Articular spacers in two-stage revision arthroplasty for prosthetic joint infection of the hip and the knee

Use of articular antibiotic-eluting cement spacers during two-stage revision arthroplasty for prosthetic joint infection (PJI) is a long-established and proven adjunctive technique during first-stage surgery. Articular spacers come in many forms, either static or dynamic. The authors present an instructional review of current evidence regarding their use.

A total of 45 studies (for spacer use in PJI involving either hip or knee) were analysed for data regarding eradication rate, functional outcomes, mechanical complications and the impact on second-stage surgery. A large number of case series and retrospective cohort studies were retrieved, with only a small number of prospective studies (2).

High levels of infection eradication were commonly reported (>80%). Outcome scores were commonly reported as indicating good-to-excellent function and pain levels. Second-stage procedures were often not required when dynamic spacers were used. Static spacers were associated with more mechanical complications in both the hip and the knee. In the hip, dynamic spacers were more commonly associated with instability compared to static spacers. Consideration should be given to the use of dual-mobility or constrained definitive acetabular components in these cases at second-stage surgery.

The use of antibiotic-eluting polymethylmethacrylate articular spacers in two-stage revision for PJI of hip and knee arthroplasty achieves a high rate of infection eradication. Dynamic spacers may confer a variety of benefits compared to static spacers, with a similar rate of infection eradication.

Malar reshaping technique using bidirectional barb thread suspension procedure for 3-dimensional aging in Asian faces

Background: Aging is a natural process that causes skin texture changes, facial volume loss, and altered 3-dimensional topography of the underlying tissues.

Objective: The aim of this study is to assess the malar reshaping strategy in Asian patients using bidirectional suspension-barbed threads.

Methods: A prospective interventional study was conducted on Asian patients presenting with mild-to-moderate facial aging who were treated with the Definisse double-needle thread in the Hong Kong Special Administrative Region. The primary endpoint was assessed using the Global Aesthetic Improvement Scale and scoring the benefit of anterior projection using a questionnaire. Patient safety was the secondary endpoint measured.

Results: Twenty Asian patients (4 men [20%] and 16 women [80%]; age <45 to ≥45 years) were included in the study. The patients experienced marked improvement (score 2) in their appearance, except for the follow-up after 1 month. One month after the procedure, patients scored 1 for optimal cosmetic improvement in their looks. The nasolabial fold disappeared in all patients (n = 20 [100%]) and the face looked slimmer. Nine patients (45%) reported that the focus seemed centralized. Four patients (20%) reported prominence of the nose and chin. Redness, swelling, and bruising were the most common adverse events experienced by 75% of patients (n = 15), followed by pain (n = 6; 30%). All adverse events resolved within 4 weeks after their incidence. Because 80% of our patients were women, these positive cosmetic outcomes may be of interest across the aging female population.

Conclusion: Overall, 3-dimensional facial rejuvenation with the Definisse thread seems to be an effective, safe, and minimally invasive office-based procedure to achieve immediate and long-term effects. These absorbable barbed sutures used in the malar reshaping technique can result in satisfactory esthetic enhancement of 3-dimensional aging, including sagginess, jowling, central facial heaviness, and tissue descent in female and male Asian patients.

Assessment of prescribing pattern of drugs and completeness of prescriptions as per the World Health Organization prescribing indicators in various Indian tertiary care centers: A multicentric study by Rational Use of Medicines Centers-Indian Council of Medical Research network under National Virtual Centre Clinical Pharmacology activity

OBJECTIVE

The rational use of medicines as per the World Health Organization (WHO) should be practiced globally. However, data regarding the completeness of the prescriptions and their rational use is lacking from developing countries like India. Thus, the aim of this study was to assess the prescribing patterns of drugs and completeness of prescriptions as per WHO core drug use and complementary indicators to provide real-life examples for the Indian Council of Medical Research (ICMR) online prescribing skill course for medical graduates.

METHODS

Prescriptions of the patients, fulfilling inclusion criteria, attending Outpatient Departments of various specialties of tertiary care hospitals, were collected by thirteen ICMR Rational use of medicines centers located in tertiary care hospitals, throughout India. Prescriptions were evaluated for rational use of medicines according to the WHO guidelines and for appropriateness as per standard treatment guidelines using a common protocol approved by local Ethics committees.

RESULTS

Among 4838 prescriptions, an average of about three drugs (3.34) was prescribed to the patients per prescription. Polypharmacy was noted in 83.05% of prescriptions. Generic drugs were prescribed in 47.58% of the prescriptions. Further, antimicrobials were prescribed in 17.63% of the prescriptions and only 4.98% of prescriptions were with injectables. During the prescription evaluation, 38.65% of the prescriptions were incomplete due to multiple omissions such as dose, duration, and formulation.

CONCLUSION

Most of the parameters in the present study were out of the range of WHO-recommended prescribing indicators. Therefore, effective intervention program, like training, for the promotion of rational drug use practice was recommended to improve the prescribing pattern of drugs and the quality of prescriptions all over the country.

Epidemiological and diagnostic aspects of feline leishmaniasis with emphasis on Brazil: a narrative review

The leishmaniases are a group of diseases caused by the protozoan parasite belonging to the genus Leishmania. In the New World, although dogs are considered the main parasite reservoir, in the last two decades, several studies have confirmed the role of cats (Felis catus) in the epidemiology of the disease and feline leishmaniasis (FeL) is now considered to be an emerging disease. The present review summarizes the current knowledge about FeL, focusing on important immunopathological aspects, epidemiology, and diagnostic methods applied for felines in Brazil. Cats are infected with the same species of Leishmania found in dogs (i.e., Leishmania infantum). Like dogs, skin lesions are the most common in cats with clinical FeL, mainly affecting the cephalic region and less frequently the legs which may be accompanied by generalized signs or visceral involvement. Information on the immune response of cats to Leishmania infection is scarce; however, efficient infection control is seen in most cases. For diagnosis, generally, the same methods as those in dogs are used, mainly serological tools. But there is a lack of studies focusing the performance of these methods for diagnosing FeL. The estimated overall prevalence of FeL in Brazil is 8%, with L. infantum being the most prevalent species. However, infections with Leishmania braziliensis and Leishmania amazonensis have also been reported. In conclusion, although there has been an increase in the publication related to FeL in Brazil in recent years, there is a lack of research relating immune response and diagnosis of these animals. Cats have been shown to be competent hosts for Leishmania parasites, and their role in the epidemiology of the disease cannot be underestimated, especially in areas of Brazil where the disease is historically endemic.

High spatial-density, cladding-pumped 6-mode 7-core fiber amplifier for C-band operation

We present a C-band 6-mode 7-core fiber amplifier in an all-fiberized cladding-pumped configuration for space division multiplexed transmission supporting a record 42 spatial channels. With optimized fiber components (e.g. passively cooled pump laser diode, pump coupler, pump stripper), high power multimode pump light is coupled to the active fiber without any noticeable thermal degradation and an average gain of 18 dB and noise figure of 5.4 dB are obtained with an average differential modal gain of 3.4 dB.

Multicentric Hospital-Based Surveillance of Pertussis Amongst Infants Admitted in Tertiary Care Facilities in India

OBJECTIVE

To estimate the disease and economic burden of pertussis amongst hospitalised infants in India.

DESIGN

Multicentric hospital-based surveillance study.

PARTICIPANTS

Hospitalised infants with clinical suspicion of pertussis based on predefined criteria.

OUTCOME MEASURES

Proportion of infants with laboratory-confirmed pertussis, economic burden of pertussis amongst hospitalised infants.

RESULTS

693 clinically suspected infants were recruited of which 32 (4.62%) infants had laboratory-confirmed pertussis. Progressive cough with post-tussive emesis (50%) and pneumonia (34%) were the common clinical presentations; apnea in young infants was significantly associated with pertussis. Infants with pertussis were more likely to be younger (median age 102.5 days vs.157 days) and born preterm (42.9% vs 24.5%). Almost 30% infants with pertussis had not received vaccine for pertussis with 50% of these infants aged less than 2 months. Pertussis was associated with higher costs of hospitalisation, pharmacy and loss of working days by caregivers as compared to non-pertussis cases.

CONCLUSIONS

Younger infants, those born preterm and those inadequately immunised against pertussis are at higher risk of pertussis infection. Timely childhood immunisation and introduction of maternal immunisation for pertussis can help in reducing the disease burden.

AB0276 HOW FAST CAN METHOTREXATE BE ESCALATED IN RHEUMATOID ARTHRITIS? A MULTICENTRE, PARALLEL-GROUP RANDOMIZED CONTROLLED TRIAL (MEIRA)

Background:

Literature regarding the optimal dose escalation strategy of methotrexate (MTX) in RA is scant and ambiguous (1). Concerns regarding the safety of rapid escalation may lead to delayed attainment of the optimal dose and treatment target.

Objectives:

To compare the efficacy, safety and tolerability of fast versus usual dose escalation of oral MTX in RA.

Methods:

This multicenter, open-label (assessor blinded) RCT included patients with active RA (SJC≥2 and TJC≥4) aged 18-55 years, not on DMARDs (except HCQ and/or low-dose prednisolone) and with disease duration <5 years. Patients were randomized 1:1 into two groups with the same starting dose of oral MTX (15 mg/week), but escalated either by 5 mg every 2 weeks (fast escalation group) or 5 mg every 4 weeks (usual escalation group), till a maximum of 25 mg/wk. Primary outcome was proportion of EULAR good responders at 16 weeks. Secondary outcomes were change in DAS28-3 and EULAR responders (good or moderate) at 8 and 16 weeks, change in Indian HAQ at 16 weeks, and symptomatic (questionnaire based) and laboratory adverse effects over 16 weeks. RBC MTX polyglutamate-3 levels were measured using HPLC in both groups. There was an open-label extension phase till 24 weeks (use of other DMARDs was permitted beyond 16 weeks if target was not met), and DAS28-3 at 24 weeks was compared.

Trial Reg: CTRI/2018/12/016549

Results:

178 patients (mean age 39.8 (8.6) years, 84% females) with mean disease duration of 1.9 (1.4) years were randomized (89 in each group). Mean DAS28ESR-3 and DAS28CRP-3 at enrollment were 6.3 (0.9) and 5.4 (1.1). At 16 weeks, there was no significant difference in good EULAR response by DAS28ESR-3 (5.6, 7.9%, p=0.9) or DAS28CRP-3 (28.1, 22.5%, p=0.8) between the two groups (Figure 1). The change in DAS28-ESR-3 at 8, 16 and 24 weeks (or by DASCRP-3, not shown) and improvement in HAQ at 16 weeks were also not significantly different (Table 1). Notably, there was no significant difference in symptomatic GI or CNS adverse effects, incidence of cytopenia, transaminitis or rates of drug discontinuation. RBC MTX polyglutamate-3 levels at 8 and 16 weeks were also similar (Table 1).

Table 1.

Key secondary efficacy and safety outcomes

ParameterUsualFastp-valueEfficacyDelta DAS28-ESR-3 (Mean±SD) -8 wk  -ITT (n=178)-0.9 ± 1.0-0.8 ± 0.90.5  -PP (n=139)-1.2 ± 1.0-1.1 ± 1.00.5 -16 wk  -ITT-1.3 ± 1.1-1.3 ± 1.00.9  -PP-1.6 ± 1.1-1.6 ± 0.91 -24 wk  -ITT-1.6 ± 1.3-1.5 ± 1.10.3  -PP-2.1 ± 1.2-1.8 ± 1.10.14Delta Indian HAQ (16 wk)-0.7 ± 0.6-0.8 ± 0.60.2Adverse effectsSerious AE00-Death00-Symptomatic AE ever* n (%)Vomiting7 (8)7 (8)1Nausea22 (26)26 (30)0.5Stomach ache16 (19)17 (20)0.9Loss of appetite/bad taste21 (25)27 (31)0.3Lethargy20 (24)21 (25)1Dizziness19 (23)16 (19)0.5Irritability/anxiety14 (16)14 (16)1Laboratory AE ever* [n/N times done (%)]Transaminitis episodes (>40IU/L)52/224 (23)52/219 (24)0.9  -Significant (>80 IU/L)5/224 (2)8/219 (4)0.4Thrombocytopenia episodes (<150000/uL)10/224 (5)13/218 (6)0.5 -Significant (<100000/uL)2/224 (1)2/218 (1)1Leucopenia episodes (<4000/uL)2/224 (1)3/220 (1.5)0.8 -Significant (<3500/uL)1/224 (0.5)2/220 (1)0.8Methotrexate levelsMTX-polyglutamate-3 (nmol/L)-8 wk25.8 ± 10.526.9 ± 13.60.6-16 wk40.7 ± 20.940.1 ± 23.40.9

*Ever=any time during the study

ITT= intention-to-treat, PP=per-protocol, AE=adverse effect

Figure 1.

EULAR response and change in DAS28ESR-3 over time

Conclusion:

A faster escalation of MTX (5 mg every 2 weeks) reaching 25 mg/week by 4 weeks did not have a significantly higher rate of adverse effects (symptomatic or laboratory) compared to an escalation by 5 mg every 4 weeks. Although not more efficacious, it may shorten the time to recognize MTX failure, and optimize treat-to-target.

References:

[1]Visser K, Katchamart W, Loza E, et al. Multinational evidence-based recommendations for the use of methotrexate in rheumatic disorders with a focus on RA: integrating systematic literature research and expert opinion of a broad international panel of rheumatologists in the 3E Initiative. Ann Rheum Dis. 2009;68(7):1086–93

Disclosure of Interests:

None declared

POS0679 A NEW QUESTIONNAIRE AND SCORE (MISA) FOR ASSESSING METHOTREXATE INTOLERANCE IN RHEUMATOID ARTHRITIS

Background:

Methotrexate (MTX) intolerance refers to unpleasant symptoms that accompany use of MTX and may lead to its discontinuation. However, it lacks a validated score in RA patients; with the only option being to use the MISS score which was validated for use in children and not adults.

Objectives:

To develop and validate a questionnaire and score (s) for measuring MTX intolerance and its severity in rheumatoid arthritis.

Methods:

A 10-item questionnaire called ‘Methotrexate Intolerance and Severity assessment in Adults’ (MISA) was validated in 105 RA patients. A score was calculated by adding the scores of first 7 questions (0 to 3 based on severity on symptoms), to last 3 questions (0 or 1); it ranged from 0 to 24 (MISA score) and was assessed for correctly classifying MTX intolerance (compared to an interview) by ROC analysis. Its area-under-curve (AUC) was compared with ‘Methotrexate Intolerance Severity Score’ (MISS), developed for children. Subsequently, it was administered to 414 RA patients to assess the prevalence and associations of MTX intolerance. In addition, the MISA cross-products score, that was calculated by adding the cross-products (severity (1 to 3) x duration per week (0.5 to 7 days)) of symptoms, was compared to MISA and MISS for assessing severity of intolerance.

Results:

In the initial phase, 105 RA patients on MTX≥6 months were included, a majority were female (87%), mean age was 51 (13.4) years and methotrexate dose was 18.8±6 mg/week. Thirty-five (33%) were found to be intolerant to MTX based on interview. MISA score had a good predictive ability (AUC of 0.904), to correctly classify MTX intolerance, and was better than MISS score (AUC of 0.823) (Figure 1A). The optimal cut-off for MISA was ≥1, with a sensitivity and specificity of 91.4% and 84.3%. Using the MISA score (≥1), 38.4% of 414 RA patients were found to have MTX intolerance: with nausea, lethargy and irritability being common symptoms. (Figure 1B, C) On multivariable analysis, age (OR 0.972) and BMI (OR 1.061) were significant predictors of MTX intolerance. (Table 1) On assessing for severity of intolerance, MISA cross product score performed the best, with an area-under-curve of 0.899 (95% CI 0.831-0.966), being higher than AUC for MISS and MISA score which were 0.847 (95% CI 0.768-0.927) and 0.837 (95% CI 0.754-0.920).

Conclusion:

MISA is the first validated questionnaire for assessing methotrexate intolerance in rheumatoid arthritis, with the MISA score having a good accuracy (at cut-off ≥1), to detect MTX intolerance. Methotrexate intolerance was present in more than one-third of RA patients, with nausea, lethargy and irritability being most common.

Table 1.

Baseline characteristics of 414 RA patients.

VariableAll(n=414)Tolerant(n=255)Intolerant(n=159)p-valuetol. vs ntol.P-valuemultivariablemodelFemales, n (%)370 (89)231 (91)139 (87)0.31Age, yrs, mean (SD)50 (12.5)51.2 (12.6)48.2 (12.2)0.016*0.008**Duration of RA, yrs, mean (SD)10.0 (7.0)10.8 (7.4)9.6 (6.3)0.168BMI, Kg/m2a, mean (SD)24.0 (4.9)23.6 (4.9)24.6 (4.7)0.1070.03*RF positiveb, n (%)300 (73)191 (82)109 (78)0.29CDAI, mean (±SD)14.0 (11.8)14 (12.1)14.1 (11.4)0.69Dose of MTX, mg/wk, mean (SD)18.6 (5.6)18.6 (5.5)18.7 (5.8)0.83Injectable MTX, n (%)47 (11)25 (10)22 (14)0.21Use of FA, n (%)395 (95)241 (95)154 (97)0.27Use of other DMARD, n (%)272 (66)160 (62)112 (70)0.11HCQ n (%)209 (51)123 (48)86 (54)0.25Prednisolone n (%)156 (38)87 (34)69 (43)0.0580.21Using antiemetics, n (%)12 (3)1 (0.5)11 (7)<0.001

a Available for 262 patients bAvailable for 372 patients

Figure 1.

Figure showing the ROC curve for MISA and MISS questionnaires for MTX intolerance (A), Bar diagram showing the prevalence of various symptoms of intolerance in 414 RA patients (B), and Box-and-whiskers plot showing the duration of unpleasant symptoms (C).

Disclosure of Interests:

None declared

Mental health impact of covid on athletes

Introduction

The coronavirus pandemic continues to impact all aspects of the daily life of the public worldwide. With decreased economic activity, the sports industry faces significant challenges of maintaining athletes’ mental health while seeking the best strategies for eventual return to sports competition.

Objectives

We aim to evaluate COVID-19 related factors impacting on the mental health of athletes and provide appropriate management steps.

Methods

We examined MeSH terms “Athletes,” “Sports,” “COVID-19,” in the context of “Mental Health,” “Mental Disorders,” “Behavioral Medicine,” “Risk Factors.” We identified seven studies for the qualitative synthesis per the PRISMA guidelines, searching Medline, PubMed, PubMed Central, and PsychInfo databases until July 2020.

Results

The pandemic has negatively impacted athletes’ mental wellbeing due to decreased physical activities, limited resources, fears, and delays or cancellations of the sporting event. The negative psychological impact on athletes is due to self-isolation measures leading to worries of less preparedness for the lockdown, reduced physical activity, loss of competitive advantages, fear of being infected, social isolation, and loneliness. During this period, athletes struggled to maintain baseline routine and engaged in excessive calorie intake, eating low-quality food, substance use, and sleep disruption. It has caused anxiety, depression, PTSD, and mood disorder at varying degrees of severity in athletes.

Conclusions

Limited resources during a pandemic have caused adverse mental impact on athletes. We recommend improving physical activity through confined or virtual training programs with colleagues. A collaborative approach is required by clinicians, psychologists, coaches, sports organizations, government bodies to limit the pandemic’s mental health impact.

Safety and Effectiveness of Dapoxetine On Demand in Chinese Men With Premature Ejaculation: Results of a Multicenter, Prospective, Open-Label Phase IV Study

INTRODUCTION

Dapoxetine on demand has been approved for premature ejaculation (PE) management in China; however, studies on the efficacy and safety of this treatment in the Chinese population are scarce.

AIM

The aim of this study was to evaluate the safety and effectiveness of dapoxetine 30 mg and 60 mg on demand in Chinese men with PE.

METHODS

Phase IV real-world study on 1,252 patients with PE. If men reported no response to dapoxetine 30 mg after 4 weeks treatment, dapoxetine has been uptitrated at 60 mg for 4 weeks more.

MAIN OUTCOME MEASURE

Self-reported data were collected for demographics, general and sexual health characteristics, PE severity, and treatment safety and effectiveness, as measured by the PE profile questionnaire.

RESULTS

Adverse events (AEs), such as nausea, thirst, headache, and dizziness, similarly to previous literature, were detected. The treatment-emergent AEs rate was higher in the patients treated with 30 and 60 mg (n = 192) compared with those treated with the dapoxetine 30 mg only (n = 1060) (34.4% vs 15.8%, respectively). No new safety concerns were observed. The overall effectiveness rates were 88.2% in subjects using 30 mg of dapoxetine, whereas a rescue from the previous failure was in 55.7% in the patients who received 60 mg after the initial 30 mg. Overall, 83.2% responded to dapoxetine at dosages equal to or lower than 60 mg.

CONCLUSION

The results in this study demonstrated in a large Chinese population that on-demand dapoxetine is a safe and effective symptomatic treatment in patients with PE. J Peng, L Yang, L Liu, et al. Safety and Effectiveness of Dapoxetine On Demand in Chinese Men With Premature Ejaculation: Results of a Multicenter, Prospective, Open-Label Phase IV Study. Sex Med 2021;9:100296.

Practical consensus recommendations regarding the management of sentinel lymph node issues in early breast cancer

Axillary lymph node involvement is a very important poor prognostic factor in the clinical staging and management of breast cancer patients. Traditionally, axillary lymph node dissection (ALND) has been used for determining the status of the axillary lymph nodes. More recently the sentinel lymph node biopsy (SLNB) procedure has gained wider acceptance as the standard of care, having the advantage of being less invasivewhile providing good accuracy. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at these practical consensus recommendations in regards with the use of the two different procedures and other issues in patients with early breast cancer for the benefit of community oncologists.