Drug Of First Choice Research Articles

Clinical effects of metoprolol in obstructive hypertrophic cardiomyopathy (TEMPO). A randomized, double-blinded, placebo-controlled crossover trial

Abstract Background Treatment with beta blockers (BB) has been used for symptomatic relief in patients with obstructive hypertrophic cardiomyopathy (HCM) for decades. Even so, the guideline recommendation for the use of BB rests on expert opinions and observational cohort studies. Providing comprehensive high-quality data on the effects of BB in obstructive HCM is essential, especially in the context of newly developed pharmacological treatment strategies specifically targeting this disease (1). Purpose The study aimed to investigate the effects of metoprolol on left ventricular outflow tract (LVOT) obstruction, symptoms, and exercise capacity in patients with obstructive HCM. Methods This double-blinded, placebo-controlled, randomized crossover trial enrolled 30 patients with obstructive HCM and New York Heart Association (NYHA) class ≥ II symptoms from 1 May 2018 to 1 September 2020. Patients received metoprolol or placebo for two consecutive two-week periods in random order. The effect parameters were LVOT gradients, NYHA class, Canadian Cardiovascular Society (CCS) grading angina class, Kansas City Cardiomyopathy Questionnaire Overall Summary Score (KCCQ-OSS), and cardiopulmonary exercise testing. Results Compared with placebo, the LVOT gradient during metoprolol was lower at rest (25 [15–58] mmHg versus 72 [28–87] mmHg; p=0.007), at peak exercise (28 [18–40] mmHg versus 62 [31–113] mmHg; p<0.001), and post-exercise (45 [24–100] mmHg versus 115 [55–171] mmHg; p<0.0001) (figure 1). During metoprolol treatment, 14% of patients were in NYHA class III compared with 38% on placebo (p<0.01). Likewise, no patients were in CCS class ≥ III during metoprolol compared with 10% during placebo (p<0.01). These findings were confirmed by a higher KCCQ-OSS score during metoprolol (76.2 (16.2) versus 73.8 (19.5), p=0.039) (figure 2). Peak oxygen consumption did not differ between study arms. Conclusion Compared with placebo, metoprolol reduced LVOT obstruction at rest and during exercise, provided symptom relief, and improved quality of life in patients with obstructive HCM. However, exercise capacity remained unchanged. Findings from the present study support the guideline recommendations that BB should be the first drug of choice in patients with obstructive HCM who develop symptoms. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): Novo nordic foundation, Skibsreder Per Henriksen, R. og hustrus Foundation

Knowledge of local anesthetics anaphylaxis among dental practitioners in a Nigerian tertiary hospital


 
 
 
 Background: Anaphylaxis is an acutely presenting life-threatening medical emergency. Studies have shown that dentists feel inadequately able to recognize and treat anaphylaxis. This study aims to determine the level of knowledge of local anesthetic (LA) anaphylaxis among dentists in a Nigerian Teaching Hospital.
 Methods: This cross-sectional, questionnaire-based study was conducted among dental practitioners at the Dental complex of the University of Benin Teaching Hospital, Nigeria from August 2020 to January 2021. The questionnaire consisted of 21 items divided into four main sections: (1) Demographic characteristics, (2) general knowledge on local anesthetic anaphylaxis, (3) knowledge on signs and symptoms of local anesthetic anaphylaxis, (4) knowledge on treatment of local anesthetic anaphylaxis. Data was analyzed using Statistical Package for Social Sciences version 20.0, IBM, Armonk, NY, USA.
 Results: The 101 respondents approached agreed to participate in the study. There were more males (64.4%) compared to females. Majority of the respondents were aged 30 -39 years. None of the respondents knew completely all the signs and symptoms of anaphylactic reaction from LA. None of the respondents got the complete drugs to be kept in the office for LA anaphylaxis. Less than half (43.6%) of the respondents knew that epinephrine is the drug of first choice for anaphylactic reactions. Only 50 (49.5%) of the respondents knew that the best route for epinephrine administration is intramuscular route.
 Conclusion: Adequate knowledge on anaphylaxis from local anesthesia is lacking among dental practitioners in our centre.
 
 
 

A CASE OF RECURRENT PANCREATITIS DUE TO HYPERTRIGLYCERIDEMIA

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Hypertriglyceridemia (HTG) accounts for 10% of all cases of acute pancreatitis (AP). It can present as acute or recurrent episodes of AP typically in the presence of coexistent conditions, such as inadequately controlled diabetes (DM), excess alcohol consumption or medication use. We present a case of recurrent pancreatitis in a patient with history of HTG and non-compliance with medication. CASE PRESENTATION: A 39-years-old female with history of HTG, DM and alcohol dependance disorder presented to the ED with 1-day history of severe epigastric pain radiating to her back, associated with nausea and non-bilious vomiting. On examination she was hemodynamically stable. There was marked tenderness to palpation in the epigastric region. Her initial laboratory findings were significant for fasting serum glucose (FSG) of 323 mg/dL, severe hyponatremia 118mEq/L, Calc Osmolality 249mOsm/L, total cholesterol 794 mg/dL and triglycerides 6088 mg /dl. Computed tomogram of the abdomen showed moderate fluid and diffuse peripancreatic inflammatory stranding. The patient was managed for AP with intravenous fluids (IV D5-NS), fixed rate insulin infusion and narcotics for pain control. She was also commenced on Atorvastatin 40mg and Gemfibrozil 600mg, twice daily. Once the patient's condition stabilized, she was discharged with subcutaneous insulin, Metformin and lipid lowering agents. DISCUSSION: Hypertriglyceridemia is a rare but well-known cause of acute pancreatitis. Although the precise mechanism is not known, it is proposed that HTG causes an excess of free fatty acids (FFAs) and elevated chylomicrons leading to rise in plasma viscosity, which may induce ischemia in pancreatic tissue and trigger organ inflammation.[1] The clinical presentation includes epigastric pain, increased serum levels of pancreatic enzymes and typical AP findings on imaging.[2] Serum triglyceride levels rapidly decrease within the first 48 hours of onset of acute AP, therefore earliest possible determination of serum triglyceride levels is crucial [3].Multiple treatment modalities including Insulin and/or heparin, plasmapheresis and oral lipid lowering agents have been evaluated. Fibrates have been proven effective in lowering triglyceride levels and raising HDL levels, and are generally considered to be first-choice drugs for the treatment of HTG [4,5]. Our patient showed good response to treatment with Insulin infusion and fibrates. She refused plasmapheresis trial. CONCLUSIONS: We suggest routine testing of triglyceride levels in patients presenting with signs and symptoms suggestive of acute pancreatitis especially in those with pre-existing medical co-morbidities. REFERENCE #1: 1.Nicolò de Pretis, Antonio Amodio, Luca Frulloni Hypertriglyceridemic pancreatitis: Epidemiology, pathophysiology and clinical managementUnited European Gastroenterol J. 2018 Jun; 6(5): 649–655. REFERENCE #2: 2. Scherer J, Singh VP, Pitchumoni CS, Yadav D Issues in hypertriglyceridemic pancreatitis: an update.J Clin Gastroenterol. 2014 Mar; 48(3):195-203. REFERENCE #3: 3. Maki KC, Bays HE, Dicklin MR. Treatment options for the management of hypertriglyceridemia: strategies based on the best-available evidence. J. Clin. Lipidol. 6(5), 413–426 (2012) DISCLOSURES: no disclosure on file for Moses Bachan; no disclosure on file for Zinobia Khan; No relevant relationships by Dileep Kumar, source=Web Response No relevant relationships by Ambreen Shahzadi, source=Web Response

Бактериальные конъюнктивиты (обзор литературы)

The article is devoted to bacterial conjunctivitis. The review of scientific works on this problem presents the clinic, diagnosis and comprehensive treatment of this ophthalmopathology. At the same time, much attention is paid to antibiotic therapy of bacterial conjunctivitis. A special place in it is occupied by antibiotic fluoroquinolones, which have a wide spectrum of action, including gram-positive and gram-negative causative agents of eye infections, and can be considered the drugs of first choice in bacterial conjunctivitis, especially resistant to other antibiotics. Key words: bacterial conjunctivitis, clinic, diagnosis, treatment.

Pericarditi acute e ricorrenti in Pediatria

Chest pain in children and adolescents is rarely associated with an underlying heart disease. How-ever, when it does occur, pericarditis is the most common cause. Most cases are of unknown origin (idiopathic) and mild. Up to 15-35% of paediatric patients with idiopathic pericarditis experience a recurrence during their lives and clinical management in these cases may be challenging. NSAIDs are the first-choice drugs for the treatment of acute idiopathic pericarditis. Corticosteroids should be reserved for refractory pericarditis and autoimmune or autoinflammatory disorders with peri-cardial involvement. Colchicine plays a central role for the management of recurrent forms while anakinra has recently emerged as a remedy for colchicine-resistant and corticosteroid-dependent recurrent pericarditis.

Oncologists' attitudes towards prophylaxis of cancer associated venous thromboembolism: A prospective, descriptive study.

Cancer-associated venous thromboembolism creates a big burden on both patients and healthcare systems. Clinical guidelines have a consensus on the initiation of prophylactic treatment for hospitalised patients, however a debate still exists for ambulatory cancer patients. Therefore, this study aimed to identify attitudes and practices of medical oncologists on cancer-associated venous thromboembolism management. An online survey consisting of 22 questions was developed by researchers in the view of previous studies and delivered to 100 medical oncologists registered to the national society of medical oncology by e-mail between September and October 2018. Descriptive and statistical analyses were performed using Statistical Package for Social Science (SPSS) version 23.0 (ICM Corp. Released 2015. IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp). A total of 62 medical oncologists (75.8% male) responded to the survey (response rate of 62%). The most critical three risk factors considered for initiating prophylaxis were prior venous thromboembolism history, immobilisation and tumour/cancer type for inpatients and outpatients (χ2 test, p < 0.001). The first choice of drug for prophylaxis was mostly low molecular weight heparins (n = 60, 96.8%). In the absence of contraindications, physicians initiate prophylaxis 'usually' for inpatients (n = 25, 40.3%) and outpatients (n = 5, 8.1%). However routine use of the Khorana score is not incorporated into the risk assessment process of cancer patients. Attitudes of oncologists towards thromboprophylaxis in cancer patients are consistent with previous studies in the literature. The respondents are aware of the venous thromboembolism risk of cancer patients, however raising awareness on both cancer-associated venous thromboembolism and current guideline recommendations is needed.

Management of Feline Hyperthyroidism and the Need to Prevent Oxidative Stress: What Can We Learn from Human Research?

Feline hyperthyroidism is a clinical syndrome related to an excessive production of thyroid hormones, and it is considered as a spontaneous animal model for human thyrotoxicosis. Many shared features between the feline and the human disease have been identified so far, including pathogenesis, clinical signs, and treatment options. Although methimazole is considered the first-choice drug in both species, several side effects have been described. Furthermore, methimazole could interfere with the oxidative status, already perturbated by the disease. It has been reported in humans that dietary management, mainly through antioxidant supplementation, could mitigate this oxidative burden. The purpose of the review is to describe current therapeutic options in the course of feline hyperthyroidism and to summarize the state of the art relationship between dietary antioxidants administration and the reduction of methimazole side-effects in humans to support the use of this approach also in cats.

Association of SLC22A1 rs622342 and ATM rs11212617 polymorphisms with metformin efficacy in patients with type 2 diabetes.

Metformin is the first-choice oral anti-hyperglycemic drug for type 2 diabetes mellitus (T2DM) patients. There are controversies about the association of SLC22A1 rs622342, which was not reported in the Chinese population, and ataxia-telangiectasia mutated (ATM) rs11212617 polymorphisms with metformin efficacy in T2DM. Our study was to investigate the effects of the two single nucleotide polymorphisms on the efficacy of metformin in T2DM of Han nationality in Chaoshan China. After enrollment, 82 newly diagnosed T2DM patients went on 2-month metformin monotherapy. According to BMI before treatment, the patients were divided into a normal weight group (≥18.5 and <25 kg/m2) and an overweight group (BMI ≥ 25 and <30 kg/m2). T-test, Pearson χ2 test, and regression analysis, which adjusted for age, BMI, sex, the dose of metformin, education, tea drink, smoking, and sweet, were used to evaluate the effects of rs622342 and rs11212617 on several variables, such as fasting plasma glucose (FPG). Compared with the AA or CC genotype, patients with AC genotype of rs622342 achieved greater reduction in Δ60FPG and Δ(60-30)FPG (P = 0.00820, 0.00089, respectively). For 11212617, the reduction in Δ30FPG and Δ60FPG was significantly different among patients with the AC genotype (P = 0.00026, 0.00820, respectively). Our results indicated that common variants of SLC22A1 rs622342 and ATM rs11212617 were associated with the efficacy of metformin in T2DM of Han nationality in Chaoshan China.

Effect and underlying mechanism of morin on the pharmacokinetics of diclofenac sodium in rats

1. Morin, a natural flavonol, is present in many plants. It has anti-inflammatory and immunomodulatory activities and is often used as an adjuvant treatment for arthritis. Diclofenac sodium is the first-choice drug in the treatment of rheumatoid arthritis. However, the herb-drug interaction (HDI) between morin and diclofenac sodium remains unclear. 2. The aim of the present research was to investigate whether and how morin affect the pharmacokinetic profile of diclofenac sodium. 3. The enzyme kinetic and pharmacokinetic studies showed that morin significantly accelerated the metabolism and reduced systemic exposure of diclofenac sodium. Interestingly, the effect of morin on the pharmacokinetic profile of diclofenac sodium was not in a dose-dependent manner. Therefore, the effect of morin on P-glycoprotein (P-gp) was further investigated. 4. The results implied that the influence mechanism of morin on the pharmacokinetic of diclofenac sodium might be related to CYP2C9 and P-gp. Attention should be paid to the risk of HDI between morin and diclofenac sodium in clinical practice.

Effectiveness of PPI treatment and guideline adherence in 236 patients with eosinophilic oesophagitis-Results from the population-based DanEoE cohort shows a low complication rate.

BackgroundProton pump inhibitors (PPIs) are often the first drug of choice in the treatment of eosinophilic oesophagitis (EoE), and in Denmark 8 weeks of high‐dose PPI therapy is recommended as first‐line treatment followed by rebiopsying, reflecting international recommendations.AimsTo assess the population‐based effectiveness of PPIs in the treatment of EoE and evaluate whether patients were treated and followed according to the regional guideline.MethodsThis is a retrospective, registry‐based, DanEoE cohort study of 236 adult EoE patients diagnosed between 2007 and 2017 in the North Denmark Region. After patient file revision, the EoE diagnosis was defined according to the AGREE 2 consensus. Symptomatic PPI response was defined as complete symptom resolution and histological remission (<15 eosinophils per high‐power field).ResultsPPI treatment was initiated in 92% of the EoE patients. High‐ and low‐dose PPIs were prescribed in 55% and 45% of the cases, respectively. When treated with high‐dose PPIs, 68% of the patients were completely symptom‐free, and 49% were in histological remission. In 39% of high‐dose PPI‐treated patients, the symptomatic and histological responses were conflicting. While treated with PPIs, complications were rare, with <5% strictures in responders and <10% in non‐responders. Rebiopsying was done in 67% of the EoE patients started on PPIs.ConclusionsHigh‐dose PPI treatment was effective in half of the EoE patients started on PPIs, but conflicting symptomatic and histological PPI responses were common. Complications were rare when PPIs were started. One‐third of the patients were not rebiopsied as recommended.

Sex differences in antipsychotic efficacy and side effects in schizophrenia spectrum disorder: results from the BeSt InTro study

Current guidelines for patients with schizophrenia spectrum disease do not take sex differences into account, which may result in inappropriate sex-specific treatment. In the BeSt InTro study, a total of 144 patients (93 men and 51 women) with a schizophrenia spectrum diagnosis and ongoing psychosis were included and randomized to amisulpride, aripiprazole, or olanzapine in flexible dose. This trial is registered with ClinicalTrials.gov (NCT01446328). Primary outcomes were sex differences in dose, dose-corrected serum levels, efficacy, and tolerability. Dosing was higher for men than for women in the aripiprazole group (p = 0.025) and, at trend level, in the olanzapine group (p = 0.056). Dose-corrected serum levels were 71.9% higher in women than in men for amisulpride (p = 0.019) and 55.8% higher in women than in men for aripiprazole (p = 0.049). In the amisulpride group, men had a faster decrease in psychotic symptoms than women (p = 0.003). Moreover, amisulpride was more effective than the other medications in men but not in women. Prolactin levels were higher in women than in men, especially for amisulpride (p < 0.001). Also, women had higher BMI increase on amisulpride compared to the two other antipsychotics (p < 0.001). We conclude that clinicians should be aware of the risks of overdosing in women, especially for amisulpride and aripiprazole. Amisulpride is highly effective in men, but in women, amisulpride showed more severe side effects and may thus not be the drug of first choice. Our study shows that sex differences should be taken into account in future studies on antipsychotics. Future research is warranted to evaluate these preliminary results.

Metronidazole for Amoebiasis: A tale of more than half a century

Metronidazole has many unique properties such as possessing antibacterial as well as anti-protozoal activity, very minimal resistance rate, acceptable safety profile and market longevity. Metronidazole has remained as the recommended drug in the treatment of any form of amoebiasis caused by Entamoeba histolytica since its inception almost half a c entury ago. Anaphylaxis which limits the use of many antibacterial agents is hardly reported with metronidazole accounting for its favourable safety profile. Owing to its low-cost, it is considered affordable and economically accessible in developing countries which are mainly affected by amoebiasis. Its pharmacokinetic properties considered are its asset as well as drawback. For example, good bioavailability and good tissue penetration allows metronidazole to be used as oral dosage form in many indications and responsible for its efficacy in many extra-intestinal amoebiasis. However, inhibition of hepatic drug metabolizing enzymes is responsible for some significant drug interactions, and disulfiram like effect with alcohol. Unlike many other antimicrobial agents which were discovered much later, metronidazole has withstood the problem of antimicrobial resistance. Even some longer acting agents have been developed in the recent past, metronidazole remains the drug of first choice for amoebiasis documenting very high cure rate with minimal need for other treatment modalities.

The L125F MATE1 variant enriched in populations of Amerindian origin is associated with increased plasma levels of metformin and lactate

Genetic factors that affect variability in metformin response have been poorly studied in the Latin American population, despite its being the initial drug therapy for type 2 diabetes, one of the most prevalent diseases in that region. Metformin pharmacokinetics is carried out by members of the membrane transporters superfamily (SLCs), being the multidrug and toxin extrusion protein 1 (MATE1), one of the most studied. Some genetic variants in MATE1 have been associated with reduced in vitro metformin transport. They include rs77474263 p.[L125F], a variant present at a frequency of 13.8% in Latin Americans, but rare worldwide (less than 1%). Using exome sequence data and TaqMan genotyping, we revealed that the Mexican population has the highest frequency of this variant: 16% in Mestizos and 27% in Amerindians, suggesting a possible Amerindian origin. To elucidate the metformin pharmacogenetics, a children cohort was genotyped, allowing us to describe, for the first time, a MATE1 rs77474263 TT homozygous individual. An additive effect of the L125F variant was observed on blood metformin accumulation, revealing the highest metformin and lactate serum levels in the TT homozygote, and intermediate metformin values in the heterozygotes. Moreover, a molecular dynamics analysis suggested that the genetic variant effect on metformin efflux could be due to a decreased protein permeability. We conclude that pharmacogenetics could be useful in enhancing metformin pharmacovigilance in populations having a high frequency of the risk genotype, especially considering that these populations also have a higher susceptibility to the diseases for which metformin is the first-choice drug.

Diagnostisches und therapeutisches Vorgehen bei Anaphylaxie

Anaphylaxis is a suddenly occurring potentially life-threatening systemic allergic reaction. In childhood, food allergens play a major role but insect stings and drugs are also potential triggers. The symptoms appear in minutes up to few hours on the skin, airways, gastrointestinal tract and/or the cardiovascular system. Intramuscular adrenaline is the drug of first choice due to its rapid effectiveness and its low side effect potential. A detailed patient history and the determination of potential IgE antibodies must be carried out to identify the triggers. The register for anaphylaxis has improved knowledge on epidemiology. An education in anaphylaxis is useful for every patient as well as parents and caregivers. Allergen-specific immunotherapy is currently the only causal treatment option; however, at the present time it is only available for insect bites and peanut allergy.

Prevalence of Vitamin B12 Deficiency In Patients With Type II Diabetes Mellitus On Metformin

Background: Diabetes Mellitus is one of the most encountered disease in our out patient department and metformin is the first drug of choice to treat Diabetes mellitus. As metformin is one of the cheapest drug, many patients use these drug for long period of time with consultation and without consultations with doctors. Patients under long term metformin use are not aware of Vitamin B12 deficiency and its associated signs and symptoms. In Nepal due to poverty, lack of education and awareness on diabetes mellitus we doctors find much difficult to explain patients on the consequences of diseases. So I decided to do this study which could be much easier to explain patients on effect of metformin of vitamin B12 levels and the consequences life style modifications and supplement of Vitamin B12 to the patients.&#x0D; Methods: This is a Cross-Sectional Study done in the patients with Type 2 diabetes were selected based on inclusion and exclusion criteria. Basic biochemical investigation were sent the lab of the National academy of medical science. Serum B12 assay were done. Vitamin B12 deficiency is defined as values &lt;150pg/ml. Association between vitamin B12 deficiency with duration of metformin therapy, duration of diabetes, with age, sex were done.&#x0D; Results: The mean vitamin B12 level is low as the duration of metformin treatment increases. The sex, age relation with development of vitamin B12 deficiency was not significant. In my study out of 210 patients 107 patients were having severe vitamin B12 deficiency level and 63 patients had a borderline Vitamin B12 deficiency level which shows that the deficiency increases as per longer use of metformin, which shows prevalence of 50.95%.&#x0D; Conclusions: Vitamin B12 deficiency occurs in type 2 diabetes mellitus patients treated with long term metformin. The duration of metformin therapy significantly affects the development of vitamin B12 deficiency. As a treating physician we always need to explain our patients about the side effect of metformin and regular follow up and investigations must be done to early diagnosis of vitamin B12 deficiency to improve the quality of life.

Comprehensive Review on Ayurvedic Formulations and Herbal Medicines for Treatment of Rheumatoid Arthritis

Rheumatoid arthritis, an autoimmune inflammatory disorder is characterized by progressive cartilage erosion leading to joint destruction, pain, stiffness, and swelling. Although the etiology of the disease is unknown, genetic changes due to factors such as environmental agents, immune response towards infectious agents influence rheumatoid arthritis. Earlier NSAIDs were the first choice of drugs for the treatment of disease but due to having certain side effects and limitations, herbal therapies which possess higher efficacy and safety are now in demand. There are hundreds of plants that have phytoconstituents that exhibit anti-inflammatory activity. A combination of plants is used to make polyherbal formulations that act synergistically to give anti-arthritic activity. The review is about the botanicals and traditional formulations which have been clinically tested for the treatment of Rheumatoid arthritis.

The role of cannabinoids in the management of symptoms in palliative care patients

The endocannabinoid system (ECS) regulates body’s homeostasis and performs vital physiological functions. The thorough understanding of the role of endocannabinoids and the composition of cannabis containing phytocannabinoids and terpenoids play an important role in symptom management. Clinical effects of medical cannabis depend among others on the activity of the ECS in a given patient, the proportion of phytocannabinoids, and the doses used. Cannabinoids are used to treat symptoms in patients with cancer and chronic non-malignant diseases. Cannabinoids are usually not drugs of first choice and can be added to basic pharmacotherapy, which often improves the effectiveness of symptom treatment. Due to limited scientific evidence, experimental studies on the role of the ECS and clinical trials on the use of cannabinoids in the treatment of symptoms are recommended. In this article the role of the ECS and the use of cannabinoids in palliative care patients has been discussed.

A Comprehensive Review of Sarcoidosis Treatment for Pulmonologists.

Due to frequent lung involvement, the pulmonologist is often the reference physician for management of sarcoidosis, a systemic granulomatous disease with a heterogeneous course. Treatment of sarcoidosis raises some issues. The first challenge is to select patients who are likely to benefit from treatment, as sarcoidosis may be self-limiting and remit spontaneously, in which case treatment can be postponed and possibly avoided without any significant impact on quality of life, organ damage or prognosis. Systemic glucocorticosteroids (GCs) are the drug of first choice for sarcoidosis. When GCs are started, there is a > 50% chance of long-term treatment. Prolonged use of prednisone at > 10 mg/day or equivalent is often associated with severe side effects. In these and refractory cases, steroid-sparing options are advised. Antimetabolites, such as methotrexate, are the second-choice therapy. Biologics, such as anti-TNF and especially infliximab, are third-choice drugs. The three treatments can be used concomitantly. Regardless of whether treatment is started, the clinician needs to organize regular follow-up to monitor remissions, flares, progression, complications, toxicity and relapses in order to promptly adjust the drugs used.

Comparative study between fractional carbon dioxide laser versus retinoic acid chemical peel in the treatment of acanthosis nigricans.

Acanthosis nigricans (AN) is a common dermatological issue with several therapeutic modalities to treat. Despite retinoid is the first drug of choice in the treatment, the fractional-ablative carbon dioxide (CO2 ) laser has revealed as a promising procedure for the management of neck-AN, outstanding to its ability for superficial ablation of the skin surface, with trans-epidermal melanin elimination. To decide whether fractional-ablative CO2 laser or retinoic acid (5%) peel is the more effective and safe choice for AN treatment. In this study, twenty Egyptian cases with neck-AN were enrolled, where each case was exposed to four sessions with 2weeks apart of both fractional CO2 laser on the right half of the neck and retinoic acid peel on the left half of the neck. Cases were assessed by a scoring system: Acanthosis Nigricans Area and Severity Index (ANASI) score, two blinded dermatologists, and dermoscopically before and one month after treatment. We found a highly statistically significant improvement among both treated groups regarding (ANASI) score and dermatologist's assessments. Bedside, the degree of sulci cutis, cristae cutis, brown-to-dark brown dots, and milia-like cysts, dermoscopic sign improvement was evident in both treated groups. However, fractional CO2 laser shows the superior result to retinoic acid peel in the treatment. Fractional CO2 laser and retinoic acid peel are considered effective modalities for neck-AN treatment. However, fractional CO2 laser was more effective.

Comparison of the efficacy and safety of levetiracetam and phenytoin in the treatment of established status epilepticus: A systematic review and meta-analysis

Status epilepticus (SE) is the second most critical neurological illness after cerebrovascular disease. Phenytoin has traditionally been considered the second-line drug of first choice after failure of first-line treatment using benzodiazepines. In recent years, levetiracetam has been proposed as a potential substitute for phenytoin. To comprehensively evaluate the efficacy and safety of levetiracetam and phenytoin in the treatment of patients with established SE, we integrated the data from 11 eligible studies and conducted a systematic review and meta-analysis. The PubMed, Web of Science, Cochrane Library, and Embase databases were searched to identify eligible articles reporting outcomes including clinical seizure cessation within 60 min, clinical recurrence rate within 24 h, good final outcome at discharge, and adverse events (AEs) of treatment with levetiracetam and phenytoin. Our study included a total of 11 trials including a total of 1933 patients. The outcomes showed that the pooled Risk Raito (RR) of clinical seizure cessation within 60 min was 1.08 (95% CI = 1.02–1.14, P = 0.01). The pooled RR of clinical recurrence rate within 24 h was 1.03 (95% CI = 0.66–1.59, P = 0.91). The pooled RR of AEs was 0.83 (95% CI = 0.57–1.21, P = 0.34). The pooled RRs of life-threatening hypotension and acute respiratory depression were 0.29 (95% CI = 0.10–0.81, P = 0.02) and 0.63 (95% CI = 0.40–0.98, P = 0.04), respectively. Levetiracetam might be more effective than phenytoin for the treatment of established SE and is associated with a lower incidence of more serious AEs. Levetiracetam can be used as an alternative to phenytoin for the treatment of benzodiazepine-refractory SE.