Interventional management of hyperhidrosis in secondary care: a systematic review

BACKGROUND

Hyperhidrosis is uncontrollable excessive sweating, which occurs at rest, regardless of temperature. The symptoms of hyperhidrosis can significantly affect quality of life.

OBJECTIVES

To undertake a systematic review of the clinical effectiveness and safety of treatments available in secondary care for the management of primary hyperhidrosis.

METHODS

Fifteen databases (including trial registers) were searched to July 2016 to identify studies of secondary-care treatments for primary hyperhidrosis. For each intervention randomized controlled trials (RCTs) were included where available; where RCT evidence was lacking, nonrandomized trials or large prospective case series were included. Outcomes of interest included disease severity, sweat rate, quality of life, patient satisfaction and adverse events. Trial quality was assessed using a modified version of the Cochrane Risk of Bias tool. Results were pooled in pairwise meta-analyses where appropriate, otherwise a narrative synthesis was presented.

RESULTS

Fifty studies were included in the review: 32 RCTs, 17 nonrandomized trials and one case series. The studies varied in terms of population, intervention and methods of outcome assessment. Most studies were small, at high risk of bias and poorly reported. The interventions assessed were iontophoresis, botulinum toxin (BTX) injections, anticholinergic medications, curettage and newer energy-based technologies that damage the sweat gland.

CONCLUSIONS

The evidence for the effectiveness and safety of treatments for primary hyperhidrosis is limited overall, and few firm conclusions can be drawn. However, there is moderate-quality evidence to support the use of BTX for axillary hyperhidrosis. A trial comparing BTX with iontophoresis for palmar hyperhidrosis is warranted.

Transcriptional Profiling of Synovial Macrophages Using Minimally Invasive Ultrasound-Guided Synovial Biopsies in Rheumatoid Arthritis

OBJECTIVE

Currently, there are no reliable biomarkers for predicting therapeutic response in patients with rheumatoid arthritis (RA). The synovium may unlock critical information for determining efficacy, since a reduction in the numbers of sublining synovial macrophages remains the most reproducible biomarker. Thus, a clinically actionable method for the collection of synovial tissue, which can be analyzed using high-throughput strategies, must become a reality. This study was undertaken to assess the feasibility of utilizing synovial biopsies as a precision medicine-based approach for patients with RA.

METHODS

Rheumatologists at 6 US academic sites were trained in minimally invasive ultrasound-guided synovial tissue biopsy. Biopsy specimens obtained from patients with RA and synovial tissue from patients with osteoarthritis (OA) were subjected to histologic analysis, fluorescence-activated cell sorting, and RNA sequencing (RNA-seq). An optimized protocol for digesting synovial tissue was developed to generate high-quality RNA-seq libraries from isolated macrophage populations. Associations were determined between macrophage transcriptional profiles and clinical parameters in RA patients.

RESULTS

Patients with RA reported minimal adverse effects in response to synovial biopsy. Comparable RNA quality was observed from synovial tissue and isolated macrophages between patients with RA and patients with OA. Whole tissue samples from patients with RA demonstrated a high degree of transcriptional heterogeneity. In contrast, the transcriptional profile of isolated RA synovial macrophages highlighted different subpopulations of patients and identified 6 novel transcriptional modules that were associated with disease activity and therapy.

CONCLUSION

Performance of synovial tissue biopsies by rheumatologists in the US is feasible and generates high-quality samples for research. Through the use of cutting-edge technologies to analyze synovial biopsy specimens in conjunction with corresponding clinical information, a precision medicine-based approach for patients with RA is attainable.

Importance of tau in cognitive decline as revealed by developmental exposure to lead

Previous reports by us have determined that developmental exposure to the heavy metal lead (Pb) resulted in cognitive impairment in aging wildtype mice, and a latent induction in biomarkers associated with both the tau and amyloid pathways. However, the relationship between these two pathways and their correlation to cognitive performance needs to be scrutinized. Here, we investigated the impact of developmental Pb (0.2%) exposure on the amyloid and tau pathways in a transgenic mouse model lacking the tau gene. Cognitive function, and levels of intermediates in the amyloid and tau pathways following postnatal Pb exposure were assessed on young adult and mature transgenic mice. No significant difference in behavioral performance, amyloid precursor protein (APP), or amyloid beta (Aβ) levels was observed in transgenic mice exposed to Pb. Regulators of the tau pathway were impacted by the absence of tau, but no additional change was imparted by Pb exposure. These results revealed that developmental Pb exposure does not cause cognitive decline or change the expression of the amyloid pathway in the absence of tau. The essentiality of tau to mediate cognitive decline by environmental perturbations needs further investigation.

Patient-provider discordance between global assessments of disease activity in rheumatoid arthritis: a comprehensive clinical evaluation

Background

Discordance between patients with rheumatoid arthritis (RA) and their rheumatology health care providers is a common and important problem. The objective of this study was to perform a comprehensive clinical evaluation of patient-provider discordance in RA.

Methods

A cross-sectional observational study was conducted of consecutive RA patients in a regional practice with an absolute difference of ≥ 25 points between patient and provider global assessments (possible points, 0–100). Data were collected for disease activity measures, clinical characteristics, comorbidities, and medications. In a prospective substudy, participants completed patient-reported outcome measures and underwent ultrasonographic assessment of synovial inflammation. Differences between the discordant and concordant groups were tested using χ² and rank sum tests. Multivariable logistic regression was used to develop a clinical model of discordance.

Results

Patient-provider discordance affected 114 (32.5%) of 350 consecutive patients. Of the total population, 103 patients (29.5%) rated disease activity higher than their providers (i.e., ‘positive’ discordance); only 11 (3.1%) rated disease activity lower than their providers and were excluded from further analysis. Positive discordance correlated with negative rheumatoid factor and anticyclic citrullinated peptide antibodies, lack of joint erosions, presence of comorbid fibromyalgia or depression, and use of opioids, antidepressants, or anxiolytics, or fibromyalgia medications. In the prospective study, the group with positive discordance was distinguished by higher pain intensity, neuropathic type pain, chronic widespread pain and associated polysymptomatic distress, and limited functional health status. Depression was found to be an important mediator of positive discordance in low disease activity whereas the widespread pain index was an important mediator of positive discordance in moderate-to-high disease activity states. Ultrasonography scores did not reveal significant differences in synovial inflammation between discordant and concordant groups.

Conclusions

The findings provide a deeper understanding of patient-provider discordance than previously known. New insights from this study include the evidence that positive discordance is not associated with unrecognized joint inflammation by ultrasonography and that depression and fibromyalgia appear to play distinct roles in determining positive discordance. Further work is necessary to develop a comprehensive framework for patient-centered evaluation and management of RA and associated comorbidities in patients in the scenario of patient-provider discordance.

A multicentre study of long-term follow-up and owner satisfaction following enucleation in horses

BACKGROUND

Horses are reported to return to a variety of disciplines following unilateral enucleation; however, owners of horses with ocular disease are frequently reluctant to consider the procedure. There is little published information investigating owners' attitudes towards, and satisfaction following, enucleation.

OBJECTIVES

To investigate the hypotheses: 1) horses return to their previous level of work following unilateral enucleation and 2) their owners are satisfied with the post-operative outcome.

STUDY DESIGN

Retrospective case series with cross-sectional survey.

METHODS

Clinical records from eight equine referral centres in the United Kingdom were reviewed to identify horses that underwent enucleation between August 2006 and March 2015. Owner questionnaires were completed to corroborate information provided by medical records and obtain information on client perceptions.

RESULTS

A total of 170 cases were identified and 119 owner questionnaires completed. The most frequent primary uses of horses in the study were pleasure/leisure riding, showjumping and dressage, with 25.2% (n = 30) of horses used for competition. Following enucleation, 77.3% (n = 92) of horses were performing at an equivalent or higher level than prior to enucleation and 60.0% (n = 18/30) of competition horses were competing at an equivalent or higher level. Complications related to the surgical site (predominantly mild post-operative swelling) were reported in 3.7% of cases and nonocular complications in 3.7% of cases. Of owners who reported being concerned or very concerned about certain factors prior to surgery, ≥86.8% reported that these factors caused little or no issue post-surgery. Most owners, 90.8% (n = 108) were pleased with the outcome following surgery, with 21.3% (n = 23/108) wishing the procedure had been undertaken sooner.

MAIN LIMITATIONS

Retrospective data collection from clinical records and the potential for recall bias.

CONCLUSIONS

Horses can return successfully to a variety of disciplines following enucleation. Owners are satisfied with the outcome and pleased that enucleation was performed.

Effect of MTA particle size on periapical healing

AIM

To examine the effect of reduction in MTA particle size on dento-alveolar and osseous healing in dogs.

METHODOLOGY

Root canals of 24 mandibular premolars in four 2-year-old beagles were prepared and filled with gutta-percha and sealer. Two to four weeks later, during periapical surgery, the root-end cavity preparations in these teeth were filled with either grey ProRoot MTA or modified (reduced particle sizes with faster setting time) MTA. The animals were sacrificed 4 months later. Degrees of inflammation, type of inflammatory cells, fibrous connective tissue adjacent to the root-end filling materials, cementum formation over the resected roots and root-end filling materials and bone healing were examined. Data were analysed using the McNemar test.

RESULTS

No significant differences in healing of periapical tissues were found when comparing ProRoot MTA to a modified MTA containing reduced particle sizes.

CONCLUSION

Reducing the particle sizes of MTA did not impact its biological properties.

An expansion of rare lineage intestinal microbes characterizes rheumatoid arthritis

Background

The adaptive immune response in rheumatoid arthritis (RA) is influenced by an interaction between host genetics and environment, particularly the host microbiome. Association of the gut microbiota with various diseases has been reported, though the specific components of the microbiota that affect the host response leading to disease remain unknown. However, there is limited information on the role of gut microbiota in RA. In this study we aimed to define a microbial and metabolite profile that could predict disease status. In addition, we aimed to generate a humanized model of arthritis to confirm the RA-associated microbe.

Methods

To identify an RA biomarker profile, the 16S ribosomal DNA of fecal samples from RA patients, first-degree relatives (to rule out environment/background as confounding factors), and random healthy non-RA controls were sequenced. Analysis of metabolites and their association with specific taxa was performed to investigate a potential mechanistic link. The role of an RA-associated microbe was confirmed using a human epithelial cell line and a humanized mouse model of arthritis.

Results

Patients with RA exhibited decreased gut microbial diversity compared with controls, which correlated with disease duration and autoantibody levels. A taxon-level analysis suggested an expansion of rare taxa, Actinobacteria, with a decrease in abundant taxa in patients with RA compared with controls. Prediction models based on the random forests algorithm suggested that three genera, Collinsella, Eggerthella, and Faecalibacterium, segregated with RA. The abundance of Collinsella correlated strongly with high levels of alpha-aminoadipic acid and asparagine as well as production of the proinflammatory cytokine IL-17A. A role for Collinsella in altering gut permeability and disease severity was confirmed in experimental arthritis.

Conclusions

These observations suggest dysbiosis in RA patients resulting from the abundance of certain rare bacterial lineages. A correlation between the intestinal microbiota and metabolic signatures could determine a predictive profile for disease causation and progression.

Electronic supplementary material

The online version of this article (doi:10.1186/s13073-016-0299-7) contains supplementary material, which is available to authorized users.

ID: 133: SINGLE CELL GENE EXPRESSION IN CLASSICAL MONOCYTES CORRELATES WITH TREATMENT RESPONSE TO TNF-ALPHA INHIBITION IN RHEUMATOID ARTHRITIS

Background

In management of rheumatoid arthritis (RA), initiating effective treatment as soon as possible within the so-called therapeutic “window of opportunity” is the strategy, and disease remission is a primary goal. Recent work from our group demonstrated that pre-treatment serum type I IFN-β/α activity ratio>1.3 can predict non-response to anti-TNF-alpha therapy in RA patients. The cellular mechanisms that underlie the IFN-β/α activity ratio that predicts response are not known. Effects of IFN on single immune cells and uncommon cell populations may be masked in whole blood or mixed cell populations.

Methods

To better understand the underpinnings of the pre-treatment IFN-β/α activity ratio, we used single cell expression analysis to investigate whether monocyte gene expression differs significantly between RA patients according to their pre-TNF-α inhibitor serum IFN-β/α activity ratio. Single classical (CL) and single non-classical (NCL) blood-derived monocytes were isolated from 15 seropositive RA subjects prior to biologic therapy. Total serum type I IFN, IFN-α, and IFN-β activity were measured using a functional reporter cell assay. Subjects were grouped by pre-TNF-α inhibitor serum IFN-β/α activity ratio into two groups, IFN-β/α>1.3 (n=6) and IFN-β/α<1.3 (n=9). Comparisons between groups were by Mann-Whitney. Hierarchical clustering of 87 target genes was done to determine if there were functional gene expression differences between groups.

Results

Hierarchical clustering revealed striking differences of expression of gene sets in CL monocytes between patients with IFN-β/α<1.3 and IFN-β/α>1.3, the groups which correspond to response/non-response to anti-TNF-α agents. This same clustering was not observed in NCL monocytes, and the differentiation between anti-TNF-α response patient groups was lost when hierarchical clustering was done on total monocytes (CL and NCL). Two major gene sets which differentiated subjects with IFN-β/α>1.3 (non-response to anti-TNF-α group) in CL monocytes included TLR and IFN pathway genes, cell surface markers and cytokines as follows: cluster 1 (TLR2, CD16, JAK1, IFI27, IL1A, and MAVS) and cluster 2 (GMCSF, TLR7, STAT2, ILT7, MYD88).

Conclusion

These within-cell expression patterns demonstrate biological differences in CL monocytes of RA patients with an IFN-β/α>1.3, the ratio of type I IFNs previously found to be predictive of non-response to anti-TNF-α therapy. Differentiation by gene expression among the response/non-response patient groups is lost when comparing gene expression in single NCL monocytes and single mixed population monocytes (CL and NCL), suggesting that further study of CL monocytes will likely illuminate molecular differences that determine treatment response to TNF-α inhibition in RA. This work will help to develop a more individualized approach to therapy in RA based upon the underlying biology of disease in a given patient.

Explorations of Cooperation and Recalcitrance in Secure Mental Health Hospitals

This paper reports on the findings of three qualitative research studies undertaken within, respectively, medium and low secure units in one UK region, and a high secure mental health hospital in England (UK). The first study investigated alliance based involvement practices. The second explored service user and staff views and sense making of the notion of recovery. The third study is ongoing into service user and staff experiences of extreme coercive measures, such as forms of restraint and long-term seclusion or segregation. All studies utilised either semi-structured interviews or focus groups. All data was subject to thematic analysis.

Selected and emergent themes include:

– the importance of relationships and communication; security first; involvement as pacification;

– different understandings of recovery; the importance of meaningful occupation; staff-service user relationships; recovery journeys and dialogue with the past; and recovery as personal responsibility;

– good and bad coercion; cooperation, resistance and recalcitrance; and alternatives to coercion.

Findings suggest that cooperation is largely framed by services in terms of compliance with a bio-medical model. The impact of the secure environment, whilst ever-present, is not an absolute constraint on the realisation of recovery or involvement objectives. The availability of extreme coercive measures raises some seemingly paradoxical understandings from both service user and staff perspectives. Critical social theory is drawn on to illuminate the tensions between cooperation and recalcitrance and suggest further exploration of their respective legitimacy.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

A pilot study of factors associated with glycaemic control in adults with Type 1 diabetes mellitus on insulin pump therapy

AIMS

To identify the knowledge and management factors associated with glycaemic control among adults with Type 1 diabetes mellitus treated with insulin pump therapy.

METHODS

A cross-sectional study of adults with Type 1 diabetes mellitus on insulin pump therapy for at least 12 months (n = 50, 18-70 years old) was undertaken between December 2013 and May 2014. A new questionnaire was developed to evaluate participants' knowledge and management related to insulin pump therapy, and were correlated with insulin pump data, HbA1c and frequency of hypoglycaemia.

RESULTS

Participants who changed their insulin pump settings when indicated had significantly better glycaemic control than those who did not (P = 0.04). Multivariate logistic regression analysis found that better overall insulin pump therapy management was a significant predictor of better glycaemic control (odds ratio 4.45, 95% confidence interval 1.61-12.3; P = 0.004) after adjusting for potential confounders including age, gender, duration of diabetes and insulin pump therapy. However, overall insulin pump therapy knowledge was not a significant predictor of glycaemic control (P = 0.058). There was no significant association between frequency of hypoglycaemia and insulin pump therapy knowledge or management.

CONCLUSIONS

We identified some key knowledge and management factors associated with glycaemic control in adults with Type 1 diabetes mellitus on insulin pump therapy using a newly designed questionnaire. The pilot study assessed the clinical utility of this evaluation tool, which may facilitate provision of targeted education to insulin pump therapy users to achieve optimal glycaemic control.