Comparison of efficacy and safety of intralesional triamcinolone and combination of triamcinolone with 5-fluorouracil in the treatment of keloids and hypertrophic scars: Randomised control trial

The treatment of keloid and hypertrophic scar is challenging with no universally accepted mode for permanent ablation. Conventional therapies yield unpredictable results, significant complications and require elaborate hardware.

Efficacy of Neoadjuvant Intratumoral Darleukin/Fibromun (L19IL2 + L19TNF) in Patients with Clinical Stage IIIB/C Melanoma (Neo-DREAM)

Annals of Surgical Oncology -     

A biomechanical evaluation of a spacer with integrated plate for treating adjacent-level disease in the subaxial cervical spine

Background contextAdjacent level degeneration (ALD) has been reported as one of the long-term consequences of anterior discectomy and fusion despite its clinical success in treating cervical pathologies. Traditionally, ALD is treated by replacing the previously implanted plate with a longer plate, which can lead to postoperative complications. The biomechanics of SIP in the adjacent level has not been investigated.PurposeTo evaluate the multidirectional stability of a spacer with integrated plate (SIP) in comparison to a traditional spacer and plate (TSP).Study designTo evaluate the biomechanical stability of a spacer with integrated plate adjacent to a traditional spacer and plate construct in a human cervical cadaveric model.MethodsEight fresh human cervical (C2–C7) cadaver spines were mounted on a six degree-of-freedom spine simulator. The sequence of test constructs was: 1) Intact; 2) TSP (C4–C6) with SIP (C3–C4); and 3) TSP (C3–C6). An unconstrained moment of ±1.5 Nm was used in flexion-extension, lateral bending, and axial rotation. Range of motion (ROM) was measured by a digital motion analysis system. Statistical analysis was performed using ANOVA repeated measures.ResultsAll instrumented constructs significantly reduced ROM compared to the intact condition. No statistically significant difference was observed between the two-level TSP with an adjacent SIP construct and three-level TSP construct in all loading modes.ConclusionThe biomechanical study shows that adding a spacer with integrated plate adjacent to a two-level anterior plate demonstrates equivalent stability to a three-level anterior plate. The spacer with integrated plate, which preserves the originally plated fusion levels, may overcome the complications associated with the traditional technique of replacing the original plate with a longer plate. However, prospective clinical studies are required to address the clinical benefits and challenges, if any.     

Longitudinally extensive transverse myelitis as the sole presentation of neuro-Behçet's disease responding to infliximab

Context

Isolated involvement of the spinal cord is an uncommon presentation of neuro-Behçet''s disease (NBD) and it is associated with a poor prognosis for functional recovery.

Method

A case report of an 18-year-old Turkish man who presented with a progressive paraparesis and bladder dysfunction secondary to a longitudinally extensive transverse myelitis as the sole presentation of NBD.

Findings

Examination revealed a spastic paraparesis and a T7 sensory level. Magnetic resonance imaging revealed multiple enhancing lesions throughout the thoracic cord and cerebrospinal fluid showed intense neutrophilia. On further enquiry a family history of Behçet''s disease was elicited. The patient subsequently reported a history of recurrent oral ulceration and intermittent occular inflammation. A diagnosis of NBD was made and intravenous high-dose steroids commenced with poor response. In view of the poor prognosis for functional recovery associated with spinal NBD the patient was treated with infliximab, an anti-tumour necrosis factor-alpha monoclonal antibody, leading to excellent recovery of function.

Conclusion/clinical relevance

Early treatment with infliximab may facilitate a favourable functional recovery and should be considered in cases of NBD with spinal cord involvement.     

The association of 6-minute walk performance and outcomes in stable outpatients with heart failure

BACKGROUND: We sought to evaluate the prognostic value of the 6-minute walk test in stable outpatients with heart failure. METHODS AND RESULTS: We examined the association of 6-minute walk test distance and outcomes among 541 patients enrolled in the Digitalis Investigation Group trial. Patients were grouped by total distance (< or =200 m, 201 m-300 m, 301 m-400 m, and >400 m) with median follow-up of 32 months. All-cause mortality for patients who walked < or =200 m was significantly higher than patients who walked >200 m (43.9% versus 23.3%, P<0.001), but mortality was comparable among patients who walked >200 m (201 m-300 m: 23.7%, 301 m-400 m: 25.2%, >400 m 19.8%, P for trend 0.45). Results were similar for death due to worsening heart failure (< or =200 m: 29.3%, 201 m-300 m: 7.6%, 301 m-400 m: 6.7%, >400 m: 6.1%, P for trend <0.001). In multivariable analysis, distance < or =200 m remained associated with increased mortality (< or =200 m: hazard ratio (HR) 1.47, 95% CI 0.96-2.27; >200 m: HR 1.00, Referent; P=0.07) and death due to worsening heart failure (< or =200 m: HR 2.89, 95% CI 1.54-5.41; >200 m: 1.00, Referent; P=0.001). CONCLUSIONS: The 6-minute walk test identifies patients who walk less than 200 m as being at markedly increased risk of death. Changing the 6-minute walk test to a time- and distance-based standard would improve the efficiency of the test while retaining the bulk of the prognostic information.     

Clinical utility of dabigatran in United Arab Emirates: A pharmacovigilance study

Objectives:

To provide early data regarding clinical utility of dabigatran in Al-Ain, United Arab Emirates (UAE).

Methods:

This was an ethics approved retrospective cross sectional study. We retrieved a total of 76 patients who were using dabigatran from September to December 2014 in the Cardiology Clinic at Al-Ain Hospital, Al-Ain, UAE. The primary analysis was designed to test the frequency of bleeding events (rate) with dabigatran 75, 110, and 150 mg.

Results:

The mean age ± standard deviation of cohort was 67.9 ± 1.5 years (range; 29-98 years), composed of males (52.6%) with mean age of 66.3 ± 1.7 years, and females (47.4%) with mean age of 69.6 ± 1.1 years. The highest age group was those between 61-80 years (60.5%). Most comprised the age strata of ≤75 years (73.7%). The main indication for dabigatran use was atrial fibrillation. The rate of bleeding with dabigatran was 18/76 (23.7%), and melena was the leading cause of bleeding 8/76 (10.7%). The hospitalization rate was 67.1%, dabigatran withdrawal rate was 0.01%, and mortality rate was 6.5%. The cohort had exhibited incidences of minor bleeding with one fatal major bleeding, high co-morbidities, admission, and readmission, which was not directly linked to dabigatran. We did not identify any relation of death due to dabigatran.

Conclusion:

Dabigatran is a suitable alternative to warfarin obviating the need for repetitive international normalized ratio monitoring, however, it may need plasma drug monitoring.Atrial fibrillation (AF) is the most common cardiac arrhythmia that affects 1-1.5% of population worldwide.1 Atrial fibrillation prevalence increases with age, and rises from 0.7% in those between 55-59 years to 17.8% in those ≥85 years. Nearly 85% of patients with AF are aged >65 years old.2 The lifetime risk for the development of AF as demonstrated in the Framingham study was one in 4 for men and women aged ≥40 years,3 which pose certain concerns in countries with aging populations.4,5 In addition to this, hospitalization related to AF is alarmingly increasing.6 The risk of stroke in patients with AF is 5 folds, and systemic thromboembolism is 3 folds.7,8 Banerjee, et al9 has deployed stroke prevention score in patients with AF, however, the predictive value is of less magnitude. The European Society of Cardiology set estimation of stroke risk in patients with AF as per CHA₂DS₂-VASc score to determine the recommendation for initiating an oral anticoagulant,10 whereas in patients with CHA₂DS₂-VASc ≥2, HAS-BLED score can be used to assess the risk of bleeding, and commencement of anticoagulant.11Warfarin (vitamin K antagonist [VKA]) has proven efficacy in reducing the risk of stroke in patients with AF, however, it poses high bleeding incidences, emergency hospitalizations, unpredictable therapeutic effect, and multiple international normalized ratio (INR) tests leading to many limitations in its clinical utility.12 Novel oral anticoagulants (NOACs) are proved as effective anticoagulants in prevention of stroke in patients with AF. Novel oral anticoagulants were preferred in non-valvular AF, and do not require coagulation monitoring, however, strict adherence to approved indication is highly warranted.13 Dabigatran (Pradaxa^®), a competitive inhibitor of thrombin was approved in October 2010 by the United States of America Food and Drug Administration to reduce the risk of stroke, and systemic embolism in patients with non-valvular AF.14 A systematic review incorporated 6 economic reviews from diverse healthcare systems (USA, Canada, and United Kingdom) utilizing different economic models. It has suggested the benefit of dabigatran in patients with high-risk of stroke, high-risk of intra-cerebral hemorrhage, or suboptimal use of warfarin. The review outlined concerns on tolerability of dabigatran, adherence issues, and adverse consequences.15In comparison with warfarin, dabigatran 150 mg has shown low rates of stroke, and systemic embolism (dabigatran p<0.001 for superiority). However, both drugs exhibited comparable rates of major hemorrhage.16-18 Greater fatal, and non fatal bleeding events were reported with dabigatran than warfarin.19,20 A recent (2015) retrospective Medicare data analysis study20 on dabigatran’s safety highlighted that the incidence of bleeding was higher than with warfarin (33% versus 27%), major bleeding (9% versus 6%), and gastrointestinal bleeding (17% versus 10%). Intracranial hemorrhage occurred more often with warfarin than dabigatran (1.8% versus 0.6%).20 It has been documented that risks of major bleeding from dabigatran is high for patients with chronic kidney disease, and in African Americans.20 The Randomized Evaluation of Long-term Anticoagulant Therapy: Dabigatran versus warfarin-RE-LY studies18 have showed similar risk of bleeding with warfarin versus dabigatran in patients with non-valvular AF. This dictated the importance of age sub-group analysis in studies. In real clinical practice, patients from different countries may have more co-morbid conditions than those in the RE-LY study.21 The current available data around bleeding incidences from dabigatran is relevant to populations with diverse characteristics. Revealing the clinical utility of dabigatran in our Emirati population may demonstrate different perspectives. Therefore, we intend to provide early data around the clinical utility of dabigatran in United Arab Emirates (UAE) Emirati population.     

Aerobic and anaerobic exercise training in obese adults

[Purpose] Obesity is a global health problem and is associated with a multitude of complications. This study was designed to determine changes in cardiopulmonary functions after aerobic and anaerobic exercise training in obese subjects. [Subjects and Methods] Forty obese subjects, whose ages ranged between 18 and 25 years, were divided into 2 equal groups: group A received aerobic exercise training in addition to dietary measures, and group B received anaerobic exercise training for 3 months in addition to dietary measures. Measurements of systolic blood pressure, diastolic blood pressure, heart rate, maximum voluntary ventilation, maximal oxygen consumption, and body mass index were obtained for both groups before and after the exercise program. [Results] The mean body mass index, systolic blood pressure, diastolic blood pressure, heart rate, and maximal oxygen consumption decreased significantly, whereas the mean maximum voluntary ventilation increased significantly after treatment in group A. The mean maximum voluntary ventilation also increased significantly after treatment in group B. There were significant differences between the mean levels of the investigated parameters in groups A and B after treatment. [Conclusion] Aerobic exercise reduces weight and improves cardiopulmonary fitness in obese subjects better than anaerobic exercise.Key words: Obesity, Aerobic, Anaerobic