Prospective randomised controlled trial comparing trigone-sparing versus trigone-including intradetrusor injection of abobotulinumtoxinA for refractory idiopathic detrusor overactivity

Background

Botulinum toxin A is effective for treatment of idiopathic detrusor overactivity (IDO). The trigone is generally spared because of the theoretical risk of vesicoureteric reflux (VUR), although studies assessing injection sites are lacking.

Objective

Evaluate efficacy and safety of trigone-including versus trigone-sparing intradetrusor injections of abobotulinumtoxinA in patients with IDO.

Design, setting, and participants

Twenty-two patients from one centre were randomised to trigone-including or trigone-sparing injections.

Intervention

Injection of 500 U abobotulinumtoxinA diluted to 20 ml into 20 trigone-including or trigone-sparing sites.

Measurements

The primary outcome measure was total overactive bladder symptom score (OABSS) at 6 wk. The OABSS questionnaire was completed at 0, 6, 12, and 26 wk. Baseline and postinjection urodynamic studies and micturating cystourethrograms were performed. Baseline values and subsequent time points were compared by t test. A mixed-effect model was used for repeated measures in time.

Results and limitations

For symptom scores at baseline compared with scores at 6 wk postinjection, the mean total OABSS improved from 22.4 to 8.7 (p < 0.001) in the trigone-including group compared with 22.7 to 13.4 (p < 0.03) in the trigone-sparing group. The difference in mean change from baseline was 4.4 points in favour of the trigone-including group (p = 0.03). The total OABSS at 12 and 26 wk and the urgency subscale scores at 6, 12, and 26 wk showed significant improvement in favour of the trigone-including group. Mean postvoid residual volumes and clean intermittent self-catheterisation rates between the two groups were similar. No patients developed VUR. Performing injections under general anaesthetic was a limitation, as tolerability under local anaesthetic was not assessed. A further limitation is the lack of a trigone-only arm.

Conclusions

Trigone-including injections are superior to trigone-sparing injections for the treatment of refractory IDO and did not cause VUR in this study.     

元胡止痛片联合普瑞巴林治疗带状疱疹后遗神经痛的临床研究

目的 探讨元胡止痛片联合普瑞巴林治疗带状疱疹后遗神经痛的临床效果。方法 选取2019年1月—2020年12月河南科技大学第一附属医院收治的100例带状疱疹后遗神经痛患者,以随机数字表法将其随机分成对照组（n=50）和治疗组（n=50）。对照组患者口服普瑞巴林胶囊,起始剂量为75 mg/次,1次/d,1周内根据疗效和耐受性,将用药剂量增至150 mg/次,2次/d。治疗组在对照组基础上口服元胡止痛片,1.5 g/次,3次/d。两组均连续治疗4周。观察两组临床疗效、止痛起效时间及疼痛缓解时间,并比较治疗前及治疗1、2、3、4周两组疼痛视觉模拟量表（VAS）评分,同时比较治疗前后两组患者阿森斯失眠量表（AIS）评分及血清降钙素基因相关肽（CGRP）、P物质（SP）、肿瘤坏死因子（TNF）-α、白细胞介素（IL）-1β、IL-6水平。结果 治疗后,治疗组总有效率为96.0%,显著高于对照组的84.0%（P<0.05）。两组疼痛VAS评分均随治疗时间的延长而逐渐下降（P<0.05）,且治疗组治疗1、2、3、4周疼痛VAS评分均较同期对照组显著更低（P<0.05）。治疗后,治疗组止痛起效时间和疼痛缓解时间均显著短于对照组（P<0.05）。两组治疗后AIS评分均较本组治疗前显著降低（P<0.05）,且治疗组AIS评分比对照组降低作用更显著（P<0.05）。治疗后,两组血清CGRP、SP、TNF-α、IL-1β及IL-6水平均显著下降（P<0.05）;且治疗后,治疗组血清学指标的降低作用均较对照组更显著（P<0.05）。结论 元胡止痛片联合普瑞巴林治疗带状疱疹后遗神经痛的整体疗效满意,能快速且安全有效地减轻患者疼痛,改善其睡眠质量,并可显著下调血中相关疼痛介质的表达水平、抑制体内炎症反应。     

A case of idiopathic portal hypertension associated with rheumatoid arthritis

Abstract

A 53-year-old woman who had been diagnosed with rheumatoid arthritis was found to have thrombocytopenia, splenomegaly, and gastric varices. She was diagnosed as having idiopathic portal hypertension on the basis of liver biopsy and angiography. Treatment with prednisolone was not sufficiently effective for thrombocytopenia. After transabdominal devascularization with splenectomy, thrombocytopenia subsided and gastric varices disappeared. In this case, the autoimmune mechanism as well as hypersplenism was suspected of being involved in the mechanism of thrombocytopenia.     

Immunohistochemical and morphometric evaluation of COX-1 and COX-2 in the remodeled lung in idiopathic pulmonary fibrosis and systemic sclerosis ,

OBJECTIVE:

To study the expression of COX-1 and COX-2 in the remodeled lung in systemic sclerosis (SSc) and idiopathic pulmonary fibrosis (IPF) patients, correlating that expression with patient survival.

METHODS:

We examined open lung biopsy specimens from 24 SSc patients and 30 IPF patients, using normal lung tissue as a control. The histological patterns included fibrotic nonspecific interstitial pneumonia (NSIP) in SSc patients and usual interstitial pneumonia (UIP) in IPF patients. We used immunohistochemistry and histomorphometry to evaluate the expression of COX-1 and COX-2 in alveolar septa, vessels, and bronchioles. We then correlated that expression with pulmonary function test results and evaluated its impact on patient survival.

RESULTS:

The expression of COX-1 and COX-2 in alveolar septa was significantly higher in IPF-UIP and SSc-NSIP lung tissue than in the control tissue. No difference was found between IPF-UIP and SSc-NSIP tissue regarding COX-1 and COX-2 expression. Multivariate analysis based on the Cox regression model showed that the factors associated with a low risk of death were younger age, high DLCO/alveolar volume, IPF, and high COX-1 expression in alveolar septa, whereas those associated with a high risk of death were advanced age, low DLCO/alveolar volume, SSc (with NSIP), and low COX-1 expression in alveolar septa.

CONCLUSIONS:

Our findings suggest that strategies aimed at preventing low COX-1 synthesis will have a greater impact on SSc, whereas those aimed at preventing high COX-2 synthesis will have a greater impact on IPF. However, prospective randomized clinical trials are needed in order to confirm that.     

Shingles vaccine

Importance of the field: Herpes zoster or shingles is a condition with the potential to result in severe debilitation. It affects approximately 10 – 30% of the population. Until recently there were only treatments to shorten the duration and lessen the symptoms of herpes zoster, but no practical or approved method of prevention for susceptible immunocompetent adults. The live attenuated zoster vaccine (Zostavax^®, Merck & Co., Inc.) is effective in preventing shingles in individuals 60 years of age and older and recommended by the Center for Disease Control's (CDC) Advisory Committee for Immunization Practices (ACIP).

Areas covered in this review: Literature related to the live attenuated zoster vaccine is reviewed from its beginnings in the early 1970s through to the present.

What the reader will gain: Background information on herpes zoster and up to date information on the live attenuated zoster vaccine including pharmacology, efficacy and safety are covered. New areas of research in zoster vaccination are also discussed.

Take home message: The live attenuated zoster vaccine is an effective and well-tolerated method of preventing zoster and the potentially debilitating sequelae and is recommended for immunocompetent patients 60 years of age and older. Ongoing clinical trials are investigating new means of effective prevention.     

Chronic Administration of Ketamine for Analgesia

Use of the dissociative anesthetic ketamine in subanesthetic doses has demonstrated efficacy in neuropathic pain. This article reviews the scientific and clinical literature on ketamine. Mechanisms of both central and peripheral neuropathic pain are described. Studies of ketamine analgesia in postherpetic neuralgia, phantom pain, complex regional pain syndrome and cancer pain are reviewed. A range of administration methods for ketamine including neuroaxial administration are described.     

A Randomized,Prospective Study of Efficacy and Safety of Oral Tramadol in the Management of Post‐Herpetic Neuralgia in Patients from North India

Objective: To evaluate the safety and efficacy of oral tramadol therapy (50 to 200 mg/day) in the treatment for post‐herpetic neuralgia (PHN). Methods: The study was a prospective, single‐blind, non‐responder vs. responder, randomized trial conducted in 100 outpatients of PHN after oral administration of tramadol for 4 weeks. Those patients who had achieved 50% or greater pain relief after 14 days of oral tramadol treatment were categorized as responders and those reporting < 50% pain relief were categorized as non‐responders. Rescue analgesia was provided by the topical application of a cream consisting of the combination of 3.33% doxepin and 0.05% capsaicin to the affected areas of PHN patients of both groups for at least 14 days, along with tramadol therapy. The rescue analgesia was extended to 4 weeks in patients of the non‐responder group. The primary endpoints were measured using a Numerical Rating Scale (NRS) at rest and with movement. Secondary endpoints included additional pain ratings such as global perceived effect (GPE), Neuropathic Pain Symptom Inventory scores (NPSI), daily sleep interference score (DSIS), Quality of life (QOL) as per WHO QOL‐BREF Questionnaire scores, patient and clinician ratings of global improvement. The 2 groups were compared on the basis of pain intensity scores, encompassing primary as well as secondary endpoints, and QOL after 28 days of the treatment regimen. Results: Pain intensity scores measured by NRS (at resting and with movement), NPSI, and DSIS were consistently reduced (P < 0.001) over 28 days at varying intervals in both the groups, but the magnitude of reduction was higher in responders than non‐responders. A concomitant improvement (P < 0.001) was observed in GPE on days 3, 14, and 28 as compared to the respective baseline scores in both the groups. Although the WHO QOL‐BREF scores showed significant (P < 0.001) improvement in QOL of PHN patients at days 14 and 28 in both the groups, the magnitude of improvement was higher in responders as compared to non‐responders. Significant improvement in pain intensity scores and QOL in non‐responders is mainly attributed to the use of rescue analgesia for 28 days rather than recommended tramadol therapy. Conclusions: Treatment with tramadol 50 to 200 mg per day was associated with significant pain reduction in terms of enhanced pain relief, reduced sleep interference, greater global improvement, diminished side‐effect profile, and improved QOL in PHN patients from North India. Further categorization of PHN patients may be helpful so that additional or alternative therapy may be prescribed to non‐responders.