Methotrexate in refractory bilateral juvenile temporal arteritis: Report of a case

Juvenile temporal arteritis is a rare inflammatory disease of the temporal arteries that affects young adults. The clinical course is benign and the surgical excision of the affected artery is usually curative. Here we report a case of bilateral juvenile temporal arteritis with significant peripheral eosinophilia and elevated IgE, refractory to surgical excision and even to a short course of corticosteroids. Methotrexate, added as a steroid-sparing agent, resulted in a good disease control.     

甲氨蝶呤治疗强直性脊柱炎髋关节病变的临床研究

目的观察甲氨蝶呤（MTX）对强直性脊柱炎（AS）髋关节病变的临床疗效，并以柳氮磺吡啶（SSZ）作为对照，以评价MTX对AS髋关节病变的有效性及安全性。方法从住院的AS髋关节病变患者中随机选择MTX治疗的48例为观察组，并以年龄、性别、病程及病情相匹配，采用SSZ治疗的50例作为对照组，两组患者均选择一种非甾体抗炎药作为基础疗法。出院后继续原药物治疗，并随访3年的临床资料，包括临床症状、Bath AS活动指数（BASDAI）、Bath AS功能指数（BASFI）、髋关节功能评分、髋关节病变CT分期、炎性指标等实验室检查及不良反应。结果观察组第1、2、3年随访44、38、32例。对照组分别为45、38、31例。随访3年内，髋关节功能评分观察组显著高于对照组（P〈0．05）。髋关节CTI期病变，两组患者随访第2、3年与入院时比较明显减少（P〈0．05）；随访第2、3年，观察组比对照组显著下降（P〈0．05）。髋关节CTⅡ期病变，两组间各时段比较差异均无统计学意义。腰痛、腰背晨僵、BASDAI和BASFI、红细胞沉降率（ESR）、C反应蛋白（CRP），两组间对比差异均无统计学意义。不良反应以胃肠道反应为主．两组比较差异无统计学意义；随访所有病例无造血系统障碍发生。结论MTX对AS髋关节病变的疗效优于SSZ，在治疗3年内髋关节功能明显改善；MTX不良反应较轻，可作为治疗AS髋关节病变的首选药物，其更长期的疗效及安全性有待进一步观察。     

Methotrexate for Crohn's disease: experience in a district general hospital

Controlled trials have demonstrated the efficacy of methotrexate (MTX) in the induction and maintenance of remission in patients with luminal Crohn's disease, but its use outside of specialist centres remains limited. We present a case series of 24 patients treated with parenteral MTX in a district general hospital. Patients received an induction course of 25 mg weekly for 16 weeks, followed by maintenance doses of 15 mg weekly. Nineteen patients achieved remission during the induction period. Of these, 10 were maintained in remission for more than 12 months. In total, there were six relapses within 1 year and five drug withdrawals due to side effects during the observation period. Of the six relapses, three required surgical intervention (with two of these re-starting methotrexate postoperatively) and three were recommenced on maintenance MTX after a short period at an increased dose. Our results are similar to outcomes achieved in large, randomized, controlled trials and indicate that MTX can be used safely and effectively for the treatment of refractory Crohn's disease in the district general hospital setting.     

Methotrexate for Rheumatoid Arthritis

Methotrexate (MTX) has become an important drug in the treatment of rheumatoid arthritis (RA). The American College of Rheumatology convened a committee to assess the risks of development of clinically significant liver disease (CSLD) during MTX treatment, to evaluate the risk and role of surveillance liver biopsies, and to provide recommendations about monitoring patients for liver toxicity. The committee recommends obtaining liver blood tests (alanine aminotransferase [ALT], aspartate aminotransferase [AST], alkaline phosphatase, albumin, bilirubin), hepatitis B and C serologic studies, and other standard tests including complete blood cell count and serum creatinine tests prior to starting treatment with MTX. A pretreatment liver biopsy should be considered only for patients with a history of prior excessive alcohol consumption, persistently abnormal baseline AST values, or chronic hepatitis B or C infection. At intervals of every 4–8 weeks the AST, ALT, and albumin levels should be monitored. Routine surveillance liver biopsies are not recommended for RA patients receiving traditional doses of MTX. However, a biopsy should be performed if a patient develops persistent abnormalities on liver blood tests. These are defined as elevations (above the upper limit of laboratory normal) in the AST in 5 of 9 determinations within a given 12-month interval (6 of 12 if tests are performed monthly) or a decrease in serum albumin below the normal range. The recommendations for monitoring and selection of patients for liver biopsy identify patients at potential risk for CSLD, and thus significantly reduce the number of patients who would be exposed to this procedure. Close monitoring is essential to reduce the risk of unrecognized serious liver disease. These recommendations should be revised as necessary to reflect new and compelling information.     

The effectiveness of callback counselling for smoking cessation: a randomized trial

Aims . The development of acceptable, widely available and effective smoking cessation methods is central to public health strategy for tobacco control. We examined the effectiveness of a telephone callback counselling intervention, compared to the provision of self-help resources alone. Methods . Participants were 998 smokers calling a state-wide "Quitline" service randomly allocated to either callback counselling or ordinary care. The callback condition consisted of a series of brief counselling calls at strategic times in addition to ordinary care. The number of calls varied according to caller needs, and most occurred generally just before the person's quit day and in the week or two after it. The service was delivered by trained telephone counsellors. Results . At the 3-month follow-up, significantly more participants in the callback group (24%) reported that they were quit, compared to those in the usual care comparison group (13%). The difference in point prevalence of smoking declined to 6% by the 12-month follow-up. Using sustained abstinence there was a significant benefit of callback counselling at 12-month follow-up. Treating dropouts as smokers reduced the overall magnitude of the effects somewhat. The benefit of callbacks was to marginally increase quit attempts and to significantly reduce relapse. Conclusion . Our findings are consistent with those of other studies demonstrating benefits of callback telephone counselling to facilitate cessation. Such counselling provides a flexible, relatively inexpensive and widely available form of cessation service. It appears to encourage a greater proportion of quit attempts and to reduce the rate of relapse among those quitting. Further research is required to determine ways to enhance effectiveness, particularly studies of how to reduce relapse.     

Living kidney donor experiences: implications for counselling

This study adds to previous, mostly quantitative, investigation into the experiences of living related kidney donors. Such investigation is important so that potential donors are supported effectively and donation programmes remain relevant and specific to need. Exploration takes place into donor decision-making processes and the most effective forms of professional support. A non-probability sampling technique highlighted eight living related kidney donors who were interviewed using a semi-structured interview format. Raw data was analysed through the qualitative technique of Interpretative Phenomenological Analysis. The decision to donate is made rapidly, decisively and rationally. Professional support provides reassurance to donors, particularly when experiencing acute psychological reaction. The need to provide support to the parents of living donors is specifically highlighted. A comprehensive range of Master Themes are generated through Interpretative Phenomenological Analysis and these reflect the complexity of the donation experience. This suggests donors are concerned with the management of psychological experience rather than with reviewing the appropriateness of an original decision to donate. Evidence indicates that concepts of attitude and self-efficacy belief can develop understanding of the psychological experience of being a living kidney donor. A counselling perspective, with Social Cognitive Theory at its core, is highlighted as a valid method for providing professional support to donors before and after surgery.     

Methotrexate pneumonitis in rheumatoid arthritis: potential risk factors. Four case reports and a review of the literature

Methotrexate pneumonitis is emerging as one of the most unpredictable and potentially serious adverse effects associated with the use of low dose, pulse methotrexate in treating rheumatoid arthritis (RA). We report 4 new cases of methotrexate pneumonitis in patients with RA and review 6 published cases. A greater than expected proportion of patients had a smoking history, preexisting pulmonary disease and were male. Prognosis was better in those patients treated with corticosteroids.     

Methotrexate: bioavailability and pharmacokinetics

Six adult patients with squamous cell carcinoma of the head and neck were treated with single low doses of methotrexate (MTX) (30 mg/m2) iv, im, and orally in the form of commercial tablets. A randomized crossover design was employed. Plasma concentrations were measured by a modified EMIT assay over a period of 24 hours following each dose. The mean (+/- SD) parameters following iv MTX were as follows: total-body clearance, 124 (36) ml/minute; Vss, 0.56 (0.18) L/kg; V lambda, 0.69 (0.24) L/kg; and beta-half-life, 3.20 hours. The absolute systemic bioavailability of the oral tablets was 36% (+/- 10%). After im administration, the systemic bioavailability was 93% (+/- 14%). Dose-dependent gastrointestinal absorption is suggested as the mechanism for the low availability of the oral tablets. Administration of MTX by the oral route will require further study to determine the optimal method of dosing.     

Methotrexate in pregnancy: reply

We would like to thank Lloyd and colleagues for their interestin our recent case report. We would certainly agree that anypatient exposed to any dose of methotrexate during pregnancyor in the 6 months prior to conception is at risk of fetal abnormality.Our advice     

Methotrexate for systemic lupus erythematosus: a retrospective analysis of 17 unselected cases.

We report a retrospective study of 17 patients with systemic lupus erythematosus who were treated with oral methotrexate given as a mean weekly dose of 8.47 +/- 1.72 mg. Methotrexate treatment resulted in symptomatic improvement in 57% of patients and allowed the reduction of the mean daily dose of prednisone from 16.66 mg initially to 8.99 mg at one year follow-up. Twelve of 17 patients (70.6%) experienced at least one episode of toxicity. Factors which might be associated with toxicity are analyzed. Because of its potential as a corticosteroid-sparing agent, controlled studies of methotrexate for the treatment of systemic lupus erythematosus are indicated.