Evaluation of 99mTc-sulfadiazine as Bacillus microorganisms infection imaging agent using animal model

Bacterial infection is one of the vital sources of morbidity and mortality. The development of single photon emission computed tomography [SPECT] radiotracer agents using antibiotics, for targeting in-vivo bacteria, helps in antibiotic dose calibration, targeted infection therapy and reduction in mortality rate. The aim of this study was to appraised [99m]Tc-labeling sulfadiazine as a radiopharmaceutical for bacillus infections imaging. Radiolabeling of sulfadiazine with technetium-99m was carried out by subsequent addition of 1.5 mL aqueous solution of sulfadiazine [1mg/mL], 120Mug stannous tartrate, gentistic acid as stabilizing agent and 185 MBq normal saline solution of 99mTcO4 -1 [pertechnetate] at pH = 5. The reaction mixture was incubated for 40 min at room temperature with light stirring. The quality control analysis [ITLC-SG and paper chromatography analysis] revealed 98% labeling yield. Biodistribution and scintigraphic study was carried using bacillus bacterial infection induced New Zealand white rabbits. Due to the ease of [99m]Tc-sulfadiazine conjugation method, high labeling efficiency, shelf stability [>95% up to 6h], blood serum stability [90% up to 6h] and high uptake in the infected muscle [T/NT =2.21 at 1h], [99m]Tc-SDZ could be used as radiopharmaceutical of choice for further pre-clinical and clinical studies

Post interferon therapy decreases male fertility through gonadotoxic effect

Prevalence of hepatitis C virus [HCV] has been seen in more than 15% of Pakistani population. For the treatment of this infection, only two medicines, interferon, and ribavirin were approved in 1998. The concerned physicians evaluate side effects of these two antiviral drugs only during the treatment period. The long-term extra hepatic side effects are being neglected. This retrospective study was conducted with reference to induced infertility in HCV treated 40 male patients from the period 2008-2015. Possible effects of interferon therapy on fertility hormones and seminal parameters were assessed. Level of fertility hormones like serum Follicle Stimulating Hormone [FSH], Luteinizing Hormone [LH], and testosterone was measured. For seminal parameters, guidelines from World Health Organization [WHO] were followed. Among forty cases of HCV patients who received interferon, only 14 [35%] have children and 26 [65%] could not conceive [p = 0.0372]. After HCV treatment, HCV positive patients showed a significant change in the level of FSH, LH [p<0.05]. Especially, it decreased testosterone level [p=0.0096]. Similarly, HCV treatment significantly decreased sperm count [p = 0.001] and motility [p = 0.0005]

Insidious sensorineural hearing loss in chronic suppurative otitis media

Background: Sensorineural hearing loss may be one of the outcome of chronic suppurative otitis media

Objective: To evaluate the association of chronic suppurative otitis media with sensorineural hearing loss and also to find out whether the disease duration had any impact on hearing

Methodology: This was a cross sectional study conducted at Aga Khan University Hospital. Charts of all patients who underwent surgery for chronic suppurative otitis media from 1stJanuary 2004 to 31stDecember 2009 were reviewed. One hundred and fifty five patients out of 562 met our inclusion criteria and were included in the study. The contralateral ear was taken as control. History record and audiograms were reviewed from the patient charts for the duration of disease and evidence of SNHL at three speech frequencies [[500, 1000, and 2000 Hz]. The data was entered and analyzed by SPSS version 16

Results: Of 155 patients, 46 [29.6%] had SNHL. In a group of patients with epithelial disease[cholesteatoma] 16 out of 45 patients had SNHL whereas in the group of patients with mucosal disease [formerly known as tubotympanic type] 30 out of 110 patients had SNHL. This hearing loss found to be worsening with the duration of disease in both groups [p=0.000]

Conclusion: A significant association of SNHL was found with CSOM and disease duration. Early surgicaltreatment should be offered in order to prevent irreversible SNHL

Cognitive dysfunction in patients with systemic lupus erythematosus

Objective: To determine the frequency of cognitive dysfunction in patients with Systemic Lupus Erythematosus in a Pakistani population, presenting at a tertiary care Rheumatology setting

Methods: This cross-sectional study was conducted at the Division of Rheumatology, Fatima Memorial Hospital, Lahore, from March to June 2016. A total of 43 consecutive patients, who fulfilled the 2012 SLICC [Systemic Lupus International Collaborating Clinics] classification criteria for Systemic Lupus Erythematosus [SLE], were enrolled. Cognitive function was assessed using Montréal Cognitive Assessment [MoCA] questionnaire. Demographic data and disease dynamics were collected in a proforma. Cognitive dysfunction was defined as score < 26/30, adjusted for duration of formal education. SPSS version 16.0 for windows was used to analyse data and to calculate frequency of cognitive dysfunction

Results: Out of 43 enrolled patients, 95.3% were females and 4.7% were males, with mean age of 28.72 +/- 9.25 years and mean formal education duration of 10.98 +/- 3.29 years. The mean disease duration was 24.21 +/- 30.46 months. Anti-nuclear antibodies [ANA] were present in all patients and anti-ds DNA in 93% patients. Cognitive dysfunction according to MoCA score was found in 65.1% [n=28] patients. For patients with disease duration more than two years, cognitive dysfunction was found in 60% patients [p>0.05] and for duration of formal education less than 12 years in 74.1% patients [p>0.05]

Conclusion: In this study, two third of SLE patients had Cognitive dysfunction. Hence, there is an increasing need to recognise and initiate early therapy for this overlooked aspect of SLE with an aim to achieve better quality of life

Radiological presentation of post primary tuberculosis in adult sputum smear positive patients

Background: Pulmonary Tuberculosis [TB] is traditionally classified into primary and post primary tuberculosis; both have distinct characteristics on radiology. Adetailed knowledge of different radiological patterns is helpful in diagnosis of TB

Objective: To determine the frequency of various radiological presentation of post primary tuberculosis in adult sputum smear positive patients

Methodology: This cross sectional study was carried out at Department of Pulmonology, Sheikh Zayed Medical College / Hospital, Rahim Yar Khan on adult sputum smear positive pulmonary TB patients. A total of 250 new cases of pulmonary TB with no previous history of Anti-Tuberculosis treatment were included in this study. Socio demographic data and findings of X -ray Chest from each sputum smear positive patient were collected and recorded on a predesigned performa. The data was entered and analyzed by using SPSS version 17

Result: Out of 250 patients, 146 were male and 104 were female with mean age of 35.76 +/- 16.25 years. Left lung was most affected in 40.4% cases, right lung in 35.6%, while 24% has bilateral involvement. Duration of illness prior to diagnosis was 3 +/- 1.66 months. Among the radiological presentation, cavitation was seen in 49.2% cases, alveolar consolidation in 42.4%, nodular pattern in 3.2%, reticulonodular pattern in 3.2% and reticular pattern in 2% cases. There was significant association of alveolar consolidation with male gender [0.03] while reticulonodular pattern was significantly seen in female gender [0.007]. Majority of the patients were young; 42.8% were below the age of 30 years and 82% patients were below the age of 50 years and there was a delay of > 03 months in the diagnosis

Conclusion: According to this study, cavitations and alveolar consolidation were the commonest radiological presentations of post primary TB. Majority of patients were young and there was a considerable delay in diagnosis

Frequency of dyslipidemia in patients with lupus nephritis

Objective: To determine the frequency of dyslipidemia in patients with lupus nephritis and its association with the degree of proteinuria

Methods: This cross-sectional analytic study included 65 patients who fulfilled the ACR [American College of Rheumatology] criteria for SLE and had renal involvement, presenting to the Division of Rheumatology, Fatima Memorial Hospital [FMH], and Lahore from 21[st] Sep 2016 to 20[th] Dec 2016. After 12 hours overnight fast their blood samples were assessed for total cholesterol [TC], triglycerides [TG], high density lipoprotein [HDL] and low density lipoprotein [LDL]. Patient demographic variables [age, sex] and disease characteristics [disease duration, degree of proteinuria, steroid dose] were noted. Patients were categorized into two groups on the basis of degree of proteinuria: having proteinuria >1gm or

Results: Most common lipid abnormality found in our study was hypertriglyceridemia [58.5%]. Total Cholesterol and LDL-C was high in 55.4% and 30.8% subjects respectively. Low HDL was found in 21.5% subjects. Increased frequency of dyslipidemia was noticed in those subjects who had proteinuria >1gm [P value < 0.05]

Conclusion: Dyslipidemia was observed in a high frequency in patients with lupus nephritis and was strongly associated with their degree of proteinuria

Radiolabeling of benzylpenicillin with lutetium-177: quality control and biodistribution study to develop theranostic infection imaging agent

Benzylpenicillin acts through binding with beta-lactamase enzyme and inhibiting the bacterial cell wall biosynthesis. Therefore, the radiolabeling of benzylpenicillin with lutetium-177 is expected to serve as a theranostic agent for deep-seated bacterial infections. The radiolabeling of benzylpenicillin resulted tilde 93% radiochemical yield at optimized reaction conditions. Radiochemical purity analysis was tested with the help of Whatman No. 2 paper and instant thin layer chromatography. Biodistribution study with healthy New Zeeland white rabbit revealed moderate accumulation in different organs. Kidneys are the major organs, showed not more than 4.57+/-0.89% injected dose per gram organ [ID/gm organ] at 1 h time point and 3.48+/-1.11% ID/gm organ at 6 h time point. The accumulation of tracer agent in liver was found in the range of 7.42+/-2.42% to 9.09+/-2.76 ID/gm organ. The glomerular filtration rate studies revealed rapid clearance - omitting the chance of nephrotoxicity. The radiolabeling yield, biodistribution and glomerular filtration rate results revealed [177]Lu-benzylpencillin could be a potential candidate to diagnose the deep-seated bacterial infection

Frequency of HCV seropositivity in lichen planus

Objective To determine the frequency of Hepatitis C [HCV] seropositivity in patients of lichen planus [LP]

Methods This observational cross-sectional study was conducted over a period of 6 months, at Dermatology Department PNS Shifa hospital Kaitachi. Eighty-two [n=82] patients with a diagnosis of LP fulfilling the inclusion and exclusion criteria were enrolled using non-probability consecutive sampling technique. Detailed history, physical examination and biochemical measurements were recorded. Outcome variable i.e. HCV seropositivity was determined in laboratory with third generation ELISA technique. All data were entered and analyzed using SPSS Version 20.0

Results The mean age of study population was 39.32+/-13.212 years. On analysis of demographics data it was observed that 25 [30.5%] were below 30 years of age and 57 [69.5%] were of age 30 years and above. 39 [47.6%] were males and 43 [52.4%] were females. On analysis of frequency of outcome variable, 15 patients [18.3%] were HCV positive out of 82 patients irrespective of gender, morphological pattern and site of disease

Conclusion HCV positivity is common in patients with lichen planus in Pakistani population. Age, gender, morphological pattern and site of involvement have no effect of HCV positivity

Frequency of rheumatoid factor in patients with hepatitis C infection associated polyarthropathy

Objective: To determine the frequency of Rheumatoid Factor [RF] in patients with Hepatitis C infection [HCV] associated polyarthropathy at Combined Military Hospital Quetta

Study Design: Cross-sectional study

Place and Duration of Study: Department of Medicine, Combined Military Hospital Quetta, from 1st Oct 2012 to 31st Mar 2013

Material and Methods: Two hundred and seven patients having confirmed Hepatitis C infection [positive anti HCV antibodies and positive HCV RNA by Qualitative PCR] with polyarthropathy were included in this study. These patients were screened for RF by immunonochromatography based RF Latex assay kit

Results: Out of 207 patients, 138 [66.67%] were males and 69 [33.33%] were females. The age among all subjects ranged from 21-55 years and mean age of all subjects was 44.29 +/- 4.61 years, the youngest patient was 21 years old and eldest was 55 years old. Most of the patients 97 [47%] were in the age group of 36-45 years. RF was positive in 88 [42.51%] patients and it was negative in 119 [57.49%] patients suffering from hepatitis C infection associated polyarthropathy. The frequency of RF in female patients was 66 [48%] and in male patients was 22 [32%] and it was significantly [p-value=0.0367] greater in female patients as compared to male patients

Conclusion: The detection of Rheumatoid Factor [RF] is of little utility as a diagnostic tool for concurrent RA in patients of chronic HCV infection because a high percentage of them were having serum RF reactivity

Role of cutting-out technique in removal of a bent Kuntscher nail using steel cutting blade at periphery healthcare

Objective: To demonstrate the effectiveness of cutting-out nail technique using simple, cheap and readily available steel cutting blade to remove bent Kuntscher nail

Method: This study was carried out for a period of three years, from July 2014 to June 2017, in the department of orthopedic surgery at DHQ Hospital Vehari. Inclusion criteria were either gender of age between 15 to 60 years. All patients underwent removal of Kuntscher nail using the technique in which the nail was cut with the help of a simple metal cutting blade, and both fragments were removed from the fracture site. Ten cases were included in the study. The patients under went pre operative, general and systemic examination. The initial investigation comprised of baseline pre-operative investigation, skiagrams of the fractured bone. Osteosyntheses was done with the use of over sized nail or dynamic plate. Bone grafting was done to augment the union, in each case. Usually patients were discharged on fourth postoperative day. All patient were observed in post-operative period for detection of complications

Results: A total number of ten patients were included in this study. The mean age of all patients was 36 +/- 6 years. Patients came from less educated background. 80% of the patients were male and 20% were female. In 20% patients' angulation was less than ten degree and nail was removed proximally. Among 50% patients over size nail was used and other 30% patients compression plate was used. All patients were made mobile with help of crutches. Early range of motion was started and the union at the fracture site was achieved after 3 to 4 months. According to Flynn Criteria outcome was excellent

Conclusion: The use of cut-and-remove technique for removal of bent Kuntscher nail is better option in peripheral hospitals, as it is a simple operating technique, which gives satisfactory outcome with minimum complication rates, lesser operating time and lesser expense to accomplish the goal of treatment. So it could be considered as a favorable treatment option where advanced gadgetries for transecting the nail may not be present

Aplasia cutis congenita with rare association and unusual presentation

Aplasia cutis congenita [ ACC] is a congenital absence of skin most commonly affecting scalp. In very rare instances it can involve extremities and trunk. It is usually diagnosed clinically at birth. Most cases are sporadic with a few reports of familial occurrence. Here, we present two cases of which one had scalp involvement correlating to antenatal methimazole intake and the other one had unusual presentation with involvement of deep tissues up to the periosteum of right lower limb. Both cases were managed conservatively and successfully discharged home. But unfortunately were lost to follow-up. ACC is a rare condition with varying degree of severity depending upon the extent and depth of the involvement of the skin and underlying tissues. Mild cases do not need specific intervention while severe cases need to be managed by a multidisciplinary team of pediatrician, dermatologist and plastic surgeon. Methimazole is a known teratogen associated with this condition hence should be avoided in pregnancy

Synthesis, characterization and antinociceptive activities of Novel 2-[2,4-dichlorophenyl]-4H-chromen-4-one

A novel flavone derivative has been synthesized in good yield from ketone and aldehyde. The structure has been established by different spectroscopic techniques like H NMR, C NMR, IR and elemental analysis. The compound was then screened for its acute toxicity and antinociceptive activity studies on animal model. The novel compound was safe upto a maximum dose of 500mg/kg body weight oral dose in mice and showed 65.92 and 82.18% pheriperal analgesic activity at 15 and 30mg/kg body weight doses. Central antinociceptive activity of the compound was 53.13 and 64.44% at 15 and 30mg/kg body weight respectively

Knowledge, attitudes and practices of lady health workers regarding family planning program in tehsil muzaffargarh

Objective: To assess the knowledge, attitudes and practices of lady health workers [LHWs] regarding implementation of family planning program in Tehsil MuzaffarGarh

Study Design: Cross sectional study

Place and Duration of Study: It was carried out from December 2015 to May 2016 involving Lady Health Workers from 10 union councils of Tehsil Muzaffar Garh including both urban and rural areas

Material and Methods: The data were collected by interviewing 307 LHWs using a structured closed ended questionnaire

The data were entered and analyzed through SPSS version 22

Results: Lady health workers [LHWs] demonstrated a good knowledge ranging from 78% to 99% of different aspects of family planning. They were poorly informed regarding pregnancy complications, breast feeding and infertility. Almost all of them 305 [99%] showed positive attitude regarding job, trainings, compatibility of family planning with religion, although were unsatisfied with their salaries and monetary incentives

Conclusions: LHWs have a good knowledge and positive attitude towards family planning except knowledge about infertility, pregnancy complications and breast feeding. Family planning practices are difficult in rural areas because of low literacy rate and dominance of mothers in law, which needs attention

Comparision of post operative chronic pain after excision of ilioinguinal nerve in lichtenstein's hernioplasty

Objective: To provide a comparative analysis of mean post-operative pain score after preservation and elective excision of ilioinguinal nerve [UN] using standard Lichtenstein hernia repair [LHR] technique

Study Design: Randomized controlled trial

Place and Duration of Study: Department of Surgery Combined Military Hospital [CMH] Rawalpindi/ Peshawar, from 15 May 2013 to 15 May 2014

Materials and Methods: One hundred and fifty patients with diagnosis of inguinal hernia satisfying inclusion/exclusion criteria were included. Patients were divided into two groups randomly. In group A, UN was carefully protected while excision were done in group B. Demographic as well as data concerning groin pain at 03 months post operatively were collected and analyzed using SPSS

Results: A total of 150 patients were included. Mean age in group A was 37.32 +/- 10.45 years while in group B was 36.56 +/- 10.26 years [p=0.653]. Majority of the patients in both groups were male [group A 89.33% [67], 92% [69] in group-B], while female constituted only minority [8 [10.67%] in group A and 6 [8%] group-B], the difference being statistically insignificant [p=0.571]. Majority of the patients had indirect hernia and mean operation time was similar in both groups. Mean postoperative pain score was 3.76 +/- 1.11 and 2.82 +/- 0.677 in group A and B respectively, the difference being statistically significant [p<0.001]

Conclusion: Mean post-operative pain score is higher in preservation techniques compared to elective excision of UN for the treatment of inguinal hernia

Adherence to methotrexate therapy in rheumatoid arthritis

Objective: To determine adherence to methotrexate [MTX] therapy in patients with Rheumatoid Arthritis [RA] and to identify factors that promote either adherence or non adherence

Methods: One hundred Rheumatoid Arthritis patients on MTX for at least two months were enrolled. Questionnaire was completed by direct interview. Details recorded were, demographics [age, sex, education, monthly income], disease duration, duration on MTX and current dose. Disease Activity Score on 28 joint counts [DAS 28] at the current visit, concomitant drugs taken and number of doses of MTX missed in the previous 8 weeks were noted. Non adherence was defined as omission of any three or more prescribed doses of MTX in previous 8 week. Patients were asked for the factors that motivated their adherence to MTX as well as factors for non adherence. Presence of side effects due to MTX was also recorded

Result: Non adherence was found among 23% of cases. Patients of low socioeconomic group [p <0.0001] and on MTX for longer duration [p <0.001] had higher non adherence. Non adherent patients had significantly higher disease activity as measured by DAS 28 [p<0.001]. Good counseling and education by the doctor was a strong predictor of adherence [p <0.001]. Lack of affordability [p <0.001]; lack of availability at local pharmacy [p <0.001]; lack of family support [p <0.001] and lack of awareness regarding need and importance of MTX [p < 0.001were found as significant factors for non adherence

Conclusion: MTX non adherence in RA is noted in about one fourth of study group. Various economical and social issues lead to non adherence but good patient education and counseling by doctor could promote adherence in this study group

Polio immunization and awareness: a cross sectional study in shangla and swat districts,pakistan

Objective: To assess polio immunization coverage, awareness about polio and its vaccination and to find reasons of polio vaccination refusals in districts Swat and Shangla [the two conflict affected areas in recent past]

Methodology: This Cross-sectional descriptive study was carried out in Swat and Shangla districts, KPK, from January to July 2014. It was a door to door survey of 800 families selected by random sampling from four different localities of these two districts. Information gathered included educational status of both parents, number of children less than 5 years, polio vaccination history [both routine immunization and house to house approach] complete polio vaccination history, polio awareness level of parents and reasons of refusals to polio vaccination. Data collected was analyzed with SPSS version 21. Chi-square test was used to ascertain the association between various categorical variables and p value less than 0.05 was considered significant

Results: There were total 1775 children in age group 0-5 years in the 800 households under study. The children, who got vaccinated against polio, were 1392 [78 %]. Out of rest, 294 [16.5 %] had not been vaccinated against polio and the parents of remaining 89 [5%] children did not remember whether vaccination against polio was done or not. There was a significant association between educational status [minimum matriculate] of parents and polio vaccination [p=0.000]

Conclusion: The present day situation of polio vaccination is encouraging in areas under research. Law and order situation, illiteracy and misperceptions about the vaccine should be addressed along with the capacity building of the health care staff as soon as possible through sincere coordinated efforts for complete eradication of polio by all concerned institutions

Efficacy of vacuum assisted closure in management of open wounds as compared to moist wound dressing-experience at CMH Rawalpindi

Objective: To compare the efficacy of vacuum assisted closure [VAC] therapy against regular moist wound dressings in reducing the surface area of open chronic wounds by at least 5 mm2 in terms of early closure of wound

Study Design: Randomized controlled trail

Place and Duration of Study: This study was conducted at general surgery department CMH/MH Rawalpindi from Jun 2011 to Dec 2011 over a period of 06 months

Material and Methods: A total of 278 patients [139 in each group] were included in this study. Group A received VAC therapy while moist wound dressings applied in group B

Results: Mean age was 54.9 +/- 7.2 and 53.4 +/- 8.9 years in group A and B, respectively [statistically insignificant [p=0.12]. In group A, 96 patients [69.0%] and in group B 92 patients [66.2%] were male while 43 patients [31.0%] in group A and 47 patients [33.8%] in group B were female the difference being statistically insignificant [p=0.608]. In group A, 63 [45.3%] patients showed significant reduction in the size of the wound while only 41 [29.5%] patients in group B had adequate wound healing at the end of 04 weeks, the difference being statistically significant [p=0.0064]

Conclusion: VAC therapy decreases wound size more effectively than moist wound dressing technique. It definitely reduces hospital stay and ensures early return to work

Awareness of hookah smokers regarding its harmfulness among attendee of cafés in Erbil city

Background and objective: Hookahs are water pipes that are used to smoke specially made tobacco that comes in different flavors. Hookah has many of the same health risks as cigarette smoking. This study aimed to assess the awareness of hookah smokers about its harmfulness and identify the reasons for smoking hookah

Methods: This study was conducted in all venues of cafes and restaurants located geographically in Erbil city during the period from June 27[th], 2014 to February 4[th], 2015. A questionnaire was used to obtain the smoking pattern, awareness and perceptions of 325 male peoples towards the harmfulness of smoking. Direct interview was used for data collection

Results: A total number of 325 male people participated in this study. Their age ranged from 18-25 years. Most of them were singles, from urban areas and preferred to smoke in café [61.8%]. More than one person was using the same hookah. The average duration of smoking was more than 46 minutes. Around half of the participants [49.5 %] were smoking hookah with friends as a group activity and 35.1% had a headache and dizziness during smoking hookah. The overall awareness about the harmfulness of smoking the hookah was poor [56%]

Conclusion: The overall awareness about harmful of smoking hookah was poor among attendees of cafes

Pattern of initial clinical manifestations of systemic lupus erythematosus in a tertiary care hospital

Objective: To determine the pattern of initial clinical manifestations of Systemic Lupus Erythematosus [SLE] and to compare these features with those recorded elsewhere in Pakistan

Methods: This cross-sectional, descriptive study was performed in the Department of Rheumatology, Fatima Memorial Hospital, Lahore, Pakistan, from November 2015 to January 2016. Sixty one patients of SLE diagnosed as per ACR [American College of Rheumatology] 1982 revised criteria, were enrolled. The patients were evaluated for the initial clinical manifestations of SLE. The information was collected on a specially designed proforma and analyzed by using SPSS version 17

Results:Out of 61 patients, 49 [80.3%] were females and 12 [19.7%] males, showing a female to male ratio of 4:1. The mean age of patients was 26.2 +/- 7.9 years. Fatigue was the most common presenting feature in 56 [91.8%] patients, followed by joint pains in 55 [90.2%] and fever in 54 [88.5%]. Renal involvement was found in 46 [75.4%]. Comparison of these presenting features was made with other studies carried out in Northern Pakistan [Islamabad] and in central Punjab [Pakistan]. There were statistically significant differences in fever, fatigue and arthritis between our patients and the other two above mentioned study groups. However, comparison of renal manifestations showed significant difference only with Islamabad study, and not with previous study from central Punjab

Conclusion:In this study, majority of patients presented with combination of fatigue, fever, rash and arthritis. Almost three-fourth of patients had renal manifestations at initial presentation. Therefore, it is important for clinicians to have high index of suspicion for SLE, when patients present with above symptoms