Cognitive dysfunction (CD) is a common yet often clinically subtle manifestation that considerably impacts the health-related quality of life in patients with systemic lupus erythaematosus (SLE). Given the inconsistencies in CD assessment and challenges in its attribution to SLE, the reported prevalence of CD differs widely, ranging from 3 to 88%. The clinical presentation of CD in SLE is non-specific and may manifest concurrently with overt neuropsychiatric illness such as psychosis or mood disorders or as isolated impairment of attention, working memory, executive dysfunction or processing speed. Despite the lack of standardized and sensitive neuropsychological tests and validated diagnostic biomarkers of CD in SLE, significant progress has been made in identifying pathogenic neural pathways and neuroimaging.Furthermore, several autoantibodies, cytokines, pro-inflammatory mediators and metabolic factors have been implicated in the pathogenesis of CD in SLE. Abrogation of the integrity of the blood-brain barrier (BBB) and ensuing autoantibody-mediated neurotoxicity, complement and microglial activation remains the widely accepted mechanism of SLE-related CD. Although several functional neuroimaging modalities have consistently demonstrated abnormalities that correlate with CD in SLE patients, a consensus remains to be reached as to their clinical utility in diagnosing CD. Given the multifactorial aetiology of CD, a multi-domain interventional approach that addresses the risk factors and disease mechanisms of CD in a concurrent fashion is the favourable therapeutic direction. While cognitive rehabilitation and exercise training remain important, specific pharmacological agents that target microglial activation and maintain the BBB integrity are potential candidates for the treatment of SLE-related CD.

With the emergence of wheat allergy in East Asian countries, WDEIA has become an important condition for physicians and Singapore is no exception. Under-recognition combined with life-threatening symptoms warrants better public awareness measures. In addition, further studies are necessary to identify possible unique genetic and environmental exposures that could explain the inter-regional differences of WDEIA.

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BackgroundCatastrophic antiphospholipid syndrome (CAPS) is a rare condition associated with high mortality1. Prompt recognition and treatment is important for optimal outcomes. Clinical features of CAPS can overlap with obstetric complications, leading to diagnostic challenge2.ObjectivesDescribe two patients with CAPS during immediate post-partum period.MethodsWe report two cases in a single centre over two years.ResultsA 38 year old with obstetric Antiphospholipid syndrome (APS) presented with epigastric pain, transaminitis and thrombocytopenia in keeping with evolving HELLP syndrome. Spontaneous complete miscarriage ensued. Post-delivery, she developed worsening abdominal pain and transaminitis (Table 1). Imaging demonstrated hepatic infarcts and patchy ground glass lung opacities. She was treated for CAPS with intravenous steroids and anticoagulation, and recovered.A 39 year old with primary APS (deep venous thrombosis and obstetric features) whose antenatal course was fraught with minor per vaginal bleeding (PVB) presented with heavy PVB at 22 weeks gestation requiring cessation of anticoagulation. She developed a deep venous thrombosis. Risk of clot propagation versus bleeding prompted cautious anticoagulation. Labour was induced for declining maternal health and poor foetal prognosis at 24 weeks, 3 days. Post-delivery, she developed abdominal pain, headache, transaminitis and worsening thrombocytopenia with heavy PVB requiring uterine artery embolization. Given features that were consistent with micro thrombi and ischaemia (Table 1), she was treated as for CAPS and HELLP syndrome with intravenous steroids, plasma exchange (PLEX) and intravenous immunoglobulin (IVIG), and recovered.Table 1 Case 1 Case 2 Gestational age on admission 17 weeks 5 days22 weeks 5 days Treatment during pregnancy prior to CAPS LMWH^ once daily, AspirinLMWH twice daily, Aspirin, Steroids, Hydroxychloroquine, monthly IVIG Time of onset of CAPS 2nd day after foetal loss4th day after foetal loss Organ involvement Hepatic, Pulmonary, PlacentaHepatic, Central nervous system, Placenta Laboratory results at onsets of CAPS Haemoglobin (g/dL) 7.410.1 Platelets (x109/L) 8228 AST°/ALT«/LDH◊ (U/L) 137/140/6901199/1130/2206 Estimated proteinuria (g/day) 2.72.3 Positive serologies Anti-RoAnti-nuclear antibody, Anti-double stranded DNA, Lupus anticoagulant, Anti-cardiolipin IgM/IgG, B2 glycoprotein IgM/IgG Treatment IV MP*, LMWH 1mg/kg/day twice dailyIV MP, PLEX, IVIG, LMWH 1mg/kg/day twice daily Outcomes Obstetric Intra-uterine foetal demise Maternal Recovery ^Low molecular weight heparin. °Aspartate aminotransferase. «Alanine aminotransferase. ◊Lactate dehydrogenase. *Intravenous MethylprednisoloneConclusionRecognition of CAPS is complex in pregnancy. Vigilance is required for urgent aggressive treatment to improve outcomes in this uncommon condition.References[1] Bucciarelli S, Espinosa G, Cervera R, et al. Mortality in catastrophic antiphospholipid syndrome: causes of death and prognostic factors in a series of 250 patients. Arthritis Rheu...

To characterise gout patients at high risk of hospitalisation and to develop a web-based prognostic model to predict the likelihood of gout-related hospital admissions. This was a retrospective single-centre study of 1417 patients presenting to the emergency department (ED) with a gout flare between 2015 and 2017 with a 1-year look-back period. The dataset was randomly divided, with 80% forming the derivation and the remaining forming the validation cohort. A multivariable logistic regression model was used to determine the likelihood of hospitalisation from a gout flare in the derivation cohort. The coefficients for the variables with statistically significant adjusted odds ratios were used for the development of a web-based hospitalisation risk estimator. The performance of this risk estimator model was assessed via the area under the receiver operating characteristic curve (AUROC), calibration plot, and brier score. Patients who were hospitalised with gout tended to be older, less likely male, more likely to have had a previous hospital stay with an inpatient primary diagnosis of gout, or a previous ED visit for gout, less likely to have been prescribed standby acute gout therapy, and had a significant burden of comorbidities. In the multivariable-adjusted analyses, previous hospitalisation for gout was associated with the highest odds of gout-related admission. Early identification of patients with a high likelihood of gout-related hospitalisation using our web-based validated risk estimator model may assist to target resources to the highest risk individuals, reducing the frequency of gout-related admissions and improving the overall health-related quality of life in the long term. Key points • We reported the characteristics of gout patients visiting a tertiary hospital in Singapore. • We developed a web-based prognostic model with non-invasive variables to predict the likelihood of gout-relatedhospital admissions.