Acute pancreatitis caused by methimazole/carbimazole assumption: a case-series

The World Health Organization (WHO) has listed 525 different drugs, that can lead to acute pancreatitis cases, as a medication side-effect. Among them, methimazole (MMI also known as thiamazole, the active form of carbimazole [CBZ]) was included. We reported case reports of patients with overall features compatible with acute pancreatitis episodes following and presumably triggered by the exposure to MMI and its prodrug CBZ. A systematic search was performed on MEDLINE (PubMed). We included case reports of patients with overall features compatible with acute pancreatitis episodes following and presumably triggered by the exposure to MMI and its prodrug CBZ Data extraction and analysis were undertaken in duplicate. We identified 7 case reports. Most patients were female, and one patient was male. Mean age at baseline ranged from 18 to 80 years old. The average time, that elapses between the initiation of the therapy with MMI/CBZ and the onset of typical clinical signs and symptoms pathognomonic of acute pancreatitis, was 2-3 weeks. Based on the data derived from these case reports, it could be considered the possibility of a potential association between MMI/CBZ exposure. Evidence is, however, limited and requires more studies of high quality to confirm this association.

Could the human papillomavirus recombinant vaccine be a new valid approach in the management of ano-genital warts?

In line with previous case-reports, the study conducted by Hoom Choi ascertained the effectiveness of the HPV vaccine as a promising approach in the therapeutic management of ano-genital warts. The uncertain length of time and the varying effectiveness of traditional treatments encourage a reduction in the use of them and the development of a therapeutic use of HPV-vaccination. While the efficacy, safety profile and effects of the HPV vaccination in preventing ano-genital warts is well-know, therapeutic HPV vaccination has not been evaluated in a Randomized Prospective Trial, to date, and has not received a formal approval and an off-label indication for the treatment of those lesions. For these reasons, RCTs or cohort studies are warranted.

Time to Treatment Intensification in Patients Receiving DPP4 Inhibitors Versus Sulfonylureas as the First Add-On to Metformin Monotherapy: A Retrospective Cohort Study

Background: To verify whether, in patients on metformin (MET) monotherapy for type 2 diabetes (T2D), the add-on of a dipeptidyl peptidase inhibitor (DPP4i) compared to a sulfonylurea (SU) can delay the time to the subsequent treatment intensification (TI).

Methods: Population-based administrative data banks from four Italian geographic areas were used. Patients aged ≥18 years on MET monotherapy receiving first DPP4i or SU dispensing between 2008 and 2015 (cohort entry) were followed up to the occurrence of TI (insulin dispensing or add-on of a third non-insulin hypoglicemic >180 days after cohort entry), treatment discontinuation, switch, cancer, death, TI occurrence within, end of data availability, end of study period (31 December 2016), whichever came first. Patients on MET + DPP4i were matched 1:1 with those on MET + SU by sex, age, year of cohort entry, and data bank. Hazard Ratio (HR) and 95% confidence intervals (95%CI) were estimated using multivariable Cox regression model including matching variables and potential confounders measured at baseline. Different sensitivity analyses were performed: i) matching at 180 days after cohort entry, ii) intent to treat (ITT) analysis, iii) matching by duration of MET monotherapy, iv) matching by propensity score.

Results: The matched study cohort included 10,600 patients. Overall, 763 TI were observed (4.5/100 person-years; mean follow-up = 1.6 years). The primary analysis showed no difference in time to TI between the two groups (HR = 1.02; 95% CI = 0.88–1.19). Sensitivity analyses confirmed this result, except from the ITT analysis (HR = 1.27; 1.13–1.43).

Conclusion: The use of a DPP4i rather than a SU as add-on to MET monotherapy was not associated with a delay in treatment intensification.

Accuracy comparison of the new and previous Kodex occlusion tool software versions to assess pulmonary vein occlusion in atrial fibrillation cryoablation

Background

Atrial fibrillation (AF) is the most frequent sustained arrhythmia worldwide and Cryoballoon ablation (CB) has become a consolidated alternative to the radiofrequency pulmonary vein (PV) isolation. However, CB requires fluoroscopy and dye injections to verify the occlusion grade. The accuracy of the earlier version of the Kodex Occlusion Tool software has been studied.

Purpose

The purpose of this study was to verify the accuracy of the second generation Kodex Occlusion Tool Software of a new dielectric system imaging compared to its first generation to detect PV occlusion during CB ablation in patients with AF.

Methods

15 consecutive patients with paroxysmal AF were enrolled in the study and underwent the procedure with the guidance of the first generation version (1.4.6) of the Kodex Occlusion Tool software. The Kodex recorded procedural data were used to replay the case using the Kodex second generation version (1.4.7) of the Occlusion Tool software when clinically available. After transseptal access, a detailed image reconstruction of left atrium and PVs was achieved with an octa-polar circular mapping catheter, PV occlusion was assessed with the Occlusion Tool Software and compared with standard dye injection and angiography, the cryoablation was then performed with a cryoballoon catheter.

Results

A total of 74 PVs CB occlusions were tested. The old version showed 90.7% sensitivity and 74.2% specificity in assessing a complete PV occlusion verified with contrast medium injection. The positive predictive value was 82.9%, and the negative predictive value was 85.2%. The new version showed 94.8% sensitivity and 93.7% specificity in assessing a complete PV occlusion verified with same contrast medium injection data. The positive predictive value was 98.2%, and the negative predictive value was 93.7%. Acute isolation was achieved in all PVs and no 30-day complication was observed.

Conclusion

This study demonstrates an increased accuracy of new Occlusion Tool software of the Kodex dielectric imaging system to assess the degree of PV occlusion during a CB ablation.

Funding Acknowledgement

Type of funding sources: None.

Effects of early extubation followed by noninvasive ventilation versus standard extubation on the duration of invasive mechanical ventilation in hypoxemic non-hypercapnic patients: a systematic review and individual patient data meta-analysis of randomized controlled trials

Background

Usefulness of noninvasive ventilation (NIV) in weaning patients with non-hypercapnic hypoxemic acute respiratory failure (hARF) is unclear. The study aims to assess in patients with non-hypercapnic hARF, the efficacy of NIV after early extubation, compared to standard weaning.

Methods

In this individual patient data meta-analysis, we searched EMBASE, Medline and Cochrane Central Register of Controlled Trials to identify potentially eligible randomized controlled trials published from database inception to October 2020. To be eligible, studies had to include patients treated with NIV after early extubation and compared to conventional weaning in adult non-hypercapnic hARF patients. Anonymized individual patient data from eligible studies were provided by study investigators. Using one-step and two-step meta-analysis models we tested the difference in total days spent on invasive ventilation.

Results

We screened 1605 records. Six studies were included in quantitative synthesis. Overall, 459 participants (mean [SD] age, 62 [15] years; 269 [59%] males) recovering from hARF were included in the analysis (233 in the intervention group and 226 controls). Participants receiving NIV had a shorter duration of invasive mechanical ventilation compared to control group (mean difference, − 3.43; 95% CI − 5.17 to − 1.69 days, p < 0.001), a shorter duration of total days spent on mechanical ventilation (mean difference, − 2.04; 95% CI − 3.82 to − 0.27 days, p = 0.024), a reduced risk of ventilatory associated pneumonia (odds ratio, 0.24; 95% CI 0.08 to 0.71, p = 0.014), a reduction of time spent in ICU (time ratio, 0.81; 95% CI 0.68 to 0.96, p = 0.015) and in-hospital (time ratio, 0.81; 95% CI 0.69 to 0.95, p = 0.010), with no difference in ICU mortality.

Conclusions

Although primary studies are limited, using an individual patient data metanalysis approach, NIV after early extubation appears useful in reducing total days spent on invasive mechanical ventilation.

Trial registration

The protocol was registered to PROSPERO database on 12/06/2019 and available at PROSPERO website inserting the study code i.e., CRD42019133837.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03595-5.

Accuracy comparison of the new and previous kodex occlusion tool software versions to assess pulmonary vein occlusion in atrial fibrillation cryoablation

Funding Acknowledgements

Type of funding sources: None.

Background. Atrial fibrillation (AF) is the most frequent sustained arrhythmia worldwide and Cryoballoon ablation (CB) has become a consolidated alternative to the radiofrequency pulmonary vein (PV) isolation. However, CB requires fluoroscopy and dye injections to verify the occlusion grade. The accuracy of the earlier version of the Kodex Occlusion Tool software has been studied.

Purpose. The purpose of this study was to verify the accuracy of the second generation Kodex Occlusion Tool Software of a new dielectric system imaging compared to its first generation to detect PV occlusion during CB ablation in patients with AF.

Methods. 15 consecutive patients with paroxysmal AF were enrolled in the study and underwent the procedure with the guidance of the first generation version (1.4.6) of the Kodex Occlusion Tool software. The Kodex recorded procedural data were used to replay the case using the Kodex second generation version (1.4.7) of the Occlusion Tool software when clinically available. After transseptal access, a detailed image reconstruction of left atrium and PVs was achieved with an octa-polar circular mapping catheter, PV occlusion was assessed with the Occlusion Tool Software and compared with standard dye injection and angiography, the cryoablation was then performed with a cryoballoon catheter.

Results. A total of 72 PVs CB occlusions were tested. The old version showed 90.7% sensitivity and 76.5% specificity in assessing a complete PV occlusion verified with contrast medium injection. The positive predictive value was 80.3%, and the negative predictive value was 88.6%. The new version showed 94.8% sensitivity and 93.7% specificity in assessing a complete PV occlusion verified with same contrast medium injection data. The positive predictive value was 98.2%, and the negative predictive value was 93.7%. Acute isolation was achieved in all PVs and no 30-day complication was observed.

Conclusion. This study demonstrates an increased accuracy of new Occlusion Tool software of the Kodex dielectric imaging system to assess the degree of PV occlusion during a CB ablation. Abstract Figure. Occlusion tool software 1.4.6 vs 1.4.7

Methimazole Treatment and Risk of Acute Pancreatitis: A Population-based Cohort Study

CONTEXT

A warning has been recently issued by the European Medicine Agency (EMA) regarding a potential increased risk of acute pancreatitis (AP) in methimazole (MMI) users.

OBJECTIVE

To investigate the association between MMI and the diagnosis of AP in a population-based study.

MATERIALS AND METHODS

A retrospective analysis of administrative health databases was conducted (2013-2018). Relevant data were obtained from: (1) inhabitants registry, (2) hospital discharge records (ICD-9-CM 577.0), and (3) drug claims registry (ATC H03BB02). We evaluated AP risk in MMI users in 18 months of treatment, stratifying results by trimester. Poisson regression was used to estimate the age- and sex-adjusted rate ratios (RR), and the relative 95% confidence intervals (CI), comparing rates of AP between MMI users and nonusers. The absolute risk of AP in MMI users was also calculated.

RESULTS

A total of 23 087 new users of MMI were identified. Among them, 61 hospitalizations occurred during the study period. An increase in AP risk was evident during the first 3 trimesters of therapy (RR 3.40 [95% CI: 2.12-5.48]; RR 2.40 [95% CI: 1.36-4.23]; RR 2.80 [95% CI: 1.66-4.73]), but disappeared thereafter. The AP absolute risk in MMI users during the first 18 months of treatment was less than 0.4% in all sex and age classes.

CONCLUSIONS

Our results support the EMA warning, suggesting an increased risk of AP associated with MMI use. However, such an increase seems limited to the first months of MMI treatment. Moreover, in absolute terms, the probability of AP is low among patients, well below 1%.

Is Caloric Restriction Associated with Better Healthy Aging Outcomes? A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: Global dietary patterns have gradually shifted toward a 'western type' with progressive increases in rates of metabolic imbalance. Recently, animal and human studies have revealed positive effects of caloric restriction (CR) on many health domains, giving new knowledge for prevention of ill and health promotion; Methods: We conducted a systematic review (SR) of randomized controlled trials (RCTs) investigating the role of CR on health status in adults. A meta-analysis was performed on anthropometric, cardiovascular and metabolic outcomes; Results: A total of 29 articles were retrieved including data from eight RCTs. All included RCTs were at low risk for performance bias related to objective outcomes. Collectively, articles included 704 subjects. Among the 334 subjects subjected to CR, the compliance with the intervention appeared generally high. Meta-analyses proved benefit of CR on reduction of body weight, BMI, fat mass, total cholesterol, while a minor impact was shown for LDL, fasting glucose and insulin levels. No effect emerged for HDL and blood pressure after CR. Data were insufficient for other hormone variables in relation to meta-analysis of CR effects; Conclusion: CR is a nutritional pattern linked to improved cardiometabolic status. However, evidence is limited on the multidimensional aspects of health and requires more studies of high quality to identify the precise impact of CR on health status and longevity.

Incidence and prevalence of hyperthyroidism: a population-based study in the Piedmont Region, Italy

PURPOSE

Unrecognized and untreated hyperthyroidism leads to serious clinical complications with adverse outcomes for patients and increasing costs for the health care system. Hence, adequate knowledge of the epidemiological features of such condition is desirable to plan effective interventions. The aim of our study was to estimate incidence and prevalence of hyperthyroidism in the mildly iodine-deficient Italian Region of Piedmont.

METHODS

A retrospective cohort study was conducted using Administrative Health Databases of the Piedmont Region, Italy (2012-2018). Hyperthyroidism cases were defined as the subjects who had at least one of the following claims: (i) hospital discharge records with hyperthyroidism diagnosis code; (ii) exemption from co-payment for hyperthyroidism; (iii) prescription of one of the following medications: methimazole, propylthiouracil, or potassium perchlorate.

RESULTS

The overall prevalence was 756 per 100,000 inhabitants [95% CI 748-764], and the overall incidence was 81 per 100,000-person year [95% CI 80-82]. The prevalence and incidence increased with age and were two-fold higher among women than men. Women also showed two distinct peaks in incidence at the age of 30 and 50; after the age of 60, the trend became similar between sexes. With regard to the geographic distribution, an increasing gradient of incidence was observed from the northern to the south-western areas of the Region.

CONCLUSION

This is the first Italian study based on health databases to estimate the incidence and prevalence of hyperthyroidism in the general population. This approach can represent an inexpensive and simple method to monitor patterns of hyperthyroidism in iodine-deficient areas.