aswin nair | Christian Medical College, Vellore (original) (raw)
Papers by aswin nair
Modern Rheumatology
Objective To compare the clinical and angiographic responses of mycophenolate mofetil (MMF) versu... more Objective To compare the clinical and angiographic responses of mycophenolate mofetil (MMF) versus methotrexate (MTX) in Takayasu arteritis (TAK). Methods This was an open-label, outcome assessor–blinded trial. Adult patients with active TAK were randomized 1:1 to MMF 1 g twice daily or MTX 20 mg once weekly by a computer-generated program. All patients were started on 0.5 mg/kg of steroids with a predetermined tapering protocol. The primary outcome was the treatment response as defined by Indian Takayasu arteritis score at 9 months. The secondary end points included the time to first failure and angiographic progression. Results A total of 52 patients (26 in each arm) were recruited. The rate of responders was 71.43% (15/21) in the MMF arm and 63.64% (14/22) in the MTX arm (P = .58). The median time to the first failure was 9 months (range: 3–9) and 4.5 months (range: 3–9) in the MMF and MTX arms, respectively (P = .052). In both groups, 15% of patients (n = 3) had a progressive di...
Indian Journal of Rheumatology, 2020
Background: Impact of COVID-19 pandemic and consequential lockdown in India, on patients with chr... more Background: Impact of COVID-19 pandemic and consequential lockdown in India, on patients with chronic rheumatic diseases (CRD) pertaining these components of interest: (a) physical health, (b) mental health, (c) facets of social well-being, (d) health-care accessibility, and (e) COVID-19 related knowledge, attitude, and practices (KAP) was assessed. Methods: An online/onsite self-reported questionnaire-based cross-sectional survey was utilized to capture responses during May 20, 2020, to June 6, 2020, from CRD (both inflammatory and non-inflammatory) patients satisfying eligibility criteria, at a tertiary hospital in India. Adverse impact was defined as strong agreement/agreement on Likert scale to an impact on the individual components of interest. Results: From 1533 completed responses analyzed, adverse impact was noted on physical health (32.3%), mental health (42.9%), social health (54.8%), occupational life (55.9%), and financial condition (54.4%). Self-reported COVID-19 diagnosis (1.4%), flare/possible flare of CRD (41.3%), and symptoms of mental distress (64%) were also reported. Awareness and utilization of tele-video consultation (TVC) were 27.3% and 11.2%, respectively, with 89.9% expressing difficulty in procuring medication. COVID-19 KAP assessment revealed awareness of COVID-19 suspect symptoms and safety practices to be >60% and >70% respectively, with safety adherence being >75%. Conclusion: Majority of respondents reported adverse impact on social health, occupational life, financial condition, and interruption of CRD management, possibly complicated by the lack of awareness and low utilization of TVC. Although mental distress was greatly reported in the participants, a general preponderance toward self-education of current scenario and safety adherence was noted, indicating a favorable reception of future health-care directives.
Rheumatology, 2019
Objectives To develop and replicate, using data-driven methods, a novel classification system in ... more Objectives To develop and replicate, using data-driven methods, a novel classification system in Takayasu’s arteritis based on distribution of arterial lesions. Methods Patients were included from four international cohorts at major academic centres: India (Christian Medical College Vellore); North America (National Institutes of Health, Vasculitis Clinical Research Consortium and Cleveland Clinic Foundation). All patients underwent whole-body angiography of the aorta and branch vessels, with categorization of arterial damage (stenosis, occlusion or aneurysm) in 13 territories. K-means cluster analysis was performed to identify subgroups of patients based on pattern of angiographic involvement. Cluster groups were identified in the Indian cohort and independently replicated in the North American cohorts. Results A total of 806 patients with Takayasu’s arteritis from India (n = 581) and North America (n = 225) were included. Three distinct clusters defined by arterial damage were ide...
Current allergy and asthma reports, 2017
Chikungunya virus (CHIKV) has been involved in epidemics in African and Asian subcontinents and, ... more Chikungunya virus (CHIKV) has been involved in epidemics in African and Asian subcontinents and, of late, has transcended to affect the Americas. Aedes aegypti and Aedes albopictus are the major vectors for CHIKV infection, which results in dissemination of virus to various vital organs. Entry of virus into these tissues causes infiltration of innate immune cells, monocytes, macrophages, neutrophils, natural killer cells, and adaptive immune cells. Macrophages bearing the replicating virus, in turn, secrete pro-inflammatory cytokines IL-1β, TNF-α, and IL-17. Together, this pro-inflammatory milieu induces osteoclastogenesis, bone loss, and erosion. CHIKV is characterized by fever, headache, myalgia, rash, and symmetric polyarthritis, which is generally self-limiting. In a subset of cases, however, musculoskeletal symptoms may persist for up to 3-5 years. Viral culture and isolation from blood cells of infected patients are the gold standards for diagnosis of CHIKV. In routine practic...
Rheumatology, 2020
Objectives To describe the clinical profile of Asian Indian patients with Takayasu’s arteritis (T... more Objectives To describe the clinical profile of Asian Indian patients with Takayasu’s arteritis (TAK) and to compare clinical features and outcome of childhood-onset Takayasu’s arteritis (cTAK) with adult-onset TAK (aTAK). Methods Data related to clinical features and response to treatment of patients with cTAK (age of onset <16 years) and aTAK from a large observational cohort in our tertiary care teaching hospital were noted and compared. Results Altogether, 602 patients (cTAK = 119; aTAK = 483) were studied. Patients with cTAK had a blunted female: male ratio; but fever, elevated acute phase reactants, involvement of abdominal aorta or its branches, hypertension, abdominal pain, elevated serum creatinine and cardiomyopathy were more common in cTAK as compared with aTAK. Patients with aTAK were more likely to have aortic-arch disease and claudication than cTAK. During follow-up, complete remission was more common in cTAK (87% vs 66%; P < 0.01), but subsequent relapses were eq...
Rheumatology
Background: Takayasu's arteritis (TAK) is characterized by variable patterns of damage throughout... more Background: Takayasu's arteritis (TAK) is characterized by variable patterns of damage throughout the large arteries. Methods: Data was used from patients with TAK from four independent cohorts: one in India and three in North America (NA). All patients underwent whole-body angiography of the aorta and branch vessels, with categorization of involvement (stenosis, occlusion, or aneurysm) in 13 arterial territories. K-means cluster analysis was performed to identify subgroups of patients based on pattern of angiographic involvement. Cluster groups were identified in the Indian cohort and independently validated in the NA cohorts. Results: 581 and 225 patients with TAK were included from the Indian and NA cohorts, respectively. Three distinct clusters were identified in the Indian cohort and validated in the NA cohorts. Patients in Cluster 1 had significantly more disease in the abdominal aorta, renal, and mesenteric arteries (p < 0.01). Patients in Cluster 2 had significantly more bilateral disease in the carotid and subclavian arteries (p < 0.01). Compared to Clusters 1 and 2, patients in Cluster 3 had asymmetric disease with fewer involved territories (p < 0.01). In the Indian and the
Open Rheumatology Journal, Feb 28, 2017
Background: Arterial inflammation Takayasu arteritis (TA) is an outcome of balance between pro-an... more Background: Arterial inflammation Takayasu arteritis (TA) is an outcome of balance between pro-and anti-inflammatory cytokines. Comprehensive assessment of these cytokines is important for understanding pathogenesis and assessing disease activity.
Clinical and experimental rheumatology, 2019
OBJECTIVES Early identification of patients with rheumatoid arthritis (RA) is essential to allow ... more OBJECTIVES Early identification of patients with rheumatoid arthritis (RA) is essential to allow prompt therapy. In this study, we aimed to evaluate the performance of the newly proposed ERA criteria, compared to the 1987 ACR and 2010 ACR/EULAR criteria in an international multicentre study. METHODS A total of 606 patients with disease duration ≤2 years and age ≥16 years who were diagnosed as RA or non-RA were enrolled from China, Sweden and India. The clinical and laboratory parameters were recorded. We compared the sensitivity, specificity, predictive value, likelihood ratio (LR), and the area under the ROC curve (AUC) of three criteria in these cohorts. Concordance between the three criteria was calculated with the Kappa coefficient. RESULTS Three hundred and twelve RA and 294 non-RA patients were included. The Early Rheumatoid Arthritis (ERA) criteria had significantly higher specificity compared to the 2010 ACR/ EULAR criteria (83.7% vs. 78.2%, p=0.02) and sensitivity were simi...
Consensus on treatment of idiopathic inflammatory myositis (IIM), particularly with regard to fla... more Consensus on treatment of idiopathic inflammatory myositis (IIM), particularly with regard to flares and interstitial lung disease (ILD), does not exist. We studied the long-term outcome and treatment response in our large, retrospective cohort of adult South-Asian patients exclusively with IIM. Electronic records of IIM patients satisfying inclusion and exclusion criteria were studied longitudinally at presentation, at 3, 6, 12, 18 and 24 months and thereafter yearly till their last follow up (F/u) visit. Depending on clinical, imaging, and muscle enzyme profile during the F/u period, patients were categorised as complete (CR) and partial responders (PRs). Parameters favouring CR were assessed using multivariate logistic regression analysis. Outcome parameters and flares on immunosuppressants (IS) were then assessed in patients with/without ILD. Two hundred thirty-two patients with median F/u duration of 44.5 months (25–80.25) were included. ILD was seen in 40.1%. Patients with non...
There is a paucity of real-world data on mycophenolate mofetil/mycophenolate sodium in systemic s... more There is a paucity of real-world data on mycophenolate mofetil/mycophenolate sodium in systemic sclerosis-related interstitial lung disease. To study the efficacy of mycophenolate mofetil/ mycophenolate sodium in systemic sclerosis-related interstitial lung disease. In this single-centre study, clinical, laboratory and imaging details of consecutive patients with systemic sclerosis-related interstitial lung disease receiving mycophenolate mofetil/mycophenolate sodium from rheumatology and pulmonology clinics between January 2008 and March 2017 were retrospectively retrieved. The change in percentage of predicted normal forced vital capacity at last follow-up visit as compared with baseline was studied. In addition, high-resolution computed tomography scans at baseline and 2-year follow-up visit were scored as either stable/improved or worsened by experienced thoracic radiologists blinded to the clinical details of patients. Altogether, 88 patients (85.2% females) with mean age (SD) ...
Human Genomics
Home to a culturally heterogeneous population, India is also a melting pot of genetic diversity. ... more Home to a culturally heterogeneous population, India is also a melting pot of genetic diversity. The population architecture characterized by multiple endogamous groups with specific marriage patterns, including the widely prevalent practice of consanguinity, not only makes the Indian population distinct from rest of the world but also provides a unique advantage and niche to understand genetic diseases. Centuries of genetic isolation of population groups have amplified the founder effects, contributing to high prevalence of recessive alleles, which translates into genetic diseases, including rare genetic diseases in India.Rare genetic diseases are becoming a public health concern in India because a large population size of close to a billion people would essentially translate to a huge disease burden for even the rarest of the rare diseases. Genomics-based approaches have been demonstrated to accelerate the diagnosis of rare genetic diseases and reduce the socio-economic burden. Th...
Annals of the Rheumatic Diseases
Background Nucleosomes are basic elements of chromatin and are considered to be the major antigen... more Background Nucleosomes are basic elements of chromatin and are considered to be the major antigens in the pathophysiology of systemic lupus erythematosus (SLE). Objectives This study aimed to look for associations between anti nucleosome antibodies and clinical and laboratory parameters in SLE Methods This retrospective study was done in department of Clinical immunology & Rheumatology in Christian Medical College, Vellore, India. Patients with SLE by SLICC 2012 criteria between March 2013 and September 2015 subjected to anti nucleosome antibody test formed the study cohort. A cut off of ≥20 U/ml by ELISA was defined as per manufacturer's (Euroimmune, Germany) instructions. Associations of anti nucleosome antibody with clinical and laboratory parameters in SLE was studied. Results Anti nucleosome antibody was available for 238 patients with SLE. Mean age of the patients was 28.98±9.01 years with male to female ratio of 17: 221. Median disease duration was 8 (5–12) months prior to doing this test. Positive titers of anti nucleosome antibody (≥20 U/ml) were noted in 107 patients (46.5%). Renal involvement was seen in 134 (56.3%) patients. Univariate analysis reflected raised anti-c1q antibody, ESR, urinary protein creatinine ratio (UPC), anti dsDNA antibody, SLE disease activity index (SLEDAI), renal SLEDAI, low C3 and C4 as significant association of elevated anti nucleosome antibody levels. No significant association with arthritis, serositis, major infections, serositis, anti-phospholipid antibodies, autoimmune hematological cutaneous, neuropsychiatric, cardiovascular, respiratory, vasculitic and gastrointestinal manifestation was present. Multivariate regression analysis showed that raised anti-c1q antibodies and DsDna were associated with raised anti nucleosome antibody with odds ratio of 17.46 (95 CI: 1.46–213.86, p=0.02) and 82.94 (95 CI: 3.62–189.93, p=0.006) respectively. Conclusions As per literature search, this is the largest single centre study of anti nucleosome antibody in SLE. In this study, raised anti-c1q antibodies and DsDna were independently associated with raised anti nucleosome antibody in SLE. Disclosure of Interest None declared
Annals of the Rheumatic Diseases
Background Mycophenolatemofetil (MMF) is an effective therapeutic agent with high safety profile ... more Background Mycophenolatemofetil (MMF) is an effective therapeutic agent with high safety profile in the management of lupus nephritis. Objectives This retrospective study was conducted to assess the efficacy and side effect profile of MMF and deflazacort in patient with neuropsychiatry lupus (NP SLE). Methods Patients of SLE by SLICC 2012 between January 2005 and May 2015 satisfying ACR 1997 criteria for NP SLEwere recruited from department of Clinical immunology & Rheumatology, Christian Medical College, Vellore, India. Patients consistently using MMF as the second line agent were enrolled. Clinical response, SLEDAI and side effect profile were noted from electronic medical records. Clinical improvement was defined as remission of presenting neurological symptom with no new neurological symptom. Results Of the 140 patients with NP SLE, 88 fulfilled the inclusion criteria. Mean age of the cohort was 25.51±7.82 years with female to male ratio of 84: 4. Median duration of neurological symptoms prior to presentation was 90 (17.5 – 317.5) days. Median duration of follow up was 33 (3–129) months. Among the various NP SLE manifestations, seizure was the most common presentation (n=37, 42.05%). Renal involvement was seen in 49 (55.7%) patients. MRI findings varied from white and grey matter hyper -intensities to ventricular dilatation and brain atrophy. Of the 88 patients on MMF, 13 were pulsed with 1 gm methylprednisolone for 3 days and 8 were pulsed with oral dexamethasone pulse of 40 mg/day for 5 days. Subsequently, oral steroids was started at a dose of 1 mg/kg & tapered after 8–12 weeks to mean deflazacortdose (prednisoloneeqyuivalent) of 11.07±7.77 (9.33±5.88) mg at the end of 1 year. IMAGE: Showing various parameters at baseline and follow up as below. Major adverse events included lower respiratory tract infection in 2 patients and 1 fatality due to sepsis from gastroenteritis. Of 68 patient with median duration of follow up of 33 (3–129) months, 17 were only on MMF without any steroids, 14 not on either steroids or MMF and 6 were only on maintenance low dose steroids.Table 1. Comparing side effect profile of patients on deflazacort and prednisolone (n=88) Deflazacort Prednisolone P value Number of patients 70 18 0.001 Cushingoid habitus 7 16 0.000 Serious Infections 0 3 0.006 Steroid induced hypertension 1 4 0.000 Steroid induced diabetes 4 6 0.001 Deflazacort was equally efficacious and had better toxicity profile than prednisolone. Conclusions In patients of NP SLE, MMF is efficacious in inducing remission and preventing relapse of disease with a good safety profile. Deflazacort was found to have superior toxicity profile with equal efficacy as to prednisolone in NP SLE patients. Disclosure of Interest None declared
Dermatological Emergencies
Clinical rheumatology, 2018
Sacroiliitis is one of the criteria for classification as spondyloarthritis (SpA), though not uni... more Sacroiliitis is one of the criteria for classification as spondyloarthritis (SpA), though not unique to SpA. Other conditions including gout may be erroneously diagnosed as SpA due to sacroiliitis. The objective was to identify specific CT findings in sacroiliitis associated with SpA and gout. In this retrospective study, CT images of patients with sacroiliitis and clinical diagnosis of gout or SpA from 2010 to 2015 were independently reviewed by two radiologists, blinded to diagnosis. Axial and coronal oblique images were analyzed for characteristics of erosions. The receiver operator characteristic curve was constructed to analyze the discriminating ability of radiological findings. CT SI joint images of 11 patients with gout and 224 patients with SpA were re-analyzed. There was excellent agreement between the radiologists (ICC from 0.78 to 1). Erosions were more numerous in SpA. Erosions in gout were associated with tophi in 65.7% (73/111). Erosions in gout were para-articular an...
Rheumatology international, 2017
The aim of the study was to explore utility of serial serum myeloid-related protein 8/14 (MRP8/14... more The aim of the study was to explore utility of serial serum myeloid-related protein 8/14 (MRP8/14) as a biomarker of clinical disease activity and angiographic progression in Takayasu arteritis (TA). Serum MRP8/14 levels were assayed by commercial ELISA for 85 TA patients and 24 healthy controls at baseline, and for 56 and 21 TA patients during follow-up visits R1 and R2, respectively. Disease was categorised as active, indeterminate and stable according to Indian Takayasu Arteritis score (ITAS 2010), ITAS-A(CRP) and angiography. Patients were divided into responders and non-responders/relapsers based on treatment response. Non-parametric tests were used for inter-group comparisons at baseline and during follow-up time points. Generalised Estimating Equation was used to study association between changes in serial MRP8/14 levels and disease activity. At baseline, median MRP8/14 levels were higher in patients with TA than healthy controls [7353 (4524 to11283) vs 4896 (3194 to 8474.5) ...
International journal of rheumatic diseases, Jan 11, 2017
Normal C-reactive protein (CRP) in active Takayasu arteritis (TA) is a dilemma. We attempted to v... more Normal C-reactive protein (CRP) in active Takayasu arteritis (TA) is a dilemma. We attempted to validate our pilot study finding of rs1205 in CRP gene being protective against TA. Genomic DNA of 104 patients and 185 sex-matched healthy controls were genotyped for rs1205 by Taqman assay. Clinical details, demography, angiographic and activity scores (Indian Takayasu arteritis score 2010) were recorded prospectively at baseline and during follow-up visits for 12 months. Minor allele frequency (MAF) and genotype distribution between patients and controls as well as patient subgroups were compared using χ(2) test with Bonferroni correction (pc ) and logistic regression was performed to determine independent associations. The majority of patients (n = 84) and controls (n = 166) were females. MAF of T allele of rs1205 was less frequent in patients (27%) as compared to controls (37.6%), P = 0.013, pc = 0.026 with an odds ratio of 0.632 irrespective of gender. Frequency of CC genotype was h...
Clinical Rheumatology
High cost deters continuous use of tumor necrosis factor α blockers (TNFi) in developing countrie... more High cost deters continuous use of tumor necrosis factor α blockers (TNFi) in developing countries. The objective of this study was to evaluate outcome and expenditure incurred in Spondyloarthritis (SpA) patients beyond a year of follow-up after receiving four doses of infliximab (IFX) over and above background therapy of methotrexate (MTX) and sulfasalazine (SSZ) combination. Electronic medical records were screened for patients with SpA satisfying the Assessment of Spondyloarthritis International Society (ASAS) criteria between 2008 and 2014. Patients who completed at least 1 year of follow-up after receiving four doses of IFX (5 mg/kg at 0, 2, 6, and 14 weeks) on a background therapy of MTX (10-25 mg/week) and SSZ (2-3 g/day) combination were enrolled after obtaining an informed consent. Primary outcome assessed was &amp;quot;time to disease flare&amp;quot;. Changes in acute phase reactants, patient reported outcomes (BASDAI, BASFI), and cost were also assessed. Forty-five patients were enrolled. Mean (SD) duration of follow up after fourth IFX dose was 28.9 (18.7) months. Disease flare occurred in 33.3% (15/45) after a mean (SD) duration of 14.5 (10.8) months as compared to 4-6 months described in literature on discontinuing TNFi. Reduction in ESR, CRP, BASDAI and BASFI continued to be statistically significant at follow-up as compared to baseline. As compared to continuous IFX therapy, this treatment reduced cost by 57.1% for each patient-month of follow-up. Short course IFX dosing followed by continuation of MTX and SSZ combination can prolong time to disease flare and decrease requirement for additional IFX dose in SpA. This regimen could be a cost saving option for patients with SpA.
Modern Rheumatology
Objective To compare the clinical and angiographic responses of mycophenolate mofetil (MMF) versu... more Objective To compare the clinical and angiographic responses of mycophenolate mofetil (MMF) versus methotrexate (MTX) in Takayasu arteritis (TAK). Methods This was an open-label, outcome assessor–blinded trial. Adult patients with active TAK were randomized 1:1 to MMF 1 g twice daily or MTX 20 mg once weekly by a computer-generated program. All patients were started on 0.5 mg/kg of steroids with a predetermined tapering protocol. The primary outcome was the treatment response as defined by Indian Takayasu arteritis score at 9 months. The secondary end points included the time to first failure and angiographic progression. Results A total of 52 patients (26 in each arm) were recruited. The rate of responders was 71.43% (15/21) in the MMF arm and 63.64% (14/22) in the MTX arm (P = .58). The median time to the first failure was 9 months (range: 3–9) and 4.5 months (range: 3–9) in the MMF and MTX arms, respectively (P = .052). In both groups, 15% of patients (n = 3) had a progressive di...
Indian Journal of Rheumatology, 2020
Background: Impact of COVID-19 pandemic and consequential lockdown in India, on patients with chr... more Background: Impact of COVID-19 pandemic and consequential lockdown in India, on patients with chronic rheumatic diseases (CRD) pertaining these components of interest: (a) physical health, (b) mental health, (c) facets of social well-being, (d) health-care accessibility, and (e) COVID-19 related knowledge, attitude, and practices (KAP) was assessed. Methods: An online/onsite self-reported questionnaire-based cross-sectional survey was utilized to capture responses during May 20, 2020, to June 6, 2020, from CRD (both inflammatory and non-inflammatory) patients satisfying eligibility criteria, at a tertiary hospital in India. Adverse impact was defined as strong agreement/agreement on Likert scale to an impact on the individual components of interest. Results: From 1533 completed responses analyzed, adverse impact was noted on physical health (32.3%), mental health (42.9%), social health (54.8%), occupational life (55.9%), and financial condition (54.4%). Self-reported COVID-19 diagnosis (1.4%), flare/possible flare of CRD (41.3%), and symptoms of mental distress (64%) were also reported. Awareness and utilization of tele-video consultation (TVC) were 27.3% and 11.2%, respectively, with 89.9% expressing difficulty in procuring medication. COVID-19 KAP assessment revealed awareness of COVID-19 suspect symptoms and safety practices to be >60% and >70% respectively, with safety adherence being >75%. Conclusion: Majority of respondents reported adverse impact on social health, occupational life, financial condition, and interruption of CRD management, possibly complicated by the lack of awareness and low utilization of TVC. Although mental distress was greatly reported in the participants, a general preponderance toward self-education of current scenario and safety adherence was noted, indicating a favorable reception of future health-care directives.
Rheumatology, 2019
Objectives To develop and replicate, using data-driven methods, a novel classification system in ... more Objectives To develop and replicate, using data-driven methods, a novel classification system in Takayasu’s arteritis based on distribution of arterial lesions. Methods Patients were included from four international cohorts at major academic centres: India (Christian Medical College Vellore); North America (National Institutes of Health, Vasculitis Clinical Research Consortium and Cleveland Clinic Foundation). All patients underwent whole-body angiography of the aorta and branch vessels, with categorization of arterial damage (stenosis, occlusion or aneurysm) in 13 territories. K-means cluster analysis was performed to identify subgroups of patients based on pattern of angiographic involvement. Cluster groups were identified in the Indian cohort and independently replicated in the North American cohorts. Results A total of 806 patients with Takayasu’s arteritis from India (n = 581) and North America (n = 225) were included. Three distinct clusters defined by arterial damage were ide...
Current allergy and asthma reports, 2017
Chikungunya virus (CHIKV) has been involved in epidemics in African and Asian subcontinents and, ... more Chikungunya virus (CHIKV) has been involved in epidemics in African and Asian subcontinents and, of late, has transcended to affect the Americas. Aedes aegypti and Aedes albopictus are the major vectors for CHIKV infection, which results in dissemination of virus to various vital organs. Entry of virus into these tissues causes infiltration of innate immune cells, monocytes, macrophages, neutrophils, natural killer cells, and adaptive immune cells. Macrophages bearing the replicating virus, in turn, secrete pro-inflammatory cytokines IL-1β, TNF-α, and IL-17. Together, this pro-inflammatory milieu induces osteoclastogenesis, bone loss, and erosion. CHIKV is characterized by fever, headache, myalgia, rash, and symmetric polyarthritis, which is generally self-limiting. In a subset of cases, however, musculoskeletal symptoms may persist for up to 3-5 years. Viral culture and isolation from blood cells of infected patients are the gold standards for diagnosis of CHIKV. In routine practic...
Rheumatology, 2020
Objectives To describe the clinical profile of Asian Indian patients with Takayasu’s arteritis (T... more Objectives To describe the clinical profile of Asian Indian patients with Takayasu’s arteritis (TAK) and to compare clinical features and outcome of childhood-onset Takayasu’s arteritis (cTAK) with adult-onset TAK (aTAK). Methods Data related to clinical features and response to treatment of patients with cTAK (age of onset <16 years) and aTAK from a large observational cohort in our tertiary care teaching hospital were noted and compared. Results Altogether, 602 patients (cTAK = 119; aTAK = 483) were studied. Patients with cTAK had a blunted female: male ratio; but fever, elevated acute phase reactants, involvement of abdominal aorta or its branches, hypertension, abdominal pain, elevated serum creatinine and cardiomyopathy were more common in cTAK as compared with aTAK. Patients with aTAK were more likely to have aortic-arch disease and claudication than cTAK. During follow-up, complete remission was more common in cTAK (87% vs 66%; P < 0.01), but subsequent relapses were eq...
Rheumatology
Background: Takayasu's arteritis (TAK) is characterized by variable patterns of damage throughout... more Background: Takayasu's arteritis (TAK) is characterized by variable patterns of damage throughout the large arteries. Methods: Data was used from patients with TAK from four independent cohorts: one in India and three in North America (NA). All patients underwent whole-body angiography of the aorta and branch vessels, with categorization of involvement (stenosis, occlusion, or aneurysm) in 13 arterial territories. K-means cluster analysis was performed to identify subgroups of patients based on pattern of angiographic involvement. Cluster groups were identified in the Indian cohort and independently validated in the NA cohorts. Results: 581 and 225 patients with TAK were included from the Indian and NA cohorts, respectively. Three distinct clusters were identified in the Indian cohort and validated in the NA cohorts. Patients in Cluster 1 had significantly more disease in the abdominal aorta, renal, and mesenteric arteries (p < 0.01). Patients in Cluster 2 had significantly more bilateral disease in the carotid and subclavian arteries (p < 0.01). Compared to Clusters 1 and 2, patients in Cluster 3 had asymmetric disease with fewer involved territories (p < 0.01). In the Indian and the
Open Rheumatology Journal, Feb 28, 2017
Background: Arterial inflammation Takayasu arteritis (TA) is an outcome of balance between pro-an... more Background: Arterial inflammation Takayasu arteritis (TA) is an outcome of balance between pro-and anti-inflammatory cytokines. Comprehensive assessment of these cytokines is important for understanding pathogenesis and assessing disease activity.
Clinical and experimental rheumatology, 2019
OBJECTIVES Early identification of patients with rheumatoid arthritis (RA) is essential to allow ... more OBJECTIVES Early identification of patients with rheumatoid arthritis (RA) is essential to allow prompt therapy. In this study, we aimed to evaluate the performance of the newly proposed ERA criteria, compared to the 1987 ACR and 2010 ACR/EULAR criteria in an international multicentre study. METHODS A total of 606 patients with disease duration ≤2 years and age ≥16 years who were diagnosed as RA or non-RA were enrolled from China, Sweden and India. The clinical and laboratory parameters were recorded. We compared the sensitivity, specificity, predictive value, likelihood ratio (LR), and the area under the ROC curve (AUC) of three criteria in these cohorts. Concordance between the three criteria was calculated with the Kappa coefficient. RESULTS Three hundred and twelve RA and 294 non-RA patients were included. The Early Rheumatoid Arthritis (ERA) criteria had significantly higher specificity compared to the 2010 ACR/ EULAR criteria (83.7% vs. 78.2%, p=0.02) and sensitivity were simi...
Consensus on treatment of idiopathic inflammatory myositis (IIM), particularly with regard to fla... more Consensus on treatment of idiopathic inflammatory myositis (IIM), particularly with regard to flares and interstitial lung disease (ILD), does not exist. We studied the long-term outcome and treatment response in our large, retrospective cohort of adult South-Asian patients exclusively with IIM. Electronic records of IIM patients satisfying inclusion and exclusion criteria were studied longitudinally at presentation, at 3, 6, 12, 18 and 24 months and thereafter yearly till their last follow up (F/u) visit. Depending on clinical, imaging, and muscle enzyme profile during the F/u period, patients were categorised as complete (CR) and partial responders (PRs). Parameters favouring CR were assessed using multivariate logistic regression analysis. Outcome parameters and flares on immunosuppressants (IS) were then assessed in patients with/without ILD. Two hundred thirty-two patients with median F/u duration of 44.5 months (25–80.25) were included. ILD was seen in 40.1%. Patients with non...
There is a paucity of real-world data on mycophenolate mofetil/mycophenolate sodium in systemic s... more There is a paucity of real-world data on mycophenolate mofetil/mycophenolate sodium in systemic sclerosis-related interstitial lung disease. To study the efficacy of mycophenolate mofetil/ mycophenolate sodium in systemic sclerosis-related interstitial lung disease. In this single-centre study, clinical, laboratory and imaging details of consecutive patients with systemic sclerosis-related interstitial lung disease receiving mycophenolate mofetil/mycophenolate sodium from rheumatology and pulmonology clinics between January 2008 and March 2017 were retrospectively retrieved. The change in percentage of predicted normal forced vital capacity at last follow-up visit as compared with baseline was studied. In addition, high-resolution computed tomography scans at baseline and 2-year follow-up visit were scored as either stable/improved or worsened by experienced thoracic radiologists blinded to the clinical details of patients. Altogether, 88 patients (85.2% females) with mean age (SD) ...
Human Genomics
Home to a culturally heterogeneous population, India is also a melting pot of genetic diversity. ... more Home to a culturally heterogeneous population, India is also a melting pot of genetic diversity. The population architecture characterized by multiple endogamous groups with specific marriage patterns, including the widely prevalent practice of consanguinity, not only makes the Indian population distinct from rest of the world but also provides a unique advantage and niche to understand genetic diseases. Centuries of genetic isolation of population groups have amplified the founder effects, contributing to high prevalence of recessive alleles, which translates into genetic diseases, including rare genetic diseases in India.Rare genetic diseases are becoming a public health concern in India because a large population size of close to a billion people would essentially translate to a huge disease burden for even the rarest of the rare diseases. Genomics-based approaches have been demonstrated to accelerate the diagnosis of rare genetic diseases and reduce the socio-economic burden. Th...
Annals of the Rheumatic Diseases
Background Nucleosomes are basic elements of chromatin and are considered to be the major antigen... more Background Nucleosomes are basic elements of chromatin and are considered to be the major antigens in the pathophysiology of systemic lupus erythematosus (SLE). Objectives This study aimed to look for associations between anti nucleosome antibodies and clinical and laboratory parameters in SLE Methods This retrospective study was done in department of Clinical immunology & Rheumatology in Christian Medical College, Vellore, India. Patients with SLE by SLICC 2012 criteria between March 2013 and September 2015 subjected to anti nucleosome antibody test formed the study cohort. A cut off of ≥20 U/ml by ELISA was defined as per manufacturer's (Euroimmune, Germany) instructions. Associations of anti nucleosome antibody with clinical and laboratory parameters in SLE was studied. Results Anti nucleosome antibody was available for 238 patients with SLE. Mean age of the patients was 28.98±9.01 years with male to female ratio of 17: 221. Median disease duration was 8 (5–12) months prior to doing this test. Positive titers of anti nucleosome antibody (≥20 U/ml) were noted in 107 patients (46.5%). Renal involvement was seen in 134 (56.3%) patients. Univariate analysis reflected raised anti-c1q antibody, ESR, urinary protein creatinine ratio (UPC), anti dsDNA antibody, SLE disease activity index (SLEDAI), renal SLEDAI, low C3 and C4 as significant association of elevated anti nucleosome antibody levels. No significant association with arthritis, serositis, major infections, serositis, anti-phospholipid antibodies, autoimmune hematological cutaneous, neuropsychiatric, cardiovascular, respiratory, vasculitic and gastrointestinal manifestation was present. Multivariate regression analysis showed that raised anti-c1q antibodies and DsDna were associated with raised anti nucleosome antibody with odds ratio of 17.46 (95 CI: 1.46–213.86, p=0.02) and 82.94 (95 CI: 3.62–189.93, p=0.006) respectively. Conclusions As per literature search, this is the largest single centre study of anti nucleosome antibody in SLE. In this study, raised anti-c1q antibodies and DsDna were independently associated with raised anti nucleosome antibody in SLE. Disclosure of Interest None declared
Annals of the Rheumatic Diseases
Background Mycophenolatemofetil (MMF) is an effective therapeutic agent with high safety profile ... more Background Mycophenolatemofetil (MMF) is an effective therapeutic agent with high safety profile in the management of lupus nephritis. Objectives This retrospective study was conducted to assess the efficacy and side effect profile of MMF and deflazacort in patient with neuropsychiatry lupus (NP SLE). Methods Patients of SLE by SLICC 2012 between January 2005 and May 2015 satisfying ACR 1997 criteria for NP SLEwere recruited from department of Clinical immunology & Rheumatology, Christian Medical College, Vellore, India. Patients consistently using MMF as the second line agent were enrolled. Clinical response, SLEDAI and side effect profile were noted from electronic medical records. Clinical improvement was defined as remission of presenting neurological symptom with no new neurological symptom. Results Of the 140 patients with NP SLE, 88 fulfilled the inclusion criteria. Mean age of the cohort was 25.51±7.82 years with female to male ratio of 84: 4. Median duration of neurological symptoms prior to presentation was 90 (17.5 – 317.5) days. Median duration of follow up was 33 (3–129) months. Among the various NP SLE manifestations, seizure was the most common presentation (n=37, 42.05%). Renal involvement was seen in 49 (55.7%) patients. MRI findings varied from white and grey matter hyper -intensities to ventricular dilatation and brain atrophy. Of the 88 patients on MMF, 13 were pulsed with 1 gm methylprednisolone for 3 days and 8 were pulsed with oral dexamethasone pulse of 40 mg/day for 5 days. Subsequently, oral steroids was started at a dose of 1 mg/kg & tapered after 8–12 weeks to mean deflazacortdose (prednisoloneeqyuivalent) of 11.07±7.77 (9.33±5.88) mg at the end of 1 year. IMAGE: Showing various parameters at baseline and follow up as below. Major adverse events included lower respiratory tract infection in 2 patients and 1 fatality due to sepsis from gastroenteritis. Of 68 patient with median duration of follow up of 33 (3–129) months, 17 were only on MMF without any steroids, 14 not on either steroids or MMF and 6 were only on maintenance low dose steroids.Table 1. Comparing side effect profile of patients on deflazacort and prednisolone (n=88) Deflazacort Prednisolone P value Number of patients 70 18 0.001 Cushingoid habitus 7 16 0.000 Serious Infections 0 3 0.006 Steroid induced hypertension 1 4 0.000 Steroid induced diabetes 4 6 0.001 Deflazacort was equally efficacious and had better toxicity profile than prednisolone. Conclusions In patients of NP SLE, MMF is efficacious in inducing remission and preventing relapse of disease with a good safety profile. Deflazacort was found to have superior toxicity profile with equal efficacy as to prednisolone in NP SLE patients. Disclosure of Interest None declared
Dermatological Emergencies
Clinical rheumatology, 2018
Sacroiliitis is one of the criteria for classification as spondyloarthritis (SpA), though not uni... more Sacroiliitis is one of the criteria for classification as spondyloarthritis (SpA), though not unique to SpA. Other conditions including gout may be erroneously diagnosed as SpA due to sacroiliitis. The objective was to identify specific CT findings in sacroiliitis associated with SpA and gout. In this retrospective study, CT images of patients with sacroiliitis and clinical diagnosis of gout or SpA from 2010 to 2015 were independently reviewed by two radiologists, blinded to diagnosis. Axial and coronal oblique images were analyzed for characteristics of erosions. The receiver operator characteristic curve was constructed to analyze the discriminating ability of radiological findings. CT SI joint images of 11 patients with gout and 224 patients with SpA were re-analyzed. There was excellent agreement between the radiologists (ICC from 0.78 to 1). Erosions were more numerous in SpA. Erosions in gout were associated with tophi in 65.7% (73/111). Erosions in gout were para-articular an...
Rheumatology international, 2017
The aim of the study was to explore utility of serial serum myeloid-related protein 8/14 (MRP8/14... more The aim of the study was to explore utility of serial serum myeloid-related protein 8/14 (MRP8/14) as a biomarker of clinical disease activity and angiographic progression in Takayasu arteritis (TA). Serum MRP8/14 levels were assayed by commercial ELISA for 85 TA patients and 24 healthy controls at baseline, and for 56 and 21 TA patients during follow-up visits R1 and R2, respectively. Disease was categorised as active, indeterminate and stable according to Indian Takayasu Arteritis score (ITAS 2010), ITAS-A(CRP) and angiography. Patients were divided into responders and non-responders/relapsers based on treatment response. Non-parametric tests were used for inter-group comparisons at baseline and during follow-up time points. Generalised Estimating Equation was used to study association between changes in serial MRP8/14 levels and disease activity. At baseline, median MRP8/14 levels were higher in patients with TA than healthy controls [7353 (4524 to11283) vs 4896 (3194 to 8474.5) ...
International journal of rheumatic diseases, Jan 11, 2017
Normal C-reactive protein (CRP) in active Takayasu arteritis (TA) is a dilemma. We attempted to v... more Normal C-reactive protein (CRP) in active Takayasu arteritis (TA) is a dilemma. We attempted to validate our pilot study finding of rs1205 in CRP gene being protective against TA. Genomic DNA of 104 patients and 185 sex-matched healthy controls were genotyped for rs1205 by Taqman assay. Clinical details, demography, angiographic and activity scores (Indian Takayasu arteritis score 2010) were recorded prospectively at baseline and during follow-up visits for 12 months. Minor allele frequency (MAF) and genotype distribution between patients and controls as well as patient subgroups were compared using χ(2) test with Bonferroni correction (pc ) and logistic regression was performed to determine independent associations. The majority of patients (n = 84) and controls (n = 166) were females. MAF of T allele of rs1205 was less frequent in patients (27%) as compared to controls (37.6%), P = 0.013, pc = 0.026 with an odds ratio of 0.632 irrespective of gender. Frequency of CC genotype was h...
Clinical Rheumatology
High cost deters continuous use of tumor necrosis factor α blockers (TNFi) in developing countrie... more High cost deters continuous use of tumor necrosis factor α blockers (TNFi) in developing countries. The objective of this study was to evaluate outcome and expenditure incurred in Spondyloarthritis (SpA) patients beyond a year of follow-up after receiving four doses of infliximab (IFX) over and above background therapy of methotrexate (MTX) and sulfasalazine (SSZ) combination. Electronic medical records were screened for patients with SpA satisfying the Assessment of Spondyloarthritis International Society (ASAS) criteria between 2008 and 2014. Patients who completed at least 1 year of follow-up after receiving four doses of IFX (5 mg/kg at 0, 2, 6, and 14 weeks) on a background therapy of MTX (10-25 mg/week) and SSZ (2-3 g/day) combination were enrolled after obtaining an informed consent. Primary outcome assessed was &amp;quot;time to disease flare&amp;quot;. Changes in acute phase reactants, patient reported outcomes (BASDAI, BASFI), and cost were also assessed. Forty-five patients were enrolled. Mean (SD) duration of follow up after fourth IFX dose was 28.9 (18.7) months. Disease flare occurred in 33.3% (15/45) after a mean (SD) duration of 14.5 (10.8) months as compared to 4-6 months described in literature on discontinuing TNFi. Reduction in ESR, CRP, BASDAI and BASFI continued to be statistically significant at follow-up as compared to baseline. As compared to continuous IFX therapy, this treatment reduced cost by 57.1% for each patient-month of follow-up. Short course IFX dosing followed by continuation of MTX and SSZ combination can prolong time to disease flare and decrease requirement for additional IFX dose in SpA. This regimen could be a cost saving option for patients with SpA.