Comparative risk of gout flares when initiating or escalating various urate-lowering therapy: a systematic review with network meta-analysis

OBJECTIVE

Systematically examine: comparative flare risk post initiation or escalation of different urate-lowering therapies (ULTs); comparative flare risk with and without concomitant flare prophylaxis; adverse event rates associated with flare prophylaxis; and optimal duration of flare prophylaxis.

METHODS

We searched Medline, Embase, Web of Science, Cochrane database and clinical trial registries from inception to November 2021 for trials investigating adults with gout initiating or escalating ULT. We performed random-effects network meta-analyses and calculated risk ratios (RR) between treatments. Bias was assessed using the Revised Cochrane risk-of-bias tool.

RESULTS

We identified 3775 records, of which 29 publications (27 trials) were included. When compared to placebo+prophylaxis, the RR of flares ranged from 1·08 [95% confidence interval (95% CI) 0·87-1·33] for febuxostat 40mg+prophylaxis to 2·65 [95% CI 1·58-4·45] for febuxostat 80mg+lesinurad 400mg+prophylaxis. Compared to ULT alone, the RR of flares was lower for ULT+rilonacept 160mg (RR=0·35 [95% CI 0·25-0·50]), ULT+rilonacept 80mg (RR=0·43 [95% CI 0·31-0·60]) and ULT+colchicine (RR=0·50 [95% CI 0·35-0·72]). There was limited evidence for other flare prophylaxis, and on prophylaxis harms and optimal duration. Primarily due to missing outcome data and bias in the selection of reported results, 71·4% and 63·4% of studies were assessed as high risk of bias for flares and adverse events respectively.

CONCLUSION

The relative risk of flares when introducing ULT varies depending on ULT drug and dosing strategy. There was limited data on ULT escalation. Flare prophylaxis with colchicine and rilonacept reduces flare incidence. More research is required on the harms and optimal duration of prophylaxis.

Barriers and Enablers in the Use of Parenteral Methotrexate in Rheumatoid Arthritis Patients: A Scoping Review

OBJECTIVE

Methotrexate (MTX) is effective in controlling disease activity in rheumatoid arthritis (RA). Parenteral MTX may have benefits over oral MTX, but it is rarely used in practice. To better understand this low usage rate, it is necessary to explore the barriers and enablers of therapy from the perspective of RA patients. The objectives of this scoping review were to describe RA patients' perspectives on the barriers and enablers in the use of parenteral MTX and to identify the research gaps in this field.

METHODS

The search was performed in Medline, Embase, Scopus, and Cochrane Library from inception to May 2021. Data synthesis was conducted using the Theoretical Framework of Acceptability. This scoping review included any type of study that explored the use of parenteral MTX by adult RA patients from the patients' perspective, written in English.

RESULTS

Fifteen studies were included; findings related to the constructs "affective attitude," "burden," "intervention coherence," and "self-efficacy" were explored the most, while some were rarely ("opportunity cost" and "perceived effectiveness") or not ("ethicality") reported. RA patients were generally satisfied with MTX injections ("affective attitude"). From the burden construct, the requirement for dexterity for administering MTX by injection was considered a barrier, whereas the lack of significant pain from MTX injection was considered an enabler.

CONCLUSION

The findings suggested that patients generally preferred parenteral MTX formulations with attributes that facilitate self-administration. However, much of the identified research focused on prefilled pen devices, and significant gaps were identified, such as a lack of qualitative research.

The Association between Proton Pump Inhibitors and Myocardial Infarction: What Do Food and Drug Administration Data Tell Us?

Objective:

There is limited and conflicting evidence on the association between proton pump inhibitors (PPIs) and myocardial infarction (MI). This study aims to examine the occurrence of MI associated with PPI use from the Food and Drug Administration (FDA) Adverse Event Reporting System database.

Methods:

This is a cross-sectional study using data from the FDA dated from December 2013 to April 2018. Standard descriptive statistics were used to describe demographic information. Logistic regression analyses were performed to investigate the association between the independent variables and MI.

Findings:

Among the 52,443 individuals who were taking a PPI and experienced an adverse event which was registered on the FDA database, 726 (1.38%) experienced MI. Of all the PPIs, esomeprazole had the largest proportion of users experiencing MI (1.81%). Compared to other PPIs, esomeprazole was associated with a significantly higher rate of MI (odds ratio [OR] =1.53, P < 0.001), whereas lansoprazole was associated with a lower rate of MI (OR = 0.74, P = 0.03).

Conclusion:

Among the PPIs, esomeprazole appeared to have the highest risk of MI. Although the observed associations do not infer causality, this study highlighted a need for further studies to determine if a PPI, especially esomeprazole, can indeed cause MI.

Influenza B outbreak in female psychiatric ward of Hospital Kuala Lumpur, Malaysia

Influenza outbreaks in tropical countries are rarely reported. This article reports four cases of influenza within a psychiatric ward of a tertiary hospital in Malaysia. These were patients with severe mental illness who were involuntarily admitted and did not show the classical triad of influenza-like-illness (ILI) at the beginning. However, severe respiratory complications developed requiring intubation. Referral and cooperation with the infectious disease team was initiated to help manage the outbreak while continuing psychiatric treatment. Incidences of influenza among hospitalised psychiatric patients should be treated seriously with immediate multidisciplinary approach to prevent severe unwanted complications.

The BRAF and NRAS mutation prevalence in dermoscopic subtypes of acquired naevi reveals constitutive mitogen-activated protein kinase pathway activation

BACKGROUND

Acquired naevi can have unique dermoscopic patterns that correspond to distinct microanatomical growth patterns. Previous studies on acquired naevi stratified according to dermoscopic pattern focused on the frequency of somatic BRAF mutations, whereas NRAS mutations remained to be elucidated.

OBJECTIVES

To investigate the BRAF and NRAS mutation prevalence and activation of the mitogen-activated protein kinase (MAPK) pathway in distinct dermoscopic subtypes of acquired naevi.

METHODS

Common mutations present in BRAF and NRAS were assessed in 40 globular, reticular and peripheral rim of globules (PG) subtypes of acquired naevi from 27 participants (19 male, 8 female; mean age 46·7 years) selected from 1261 eligible volunteers. Mutations were determined using the highly sensitive and quantitative QX200 droplet digital™ polymerase chain reaction (ddPCR) system.

RESULTS

The BRAF V600E (c.1799T>A or c.1799_1800delTGinsA) and BRAF V600K mutations were detected in 85% (n = 34/40) of naevi. All BRAF wild-type naevi (15%; n = 6/40) harboured an NRAS codon 12/13 or 61 mutation. BRAF mutations were present in 92% (n = 12/13) of globular and 100% (n = 12/12) of PG naevi, whereas reticular naevi were 67% (n = 10/15) BRAF- and 33% (n = 5/15) NRAS-mutant (P = 0·037).

CONCLUSIONS

We discovered that 100% of the assessed acquired naevi had either a BRAF or NRAS mutation. Using sensitive techniques capable of single-cell mutation detection, it is likely that all acquired naevi will be mutated for BRAF or NRAS. Because both of these mutations are prevalent in distinct dermoscopic naevus subsets, our study supports the role of the MAPK pathway in the development of benign melanocytic proliferations, indicating that additional genomic events besides somatic mutations in BRAF or NRAS are required for melanoma development.

[Risk factors for acute rejection in living-donor kidney transplant recipients in China: a subgroup analysis of a multi-center, registry study]

Objective: To evaluate pre-and early post-transplantation risk factors for acute rejection(AR) in kidney recipients. Methods: This subgroup analysis of a multi-center registry study was conducted on living-donor kidney transplant recipients in China with 10 years of follow-up. This study analyzed 1 255 recipients including 921 males(73.4%) and with a mean age of (33±10)years. Data from patients were first analyzed with univariate analysis and then multivariate analysis was used for finding out the potential risk factors of AR. Results: A total of 106(8.4%) patients were suspected with AR after kidney transplantation, while 1 149 patients were considered as non-AR. Multivariable analysis demonstrated a significant influence of recipient age and cold ischemia time(CIT) on the occurrence of AR(OR: 0.956, 95% CI: 0.923-0.990; OR: 1.006, 95% CI: 1.002-1.011, respectively). The frequency of severe infection was significantly higher in the AR group than non-AR group(38.7% vs 10.8%; P<0.000 1). The occurrence of new-onset diabetes mellitus and tumors was similar in the two groups. Conclusions: Recipient age and CIT are risk factors for AR after living-donor kidney transplantation. Reducing CIT and intensive management of younger recipient could benefit kidney transplant patients.

Lack of clinical significance of the ImmuKnow(TM)-Cylex assay for the detection of cellular immune function in patients with renal cell carcinoma

This study aimed to explore the clinical value of the CD4(+) T cell ATP levels in patients with renal cell carcinoma through the application of the ImmuKnow(TM)-Cylex(®) assay. We recruited 104 patients with renal cancer who had undergone surgery at Fuzhou General Hospital from March 2009 to June 2012, and were subsequently treated by dendritic cell and cytokine-induced killer cell bio-therapy or interferon-α therapy. The changes in CD4(+) T cell ATP levels were detected at the perioperative period and at 10 days, 1 month, 3 months, and 1 year after the surgery using the ImmuKnow assay. In addition, the differences in ATP levels in different therapy groups were compared and the prognosis conditions were analyzed. Our results demonstrated that no significant difference in the ATP levels occurred at different time points; furthermore, there were no obviously different ATP levels between the different therapy groups, and the ATP levels were found to have no clinical significance for the assessment of renal cancer prognosis. Overall, this study suggested that CD4(+) T cell ATP levels as detected by the ImmuKnow assay have no obvious clinical value in patients with renal cancer.

One Year Results of Preoperative Single Bolus ATG-Fresenius Induction Therapy in Sensitized Renal Transplant Recipients

Sensitization in kidney transplantation is associated with more acute rejections, inferior graft survival, and an increase in delayed graft function. This study was designed to evaluate the efficacy and safety of preoperative single bolus antithymocyte globulin (ATG) induction therapy in sensitized renal transplant recipients.

METHODS

Fifty-six cadaveric donor kidney transplant recipients were divided into two groups: Group I (nonsensitized group, n = 30) and group II (sensitized group, PRA>10%, n = 26). ATG was given as a single preoperative bolus induction therapy to group II (ATG IV; 9 mg/kg). The group I patients were treated with mycophenolate mofetil preoperatively as induction therapy. The basic immunosuppressive regimen included tacrolimus (FK-506) or cyclosporine, mycophenolate mofetil, and prednisolone. After hospital discharge, patients were followed on a routine outpatient basis for 12 months.

RESULTS

Acute rejection episodes (ARE) occurred in 20% (6/30) of group I and 15.38% (4/26) of group II patients (P = NS). Infections occurred in eight patients (26.7%) as 11 episodes (36.7%), averaging 1.4 episodes per infected patient in group 1, and 6 patients (23.1%) for a total of 10 episodes (38.5%), averaging 1.7 episodes per infected patient, in group II (P = NS). Occurrence of side effects and hospital stay were almost comparable in the two groups. No delayed graft function was observed in either group. The 12-month actuarial patient and graft survival were 100% in Group I and II.

CONCLUSION

A preoperative single bolus ATG induction therapy was an effective and safe therapeutic measure, yielding an acceptable acute rejection rate in presensitized renal transplant recipients.

Use of sedation in dentistry

Fear and avoidance of dental treatment are major deterrents to oral health. Sedation can be used to control both the patient's fear and anxiety so that proper dental care can be provided for these patients. The purpose of this article is to discuss the use of sedation in dentistry and to provide a recommendation on the requirements and medico-legal aspects of sedation for the practitioner interested in incorporating sedation into their practice.

Comparison of patient-controlled sedation with propofol and alfentanil for third molar surgery--preliminary results of a pilot study

Propofol and alfentanil are commonly used for sedation and pain control. A preliminary study to compare the usefulness of these drugs was carried out in ten healthy patients requiring bilateral wisdom tooth surgery. The operations were done in two appointments with the patient receiving a different drug on each occasion. Anxiety levels were recorded on visual analogue scales pre and post-operatively. Both agents caused a decrease in anxiety scores, with propofol causing a more significant reduction. Vomiting and nausea with alfentanil was noted in three patients. Propofol also had an amnesic effect which alfentanil did not have. In conclusion, propofol would appear to be the drug of choice within the limitations of this pilot study.