Immunosuppressants in Behcet’s disease: a boon or a bane?

Adalimumab is a disease-modifying antirheumatic drug and monoclonal antibody that works by antagonising tumour necrosis factor-alpha prescribed in many rheumatological conditions like Rheumatic arthritis, Ankylosing spondylitis and Behcet’s disease. Serious side effects with this drug include heart and liver failure, nervous and blood disorders, allergic and immune system reactions and opportunistic infections. A 27-year-old female patient, known case of Behcet’s disease presented to the hospital with complaints of fever, cough and breathlessness following administration of Adalimumab, six doses over three months. Chest X-ray and BAL-CBNAAT was suggestive of Tuberculosis. AKT was started and Adalimumab was suspended until patient recover

Tocilizumab induced immunosuppression in a case of adult-onset still’s disease: are these newer biologics double edged sword?

Adult-onset still’s disease (AOSD) is a rare multisystemic inflammatory disorder of unknown etiology characterised by high spiking fever, evanescent skin rash, arthralgias, arthritis, neutrophilic leucocytosis. Initial treatment strategy includes use of hands-on drugs like non-steroidal anti-inflammatory drugs, low dose corticosteroids, conventional DMARDs. But as the disease progresses to severe form, targeted and biologic DMARDs could be the option for management. Interleukin-6 being one among the many cytokines involved in the pathogenesis of AOSD, has made itself a target for the treatment of refractory cases. Tocilizumab, a recombinant humanized anti IL-6 monoclonal antibody, is one such biologic drug available in the market that has proven its therapeutic efficacy in several clinical trials. We are presenting a case of 37-year-old female patient, known case of AOSD for 4 years. Patient was initially maintained on low dose corticosteroid and conventional DMARD like hydroxychloroquine and methotrexate. Flare ups of the disease warranted the use of tocilizumab and tofacitinib in this patient. After clinical as well as pathological improvement with tocilizumab 2 years before, signs of immunosuppression were observed when tocilizumab was reintroduced for the treatment. Patient suffered from acute pyelonephritis, septicemia, shock, oropharyngeal candidiasis and bronchitis which could be owned to immunosuppressive action of tocilizumab. One can reduce the chances of infection and other adverse effects by careful periodic monitoring of various laboratory parameters like total W.B.C., total platelet count and liver enzymes. Cautious selection of the patient is needed for the treatment with newer biologic agents

Koebner’s phenomena observed in patient receiving adalimumab in psoriasis

Koebner’s phenomena, first described in 1877 as the appearance of psoriatic lesions in the uninvolved skin of psoriatic patients as a consequence of trauma. Koebner phenomena has been associated with the use of biological response modifiers. The development of the anti-TNF therapies is a milestone in the therapy of rheumatic diseases. As in all new treatment opportunities it is of concern whether all potential undesired side effects have been evaluated. We report a case involving a 31-year-old young male patient diagnosed with psoriasis and psoriatic arthritis (PsA) since a year, who received Adalimumab as part of his treatment and developed Koebner’s phenomena.

A case series of rituximab induced tuberculosis

Rituximab has a myriad of clinical uses, ranging from its disease modifying action in rheumatoid arthritis, to its role in chemotherapy for cancer. Being an anti CD20 monoclonal antibody, it controls inflammation by targeting peripheral B cells including those present in the synovium. The use of Rituximab is associated with some side effects such as cytopenias and increased risk of infections such as JC virus reactivation leading to multifocal encephalopathy. The role of Rituximab as an immunosuppressant has been established. However, its association with tuberculosis in endemic countries like India is yet to be understood well. The study was a cross sectional study of the two cases reported about the incidence of tuberculosis in patients receiving infusions of rituximab for rheumatoid diseases. These adverse drug reactions were reported to the nearest pharmacovigilance center through the Vigiflow portal of WHO and were assessed for their causality as per the WHO scale. A 45 year old male patient, a known case of Systemic Lupus Erythematosus, presented to a tertiary care hospital with high grade fever with chills and rigors after which he was diagnosed with pleural effusion due to tuberculosis. The patient was on immunosuppressants which included Rituximab, Mycophenolate Sodium, Prednisolone and Hydroxychloroquine. Rituximab was withdrawn and the remaining medications were continued as per the initial plan. A 19 year old male patient, a known case of dermatomyositis and dilated cardiomyopathy, presented to a tertiary care hospital with complaints of fever with chills and rigors, and breathlessness on exertion which was followed by the diagnosis of miliary tuberculosis. Earlier, the patient was on Rituximab, Cyclophosphamide, Hydroxychloroquine and Prednisolone. Plan of further infusions of Rituximab and Cyclophosphamide was terminated while the remaining medications were continued. Both the patients were put on anti tubercular therapy and are now improving. The association of bacterial infections like tuberculosis with the use of Rituximab is not well understood. However, Rituximab being an immunosuppressant can be considered to be related to this infection. In our case series we readdress this association through a literature review

Studies on Combined Toxicity of Pendimethalin and Cadmium Chloride with Ameliorative Effect of Vitamin E-Selenium and Turmeric in Male Albino Rats

The present investigation was undertaken to study the pathology of pendimethalin and cadmium chloride and to evaluate the different concentration were used as ameliorative agents to reduce theoxidative damage caused by free redicals genreted by toxic pollutants at molecular levels. A total of 5 groups each of 12 rats were formed apart from control group. 2 groups of heavy metal and pesticide and 3 group of ameliorative oxidant in varying concentrations were formed Group T2 was given standard ration along with combination of cadmium chloride at 500 ppm with pendimethalin (38.7%) at 1000 ppm/kg feed, Group T3 was given cadmium chloride at 100ppm/kg feed and P pendimethalin (38.7%) at 1000 ppm/kg feed with standard ration, Group T4 was fed with the combination of cadmium chloride at 50 ppm/kg of feed with pendimethalin at 1000 ppm/kg of feed and alpha tocopherol-selenium at 18 ppm/kg of feed. Lastly group T5 and T6 were given turmeric at 0.5%and 1% concentrations respectively along with the combination of cadmium chloride at 50 ppm with pendimethalin (38.7%) at 1000ppm and alpha tocopherol-selenium at18ppm/kg of feed.  During the toxicity studies observation like effect on CNS, effect on locomotors system recorded on the days 0, 7, 14, 21 and 28 of experiment

The importance of iron in long-term survival of maintenance hemodialysis patients treated with epoetin-alfa and intravenous iron: analysis of 9.5 years of prospectively collected data

<p>Abstract</p> <p>Background</p> <p>In patients treated by maintenance hemodialysis the relationship to survival of hemoglobin level and administered epoetin-alfa and intravenous iron is controversial. The study aim was to determine effects on patient survival of administered epoetin-alfa and intravenous iron, and of hemoglobin and variables related to iron status.</p> <p>Methods</p> <p>The patients were 1774 treated by maintenance hemodialysis in 3 dialysis units in New York, NY from January 1998 to June, 2007. A patient-centered, coded, electronic patient record used in patient care enabled retrospective analysis of data collected prospectively. For survival analysis, patients were censored when transplanted, transferred to hemodialysis at home or elsewhere, peritoneal dialysis. Univariate Kaplan-Meier analysis was followed by multivariate analysis with Cox's regression, using as variables age, race, gender, major co-morbid conditions, epoetin-alfa and intravenous iron administered, and 15 laboratory tests.</p> <p>Results</p> <p>Median age was 59 years, epoetin-alfa (interquartile range) 18,162 (12,099, 27,741) units/week, intravenous iron 301 (202, 455) mg/month, survival 789 (354, 1489) days. Median hemoglobin was 116 (110, 120)g/L, transferrin saturation 29.7 (24.9, 35.1)%, serum ferritin 526 (247, 833) μg/L, serum albumin 39.0 (36.3, 41.5) g/L. Survival was better the higher the hemoglobin, best with > 120 g/L. Epoetin-alfa effect on survival was weak but had statistically significant interaction with intravenous iron. For intravenous iron, survival was best with 1–202 mg/month, slightly worse with 202–455 mg/month; it was worst with no intravenous iron, only slightly better with > 455 mg/month. Survival was worst with transferrin saturation ≤ 16%, serum ferritin ≤ 100 μg/L, best with transferrin saturation > 25%, serum ferritin > 600 μg/L The effects of each of hemoglobin, intravenous iron, transferrin saturation, and serum ferritin on survival were independently significant and not mediated by other predictors in the model.</p> <p>Conclusion</p> <p>Long term survival of maintenance hemodialysis patients was favorably affected by a relatively high hemoglobin level, by moderate intravenous iron administration, and by indicators of iron sufficiency. It was unfavorably influenced by a low hemoglobin level, and by indicators of iron deficiency.</p

Juxtaposing BTE and ATE – on the role of the European insurance industry in funding civil litigation

One of the ways in which legal services are financed, and indeed shaped, is through private insurance arrangement. Two contrasting types of legal expenses insurance contracts (LEI) seem to dominate in Europe: before the event (BTE) and after the event (ATE) legal expenses insurance. Notwithstanding institutional differences between different legal systems, BTE and ATE insurance arrangements may be instrumental if government policy is geared towards strengthening a market-oriented system of financing access to justice for individuals and business. At the same time, emphasizing the role of a private industry as a keeper of the gates to justice raises issues of accountability and transparency, not readily reconcilable with demands of competition. Moreover, multiple actors (clients, lawyers, courts, insurers) are involved, causing behavioural dynamics which are not easily predicted or influenced. Against this background, this paper looks into BTE and ATE arrangements by analysing the particularities of BTE and ATE arrangements currently available in some European jurisdictions and by painting a picture of their respective markets and legal contexts. This allows for some reflection on the performance of BTE and ATE providers as both financiers and keepers. Two issues emerge from the analysis that are worthy of some further reflection. Firstly, there is the problematic long-term sustainability of some ATE products. Secondly, the challenges faced by policymakers that would like to nudge consumers into voluntarily taking out BTE LEI

Penilaian Kinerja Keuangan Koperasi di Kabupaten Pelalawan

This paper describe development and financial performance of cooperative in District Pelalawan among 2007 - 2008. Studies on primary and secondary cooperative in 12 sub-districts. Method in this stady use performance measuring of productivity, efficiency, growth, liquidity, and solvability of cooperative. Productivity of cooperative in Pelalawan was highly but efficiency still low. Profit and income were highly, even liquidity of cooperative very high, and solvability was good

Search for stop and higgsino production using diphoton Higgs boson decays

Results are presented of a search for a "natural" supersymmetry scenario with gauge mediated symmetry breaking. It is assumed that only the supersymmetric partners of the top-quark (stop) and the Higgs boson (higgsino) are accessible. Events are examined in which there are two photons forming a Higgs boson candidate, and at least two b-quark jets. In 19.7 inverse femtobarns of proton-proton collision data at sqrt(s) = 8 TeV, recorded in the CMS experiment, no evidence of a signal is found and lower limits at the 95% confidence level are set, excluding the stop mass below 360 to 410 GeV, depending on the higgsino mass