Efficacy of methimazole before the administration of radioactive iodine in the management of Graves' disease: a systematic review and meta-analysis

BACKGROUND

The efficacy of anti-thyroid drugs in conjunction with radioactive iodine therapy in the management of Graves' disease is still controversial.

OBJECTIVE

To compare the efficacy of pretreatment with methimazole before the administration of radioactive iodine for the treatment of Graves' disease.

DESIGN AND SETTING

A systematic review and meta-analysis was conducted at a teaching/tertiary hospital in Ibadan, Nigeria.

METHODS

A systematic search of the PubMed, Embase, Cochrane Library, and Web of Science databases was performed from inception to December, 2021.

RESULTS

Five studies with 297 participants were included. There was no difference in the risk of persistent hyperthyroidism when radioactive iodine was used in conjunction with methimazole compared with when radioactive iodine was used alone (relative risk: 1.02, 95% confidence interval, CI: 0.62-1.66; P = 0.95, I2 = 0%). Subgroup analysis based on the duration between discontinuation of methimazole and the administration of radioactive iodine showed a lower risk of persistent hyperthyroidism when methimazole was discontinued within 7 days before radioactive iodine use, although this did not reach statistical significance (risk ratio: 0.85, CI: 0.28-2.58).

CONCLUSIONS

The use of methimazole before radioactive iodine administration was not associated with an increased risk of persistent hyperthyroidism. Concerns about medication toxicity and adverse effects should be considered when clinicians make decisions on combination therapies for the treatment of Graves' disease.

PROSPERO REGISTRATION

CRD42020150013, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=150013.

Variable Diagnostic Performance of Stool Xpert in Pediatric Tuberculosis: A Systematic Review and Meta-analysis

BACKGROUND

Difficult specimen collection and low bacillary load make microbiological confirmation of tuberculosis (TB) in children challenging. In this study, we conducted a systematic review and meta-analysis to assess the diagnostic accuracy of Xpert on stool for pediatric tuberculosis.

METHODS

Our search included studies from 2011 through 2019, and specific search terms were used to retrieve articles from Pubmed, EMBASE, BIOSIS, ClinicalTrials.gov, and Google Scholar. Risk of bias was assessed using the QUADAS 2 tool. The protocol was registered in PROSPERO (CRD42018083637). Summary estimates of sensitivity and specificity were conducted using meta-disc Software assuming a random-effects model.

RESULTS

We identified 12 eligible studies, which included data from 2177 children, of whom 295 (13.6%) had bacteriologically confirmed TB on respiratory specimens. The pooled sensitivity of Xpert MTB/RIF on stool specimens compared with bacteriologically confirmed tuberculosis with respiratory specimens was 0.50 (95% CI, 0.44-0.56) with an I 2 of 86%, which was statistically significant (P < .001). The pooled specificity was 0.99 (95% CI, 0.98-0.99; I 2 = 0.0%; P = .44).

CONCLUSIONS

Despite the observed heterogeneity, stool may be considered an additional specimen to support diagnosis of pulmonary TB in children, especially in settings where it is impossible to get respiratory samples. Further studies should evaluate its optimization as a diagnostic tool.

AB0385 THE EFFECTIVENESS OF THE ANTI-TUMOR NECROSIS FACTOR THERAPY INFLIXIMAB IN NEURO-BEHCET’S DISEASE: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background:

The use and benefit of biologic targeted therapy in the treatment of refractory manifestations of behcet’s syndrome remain unclearly defined due to the relative paucity of published research. Neuro-behcet’s disease represents a challenging clinical presentation. The lack of identified effective strategies in the management of refractory neuro-behcet’s adds to the disease burden and contributes to lack of tight control. [1-3]

Objectives:

The aim of this systematic review and meta-analysis is to examine the effect of anti-TNF therapy on refractory NBD by performing a systematic review and meta-analysis of the previously published studies assessing the effectiveness of anti-TNF therapy in patients with BD having refractory or recurrent neurological manifestations.

Methods:

Authors used the PICO Model (P= population, I= intervention, C= comparator, O= outcome) used for designing the research question. The PRISMA statement was used for developing the study protocol search methodology. Literature searches were done for articles in published in English language only from January 2000 till January 2020 (considering the first till the last available publication that addresses the research question and satisfied eligibility criteria). The study was registered on the Prospero PROSPERO website for systematic reviews and meta-analysis. Random-effects meta-analysis was performed. Inter-study heterogeneity was explored using I2 statistics. Cumulative meta-analysis was conducted to assess temporal trend for accumulating evidence from accruing published studies. Meta-regression was used to analyze possible confounders.

Authors of the current systematic review and meta-analysis worked on a simple score “Hamdy and Woldeamanuel simple response score, 2020”, the aim behind the score was to incorporate standard evaluation parameters for assessment of responses driven by the measures used in each study. The authors used numerical values to grade the pattern of response in each parameter considered attempting to standardize the quantification of the responses and minimize tendency towards overestimation. The score included clinical and radiographic points rated on a scale of 5.

Results:

Twenty-one studies involving 64 patients were included, 52 male patient and 12 females at a ratio of 4.3:1, with a mean age of 38 .21 years, mean disease duration of 84.76 5 months. Effect size analysis showed that 59 out of 64 patients i.e. 93.7% of the treated patients with neuro-behcet’s disease in the analysis were responders to infliximab therapy (CI 88% - 99.3%). There was no significant inter-study heterogeneity (I2 = 0%, p = 0.744). Cumulative analysis showed accumulating evidence favoring increasing effectiveness over the last 20 years. There was no statistically significant confounding of infliximab effect size by age (p = 0.89), sex ratio (p = 0.29), and disease duration (p = 0.67).

Conclusion:

In this systematic review and meta-analysis Infliximab showed a strong therapeutic effectiveness in the treatment of refractory neuro-behcet’s disease. There is an increasing trend of effectiveness observed in the last two decades which may be due to improved neuro-behcet’s diagnostic accuracy.

References:

[1]Uygunoğlu U, Siva A. Behçet’s Syndrome and Nervous System Involvement. Curr Neurol Neurosci Rep. 2018;18(7):35. Published 2018 May 23. doi:10.1007/s11910-018-0843-5.

[2]Ohno S, Ohguchi M, Hirose S, Matsuda H, Wakisaka A, Aizawa M. Close Association of HLA-Bw51 With Behçet’s Disease. Arch Ophthalmol. 1982; 100(9):1455–1458. doi:10.1001/archopht.1982.01030040433013.

[3]Kalra, S., Silman, A., Akman-Demir, G., et al. Diagnosis and management of Neuro-Behçet’s disease: international consensus recommendations. Journal of neurology, 2014; 261(9): 1662–1676. https://doi.org/10.1007/s00415-013-7209-3.

Figure 1

a. Forest plot summarizing the meta-analysis results on the effectiveness of infliximab to treat Neurobehcet disease. Overall, 94% of patients responded to infliximab.

Disclosure of Interests:

None declared

High utility of active tuberculosis case finding in an Ethiopian prison

SETTING

Hawassa Prison, Southern Region of Ethiopia.

OBJECTIVE

To determine the burden of pulmonary tuberculosis (TB) using active case finding among prisoners.

DESIGN

In this cross-sectional study, prisoners were screened for TB using a symptom screen. Those with cough of 2 weeks had spot and morning sputum samples collected for acid-fast bacilli (AFB) smear microscopy and molecular diagnostic testing (Xpert® MTB/RIF).

RESULTS

Among 2068 prisoners, 372 (18%) had a positive cough screen. The median age of these 372 persons was 23 years, 97% were male and 63% were from urban areas. Among those with a positive symptom screen, 8 (2%) were AFB sputum smear-positive and 31 (8%) were Xpert-positive. The point prevalence of pulmonary TB at the prison was 1748 per 100 000 persons. In multivariate analysis, persons with cough >4 weeks were more likely to have TB (OR 3.34, 95%CI 1.54-7.23).

CONCLUSION

A high prevalence of TB was detected among inmates at a large Ethiopian prison. Active case finding using a cough symptom screen in combination with Xpert had high utility, and has the potential to interrupt transmission of Mycobacterium tuberculosis in correctional facilities in low- and middle-income, high-burden countries.

Microscopic-observation drug susceptibility assay provides rapid and reliable identification of MDR-TB

BACKGROUND

Liquid culture systems are more rapid and sensitive for both the detection and drug susceptibility testing (DST) of Mycobacterium tuberculosis.

SETTING

St Peter's TB Specialised Hospital and public health laboratory, Addis Ababa.

OBJECTIVE

To compare the microscopic-observation drug susceptibility (MODS) assay with the BACTEC-MGIT 960 system for isoniazid and rifampicin DST (i.e., multidrug-resistant tuberculosis [MDR-TB] identification) of M. tuberculosis.

DESIGN

The evaluation was based on 58 smear- and culture-positive sputum samples from patients diagnosed in Addis Ababa, Ethiopia. BACTEC-MGIT was used as the reference standard.

RESULTS

For the detection of MDR-TB, MODS has a sensitivity, specificity and accuracy rate of respectively 95%, 100% and 98.3% (kappa 0.981, concordance 98.3%). Concurrent culture detection and DST results are obtained in a median of 9 days with MODS, while indirect DST results with BACTEC-MGIT are obtained in a median of 8 days (this does not include time to primary isolate).

CONCLUSION

MODS is an accurate, rapid and relatively inexpensive method for the identification of MDR-TB.

Clinico-mycological Profile of Dermatophytosis in a Reference Centre for Leprosy and Dermatological Diseases in Addis Ababa

To assess the clinical and fungal species spectrum of dermatophyte infection in a reference centre in Addis Ababa, 539 dermatological patients with signs of dermatophytosis were investigated. Seventy-one percent were female and 29% male, aged 2-66 years (median 9). Four hundred-fifteen (77%) had at least one skin lesion. Tinea capitis was diagnosed in 138/155 males (89%) as compared to 214/384 females (40%) (p < 0.05). T. capitis was diagnosed in 69% of the 374 children. Fingernails were affected in 132/145 (91%) of onychomycosis, 118 (90%) of these patients were females and 14 males (p < 0.05). Tinea corporis was observed in 45, and other types of tinea in 12 patients. Thirty-six percent of all patients had also other skin lesions, mostly impetigo. Of 490 cultured samples 364 (74%) grew dermatophytes: Trichophyton violaceum in 84%, Trichophyton verrucosum in 9.6%, Trichophyton tonsurans in 1.4% and T. rubrum in 0.5%. Additionally, 15 isolates were identified as white variants of T. violaceum, in 3 cases confirmed by sequencing of the rDNA ITS 2 region. T. capitis in young males and T. unguium of fingernails in females were the most common manifestations of dermatophytosis in Addis Ababa, usually caused by T.violaceum.

White variants of Trichophyton violaceum isolated in Ethiopia

Certain dermatophytes are geographically restricted and endemic in particular parts of the world, while other species may have a sporadic but worldwide distribution. Trichophyton violaceum is one of the most common dermatophytes causing tinea capitis, and is the predominant cause of tinea in Africa, South America and the Indian subcontinent. Among 1187 dermatophyte isolates collected from Ethiopian patients with various types of tinea, 32 isolates had uncharacteristic phenotypic features. Based on conventional methods complemented by sequence analysis of the rDNA ITS2 region, these isolates were identified as white variants of T. violaceum. This is the first time that white isolates of T. violaceum have been identified in Ethiopia.

Prevalence of tinea capitis in Ethiopian schoolchildren

The prevalence of dermatophytosis and the spectrum of dermatophyte species were determined in children attending two schools in Addis Ababa, Ethiopia. Demographic and clinico-dermatological data were collected. Specimens were taken for microscopy and culture from all suspected lesions. Dermatophyte species were identified by morphology and biochemical tests, supplemented by sequencing of the rDNA ITS 2 region in selected isolates. From the Biruh Tesfa Elementary School (BTES) 824 students, and from Mount Olive Academy (MOA) all 124 students, were included. In BTES 513 (62.3%) students were clinically diagnosed with dermatophytosis, 463 (90.3 %) of them with tinea capitis. In 200 consecutive samples from BTES, and in 66 from MOA, 75 and 62%, respectively, contained fungal elements at microscopy. From BTES, 163/496 (33%) samples were culture-positive, of which 149 (91.4%) grew with dark purple colonies identified as Trichophyton violaceum, while 244 (49.4%) samples were contaminated. A few strains grew slowly developing white to cream colonies, two were identified as T. verrucosum, and 12 as white T. violaceum. From MOA 44 (66.7%) of samples were culture-positive, 38 (87%) were identified as T. violaceum, and one (2.3%) as T. verrucosum, while 33% showed no growth. Four white isolates of T.violaceum were confirmed by DNA-sequencing. Dermatophytosis was thus diagnosed in 55-62% of children screened at two schools of different socioeconomic standards in the Ethiopian capital. Trichophyton violaceum constituted 87-90% of all isolates. White variants of T. violaceum were diagnosed in 16 cases.

Characterization of Candida albicans isolates from the oral cavity of HIV-positive patients

Characterization of Candida albicans isolates from the oral cavity of Ethiopian Human Immunodeficiency Virus (HIV)-positive patients and HIV-negative individuals was undertaken. After identification of isolates using conventional methods and determination of carbohydrate assimilation profiles, serotyping was performed by slide agglutination with the Iatron IF6 serotyping system. Sensitivity of the isolates to 5-Fluorocytosine (5-FC) was assessed using the broth macrodilution method. There was no difference in phenotype, by any of the three methods used, between the HIV-positive and HIV-negative individuals. Serotype A was found to be dominant in strains isolated from both HIV-positive (34/40 = 85%) and HIV-negative (17/20 = 85%) study subjects. These data suggest that the C. albicans strains causing oral candidiasis in patients with HIV infection are identical to the commensal ones found in healthy individuals.