Poincaré plot can help predict the curative effect of metoprolol for pediatric postural orthostatic tachycardia syndrome

Purpose

To study whether a Poincaré plot can help predict the curative effect of metoprolol for postural orthostatic tachycardia syndrome (POTS) in children.

Methods

Pediatric patients with POTS who were administered metoprolol were retrospectively included. The collected data included general data (sex, age, height, weight, and body mass index), the manifestations and treatment (baseline orthostatic intolerance symptom score and course of metoprolol treatment), vital signs (supine heart rate [HR], supine blood pressure, and increased HR during the standing test), HR variability indexes (standard deviation of normal-to-normal intervals [SDNN]; standard deviation of the averages of normal-to-normal intervals [SDANN]; mean standard deviation of the NN intervals for each 5-min segment [SDNNI]; root mean square of the successive differences [rMSSD]; percentage of adjacent NN intervals that differ by >50 ms [pNN50]; triangular index; ultra-low [ULF], very low [VLF], low [LF], and high frequency [HF]; total power [TP]; and LF/HF ratio), and graphical parameters of the Poincaré plot (longitudinal axis [L], transverse axis [T], and L/T). Receiver operator characteristic curves were used to calculate the predictive function of the indexes with significant differences between patients who responded and those who did not. The index combination with the highest predictive value was obtained through series-parallel analysis.

Results

Overall, 40 responders and 23 non-responders were included. The L and T in the Poincaré plots and rMSSD, pNN50, HF, and TP of the HR variability data were significantly lower in participants who responded to metoprolol than in participants who did not (p < 0.001). The L/T of participants who responded to metoprolol was greater than that of non-responders (p < 0.001). Moreover, we noted a strong correlation between every two indexes among L, T, rMSSD, pNN50, HF, TP, and L/T (p < 0.05). T < 573.9 ms combined with L/T > 2.9 had the best performance for predicting the effectiveness of metoprolol, with a sensitivity of 85.0%, specificity of 82.6%, and accuracy of 84.1%.

Conclusion

In the Poincaré plot, a T < 573.9 ms combined with an L/T > 2.9 helps predict good outcomes of using metoprolol to treat pediatric POTS.

Deep Learning Can Predict Bevacizumab Therapeutic Effect and Microsatellite Instability Directly from Histology in Epithelial Ovarian Cancer

Epithelial ovarian cancer (EOC) remains a significant cause of mortality among gynecologic cancers, with the majority of cases being diagnosed at an advanced stage. Before targeted therapies were available, EOC treatment relied largely on debulking surgery and platinum-based chemotherapy. Vascular endothelial growth factors have been identified as inducing tumor angiogenesis. According to several clinical trials, anti-vascular endothelial growth factor-targeted therapy with bevacizumab was effective in all phases of EOC treatment. However, there are currently no biomarkers accessible for regular therapeutic use despite the importance of patient selection. Microsatellite instability (MSI), caused by a deficiency of the DNA mismatch repair system, is a molecular abnormality observed in EOC associated with Lynch syndrome. Recent evidence suggests that angiogenesis and MSI are interconnected. Developing predictive biomarkers, which enable the selection of patients who might benefit from bevacizumab-targeted therapy or immunotherapy, is critical for realizing personalized precision medicine. In this study, we developed 2 improved deep learning methods that eliminate the need for laborious detailed image-wise annotations by pathologists and compared them with 3 state-of-the-art methods to not only predict the efficacy of bevacizumab in patients with EOC using mismatch repair protein immunostained tissue microarrays but also predict MSI status directly from histopathologic images. In prediction of therapeutic outcomes, the 2 proposed methods achieved excellent performance by obtaining the highest mean sensitivity and specificity score using MSH2 or MSH6 markers and outperformed 3 state-of-the-art deep learning methods. Moreover, both statistical analysis results, using Cox proportional hazards model analysis and Kaplan-Meier progression-free survival analysis, confirm that the 2 proposed methods successfully differentiate patients with positive therapeutic effects and lower cancer recurrence rates from patients experiencing disease progression after treatment (P < .01). In prediction of MSI status directly from histopathology images, our proposed method also achieved a decent performance in terms of mean sensitivity and specificity score even for imbalanced data sets for both internal validation using tissue microarrays from the local hospital and external validation using whole section slides from The Cancer Genome Atlas archive.

A comprehensive epidemiological study of rosacea in Germany

BACKGROUND

Rosacea is one of the most common skin diseases causing great distress in affected patients. For optimal patient care, epidemiological studies on disease distribution and clinical aspects are essential.

OBJECTIVES

The goal of this study was to provide an updated perspective on the current state of rosacea epidemiology in Germany.

MATERIALS & METHODS

A cohort of 777 rosacea patients was assessed based on a detailed online questionnaire. Information regarding patients' demographics, course and clinical presentation of rosacea, trigger factors, dermatological consultations, treatment adherence and satisfaction as well as quality of life were obtained.

RESULTS

There was a very high self-reported prevalence of primary and secondary rosacea features (flushing: n = 726, 93.4%; papules/pustules: n = 613, 79.0%; telangiectasia: n = 590, 75.9%; sub jective symptoms: n = 691, 88.9%). However, these clinical findings were often underdiagnosed by the treating physicians, while changes in temperature and ultraviolet radiation were potent triggers across all patients (86.3%, 77.7%, respectively). Disease-related quality of life decreased with the number of drugs prescribed as well as with uncontrolled symptom activity, and was reduced in female patients.

CONCLUSION

This study is the largest German-based assessment exclusively focusing on rosacea patients covering a variety of clinical aspects to optimize patient care.

Initial Incomplete Thermal Ablation Is Associated With a High Risk of Tumor Progression in Patients With Hepatocellular Carcinoma

Purpose

To investigate whether incomplete thermal ablation is associated with a high risk of tumor progression in patients with hepatocellular carcinoma (HCC), and to compare the efficacy of repeated thermal ablation and transarterial chemoembolization (TACE) for residual tumor after incomplete ablation.

Methods

This retrospective study included 284 patients with unresectable HCC who underwent thermal ablation from June 2014 to September 2020. The response of the initially attempted ablation was classified into complete (n=236) and incomplete (n=48). The progression-free survival (PFS) and overall survival (OS) were compared between patients with complete and incomplete responses, before and after a one-to-one propensity score-matching (PSM), and between patients in whom repeated ablation or TACE was performed after a first attempt incomplete ablation.

Results

After PSM of the 284 patients, 46 pairs of patients were matched. The PFS was significantly higher in the complete response group than in the incomplete response group (P<0.001). No difference in OS was noted between two groups (P=0.181). After a first attempt incomplete ablation, 29 and 19 patients underwent repeated ablation and TACE, respectively. There were no significant differences in PFS (P=0.424) and OS (P=0.178) between patients who underwent repeated ablation and TACE. In multivariate Cox regression analysis, incomplete response (P<0.001) and Child-Pugh class B (P=0.017) were independent risk factors for tumor progression, while higher AFP level (P=0.011) and Child-Pugh class B (P=0.026) were independent risk factors for poor OS.

Conclusion

Although patients with incomplete ablation are associated with tumor progression compared with those with complete ablation, their OS is not affected by incomplete ablation. When patients present with residual tumors, TACE may be an alternative if repeated ablation is infeasible.

Treatment Effect of Regional Sodium Citrate Anticoagulation in Elderly Patients With High-Risk Bleeding Receiving Continuous Renal Replacement Therapy

Objective

To investigate the safety and efficacy of regional citrate anticoagulation (RCA) on elderly patients at high risk of bleeding after continuous renal replacement therapy (CRRT).

Methods

A total of 31 patients at high risk of bleeding who received CRRT in the intensive care unit were collected. The patients were divided into RCA group (n = 17) and no anticoagulation group (NA, n = 14) according to whether RCA was used or not. The levels of creatinine (Cr), blood urea nitrogen (BUN), prothrombin time (PT), activated partial thromboplastin time (APTT), total calcium (tCa), ionized calcium ion (iCa²⁺), sodium ion (Na⁺), bicarbonate ion (HCO₃⁻), tCa/iCa²⁺ ratio, and pH were observed after treatment. The filter use time, number of filters used, filter obstruction events, clinical outcomes, and safety evaluation indexes were compared post-treatment.

Results

After treatment, serum Cr and BUN levels, APTT and PT levels in the RCA group were significantly lower than the NA group. The tCa, iCa²⁺, HCO₃⁻, tCa/iCa²⁺, and pH were within the normal range after RCA treatment while Na⁺ levels saw a significant increase. In the RCA group, the filter using time was significantly longer, with significantly reduced numbers of filter use within 72 h and filter disorder events. Additionally, patients in the RCA group showed significant recovery of renal function and a significant reduction in bleeding events and in-hospital mortality.

Conclusion

RCA treatment significantly improves clinical outcome of patients at high risk of bleeding after CRRT, safely and effectively prolongs the filter life and avoids coagulation incidences.

Therapeutic Effects of Urethral Sphincter Botulinum Toxin A Injection on Dysfunctional Voiding with Different Videourodynamic Characteristics in Non-Neurogenic Women

Although female dysfunctional voiding (DV) is common in urological practice, it is difficult to treat. This study evaluated the therapeutic efficacy of urethral botulinum toxin A (BoNT-A) on non-neurogenic female DV. Based on the videourodynamic study (VUDS), the DV was classified into three subgroups according to the obstructive site. A successful treatment outcome was defined as an improvement of voiding efficiency by 10% and reported global response assessment by ≥1. The study compared therapeutic efficacy, baseline urodynamic parameters, and changes in urodynamic parameters between the treatment success and failure groups and among three DV subgroups. Predictive factors for successful treatment were also investigated. A total of 81 women with DV were categorized into three groups: 55 (67.9%) had mid-urethral DV, 19 (23.5%) had distal urethral DV, and 7 (8.6%) had combined BN dysfunction and mid-urethral DV after BN transurethral incision. The treatment outcome was successful for 55 (67.9%) patients and failed for 26 (32.1%). Successfully treated patients had a significant decrease of detrusor pressure, post-void residual volume, and bladder outlet obstruction index, as well as an increase in voiding efficiency at follow-up versus the treatment failure group. The logistic regression of urodynamic parameters and clinical variables revealed that a greater volume of first sensation of filling predicts a successful BoNT-A treatment outcome (p = 0.047). The urethral BoNT-A injection is effective in treating non-neurogenic women with DV, with a success rate of 67.9%. The videourodynamic characteristics of DV may differ among patients but does not affect the treatment outcome.

A study to assess the impact of pharmaceutical care services to cancer patients in a tertiary care hospital

INTRODUCTION

Clinical pharmacist can enthusiastically involve in oncology department through utilizing the skills and knowledge to support wide variety of functions in patient care. The impact of pharmaceutical care services in oncology department were analysed through various approaches including the analysis of knowledge level of patients towards the disease and its management through patient counselling, monitoring of performance status, observing of ADR and drug safety. Incidence of cancer was scrutinized during the study.Methodology: A Prospective interventional study was conducted from November 2019 to March 2020 with the support of institutional ethical approval at oncology department of Lourdes hospital, Ernakulam. 133 patients were included with all type of cancer. Data collected through Performa with KAP questionnaire and direct interview was conducted. Statistical significance was evaluated through p value of <0.001 Result: 123 patients were completed both questionnaire. Among this 69.91% were females and most of the patients belonged to 50 - 65yeras age group and carcinoma was frequently reported type. End of the study showed significant change in the knowledge level of patients after interaction with the clinical pharmacist. 26 ADRs were reported including solitary and multiple ADRs. Recommendations associated with drug reconstitution, administration were frequently given to the nurses. Most of the interventions to improve therapeutic outcome of the patients were accepted by the oncologist.

CONCLUSION

Clinical pharmacist can actively participate in all aspects of the oncology department in association with physician and other health care providers to improve the therapeutic outcome and quality of life of patients.

Long-term vonoprazan therapy is effective for controlling symptomatic proton pump inhibitor-resistant gastroesophageal reflux disease

Vonoprazan, a novel potassium-competitive acid blocker, results in greater inhibition of gastric acid secretion than proton pump inhibitors (PPI). The aim of this study was to assess the long-term outcomes of patients with PPI-resistant gastroesophageal reflux disease (GERD) treated with vonoprazan. The medical records of patients with symptomatic GERD treated with vonoprazan for 1 year were retrospectively reviewed. Changes in abdominal symptoms were assessed using the Izumo scale, a self-reported questionnaire which is useful in evaluating the symptoms of GERD, epigastric pain, postprandial distress, constipation and diarrhea, and is commonly used in routine clinical practice. A total of 30 patients were included and stratified into a non-erosive (n=22) and erosive group (n=8). At baseline, postprandial distress symptoms were significantly greater in the non-erosive group compared with the erosive group (P=0.013). Even with vonoprazan therapy, symptoms of GERD in the non-erosive group were refractory compared with the erosive group, and required additional treatment in a larger proportion of patients (45 vs. 13%). GERD symptoms in the non-erosive group significantly improved from baseline and remained better after 1 year of vonoprazan therapy, similar to the erosive group. In addition, vonoprazan improved epigastric pain and postprandial distress symptoms in the non-erosive group, and 1 year of vonoprazan therapy did not aggravate constipation or diarrhea. In conclusion, 1 year of vonoprazan therapy improves GERD symptoms in patients with PPI-resistant GERD.

Aesthetic and therapeutic outcome of fat grafting for localized Scleroderma treatment: From basic study to clinical application

BACKGROUND

Localized scleroderma (LoS) is a rare autoimmune disease characterized by skin fibrosis and subcutaneous tissue atrophy, resulting in aesthetic impairment on patients. Fat grafting has been used to treat LoS patients, achieving aesthetic and therapeutic improvement.

AIMS

This article summarized the epidemiology and pathophysiology of LoS and the current progress and thorny questions of basic and clinical research on fat grafting treating LoS.

METHODS

The literature of the last 20 years concerning fat grafting of treating LoS was reviewed.

RESULTS

Fat grafting has been proved to produce aesthetic and therapeutic outcomes on LoS patients, including the improvement of soft tissue atrophy, skin fibrosis and pigmentation. Due to the inflammatory microenvironment of scleroderma, however, fat grafting still faces many difficulties, such as low fat retention. Novel fat grafting methods in order to supplement the deficiency of adipose-derived stem cells and improve fat retention in LoS groups have been proposed whose effectiveness and feasibility is still needed further study.

CONCLUSION

Currently, fat grafting has been regarded as an effective treatment with a combination of aesthetic and therapeutic outcomes on LoS patients.

Comparison of therapeutic effects between artificial dermis combined with autologous split-thickness skin grafting and autologous intermediate-thickness skin grafting alone in severely burned patients: A prospective randomised study

The purpose of this study was to evaluate the therapeutic effects of artificial dermis combined with autologous split‐thickness skin grafting (STSG) compared with autologous intermediate‐thickness skin grafting (ITSG) alone in severely burned patients. Fifty‐six severely burned patients admitted to our hospital from December 2017 to January 2019 were enrolled and evenly grouped according to the random number table method [AD‐STSG group: 28 patients, receiving the treatment of artificial dermis (AD) combined with autologous STSG; ITSG group: 28 patients, receiving autologous ITSG treatment alone]. The healing time and Vancouver Scar Scale (VSS) score of the donor area and graft area, survival rate and infection status of the autologous skin, psychological status (determined by Self‐rating Anxiety Scale and Self‐rating Depression Scale), and the activity of functional parts of all enrolled patients were included in the evaluation. General items of patients in AD‐STSG group and ITSG group, including age, sex, and degree of burn, were all comparable. A significantly shortened healing time of donor skin in AD‐STSG group was observed when compared with ITSG group (P < .05) while the recipient skin healed in the same tendency between the two groups. In addition, 21 days after the operation, AD‐STSG group presented with significantly higher survival rate of graft skin than ITSG group (P < .05) while same infection status was observed in the two groups. Significantly lower VSS scores were found in AD‐STSG group than that in ITSG group 3‐, 6‐ and 10‐months after operation (P < .05). Statistical difference regarding psychological status of patients from two groups was unobservable before operation while significantly lower Self‐rating Anxiety Scale (SAS) and Self‐rating Depression Scale (SDS) scores were found in AD‐STSG group than that in ITSG group 3‐, 6‐ and 10‐months after operation (P < .05). Also, AD‐STSG group presented improved mobility of functional part than that in ITSG group 10‐months after operation without statistical difference (P = .051). Artificial dermis combined with autologous split‐thickness skin grafting showed better therapeutic outcomes for the treatment of severely burned patients than autologous intermediate‐thickness skin grafting in terms of graft healing time, scar formation, psychological recovery, and perhaps in functional reconstruction.

What sticks? Patients' perspectives on treatment three years after psychotherapy: A mixed-methods approach

Objective: In the present study, a patient-focused, mixed-methods approach was applied to relate patients' personal experiences of change processes during therapy to their long-term psychometric treatment outcomes. Method: Comprehensive follow-up quantitative assessments and qualitative interviews were conducted with n = 30 patients who had completed an integrative CBT treatment three years prior. Qualitative content analysis by two independent coders was used to categorize patients' subjective explanations of therapeutic change. Correlations were applied to relate the frequency and diversity of change factors to clinically significant change of symptom distress at post-treatment and 36-month follow-up. Cluster analysis was performed to identify clusters of patients with similar patterns of change factors. Results: Qualitative content analysis with good interrater reliability revealed five main categories: (1) Therapeutic relationship (2) Activating resources (3) Motivational clarification and insight (4) Action-oriented coping strategies (5) Healing therapeutic setting. Higher levels of change factors were associated with greater relief of symptoms at post-treatment and 36-month follow-up. Cluster analysis revealed three different groups of patients. Conclusions: The analysis provides insight into therapeutic change factors from the patient's perspective. Some categories are consistent with theoretically driven models of common factors. Results may help tailor psychotherapy to patients' individual needs.

Therapeutic Effects of Botulinum Toxin A, via Urethral Sphincter Injection on Voiding Dysfunction Due to Different Bladder and Urethral Sphincter Dysfunctions

Botulinum toxin A (BoNT-A) urethral sphincter injections have been applied in treating voiding dysfunction but the treatment outcome is not consistent. This study analyzed treatment outcomes between patients with different bladder and urethral sphincter dysfunctions. Patients with refractory voiding dysfunction due to neurogenic or non-neurogenic etiology were treated with urethral sphincter 100 U BoNT-A injections. The treatment outcomes were assessed by a global response assessment one month after treatment. The bladder neck opening and urodynamic parameters in preoperative videourodynamic study were compared between successful and failed treatment groups. A total of 80 non-neurogenic and 75 neurogenic patients were included. A successful outcome was noted in 92 (59.4%) patients and a failed outcome in 63 (40.6%). The treatment outcome was not affected by the gender, voiding dysfunction subtype, bladder dysfunction, or sphincter dysfunction subtypes. Except an open bladder neck and higher maximum flow rate, no significant difference was noted in the other variables between groups. Non-neurogenic patients with successful outcomes had a significantly higher detrusor pressure, and patients with neurogenic voiding dysfunction with successful results had higher maximum flow rates and smaller post-void residuals than those who failed the treatment. However, increased urinary incontinence was reported in 12 (13%) patients. BoNT-A urethral sphincter injection is effective in about 60% of either neurogenic or non-neurogenic patients with voiding dysfunction. An open bladder neck during voiding and a higher maximum flow rate indicate a successful treatment outcome.

Modest, yet progressive: Effective therapists tend to rate therapeutic change less positively than their patients

Objective: Empirical findings on self-serving biases amongst psychotherapists are inconsistent. We tested in a large naturalistic data set, if therapists are prone to illusory superiority when estimating their patients' outcome and whether this effect is buffered by therapists' effectiveness. Method: A post-hoc analysis with N = 69 therapists, who treated N = 1080 patients, was conducted. Therapists' and patients' mean ratings for therapeutic improvement in the Clinical Global Impression Scale (CGI) were compared. Using a multilevel modelling approach, we further investigated the relation between the patient-therapist divergence in the CGI and actual therapeutic change in the Global Severity Index (GSI) of the Brief Symptom Inventory and in the Satisfaction With Life Scale (SWLS). Results: Ratings in the CGI did not show significant differences between patients' and therapists' assessment of therapeutic change. Lower estimations by therapists, compared to patients' self-report, were associated with greater therapeutic change in GSI and SWLS. Conclusions: Therapists, on a whole, did not seem to be prone to illusory superiority when assessing therapeutic outcome. Contrary, the more modest the therapists' estimation of therapeutic outcome was, the greater the actual therapeutic change.

Clinical spectrum of severe chronic central serous chorioretinopathy and outcome of photodynamic therapy

Purpose

To describe a spectrum of severe chronic central serous chorioretinopathy (cCSC) cases and their response to photodynamic therapy (PDT).

Patients and methods

A total of 66 patients (81 eyes) with active severe cCSC were studied, and their response to PDT was compared with a control group consisting of 35 active cCSCs (37 eyes) that did not display characteristics of severity. Best-corrected visual acuity (BCVA) and complete resolution of subretinal fluid (SRF) were considered as main outcome measures.

Results

In severe cCSC cases, we found cumulative areas of diffuse atrophic retinal pigment epithelium alterations in 48 eyes (59%), multiple “hot spots” of leakage in 36 eyes (44%), posterior cystoid retinal degeneration in 25 eyes (31%), and 13 eyes (16%) had a diffuse leakage on fluorescein angiography. After PDT treatment, BCVA increased in both groups, from 66 to 72 Early Treatment of Diabetic Retinopathy Study (ETDRS) letters in the case group (P<0.001), and from 78 to 82 ETDRS letters in the control group (P<0.001). SRF had resolved completely in 87% of severe cCSC cases and 95% of controls at final follow-up visit.

Conclusion

A spectrum of severe cCSC exists, and PDT seems to be an effective treatment in both severe cCSC and nonsevere cCSC in terms of resolution of SRF. Final BCVA shows a significant improvement in both groups after PDT treatment.

Magnetic Resonance Imaging Parameters in Predicting the Treatment Outcome of High-intensity Focused Ultrasound Ablation of Uterine Fibroids With an Immediate Nonperfused Volume Ratio of at Least 90

RATIONALE AND OBJECTIVES

We aimed to investigate the role of magnetic resonance imaging parameters in predicting the treatment outcome of high-intensity focused ultrasound (HIFU) ablation of uterine fibroids with a nonperfused volume (NPV) ratio of at least 90%.

MATERIAL AND METHODS

A total of 120 women who underwent HIFU treatment were divided into groups 1 (n = 72) and 2 (n = 48), comprising patients with an NPV ratio of at least 90% and less than 90%, respectively. Multivariate logistic regression analyses were carried out to investigate the potential predictors of the NPV ratio of at least 90%. The NPV ratios immediately post-treatment, therapeutic efficacy at 6 months' follow-up, and safety in terms of adverse effects and changes in anti-Mullerian hormone level were assessed.

RESULTS

By introducing multiple predictors obtained from multivariate analyses into a generalized estimating equation model, the results showed that the thickness of the subcutaneous fat layer in the anterior abdominal wall, peak enhancement of fibroid, time to peak of fibroid, and the ratio of area under the curve of fibroid to myometrium were statistically significant, except T2 signal intensity ratio of fibroid to myometrium, hence predicting an NPV ratio of at least 90%. No serious adverse effects and no significant difference between the anti-Mullerian hormone levels before or 6 months post-treatment were reported.

CONCLUSIONS

The findings in this study suggest that the achievement of NPV ratio of at least 90% in magnetic resonance imaging-guided HIFU treatment of uterine fibroids based on prediction model appears clinically possible without compromising the safety of patients.

Therapeutic effect of urethral sphincter onabotulinumtoxinA injection for urethral sphincter hyperactivity

PURPOSE

Urethral sphincter hyperactivity resulting in voiding dysfunction is frequently encountered. Medical treatment might not achieve a satisfactory result. OnabotlinumtoxinA urethral sphincter injection relaxes sphincter tonicity and possibly resumes efficient voiding. This study analyzed the treatment outcomes and predictor for successful onabotulinumtoxinA treatment on these patients.

METHODS

Patients with voiding dysfunction due to urethral sphincter hyperactivity and treated with injections of 100 U onabotulinumtoxinA into the urethral sphincter were retrospectively reviewed. Treatment outcomes were assessed 1 month after injection using the Global Response Assessment and were analyzed by demographic and baseline video-urodynamic characteristics.

RESULTS

Of the 95 patients included, satisfactory outcomes were reported in 58 (61.1%) patients. Treatment outcome was not related to age, gender, or voiding dysfunction subtype. Patients with satisfactory outcomes had a significantly smaller volume at first sensation of filling (P = 0.046), greater detrusor pressure (P = 0.027), higher maximum flow rate (P = 0.017), and smaller post-void residual (P = 0.006). In multivariate analysis, an open bladder neck during voiding was the only predictor for successful outcome (88% in satisfactory outcome, 12% in failure outcome, P < 0.001). Patients with non-neurogenic voiding dysfunction had a significantly longer therapeutic duration than those with neurogenic voiding dysfunction (9.55 ± 4.18 vs 7.44 ± 2.91 months, P = 0.033). Increased urinary incontinence was reported in 18 patients, including 6 with stress urinary incontinence and 12 with urgency urinary incontinence.

CONCLUSION

Subjective improvement was reported in 61.1% of patients with voiding dysfunction due to urethral sphincter hyperactivity after onabotulinumtoxinA urethral sphincter injection. An open bladder neck during voiding at baseline predicts a successful outcome.

Severe erythema multiforme-type drug eruption controlled by tumor necrosis factor-α antagonist: A case study

Using a tumor necrosis factor-α antagonist, the present study successfully treated a case of severe erythema multiform-type drug eruption, which occurred following anti-Helicobacter pylori therapy. A 73-year-old female suffering from upper gastrointestinal bleeding and peptic-ulcer presented with an itchy rash, fever, an increase in leukocytes and eosinophils and lymphadenectasis following oral administration of amoxicillin. Following six subcutaneous injections of etanercept (initially 50 mg, then 25 mg every 3 days), the patient was deemed to have recovered. Following the first injection, the fever was under control. On day 2, the lesions were no longer expanding. On day 4, the rash was markedly less itchy, the swelling decreased, the erythema began to crust and mucosal secretions disappeared. On day 16, the patient was deemed to have recovered and was discharged from the hospital. Her peripheral blood eosinophil count continued to rise following the injection, peaking on day 9. Following this, the count declined slowly, but remained significantly higher than normal when the patient was discharged. The present case indicates that tumor necrosis factor-α antagonist is a safe, fast and effective treatment for severe drug eruption, but it is unable to prevent the rise of peripheral blood eosinophils.

Therapeutic outcomes of mandibular advancement devices as an initial treatment modality for obstructive sleep apnea

Although continuous positive airway pressure (CPAP) is a highly efficacious treatment for obstructive sleep apnea (OSA), there is a need for alternative treatment options, such as sleep surgeries and mandibular advancement devices (MADs), to overcome the limitations of CPAP.This study aimed to analyze the therapeutic outcomes of OSA subjects who were treated with a MAD, and to estimate the clinical impact of MAD as a first-line treatment for OSA.Forty-seven patients diagnosed with OSA received an adjustable MAD as an initial treatment. Drug-induced sleep endoscopic findings and sleep parameters (both pre-MAD and post-MAD treatment), such as apnea index, oxygen saturation, and degree of daytime sleepiness, were assessed retrospectively.The MAD treatment resulted in a significant reduction in apnea-hypopnea index, and also a significant elevation in lowest oxygen saturation. Satisfactory results of MAD treatment as a first treatment modality were observed in 27 patients, and a successful outcome was reached in approximately 72% of patients. The OSA patients who had lower body mass index and upper airway narrowing at the level of palate and tongue base showed relatively higher rates of a satisfactory outcome even in cases of moderate or severe OSA.These results suggest that the use of a MAD may be an alternative treatment option in OSA patients with retropalatal and retroglossal area narrowing regardless of disease severity. Additionally, MADs can be recommended as an initial treatment modality, and the effectiveness of MADs in achieving success may not be inferior to CPAP.

Moving toward personalized medicine in rheumatoid arthritis: SNPs in methotrexate intracellular pathways are associated with methotrexate therapeutic outcome

AIM

Evaluate the potential of selected SNPs as predictors of methotrexate (MTX) therapeutic outcome.

PATIENTS & METHODS

In total, 35 SNPs in 14 genes involved in MTX intracellular pathways and Phase II reactions were genotyped in 233 rheumatoid arthritis (RA) patients treated with MTX. Binary logistic regressions were performed by genotype/haplotype-based approaches. Non-Response- and Toxicity-Genetic Risk Indexes (Non-RespGRI and ToxGRI) were created.

RESULTS

MTX nonresponse was associated to eight genotypes and three haplotypes: MTHFR rs1801131 AA and rs1801133 TT; MS rs1805087 AA; MTRR rs1801394 A carriers; ATIC rs2372536 C carriers, rs4673993 T carriers, rs7563206 T carriers and rs12995526 T carriers; CC for GGH rs3758149 and rs12681874; CGTTT for ATIC combination 1; and CTTTC for ATIC combination 2. From overall Non-RespGRI patients with indexes 6-8 had more than sixfold increased risk for MTX nonresponse than those patients with indexes 0-5. MTX-related toxicity was associated to five genotypes and two haplotypes: ATIC rs2372536 G carriers, rs3821353 T carriers, rs7563206 CC and rs12995526 CC; ADORA2A rs2267076 T; CTTCC for ATIC combination 1; and TC for ADORA2A rs2267076 and rs2298383. From overall ToxGRI, patients with indexes 3-4 had more than sevenfold increased risk for MTX-related toxicity than those patients with indexes 1-2.

CONCLUSION

Genotyping may be helpful to identify which RA patients will not benefit from MTX treatment and, consequently, important to personalized medicine in RA. Nevertheless, further studies are required to validate these findings.

Prevalence, risk factors, management, and treatment outcomes of first-line antituberculous drug-induced liver injury: a prospective cohort study

PURPOSE

Antituberculosis drug-induced liver injury (ATDILI) is one of the most deleterious side effects associated with chemotherapy against tuberculosis (TB). In this study, our objective was to determine the incidence, risk factors, and management of ATDILI and analyze its impact on the treatment outcome in patients receiving standard anti-TB chemotherapy.

METHODS

A prospective cohort study of ATDILI prevalence was conducted in 938 enrolled patients of the 1426 TB cases in Shanghai from March 2011 to September 2012. Patients were followed up until February 2014. Univariate and multivariate logistic regression analyses were used to determine the risk factors of ATDILI. Successful therapeutic outcome, rates of drug resistance conversion, sputum smear/culture conversion, and lung cavity closure were analyzed.

RESULTS

Hepatitis B surface antigen/hepatitis B e antigen-positive hepatitis B carriers, complicated with systemic lupus erythematosus, albumin ≤ 25 g/L, and chronic alcoholism were independent risk factors for ATDILI. Of the 121 cases with ATDILI (incidence rate of 12.9%), 84 (69.4%) used modified anti-TB therapy after recovery of liver function. Compared with the non-ATDILI group, patients with ATDILI exhibited remarkably decreased lung cavity closure rate (84.6% vs. 93.0%, P < 0.001) along with significantly reduced sputum smear/culture conversion rate (85.4% vs. 94.0%, P < 0.001).

CONCLUSIONS

Our findings indicated that 12.9% patients developed ATDILI during standard anti-TB therapy, resulting in poor therapeutic outcome. Hepatitis B carriers with systemic lupus erythematosus, albumin ≤ 25 g/L, and chronic alcoholism manifested increased risks for ATDILI. Copyright © 2016 John Wiley & Sons, Ltd.

Genetic polymorphisms in low-dose methotrexate transporters: current relevance as methotrexate therapeutic outcome biomarkers

Methotrexate (MTX) is used in low doses to treat a variety of diseases. Although the mechanism responsible for its therapeutic action is unknown, MTX membrane transport proteins (influx and/or efflux) can be major determinants of pharmacokinetics, adverse drug reactions and clinical response profiles. With progess in pharmacogenomics, the improvement of the prediction of patients' therapeutic outcome treated with low doses of MTX will offer a powerful tool for the translation of transporter SNPs into clinical practice and will be essential to sustain a breakthrough in the field of personalized medicine. Therefore, this paper provides an update on the current data on SNPs in genes encoding low-dose MTX membrane transport proteins and their relevance as possible biomarkers of MTX therapeutic outcome.

Determinants of decision-to-intervention time in the management and therapeutic outcome of emergency gynecological surgeries in south east Nigeria

Background

Prompt and timely response in the management of gynecological surgical cases can significantly affect the therapeutic surgical outcome of patients in emergency situations. The aim of this study was to evaluate the decision-to-intervention time (DIT), its determinants, and the significance in the therapeutic outcome of emergency gynecological surgeries managed at a federal teaching hospital in south east Nigeria over an 18-month period.

Methods

This was a prospective descriptive study of 105 emergency gynecological cases managed at a federal teaching hospital over an 18-month period. Patients were recruited at the point of admission and followed up until discharge for outcome. Data were abstracted with a data entry pro forma and then analyzed with the Epi Info™ statistical software version 7.0.

Results

The incidence of gynecological surgical emergencies was 5.1% of the total gynecological cases managed during the study period. The mean DIT was 4.25 (range 1.45–5.50) hours with delay in intervention, mainly due to delays in securing blood/blood products and other materials for resuscitation (46.7%) and a lack of finance (15.2%). Six maternal deaths were recorded, giving a case fatality ratio of 5.7%, while the commonest maternal complications associated with the delays were hemorrhage (61.9%) and the need for blood transfusion (57.1%), respectively. The risk ratio of losing ≥1,000 mL of blood, anemia, hemorrhagic shock, and wound infection in those with DIT ≥120 minutes was statistically greater and significant at 95% confidence interval.

Conclusion

Inadequacies in health care services and policies due to poor infrastructure, organizational framework, and financing were the major determinants of the prolonged DIT and therapeutic outcomes.

Therapeutic outcomes of endoscopic resection for superficial non-ampullary duodenal tumor

BACKGROUND AND AIM

Endoscopic resection (ER) is widely used as a minimally invasive therapy to remove superficial non-ampullary duodenal tumor (SNADT). However, the indication criteria have not yet been clearly determined. At our institute, ER is done only for SNADT measuring ≤ 20 mm. We report our findings on the therapeutic outcomes of ER of SNADT.

METHODS

We carried out ER in 47 patients with SNADT. Indication criteria for ER included a lesion suspected as high-grade dysplasia or mucosal cancer and measuring ≤ 20 mm. The ER methods used to carry out en bloc resection were endoscopic mucosal resection (EMR: 17 lesions) or endoscopic submucosal dissection (ESD: 30 lesions). We then analyzed the therapeutic outcomes between them.

RESULTS

There were no significant differences between the EMR and ESD groups with regard to age, sex, location of the lesion, and histology. The most frequent gross types resected by EMR and ESD were 0-IIa and 0-IIc, respectively (P=0.004). Median procedure time was significantly longer in ESD than in EMR, 79.5 and 9 min, respectively (P<0.001). R0 resection was achieved in 10 cases by EMR (59%) and in 27 cases by ESD (90%) (P=0.017). No complications occurred in cases that underwent EMR, but immediate and delayed perforations occurred in three patients who underwent ESD, although this difference was not statistically significant (P=0.467).

CONCLUSION

Using our indication criteria, which limited lesion size to ≤ 20 mm, satisfactory therapeutic outcomes of ER of SNADT were obtained.

The key role of psychosocial risk on therapeutic outcome in obese children and adolescents. Results from a longitudinal multicenter study

OBJECTIVE

Childhood obesity is high on the global public health agenda. Although risk factors are well known, the influence of social risk on the therapeutic outcome of lifestyle intervention is poorly examined. This study aims to investigate the influence of migration background, low education, and parental unemployment.

METHODS

62,147 patients participated in multidimensional lifestyle intervention programs in 179 pediatric obesity centers. Data were collected using standardized software for longitudinal multicenter documentation. 12,305 (19.8%) attended care for 6-24 months, undergoing an intensive therapy period and subsequent follow-ups for up to 3 years. A cumulative social risk score was calculated based on different risk indicators.

RESULTS

Migration background, low education, and parental employment significantly influenced the outcome of lifestyle intervention. The observed BMI-SDS reduction was significantly higher in the subgroup with low social risks factors (Δ BMI-SDS -0.19) compared to those presenting moderate (Δ BMI-SDS -0.14) and high social risk (Δ BMI-SDS -0.11).

CONCLUSION

Our data underline the effect of children's social setting on the outcome of multidimensional lifestyle intervention. The presence of a high social risk burden is a negative predictor for successful weight loss. Specific therapeutic programs need to be developed for disadvantaged children and adolescents.