The Radiographic “Air Sign” in Neonatal Mandibular Distraction Osteogenesis

Timing of extubation on post-mandibular distraction osteogenesis (MDO) surgery is critical, given that at baseline these infants have difficult airways and failed extubation requires either re-intubation of an already complex airway with a fragile, recently osteotomized mandible, or adjunctive airway measures such as CPAP that may apply unwanted pressure to the surgical site. Thus, the goal is to plan extubation when the risk of failure is minimal. Currently, there is a void in the literature addressing the timing of extubation post-MDO and no objective sign of extubation readiness has been elucidated. This study describes a simple clinical pearl to assist in the evaluation of extubation readiness in these patients. Postoperatively, we obtain weekly radiographs to assess distractor stability and advancement, and to assess for the “Air Sign”. The Air Sign describes a radiolucent space (air) visualized in the oropharynx on lateral radiographs, likely indicating that the tongue based airway obstruction has been relieved by mandibular advancement.

OP0053 IMPACT OF CORRECTING CRP THRESHOLD ACCORDING TO BMI ON DIAGNOSIS, DISEASE ACTIVITY, INDICATION OF BIOLOGICAL TREATMENT AND PREDICTION OF THERAPEUTIC RESPONSE, IN PATIENTS SUSPECTED OF AXIAL SPONDYLOARTHRITIS. RESULTS FROM DESIR COHORT

Background:Acute phase reactants are crucial parameters to consider for management of chronic inflammatory back pain (IBP) patients suspect of axial spondyloarthritis (ax-SpA). Indeed, C-reactive protein (CRP) is part of ASAS classification criteria for SpA, impacts on assessment of disease activity by ASDAS-CRP score, and should be elevated when a bDMARD is discussed in patients without radiological sacroiliac lesions. Moreover, elevated CRP is regarded predictive of favorable therapeutic response. Obesity in otherwise healthy people is associated with high CRP values. An adjusted definition of normal CRP threshold based on gender and BMI has been proposed.Objectives:The aim of this study was to assess whether correcting CRP threshold with patient’s BMI would change classification according to ASAS criteria for ax-SpA, presence of clinically relevant activity according to ASDAS-CRP, indication for TNF inhibitor (TNFi) and, as primary endpoint, improve prediction of therapeutic response to first TNFi.Methods:The study was conducted in DESIR cohort, which included 708 patients with early IBP suspect of ax-SpA. We included all patients with available data on BMI and CRP. High CRP level was defined either according to usual threshold (5 mg/L) or to the formula using BMI for adjustment. With this formula, CRP could be considered “normal” or due to obesity if: ≤ 1 + (BMI-25)/25 for men and ≤ 1 + (BMI-25)/12.5 for women (with CRP in mg/dL). We reported distribution of CRP levels in patients with high level according to usual threshold but below BMI adjusted threshold, as it is potentially suggestive of false-positive CRP due to overweight/obesity. Among them, we identified those who had no objective sign of disease activity (defined as arthritis, dactylitis, active uveitis or inflammatory bowel disease). To evaluate the impact on classification/diagnosis, we examined HLAB27-positive patients with only 2 ASAS criteria, including high CRP (the second being IBP, since it was mandatory for inclusion in DESIR cohort). Then, we calculated ASDAS-CRP score. We presented proportions of patients with ASDAS- high or very high disease activity but high CRP level possibly due to BMI only, and among those, the number concerned by a change of disease activity level when adjusting ASDAS-CRP score with minimal value for CRP (2mg/l). Among patients treated by TNFi during first 24-month follow-up, we excluded those with sacro-iliitis, and studied in others, CRP levels at last visit before treatment initiation using both thresholds. We compared proportion of ASAS40 responders using logistic regression analysis, with abnormal CRP defined after correction for BMI in patients without any sign of activity, beside other classical predictive factor of therapeutic response (age, gender, sacro-iliitis, HLAB27, psoriasis, arthritis, smoking).Results:Data were available for 634 patients. 205 had a high CRP level using usual threshold, of which 73 (35.6%) had a high CRP possibly due to BMI alone as they had no objective sign of disease activity. There were no differences in diagnosis as no patient had as only ASAS criteria: HLAB27 associated with high CRP and IBP. ASDAS-CRP score could be calculated in 626 patients. By correcting ASDAS score for patients with high CRP possibly due to BMI, 95.3% remained with same activity level (kappa for the ASDAS levels was 0.93). For impact of CRP on indication of bDMARD, 178 patients were treated by TNFi during first 24 months of follow-up: 61% of patients had an indication of TNFi according to EMA, with usual CRP threshold, and 56% with the adjusted one. Regarding response to TNFi, there were no association between any of the 2 CRP thresholds and ASAS40 response. Only sacro-iliitis on MRI was associated with ASAS40 response.Conclusion:Adjustment of CRP threshold according to BMI has a very limited impact on diagnosis, evaluation of disease activity of SpA, indication of TNFi initiation and prediction of TNFi response.Disclosure of Interests:Odile Facorat: None declared, Jacques Morel Speakers bureau: Abbvie, Biogen, BMS, Fresenius Kabi, Lilly, Mylan, Novartis, Pfizer, Sanofi, Consultant of: Abbvie, BMS, Boerhinger Ingelheim, Galpaagos, GSK, Lilly, Novartis, Sanofi, Grant/research support from: Biogen, BMS, Lilly, Novartis, Pfizer, Sanofi, Servier, Bernard Combe Speakers bureau: AbbVie; Bristol-Myers Squibb; Gilead; Janssen; Lilly; Merck; Novartis; Pfizer; Roche-Chugai; and Sanofi, Consultant of: AbbVie; Bristol-Myers Squibb; Gilead; Janssen; Lilly; Merck; Novartis; Pfizer; Roche-Chugai; and Sanofi, Grant/research support from: Novartis, Pfizer, and Roche-Chugai, Pascal Richette Consultant of: AbbVie, Amgen, Biogen, BMS, Celgene, Janssen-Cilag, Lilly, Medac, MSD, NORDIC Pharma, Novartis, Pfizer, Roche, SanofiAventis, UCB, Cédric Lukas Speakers bureau: Abbvie, Amgen, Janssen, Lilly, MSD, Novartis, Pfizer, Roche-Chugai, UCB, Consultant of: Abbvie, Amgen, Janssen, Lilly, MSD, Novartis, Pfizer, Roche-Chugai, UCB, Grant/research support from: Pfizer, Novartis and Roche-Chugai

Diagnosis of fundoplication cuff failure in patients operated by the Nissen method

The article is devoted to the treatment of patients with hiatal hernia. The aim of the study was to develop a method for diagnosing the failure of the fundoplication cuff in patients with recurrent hernia of the foodwater orifice of the diaphragm after Nissen fundoplication. The study included 42 patients. The first group consisted of 16 people with recurrent hiatal hernia. The second group consisted of 26 people without recurrence of hiatal hernia. When comparing groups of patients, a simple and objective sign of the failure of the fundoplication cuff after Nissen surgery is described.

Heterogeneity of post-COVID impairment: interim analysis of a prospective study from Czechia

We stratified post-COVID patients into four newly established clinical groups based on the presence or absence of at least one subjective respiratory symptom and at least one objective sign of pulmonary involvement. Nearly half of outpatients and one third of hospitalized post-COVID patients had objective signs of pulmonary involvement without accompanying subjective respiratory symptoms three months after diagnosis.

COMPARATIVE EVALUATION OF TACROLIMUS 0.03% OINTMENT VS OLOPATADINE 0.2% EYE DROPS IN THE TREATMENT OF VERNAL KERATOCONJUNCTIVITIS

Objective: To compare the efficacy of tacrolimus 0.03% ointment to olopatadine 0.2% eye drops in the treatment of vernal keratoconjunctivitis. Study Design: Prospective cross-sectional study. Place and Duration of Study: Eye Department Combined Military Hospital Quetta, from Feb to Jul 2019. Methodology: A total of 69 patients with active vernal keratoconjunctivitis (VKC) were included in this study.Thirty six (52.17%) patients were randomized in tacrolimus group and 33 (47.83%) in olopatadine group B.Baseline values of the subjective symptom score (SSS) and the objective sign score (OSS) were noted. Patientswere reviewed on weeks 2, 4, 8 and 12 and the scores at each visit were summed. These scores were used forcomparison between groups. Results: At the start of the study, the mean subjective symptoms score and objective sign score of group A was 9.0 ± 2.04 and 3.93 ± 1.93 respectively, while that of group B was 8.88 ± 2.18 and 4.36 ± 1.90 respectively. At the end of 12-weeks, the mean subjective symptoms score and objective sign score of group A reduced to 0.11 ± 0.32 and 0.08 ± 0.28 respectively, while that of group B reduced to 1.70 ± 0.77 and 0.64 ± 0.55 respectively. Total improvement of scores (as a percentage of baselines) among tacrolimus group was 98.3% and olopatadine group was 83%. Conclusion: Although both 0.03% tacrolimus and 0.2% olopatadine were effective in improving the signs andsymptoms of VKC, 0.03% tacrolimus was significantly superior.

Esophageal-gastrointestinal-diaphragmatic murmur - a new objective sign of diaphragmatic hernias

Aim. To present a description and scientific substantiation of a new objective sign in patients with hiatal hernias. Methods. The study included 127 patients with diaphragmatic hernia, who made up the group of patients, including 65 women and 62 men, mean age 56.2±11.4 years. The control group was represented by the results of a survey of 100 practically healthy people: 55 women and 45 men, the average age of 52.6±2.3 years. All patients included in the study group, underwent upper endoscopy and fluoroscopy of the esophagus and stomach with a suspension of barium sulfate, the results of which were compared with the data of auscultation of the chest. Results. The description and scientific substantiation of the physical sign of diaphragmatic hernias was presented, which is pathological peristalsis at four points of auscultation on the thorax. The factors that led to the choice of localization of the points at which auscultation of esophageal-gastrointestinal-diaphragmatic murmur is carried out in this pathology, are presented. Pathophysiological mechanisms causing the appearance of pathological peristalsis of the esophagus and stomach, which is the essence of the proposed symptom of hiatal hernia, were found and substantiated. Sensitivity and specificity of a new method of detecting diaphragmatic hernia were calculated, the positive and negative predictive values were determined. High efficiency of auscultation of abnormal motility as a diagnostic method was demonstrated. The frequency of clinical symptoms in patients with hiatal hernia and their comparison with the world experience of observation of patients with this pathology are shown. Conclusion. The proposed objective sign, which has a very high sensitivity and specificity, is an attempt to fill the currently existing «diagnostic gap» between the subjective sensations of a patient with diaphragmatic hernia and instrumental diagnostic methods that have certain limitations in application.

Legal Analysis of the Role of Islamic Urban and Rural Councils in Administrative Decentralization and Local Democracy in Iran

<p>Administrative decentralization is one of the most marvelous achievements of public laws in current age. Obviously, based on the title of the book namely Islamic Councils, we mean a certain type of local decentralization is shaped by geographical areas. In modern administrative laws, decentralization is raised in two geographical and technical aspects. Local councils are objective sign of geographical decentralization and legal figures of public laws such as universities are instances of technical decentralization.</p>In this concept, decentralization is shaped by two concepts of “managerial independence” and “elective decision making authority”. In modern administrative system, decentralization means to increase the authorities of elected officials whose proficiencies are assignable only in a region of the country. Before getting familiar with such great achievement, we should address the philosophy governing decentralization and its status in modern democracies.