Efficacy of Isotretinoin and Antihistamine versus Isotretinoin Alone in the Treatment of Moderate to Severe Acne: A Randomised Control Trial

Background Acne vulgaris has considerable impact on physical and psychological health. Isotretinoin is considered most effective drug available for acne therapy but with limited acceptance because of its adverse effects. Antihistamine inhibits inflammatory mediators, Propionibacterium acne induced itching, reduction of squalene and sebum in sebocyte, reduces anxiety and further lessens hormonal derangement and inhibits mast cell induced fibrosis and scars. Clinical relevance is lacking in the use of antihistamine in the treatment of acne and its potential efficacy needs to be clarified. Objective To evaluate the efficacy and safety of combining isotretinoin and antihistamine compare to isotretinoin alone in patients with moderate to severe acne at week 12. Method One hundred patients with moderate to severe acne were included in this randomised, controlled comparative study. Fifty patients were treated with isotretinoin and 50 patients were treated with additional antihistamine, levocetirizine and assessment was done at baseline, 4, 8 and 12 weeks of treatment. Result At week 12, compared to isotretinoin only group, combination of isotretinoin and levocetirizine group showed more statistically significant decrease in score of global acne grading system (51.0 vs. 38.5%) and acne lesion counts (non-inflammatory lesion: 63.2 vs. 44.5%; inflammatory lesions: 75.9 vs. 62.7%; total lesions: 66.07 vs. 48.7%; all p< 0.05). Flaring up of acne occurred less frequently and adverse effects were more tolerable in levocetirizine group. Conclusion Use of antihistamine with isotretinoin provides synergic effect while minimizing the side effect of isotretinoin and greater clearance of the lesion and scars.

Effect of probiotics on C-reactive protein levels in preterm infants: Secondary analysis of a randomized controlled trial

BACKGROUND

Excessive inflammation is associated with adverse outcomes in preterm infants. C- reactive protein (CRP) is a marker of inflammation/infection. Probiotics have anti-inflammatory properties. Randomized controlled trials (RCTs) in preterm infants have not reported effect of probiotics on CRP.

AIM

To evaluate effect of probiotics on CRP in preterm infants who had participated in a RCT of Bifidobacterium breve (B. breve) m-16v.

METHODS

Data on all infants (GA <33 weeks, n = 159) enrolled in the RCT was analyzed. For study purpose, CRP <15 mg/L and ≤10 mg/L was considered normal for the first week, and thereafter respectively. Mixed logistic regression modelling was used to assess probiotic effect on CRP levels.

RESULTS

There were 1579 CRP measurements (Probiotic: 851 vs. Placebo: 728). Baseline characteristics and number [Median (IQR)] of CRP estimations per infant [l0 (5, 20) vs. 10 (6, 17), p = 0.861] were comparable between probiotic vs. placebo group. There was no significant difference in the proportion of infants with high CRP over time (treatment by weekly time points interaction, p = 0.187), and across all time points between probiotic and placebo group (adjusted OR: 1.62, 95% CI: 0.91-2.88, p = 0.102)CONCLUSION:B. breve m-16v did not decrease CRP levels in preterm infants born <33 weeks.

High-resolution mapping and modeling of anammox recovery from recurrent oxygen exposure

Oxygen inhibits anammox, a bioconversion executed by anoxic ammonium oxidizing bacteria (AnAOB). Nonetheless, oxygen is mostly found in the proximity of AnAOB in nitrogen removal applications, being a substrate for nitritation. The experiments performed to date were mostly limited to batch activity tests where AnAOB activity is estimated during oxygen exposure. However, little attention has been paid to the recovery and reversibility of activity following aerobic conditions, of direct relevance for bioreactor operation. In this work, anoxic and autotrophic reactor cultivation at 20 °C yielded an enriched microbial community in AnAOB, consisting for 75% of a member of the genus Brocadia. High-resolution kinetic data were obtained with online ammonium measurements and further processed with a newly developed Python data pipeline. The experimentally obtained AnAOB response showed complete inhibition until micro-aerobic conditions were reached again (<0.02 mg O₂ L^-1). After oxygen inhibition, AnAOB recovered gradually, with recovery times of 5-37 h to reach a steady-state activity, dependent on the perceived inhibition. The recovery immediately after inhibition was lowest when exposed to higher oxygen concentrations (range: 0.5-8 mg O₂ L^-1) with long contact times (range: 9-24 h). The experimental data did not fit well with a conventional 'instant recovery' Monod-type inhibition model. Yet, the fit greatly improved by incorporating a dynamic growth rate formula accurately describing gradual activity recovery. With the upgraded model, long-term kinetic simulations for partial nitritation/anammox (PN/A) with intermittent aeration showed a decrease in growth rate compared to the instant recovery mode. These results indicate that recovery of AnAOB after oxygen exposure was previously overlooked. It is recommended to account for this effect in the intensification of partial nitritation/anammox.

Sentinel and Non-Sentinel Lymph Node Metastasis Prediction and Validation of the MSKCC Nomograms for Indian Breast Cancer Patients

Background: Sentinel lymph node (SLN) biopsy accurately stages the axilla, but is time consuming and resource intensive. Nomograms and scoring systems have been developed, based on clinical and pathologic data available before surgery, to attempt to predict the likelihood of lymph node metastasis before surgery. As the management of the axilla in patients with low nodal burden changes, it is also important to predict whether there will be further axillary disease in patients with a positive SLN. Aim: To explore the risk factors for SLN and non-SLN metastasis in Indian women with breast cancer, by analysis of clinical and pathologic data. To assess the validity and clinical utility of two MSKCC nomograms that predicts axillary lymph node status for Western patients. Methods: Clinical data, and pathologic data available from core biopsy, for a consecutive series of women having SLNB was analyzed, and was plotted on two MSKCC nomograms. Univariate analysis was done by χ2 and Fischer exact tests and multivariate analysis was done by logistic regression method. A receiver-operating characteristic (ROC) curve was drawn and predictive accuracy was assessed by calculating the area under the ROC curve (AUC). Results: 34% (89 out of 256) of our patients had SLN positivity. When correlated with SLN metastasis by univariate analysis, LVI (χ2 = 80, P ≤ 0.001), PNI (χ2 = 13.36, P ≤ 0.001), ER+ (χ2 = 6.85, P = 0.009), PR+ (χ2 = 7.1, P = 0.008) and age ( P = 0.03) were significant. However, multivariate analysis showed that age (OR=1.04, P = 0.007) and LVI (OR=0.07, P ≤ 0.001) were identified as independent predictors for SLN metastasis. The area under the ROC curve was 0.772 and it fairly correlated with MSKCC nomogram. Patients with MSKCC scores lower than 38% had a frequency of SLN metastasis of 7.7% (5/65) and this cut-off could be used as a guide for not doing frozen section analysis in this subgroup. Further axillary dissection showed 41% (38 out of 92) had non-sentinel nodes positive. When correlated with non-SLN metastasis by univariate analysis, LVI (χ2 = 8.8, P = 0.003), PNI (χ2 = 6.85, P = 0.009), and extracapsular extension (χ2 = 4.18, P = 0.04) were significant. Number of SLN negative ( P = 0.01), SLN ratio (number of SLN positive/total number of SLN removed) ( P = 0.01) and size of SLN metastasis ( P = 0.002) were significant. However, multivariate analysis showed that only size of SLN metastasis (OR=0.845, P = 0.02) was identified as independent predictor for non-SLN metastasis. The area under the ROC curve was 0.66 and it poorly correlated with MSKCC nomogram. Conclusion: The MSKCC nomogram can provide a fairly accurate prediction of the probability of SLN metastasis, but is not for non-SLN metastasis. An institutional nomogram for non-SLN metastasis, including additional factors such as size of SLN metastasis, may improve prediction.

Bariatric fellowship positively influences early outcomes for laparoscopic Roux-en-Y gastric bypass surgery over seven years of independent practice

Introduction Laparoscopic Roux-en-Y gastric bypass (LRYGB) is technically demanding and has an associated learning curve. We published previously that bariatric fellowship reduces the learning curve of primary LRYGB and improves patient outcomes after one year of independent practice. However, the long-term effect of fellowship is unknown. We therefore aimed to compare the 30-day outcomes of LRYGB between the first year of a surgeon's independent practice with the subsequent six years. Materials and methods A prospective database of patients undergoing primary LRYGB under a single surgeon from March 2010 until February 2017 was analysed. Two groups were studied: first year (< 1 year) and the subsequent six years (≥ 1 year) of independent practice. Patient demographics, length of hospital stay, conversion to open surgery, perioperative complications and mortality were compared. Results Among 279 eligible patients, 74 (26.5%) were in the < 1 year group and 205 (73.5%) in ≥ 1 year group. The preoperative risk scores, American Society of Anesthesiologists (ASA) grade, P = 0.00; obesity surgery mortality risk score (OS-MRS), P = 0.04) were significantly higher in ≥ 1 year group. There was no significant difference in perioperative outcomes (length of stay, P = 0.38; total complications, P = 0.20; readmissions, P = 1.00; reoperations, P = 0.60) between the two groups. Conclusions Bariatric fellowship reduces the learning curve for LRYGB and helps to achieve excellent outcomes in the first and subsequent years of independent practice. The higher risk profile of ≥ 1 year group did not equate to an increase in complications, suggesting that experience and standardisation may help in handling complex cases. To our knowledge, this represents the only such study in the literature.

Assessment of nivolumab benefit-risk profile of a 240-mg flat dose relative to a 3-mg/kg dosing regimen in patients with advanced tumors

Background

Nivolumab 3 mg/kg every 2 weeks (Q2W) has shown benefit versus the standard of care in melanoma, non-small cell lung cancer (NSCLC), and renal cell carcinoma (RCC). However, flat dosing is expected to shorten preparation time and improve ease of administration. With knowledge of nivolumab safety, efficacy, and pharmacokinetics across a wide dose range in body weight (BW) dosing, assessment of the benefit–risk profile of a 240-mg flat dose relative to the approved 3-mg/kg dose was approached by quantitative clinical pharmacology.

Patients and methods

A flat dose of 240 mg was selected based on its equivalence to the 3-mg/kg dose at the median BW of ∼80 kg in patients in the nivolumab program. The benefit–risk profile of nivolumab 240 mg was evaluated by comparing exposures at 3 mg/kg Q2W and 240 mg Q2W across BW and tumor types; clinical safety at 3 mg/kg Q2W by BW and exposure quartiles in melanoma, NSCLC, and RCC; and safety and efficacy at 240 mg Q2W relative to 3 mg/kg Q2W in melanoma, NSCLC, and RCC.

Results

The median nivolumab exposure and its distribution at 240 mg Q2W were similar to 3 mg/kg Q2W in the simulated population. Safety analyses did not demonstrate a clinically meaningful relationship between BW or nivolumab exposure quartiles and frequency or severity of adverse events. The predicted safety and efficacy were similar across nivolumab exposure ranges achieved with 3 mg/kg Q2W or 240 mg Q2W flat dose.

Conclusion

Based on population pharmacokinetic modeling, established flat exposure–response relationships for efficacy and safety, and clinical safety, the benefit–risk profile of nivolumab 240 mg Q2W was comparable to 3 mg/kg Q2W. The quantitative clinical pharmacology approach provided evidence for regulatory decision-making on dose modification, obviating the need for an independent clinical study.

Alopecia Areata and Thyroid Dysfunction Association- A Study from Eastern Nepal

Background Alopecia areata (AA) is one of the non-scarring alopecia. Its etiology has not been well established till date. The most convincing hypothesis is autoimmune process for its causation. Amongst all, most frequent association was found with thyroid disorder. Objective To study the association of thyroid dysfunction in patients with alopecia areata. Method All patients of alopecia areata attending dermatology outpatient department and currently not receiving any treatment for alopecia areata were enrolled in the study. Relevant history and examination findings were recorded in the preset pro-forma. All of them were subjected for thyroid function test by chemiluminescence microparticle immunoassay method. Then thyroid function test of cases was compared with that of equal number of age and sex matched healthy controls. Result A total of 75 patients were enrolled in both case and control groups. Mean age of case and control groups were 29.40±9.90 and 28.96±9.89 years respectively (P=0.786). Median Severity of Alopecia Tool score was 2.47 (IQR=0.96-5.79). Prevalence of thyroid disorder was significantly higher in alopecia areata group (17.3%) as compared to the control group (1.3%) (P=0.001). Likewise, in individuals with abnormal thyroid function, alopecia areata disease severity grade and median severity of alopecia tool (SALT) score was higher as compared to those with normal thyroid function. Conclusion We found a significant association between alopecia areata and thyroid dysfunction. Hence thyroid function evaluation must be considered in individuals with alopecia areata. However, further studies with larger sample size are recommended before its generalization.

Angiogenic factors: potential to change clinical practice in pre-eclampsia?

Pre‐eclampsia is a complex disease with significant maternal and fetal morbidity and mortality. Its syndromic nature makes diagnosis and management difficult. The field is rapidly evolving with the definition of pre‐eclampsia being challenged by some organisations, with proteinuria no longer being essential in the presence of other features. In the last decade, angiogenic factors, in particular soluble fms‐like tyrosine kinase 1 (sFlt‐1), have emerged as important molecules in the pathogenesis of pre‐eclampsia. Here we review the most recent evidence regarding the potential of these factors as biomarkers and therapeutic targets for pre‐eclampsia.

Tweetable abstract

A review of angiogenic factors, sFlt‐1 and PlGF, in the diagnosis, prediction and management of pre‐eclampsia.

A review of angiogenic factors, sFlt‐1 and PlGF, in the diagnosis, prediction and management of pre‐eclampsia.

Comparison of Kaposi Sarcoma Risk in Human Immunodeficiency Virus-Positive Adults Across 5 Continents: A Multiregional Multicohort Study

BACKGROUND

We compared Kaposi sarcoma (KS) risk in adults who started antiretroviral therapy (ART) across the Asia-Pacific, South Africa, Europe, Latin, and North America.

METHODS

We included cohort data of human immunodeficiency virus (HIV)-positive adults who started ART after 1995 within the framework of 2 large collaborations of observational HIV cohorts. We present incidence rates and adjusted hazard ratios (aHRs).

RESULTS

We included 208140 patients from 57 countries. Over a period of 1066572 person-years, 2046 KS cases were diagnosed. KS incidence rates per 100000 person-years were 52 in the Asia-Pacific and ranged between 180 and 280 in the other regions. KS risk was 5 times higher in South African women (aHR, 4.56; 95% confidence intervals [CI], 2.73-7.62) than in their European counterparts, and 2 times higher in South African men (2.21; 1.34-3.63). In Europe, Latin, and North America KS risk was 6 times higher in men who have sex with men (aHR, 5.95; 95% CI, 5.09-6.96) than in women. Comparing patients with current CD4 cell counts ≥700 cells/µL with those whose counts were <50 cells/µL, the KS risk was halved in South Africa (aHR, 0.53; 95% CI, .17-1.63) but reduced by ≥95% in other regions.

CONCLUSIONS

Despite important ART-related declines in KS incidence, men and women in South Africa and men who have sex with men remain at increased KS risk, likely due to high human herpesvirus 8 coinfection rates. Early ART initiation and maintenance of high CD4 cell counts are essential to further reducing KS incidence worldwide, but additional measures might be needed, especially in Southern Africa.

Lung cancer: analysis of biomarkers and methods of diagnostic and prognostic value

This paper summarizes the overwhelming evidence that targeted therapy is better than chemotherapy for the treatment of lung cancer. The focus is on lung cancer because of the sheer magnitude of this disease especially in males. In India, lung cancer constitutes 6.9 per cent of all new cancer cases and 9.3 per cent of all cancer related deaths in both sexes (1). Currently the world we reside has a norm of developing cure to an abnormal state of living body (so called disease) based on evidences, recognized during the diagnosis of the disease. It is done to ensure optimized therapy of treatment and maximize the outcome. Personalized medicine is also an uprising norm. In this kind, all the variables such as host, environment, patient, etc. are considered for an individual case and the course of treatment is followed based on the standard options available. Its main objective is the best interest of the patient. Through a survey conducted in the northern belt of the country we tried to determine the biomarkers currently being used and the scope of targeted therapy. Thus, in its most basic form medicine is not only a science but is also an art.