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Aim: To compare the efficacy of prophylactic bolus dose of ephedrine 10mg to prevent hypotension after spinal anesthesia for elective caesarean section. Methods: The study was conducted in Gynecological operation theatre suite of Bahria international teaching Hospital Lahore, from 15th September 2020 to 14th January 2021. It was quasi experimental study. It was conducted on ninety women admitted in gynecology department of Bahria international teaching Hospital Lahore, for caesarean delivery. These women were divided randomly into 2 groups: a) Patients in group E10 received ephedrine 1ml from 5ml syringe containing ephedrine 10mg/mland b)’ Results: Patients in group R acted as a control group and received normal saline 1ml from 5ml syringe.Blood pressure was recorded every minute for first 3 minutes, every 2 minutes for next 6 minutes, and then every 3 minutes till the procedure was completed. The sampling technique used was purposive sampling. Conclusion: It was concluded that prophylactic intravenous ephedrine bolus 10mg is more effective in preventing hypotension than fluid preload alone. It is simple and effective means of reducing the incidence of hypotension undergoing C- section in spinal anaesthesia. Keywords: Ephedrine, Hypotension, Spinal anesthesia.

Aim: To focus on the frequency of ICU-acquired infections in Sars Co-V2 Corona Virus disease (COVID 19) patients. Method: A retrospective observational study carried out in two tertiary care hospitals treating COVID 19 cases, Services Institute of Medical Sciences and Bahria International Hospital, Lahore. Data was collected from the medical records of the COVID 19 ICUs of both hospitals from May 1, 2020 to April30, 2021. All charts were reviewed for the evidence of positive cultures. The treatment given prior to positive cultures, after the availability of culture results and outcomes were also recorded. Results: A total of 432 records were reviewed and 400 cases were included while 32 cases were excluded because of incomplete data. The frequency of infections per 1,000 days of ICU stay was calculated in 90 (22.5%) patients. Gram-negative bacteria accounted for 68 cases (75.5%) with Pseudomonas in 44 cases (48.8%), Acinetobacter in 23/90 (25.5%) while 17 cases (18.8%) had gram positive infection with Enterococcus in 14/18 (77.77%) or 14/90 (15.55%), MRSA in 4/18 (22.22%) 4/90 (4.44%), while 5/90 (5.5%) had more than 2 isolates at same time. Among these 3 had both pseudomonas and Acinetobacter while 2 patients had Pseudomonas and Stenotrophomonas Maltophilia. Conclusion: There seems to be an increase in the infection rate among critically sick COVID 19 patients admitted in ICU. Use of steroids and Tocilizumab seems to play a role through their immunomodulatory effects. Keywords: Tocilizumab, Secondary infections

Background:Currently, conventional synthetic DMARDs (csDMARDs) are the most commonly prescribed drugs as first-line treatment for peripheral arthritis. In resource-constrained settings where biologic agents are not widely available, there are limited therapeutic options for patients with rheumatoid arthritis (RA) and seronegative inflammatory arthropathies refractory to other csDMARD therapies. Hence, in our practice, we are inclined to use combination of potent DMARDs after MTX failure, prior to considering biologic therapies. We believe that combination of DMARDs, especially combining MTX and Leflunomide (LEF) provides a potent and valuable low-cost treatment option. Efficacy of MTX and LEF is very well established, but there have been lot of concern as regards their combination use due to potential risk of hepatotoxicity.Objectives:We aimed to review our inflammatory arthropathies cohort data especially examining the safety, efficacy and drug retention of the combination usage of MTX and Leflunomide. We addressed this question using real-world data from the PRIME registry.Methods:This was a cross-sectional study conducted using data collected at the time of patient enrolment in the PRIME registry. The PRIME Registry is a large, independent, prospective, observational cohort initiated in October 2019 that comprises patients diagnosed with RA, SLE, PsA or AS by a rheumatologist, and is being actively followed up. IRB approval and informed consent was obtained. A number of clinical variables were recorded. Detailed history was gathered from every patient regarding their present and past medications usage. Questions were asked directly about the usage or otherwise of all available DMARDs and biologics. The duration of usage, any adverse events, or the reasons for discontinuation were recorded. Evaluation of disease activity and severity was made as per internationally agreed definitions.Results:The data of 766 inflammatory arthritis patients (RA=663, PsA=103) was reviewed. Among them, 241 patients (RA=196, PsA=45) were using combination therapy of MTX and LEF (combo MTX+LEF) with mean age 42.3±6 years; 42% male]. These patients had failed MTX or LEF monotherapy. Among these 241 patients, 49 patients were also on concomitant hydroxychloroquine therapy. It was noted that median drug retention of combo MTX+LEF therapy has been 9.5 months (IQR 6-16). Regarding any adverse events of combo MTX+LEF therapy, hepatotoxicity (ALT ≤3 times the upper limit of normal) was noted among 15 (6.2%) patients, hepatotoxicity (ALT ≥3 times the upper limit of normal) was noted among 8 (3.3%) patients, and troublesome gastrointestinal upset (nausea, or vomiting, or diarrhoea) in 3 (1.2%). Overall, only 13 (5.4%) patients had to discontinue this combo MTX+LEF therapy due to adverse events. Disease activity among combo MTX+LEF users was as follows: 64% (n=29) of PsA patients had achieved MDA; 42% (n=83) of RA cohort were in DAS28 remission, 46% (n=91) of RA patients were having DAS low disease activity.Conclusion:Combination of MTX and LEF was well tolerated and had good drug retention time, with 94.6% of patients having ongoing treatment to date. In low-income countries, where bDMARD availability is limited, financial arguments significantly influence decision making process, and our data provides initial evidence that MTX and LEF combination therapy could be an effective treatment option.Disclosure of Interests:Muhammad Haroon Speakers bureau: Roche, Novartis, Grant/research support from: Abbvie, Pfizer, Arfa Ashraf: None declared, Hafiza Javeria Shaheen: None declared, Sadia Asif: None declared, Shabnam Batool: None declared, Farzana Hashmi: None declared, Saadat Ullah: None declared

Background:Stress response is considered to involve the activation of both the hypothalamus-pituitary-adrenal axis and the autonomic nervous system, along with its communication with the immune system. Because many rheumatic diseases are characterized by immune-mediated joint inflammation, stressful events might contribute to the aetiology, maintenance and exacerbation of rheumatic diseases.Objectives:We aimed to examine whether real-life major stressful events lead to poor disease control among patients with Rheumatoid arthritis (RA). We addressed this question using real-world data from the PRIME registry.Methods:This was a cross-sectional study conducted using data collected at the time of patient enrolment in the PRIME registry. The PRIME Registry is a large, independent, prospective, observational cohort initiated in October 2019 that comprises patients diagnosed with RA, SLE, PsA or AS by a rheumatologist, and is being actively followed up. IRB approval and informed consent was obtained. We assessed the registry data for RA patients. The clinical variables studied were gender, age, smoking habits, body mass index, education status, marital status, disease duration, comorbidities (using Charlson Comorbidity Index). Education status was stratified by whether participants completed secondary (high) school education. Evaluation of disease activity and severity was made as per internationally agreed definitions, such as: swollen joint counts (SJC), tender joint counts (TJC), deformed joint counts, and DAS-28. Major psychological trauma or stress was defined if the patient has experienced any of the following in the past year: a) major personal injury or illness; b) death/major illness of a close relative; c) marital separation/divorce; d) loss of job; e) major financial loss; f) mass casualty incident loss.Results:The data of consecutive 507 RA patients (mean age 42.3±12.6 years, 73.6% female, disease duration of 80±22 months) was reviewed. Thirty-six percent of the cohort reported to have major psychological stress and trauma in the preceding one year. No statistical association of age, gender, and marital status was noted, but statistical association of low education status (p=0.042), longer disease duration (p=0.044), higher DAS-28 values (pConclusion:Major psychological stress and trauma in the preceding one year is associated with high disease activity among patients with RA. Therapies that focus on stress management may be important adjuncts to traditional pharmacotherapy in the treatment of inflammatory rheumatic diseases.Disclosure of Interests:Muhammad Haroon Speakers bureau: Roche, Novartis, Grant/research support from: Abbvie, Pfizer, Sadia Asif: None declared, Shabnam Batool: None declared, Farzana Hashmi: None declared, Saadat Ullah: None declared, Arfa Ashraf: None declared, Hafiza Javeria Shaheen: None declared

Background:In chronic inflammatory diseases like rheumatoid arthritis (RA), psychological stress is widely recognised as an important risk factor to negatively affect the disease course. Stress activates the hypothalamic-pituitary adrenal axis and the autonomic nervous system, which associate with the release of neurotransmitters (i.e. norepinephrine), hormones (i.e. cortisol) and activation of immune cells. Perceived stress can potentially induce the disease exacerbation, but on the other hand, the disease itself might produce significant stress to patients thus the vicious circle is formed and maintained.Objectives:We aimed to examine the prevalence of mental/emotional stress at home and its associations among patients with Rheumatoid arthritis. We addressed this question using real-world data from the PRIME registry.Methods:This was a cross-sectional study conducted using data collected at the time of patient enrolment in the PRIME registry. The PRIME Registry is a large, independent, prospective, observational cohort initiated in October 2019 that comprises patients diagnosed with RA, SLE, PsA or AS by a rheumatologist, and is being actively followed up. IRB approval and informed consent was obtained. We assessed the data for RA patients. The clinical variables studied were gender, age, smoking habits, body mass index, education status, marital status, disease duration, comorbidities (using Charlson Comorbidity Index). Education status was stratified by whether participants completed secondary (high) school education. Evaluation of disease activity and severity was made as per internationally agreed definitions, such as: swollen joint counts, tender joint counts, deformed joint counts, and DAS-28. All participants were directly inquired at the interview during the time of patient enrolment about the presence or otherwise of mental/emotional stress at home, and to rate it from 1-3 (mild, moderate, severe). For better understanding and ease of statistical analysis, dichotomous variable was made with moderate-to-severe stress patients were categorised into one group and none-to-mild stress patients into second group.Results:The data of consecutive 507 RA patients (mean age 42.3±12.6 years, 73.6% female, disease duration of 80±22 months) was reviewed. Forty-eight percent of patients accepted to have moderate-severe stress at home (moderate stress=29.9%, severe stress=18.3%). On univariate analysis, significant association of moderate-severe stress at home was noted with deformed joint counts (p=0.036), higher DAS-28 scores (pConclusion:Stress at home is common among patients with RA, and nearly half of the cohort was noted to have moderate-severe level of stress at home. Ongoing stress at home has significant association with higher RA disease activity and deformities suggesting a bidirectional relationship. These findings demonstrate an important need for integration of rheumatologic, social workers and mental health servicesDisclosure of Interests:Muhammad Haroon Speakers bureau: Roche, Novartis, Grant/research support from: Abbvie, Pfizer, Farzana Hashmi: None declared, Saadat Ullah: None declared, Arfa Ashraf: None declared, Hafiza Javeria Shaheen: None declared, Sadia Asif: None declared, Shabnam Batool: None declared