disease (AD), Vitamin B 12, vitiligo in T1DM and to find their correlation according to age and sex of the patients. METHODS: It is a retrospective study where medical records between January 2007-June 2010 of all the patients diagnosed with T1DM, followed up at Department of Endocrinology were reviewed to find out the presence of (AD), AITD, vitiligo, Vitamin B12 deficiency and Primary Gonadal Failure, which were diagnosed clinically with available investigational procedures. RESULTS: A total of 100 cases of T1DM were evaluated during the present study. The age group of patients ranged from 8 to 40 years, with the average being 21.56 years. 64% of the patients were males and the rest were females. 29 % of T1DM subjects had AITD (Hashimoto's or Graves'disease), 5% were diagnosed with Vitamin B12 deficiency, 4% had AD, and 6% showed Vitiligo. 28 % had family history of autoimmune endocrinopathy. CONCLUSION: The commonest autoimmune disorder associated with T1DM found in our study was AITD. Because genetic/ autoantibodies testing is not a feasible option, it is important to screen them with best available laboratory facilities and clinical assessment in view of high prevalence of associated autoimmune conditions.

Can soluble CD163 predict outcome of patients with acute respiratory distress from mechanical ventilation?: A pilot study.

PURPOSE: CD163 is a monocyte/macrophage-associated antigen which has recently been identified as a hemoglobin scavenger receptor and has also anti-inflammatory properties and an immunoregulatory role. This surface receptor undergoes ectodomain shedding upon an inflammatory stimulus, leading to increased fraction of soluble CD163 (sCD163). Hence, we hypothesized that the mechanical ventilation (MV) which is known to elicit inflammatory response may cause increased serum levels of sCD163 which can predict the outcome of patients from MV. SUBJECTS AND METHODS: Thirty patients with acute respiratory distress aged >18 years who required MV were enrolled for the study. Serum levels of sCD163 were estimated using quantitative immunometric sandwich enzyme immunoassay technique from 3 mL of the venous blood sample which was collected immediately and at 24 h after the patient was connected to MV. On the basis of the outcome of the patient from MV, they were divided into two groups; survivors and nonsurvivors. RESULTS: Out of the 30 patients, 18 patients survived and 12 patients expired. Serum levels of sCD163 were significantly increased in nonsurvivors when compared with survivors (P < 0.01) at 24 h after connecting to MV. sCD163 > 1020 ng/mL at 24 h of MV increases the probability of mortality by factor 6. An increase of sCD163 by 1 ng/mL significantly increases the relative probability of mortality by a factor of 1.0017 (95% confidence interval, 1.0004-1.0030, P = 0.0005). CONCLUSIONS: Elevated levels of sCD163 at 24 h of MV help in predicting the outcome of patients with acute respiratory failure from MV.