Long-term Therapy Research Articles

Effect of Statins on the Prognosis After Thoracic Endovascular Aortic Repair for Patients With Acute Type B Aortic Dissection.

To analyze the clinical efficacy of long-term statin therapy following thoracic endovascular aortic repair (TEVAR) in patients with acute type B aortic dissection (ATBAD). We retrospectively analyzed data from 645 patients treated between January 2005 and June 2022, dividing them into Statin Group (n=330) and Non-statin Group (n=315) based on whether they received long-term postoperative statin therapy. Patients were further categorized based on median admission low-density lipoprotein cholesterol (LDL-C) levels into High and Low LDL-C Groups to assess the effect of statins on the prognosis of ATBAD patients after TEVAR. The cohort had an average age of 53.44±11.42 years old, and 81.71% were male. Statin therapy significantly reduced occurrences of all-cause death (3.03% vs 8.57%, p=0.002) and aorta-related death (0.91% vs 3.81%, p=0.015), particularly in patients with high admission LDL-C levels. In addition, patients with statin therapy had a lower incidence of aorta-related adverse events (ARAE) (4.24% vs 11.11%, p=0.001). Kaplan-Meier analysis indicated statins reduced 5-year cumulative incidence rates of all-cause death and ARAE (all Log-rank p<0.05). These trends were sustained after adjustment. Multivariate Cox analysis confirmed that statin therapy was associated with reduced risks of all-cause and aorta-related deaths, as well as ARAE. Long-term statin therapy appears to decrease the risk of all-cause and aorta-related death in ATBAD patients after TEVAR, particularly patients with high admission LDL-C levels. Patients with lower LDL-C levels at admission have a reduction of aorta-related death in the follow-up period. Statin therapy also was associated with a lower incidence of ARAE in follow-up. These findings suggest that statins might be crucial in improving long-term outcomes in this patient population. Long-term statin therapy administered to patients with acute type B aortic dissection (ATBAD) following thoracic endovascular aortic repair (TEVAR) demonstrates a substantial reduction in both all-cause and aorta-related mortality. Notably, this therapeutic benefit is most evident in patients presenting with elevated low-density lipoprotein cholesterol (LDL-C) levels at admission. Furthermore, statin therapy is associated with a decreased incidence of aorta-related adverse events during follow-up. These findings underscore the pivotal role of statin therapy in enhancing long-term clinical outcomes for ATBAD patients undergoing TEVAR, thereby contributing to improved patient care and prognosis.

Efficacy analysis of rituximab in treating patients with primary membranous nephropathy dependent on calcineurin inhibitors

BackgroundThis study evaluated the efficacy of rituximab (RTX) in primary membranous nephropathy (PMN) patients with incomplete remission and drug dependence after long-term use of calmodulin inhibitors (CNIs). It aims for complete clinical and immunological remission, and cessation of CNI dependence.MethodsThirty-six patients were enrolled in the study with two groups: drug-dependent and partial remission or immune non-remission group. Both groups underwent RTX therapy with gradual CNI tapering to end CNI dependency and induce complete remission. The primary outcome was overcoming CNI dependency and achieving complete remission after 12 months of RTX therapy. Secondary outcomes included immunological remission and recurrence rates.ResultsThe drug-dependent group (20 patients) achieved significant proteinuria reduction compared to the partial remission or immune non-remission group (16 patients) (P=0.016). After 12 months of RTX treatment, all drug-dependent patients overcame CNI dependency (average withdrawal period: 5.3 ± 3.7 months), with complete remission rates increased from 10% to 70.0% and complete immunological remission rates rose from 35.0% to 90.0%. In the partial remission or immune non-remission group, 14 patients discontinued CNI (average period: 4.6 ± 4.5 months), with complete remission rates increasing from 5.0% to 68.8% and complete immunological remission rates from 6.3% to 68.8%. During follow-up, serum albumin increased, and anti-PLA2R antibodies, 24-hour proteinuria, and CD19+ cell numbers reduced, while creatinine remained stable. Three patients relapsed, four encountered adverse events, and no malignancies or other fatal adverse events were reported.ConclusionsRTX effectively achieves complete clinical and immunological remission in PMN patients dependent on or partially responsive to long-term CNI therapy, reducing recurrence and minimizing prolonged immunosuppressive therapy risks.

Superiority of denosumab over bisphosphonates in preventing and treating glucocorticoid-induced osteoporosis: a systematic review and meta-analysis with GRADE quality assessment

BackgroundThe increasing prevalence of glucocorticoid-induced osteoporosis (GIOP) due to long-term glucocorticoid therapy underscores the need for effective treatment options. Denosumab and bisphosphonates, both key in managing GIOP, require further comparative evaluation to determine their relative efficacy and safety profiles.MethodsWe conducted a systematic review and meta-analysis, adhering to PRISMA guidelines. Our analysis included randomized controlled trials (RCTs) comparing denosumab with bisphosphonates in GIOP management. The outcomes were percent changes in bone mineral density (BMD) at various sites, bone turnovers markers (BTMs) and the incidence of adverse events.ResultsOur study comprised five RCTs with 1,043 participants. The results showed a significant mean difference in BMD percentage change from baseline at LS of 2.87% (95% CI: 1.86 to 3.87, p&amp;lt;0.001) and at TH of 1.39% (95% CI: 0.15 to 2.64, p=0.03). Additionally, the safety profile of denosumab was found to be comparable to bisphosphonates, with no significant increase in the incidence of adverse events or serious adverse reactions.ConclusionsDenosumab proved more effective in enhancing BMD than bisphosphonates in GIOP, maintaining a comparable safety profile. However, the study’s limitations, including heterogeneity and the need for longer-term research, were noted.

Glycaemic Status of COPD Patients on Long-term Steroid Therapy

Background: Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases. Among the pharmacological therapy, inhaled beta-2 agonist and anticholinergics are the mainstay therapy of COPD along with corticosteroid. Steroid therapy is associated with various potential adverse effects like steroid induced deranged glycemic status. Objective: This study was aimed to assess the glycaemic status of COPD patients on long term steroid therapy. Methods: This cross-sectional observational study was conducted in the department of Medicine, Rangpur Medical College and Hospital, Rangpur, Bangladesh from January 2022 to June 2022. A total of 55 COPD patients were included in the study based on inclusion and exclusion criteria. Detailed information was obtained in each case according to protocol. Complete history was taken either from patient or accompanying attendants. A thorough clinical examination was done. Relevant investigation reports were collected. All the information was recorded according to fixed protocol. Collected data were classified, edited, coded and entered the computer for statistical analysis by using SPSS version 23. Results: Out of 55 COPD patients, the majority (41.8%) patients belonged to age 51-60 years with mean age 55.5±8.3 years. Male patients were predominant 47(85.5%) and male to female ratio was 5.88:1. Most (72.7%) of the patients received inhaled and 15(27.3%) received systemic with or without inhaled corticosteroid. Only 1 (2.5%) patient was found FBS _7.0 mmol/L in inhaled group and 2(13.3%) in systemic with or without inhaled corticosteroid group. One (2.5%) patient was found plasma glucose 2 hours after a 75-gm glucose _11.1 mmol/L in inhaled group and 2(13.3%) in systemic with or without inhaled corticosteroid group. One (2.5%) patient was found HbA1C &gt; 6.5% in inhaled group and 2(13.3%) in systemic with or without inhaled group. The differences were not statistically significant (p&gt;0.05) between two groups. Conclusion: Majority of the patients had normal HbA1c who were taking inhaled corticosteroid than systemic with or without inhaled corticosteroids. J Rang Med Col. September 2024; Vol. 9, No. 2: 27-32

The study of risk factors for osteoporosis with prolonged use of anticonvulsants: intermediate results

The mechanisms of anticonvulsant effects on bone metabolism are not studied sufficiently. This determines the relevance of research on factors that influence the development of osteoporosis in patients taking long-term anticonvulsants. The aim of the study to evaluate the effect of modifiable and non-modifiable osteoporosis risk factors on changes in bone mineral density during long-term therapy with anticonvulsants. Materials and methods. The study included 100 adult patients receiving anticonvulsants for moren12 months and 58 healthy volunteers. All participants underwent a clinical screening with assessment of factors affecting bone metabolism and a densitometric study using quantitative computed tomography at three points (L1, L2 and femoral neck). Results. CT-densitometry results showed decrease bone mineral density in the most part of the participants in both study groups. According to the data of the analysis of the influence of osteoporosis risk factors on bone mineral density values, it was found that the presence of fractures in the anamnesis and low level of motor activity increased the risk of osteoporosis development in patients taking long-term anticonvulsants (p (χ2) &lt; 0.001). Conclusion. The results of the study confirm the importance of continuing research on factors affecting bone metabolism and developing a set of preventive measures to prevent the development of osteoporosis.

Wnt Signaling Pathway in Tumor Biology

Relapse and metastasis are the major challenges that stand in the way of cancer healing and survival, mainly attributed to cancer stem cells (CSCs). Their capabilities of self-renewal and tumorigenic potential leads to treatment resistance development. CSCs function through signaling pathways such as the Wnt/β-catenin cascade. While commonly involved in embryogenesis and adult tissues homeostasis, the dysregulation of the Wnt pathway has direct correlations with tumorigenesis, metastasis, and drug resistance. The development of therapies that target CSCs and bulk tumors is both crucial and urgent. However, the extensive crosstalk present between Wnt and other signaling networks (Hedgehog and Notch) complicates the development of efficient long-term therapies with minimal side-effects on normal tissues. Despite the obstacles, the emergence of Wnt inhibitors and subsequent modulation of the signaling pathways would provide dynamic therapeutic approaches to impairing CSCs and reversing resistance mechanisms.

Proton pump inhibitors - possible side effects of long-term therapy: a review

Introduction and purpose: Proton pump inhibitors (PPIs), which have been on the market for more than 30 years, are widely regarded as safe and effective medications. For this reason, they are very popular with both doctors and patients. PPIs find their use in the treatment of such ailments as gastroesophageal reflux, gastric ulcer disease or as a shielding therapy when taking non-steroidal anti-inflammatory drugs. Nevertheless, their long-term use may be associated with many side effects. The purpose of our review is to summarize the knowledge in the current medical literature on the possible complications of chronic use of PPIs. The review is based on 30 articles from the most recent publications on chronic PPI treatment. Publications were searched for the words PPI chronic therapy, gastric cancer, omeprazole in PubMed databases. Articles from 2018-2024 represent 70% of all publications from the references. A brief description of the state of knowledge: Although the use of PPIs in the short term is relatively safe, the number of people taking these drugs has increased significantly in recent years. They are prescribed not always as indicated, patients often take them for too long - this in turn leads to an increasing incidence of side effects. Some of them can permanently affect health and significantly reduce the comfort of life - such as kidney diseases, cardiovascular disorders or gastric cancer. Summary: Considering the widespread availability and popularity of PPIs, it is important to adequately educate both patients and healthcare professionals of the possible side effects. It is crucial to use medications as prescribed, with an appropriate assessment of the risk-benefit ratio. It might result in reducing health care expenditures to deal with the consequences of IPP therapy.

Topical therapy for psoriasis: algorithms for the use of activated zinc pyrithione

Treatment of any type of psoriasis involves the use of external therapy. Recommended topical preparations include: corticosteroids, calcipotriol in combination with corticosteroids, zinc pyrithione, keratolytics, tar. A special place in the therapy of psoriasis is occupied by a drug containing activated zinc pyrithione (Skin-cap), due to its effectiveness, safety and the availability of various forms (aerosol, cream, shampoo), which allows it to be used in both short-term and long-term therapy at different stages of the disease. Complex treatment, including the use of topical forms containing activated zinc pyrithione, is a highly effective, safe, pathogenetically substantiated method of treating various forms of psoriasis, allowing to achieve rapid regression of rashes, minimize the risk of adverse effects and achieve long-term control over the disease, which significantly improves the quality of life of patients

Opioid prescriptions for insured individuals without cancer in Germany: data from the BARMER

The importance of opioids in the treatment of non-cancer pain is under debate. No current data are available from Germany on the prevalence of opioid treatment for non-cancer pain. Data on the prevalence of short- and long-term opioid prescriptions for patients without cancer, prescribed agents, co-medication, specialty of prescribing physicians, demographic and clinical characteristics of patients. Retrospective analysis of billing data of adult BARMER-insured persons without evidence of cancer (N = 6,771,075) in 2021 and for patients initiating opioid therapy in 2019 (n = 142,598). In total, 5.7% of the insured persons without acancer diagnosis received at least one prescription for an opioid in 2021, while 1.9% received long-term therapy. Tilidine and tramadol were the most frequently prescribed opioids in short- and long-term therapy. Women received opioids more frequently than men. The frequency of prescriptions significantly increased with age. In 2021, 22.5% of insured persons with long-term opioid therapy received aco-medication with pregabalin and/or gabapentin, 37.5% with an antidepressant and 58.1% with metamizole and/or NSAIDs. Atotal of 59.5% of first prescriptions were issued by general practitioners. In the first year of therapy, an average of 2.1 practices were involved in prescribing analgetics for people on long-term opioid therapy and 13different chronic diseases were documented. Opioid therapy for non-cancer-related pain is predominantly carried out by general practitioners in older and multi-morbid patients. The indication for or against opioid therapy requires shared decision-making with patients and, if necessary, their relatives, as well as areview of possible drug interactions.

A hemodialysis patient unable to walk - brown tumor as the culprit: Casereport and review of the literature.

Brown tumors are benign lesions caused by hyperparathyroidism and characterized by increased osteoclast activity and mass effect, which can lead to paraplegia when the spine is involved. Secondary hyperparathyroidism is common in patients on long-term hemodialysis therapy. We report the case of a 48-year-old man on regular dialysis who presented with leg weakness as well as back pain and was diagnosed with secondary hyperparathyroidism and thoracic spine tumor. Since the spinal cord was compressed, T12 mass excision combined with spinal canal decompression was performed under general anesthesia. Post-operative pathology demonstrated abundant fibrovascular tissue and osteoclast-like multinucleated giant cells with hemorrhage and hemosiderin pigment deposition. The patient was diagnosed with brown tumor. Following operation, the patient recovered well. He remains on regular hemodialysis with follow-ups and unaffected activities 10 years later. In dialysis patients with combined spinal tumors, brown tumors should be considered. For patients presenting with symptoms of spinal cord compression, surgical resection can lead to a favorable prognosis.

A randomized phase 3 trial of total neoadjuvant therapy (induction chemotherapy, neoadjuvant chemoradiation, neoadjuvant chemotherapy, and surgery) vs. standard long-term chemoradiation therapy (neoadjuvant chemoradiation, surgery, and adjuvant chemotherapy) in locally advanced rectal cancer

PurposeThe management of rectal adenocarcinoma has evolved during the last decade, shifting from a conventional neoadjuvant chemoradiotherapy, surgery, and adjuvant chemotherapy in all cases to a total neoadjuvant approach, especially in locally advanced tumors when a sphincter-sparing surgery has been planned. However, the exact indications and the neoadjuvant regimen with the highest response remain unresolved. We aimed to assess whether administering neoadjuvant chemotherapy before and after preoperative chemoradiotherapy could increase the pathological complete response (pCR) rates.MethodsWe conducted a phase 3, multicenter, randomized trial at four hospitals in Iran. Adult patients with a newly diagnosed, biopsy-proven, locally advanced non-metastatic rectal adenocarcinoma with an ECOG performance status of 0–2 were randomly assigned (2:2) to either the total neoadjuvant treatment (TNT) or the standard-of-care groups using a block randomized design. Investigators and participants were not masked to treatment allocation and groups. The TNT group received neoadjuvant chemotherapy with FOLFOX6 (intravenous 85 mg/m2 oxaliplatin and 400 mg/m2 leucovorin, followed by intravenous 400 mg/m2 fluorouracil bolus and then continuous infusion at a dose of 2,400 mg/m2 over 46 h every 14 days for four cycles before and four cycles after chemoradiotherapy), chemoradiotherapy (50.4 Gy during 28 fractions and 800 mg/m2 concurrent oral capecitabine twice daily 5 days per week), and total mesorectal excision. The standard-of-care group received neoadjuvant chemoradiotherapy, total mesorectal excision, and adjuvant chemotherapy (eight cycles). The primary endpoint was the pathological complete response. Safety analyses were conducted on treated patients.ResultsOverall, 25 and 27 patients were enrolled in the TNT and standard-of-care groups, respectively. Both groups were similar in terms of gender, age, and tumor differentiation. The tumors in the standard-of-care group were significantly located closer to the anal verge compared with those in the TNT group (9.4 ± 3.7 cm in TNT vs. 6.8 ± 4 cm in standard, p = 0.02). A pCR was reached in 48% (12/25) and 25.9% (7/27) of patients in the TNT and standard-of-care groups, respectively (p = 0.4). The R0 resection rates were identical between the two groups (92% vs. 88.9%, p = 0.3). Moreover, the toxicity rates were similar between the two groups.ConclusionOur results showed that TNT is a safe and feasible treatment approach in patients with rectal cancer and may improve the overall pCR rate compared with standard treatment.Clinical trial registrationhttps://irct.behdasht.gov.ir/trial/65666, identifier IRCT20220723055527N1.

Differential long-term tamoxifen therapy benefit by menopausal status in breast cancer patients: secondary analysis of a controlled randomized clinical trial.

Estrogen receptor-positive breast cancer patients have a long-term risk of distant metastatic disease, and premenopausal patients have a higher risk. Randomized studies with long-term follow-up are essential to understand treatment benefit. We elucidated the long-term tamoxifen therapy benefit by menopausal status in the Stockholm tamoxifen trials with 20 years complete follow-up. Secondary analysis of 1242 estrogen receptor-positive and HER2-negative patients that were randomly assigned to 2-5 years of 40 mg adjuvant tamoxifen or no endocrine therapy. Distant recurrence-free interval in tamoxifen-treated vs endocrine untreated patients was assessed by Kaplan-Meier, Cox proportional hazards regression, and time-varying analyses. In premenopausal patients, a statistically significant tamoxifen benefit was observed for lymph node-negative (adjusted hazard ratio [HR] = 0.46, 95% confidence interval [CI] = 0.24 to 0.87), progesterone receptor-positive (adjusted HR = 0.61, 95% CI = 0.41 to 0.91), and genomic low-risk tumors (adjusted HR = 0.47, 95% CI = 0.26 to 0.85) but only lasted beyond 10 years for genomic low-risk tumors. Postmenopausal patients showed long-term benefit for all good-prognosis markers including low-grade (adjusted HR = 0.55, 95% CI = 0.41 to 0.73), lymph node-negative (adjusted HR = 0.44, 95% CI = 0.30 to 0.64), progesterone receptor-positive (adjusted HR = 0.60, 95% CI = 0.44 to 0.80), Ki-67 low (adjusted HR = 0.51, 95% CI = 0.38 to 0.68), and genomic low-risk tumors (adjusted HR = 0.53, 95% CI = 0.37 to 0.74), and regardless of tumor size (≤20 mm: adjusted HR = 0.55, 95% CI = 0.39 to 0.77; >20 mm: adjusted HR = 0.64, 95% CI = 0.44 to 0.94). Premenopausal patients with no poor-prognosis tumor characteristics (clinical marker score = 0) showed early benefit and postmenopausal long-term benefit. Our study suggests differential tamoxifen benefit by menopausal status. Improved long-term endocrine therapy prediction in premenopausal patients is needed and could involve molecular markers because standard tumor characteristics cannot predict benefit beyond 10 years.

Management of glucocorticoid-induced diabetes

Glucocorticoid-induced diabetes (GID) is a frequent metabolic complication of glucocorticoid therapy. It results from both insulin resistance and impaired insulin secretion, exacerbated by glucocorticoid use. Despite its prevalence, consensus guidelines on screening and management remain limited. GID affects approximately one in five patients receiving long-term glucocorticoid therapy. Risk factors include older age, high BMI, prediabetes, ethnicity, and high-dose systemic glucocorticoids. All patients initiated on moderate to high doses of glucocorticoids should be assessed for GID risk factors and closely monitored for the development of hyperglycemia and diabetes. In addition, glucocorticoid therapy can significantly exacerbate hyperglycemia in individuals with pre-existing diabetes, and stringent glucose monitoring is crucial. Treatment should be tailored to individual patient. Oral anti-diabetics such as metformin and sulfonylureas might be used in selected patients with mild GID. However, insulin is the primary treatment for severe hyperglycemia. Early detection and individualized management strategies are critical to mitigate GID’s impact. Further research is needed to develop consensus guidelines and optimize treatment approaches.

How common is medication-related burden in adults with long-term therapies – a population survey using an instrument based on the PLEM model

How common is medication-related burden in adults with long-term therapies – a population survey using an instrument based on the PLEM model

Cerebral Microbleeds and Antiplatelet Therapy in Mongolian and Han Patients with Ischemic Cerebrovascular Disease.

To analyze the differences in cerebral microbleeds (CMBs) and their correlation with intracerebral hemorrhage (ICH) in Mongolian and Han Chinese patients with ischemic cerebrovascular disease. A total of 160 patients with ischemic cerebrovascular disease who took aspirin or clopidogrel for over one year were retrospectively analyzed, including 80 Mongolian and 80han patients. The incidence, number, and distribution of CMBs were compared between groups. Logistic regression was used to identify risk factors for the occurrence of cerebral hemorrhage. The detection rate of CMBs was significantly lower in Mongolian patients compared to Han patients (P = 0.040). Mongolian patients had a higher distribution of CMBs in the deep or infratentorial regions (66.6% vs 58.1%), while Han patients had a higher lobar distribution (P = 0.007). Prolonged antiplatelet therapy (over 3 years) was a risk factor for CMB development in both groups and was also linked to an increased risk of ICH. Patients with a higher number of CMBs had a greater likelihood of experiencing ICH. Mongolian patients had a lower likelihood of developing CMBs than Han patients, but with a higher deep or infratentorial distribution. The presence of CMBs, especially with long-term antiplatelet therapy, is a significant predictor of ICH. No significant difference in ICH risk was found between ethnic groups. Close monitoring of patients with CMBs during prolonged antiplatelet therapy is crucial to reduce hemorrhagic events.

Prevalence and correlates of frailty among older people with and without HIV in rural Uganda.

The relationship between HIV and frailty, a predictor of poor outcomes in the face of stressors, remains unknown in older people in sub-Saharan Africa. We analysed data from the Quality of Life and Ageing with HIV in Rural Uganda cohort study to estimate the prevalence and correlates of frailty among older people with HIV (PWH) on long-term antiretroviral therapy and among age and sex-similar HIV-uninfected comparators. Frailty was defined as a self-report of 3 or 4 (and pre-frailty as 1 or 2) of the following phenotypic variables: weight loss, exhaustion, low activity, and slowness. We estimated the prevalence of frailty and pre-frailty and fitted logistic regression models to estimate the association between HIV and frailty, adjusting for sociodemographic factors, depression, and other comorbidities. We enrolled 599 participants (49% women) with a mean age of 58 years. PWH had a similar prevalence of frailty (8.1% vs. 10.9%, p=0.24) but a lower prevalence of pre-frailty (54.2% vs. 63.2%, p=0.03) compared with their HIV-uninfected comparators. In multivariable regression models, people with depression (AOR 7.52 [95% CI: 3.67-15.40], p<0.001) and those with ≥1 comorbidities (AOR 3.15 [95% CI: 1.71-3.82], p<0.001) were more likely to be frail. HIV serostatus was not significantly associated with frailty (AOR 0.71 [95% CI: 0.37-1.34], p=0.29). Older PWH had a similar prevalence of frailty as those without HIV. These findings call for additional study of the factors that contribute to the robustness of older PWH in sub-Saharan Africa.

Safety and Efficacy of Left Atrial Appendage Closure Devices: In-Vitro Controlled Simulations and In-Vivo Correlations

The "Left Atrial Appendage Closure (LAAC) Device" is specifically designed to address the problem of stroke prevention in patients with atrial fibrillation (AF). In individuals with AF, the heart's atria (upper chambers) do not beat effectively, allowing blood to pool and potentially form clots, particularly in the left atrial appendage (LAA). These clots can then travel to the brain, causing a stroke. The purpose of the Left Atrial Appendage Closure Device is to mechanically seal off the left atrial appendage, preventing blood clots from forming there and reducing the risk of stroke in patients with atrial fibrillation who are at high risk of stroke but cannot tolerate long-term anticoagulation therapy. Hence Patients with atrial fibrillation frequently develop thrombus in the Left Atrial Appendage (LAA), which significantly increases their risk of stroke. LAA closure devices block the appendage, providing a percutaneous method of lowering this risk. With an emphasis on current developments, this research article examines the history, development effectiveness, delivery &amp; deployment and safety of LAA closure devices via in-vitro simulation testing with controlled conditions.

The risk of malignancy in patients with psoriasis treated with long-term tumor necrosis factor-α inhibitor: a systematic review and meta-analysis.

The relationship between tumor necrosis factor-α inhibitors (TNFi) and cancer risk is complex, given their pivotal role in managing chronic inflammatory conditions. Persistent concerns about TNFi therapy potentially increasing cancer risk necessitate a thorough understanding of its long-term effects on cancer development in patients with psoriasis to guide therapeutic decision-making. This systematic review and meta-analysis aimed to evaluate the association between long-term TNFi therapy and cancer risk in patients with psoriasis. Data were collected from PubMed, Embase, and the Cochrane Library, from their inception to January 1, 2024. The studies included adults with psoriasis or psoriatic arthritis receiving TNFi, presenting standardized incidence ratio (SIR) data for cancer. Data extraction followed PRISMA guidelines, with independent extraction by two authors, and pooled data synthesis was conducted using a random-effects model. The primary outcomes were SIRs for all cancers excluding non-melanoma skin carcinoma (NMSC) and for NMSC itself. The secondary outcome was the SIR of specific cancer types. The meta-analysis included eight studies with a total of 32,765 psoriasis patients. The pooled results showed no increased risk of cancers, including all cancers excluding NMSC, melanoma, lymphoma, prostate cancer, and breast cancer, among individuals receiving long-term TNFi therapy for psoriasis compared to the general population. However, subgroup analysis found an elevated risk of NMSC in patients with psoriatic arthritis and a significant increase in the risk of squamous cell carcinoma (SCC) among psoriasis patients treated with TNFi compared to the general population (SIR, 1.84; 95% CI, 1.16 - 2.92 and SIR, 2.84; 95% CI, 1.64 - 4.91, respectively). Our systematic review and meta-analysis indicate that most cancers examined did not demonstrate an increased risk following long-term TNFi therapy in psoriasis patients. However, for patients with psoriatic arthritis or those at high risk of SCC, these findings underscore the importance of personalized treatment strategies that weigh individual risks and benefits.

Exploring alternative treatment options for a patient with acute disseminated encephalomyelitis (ADEM) suffering from iatrogenic Cushing’s symptoms

A clinical decision report using: Ravaglia, S,MD, P., Piccolo G, MD, Ceroni M, MD, et al. Severe steroid-resistant post-infectious encephalomyelitis: General features and effects of IVIg. J Neurol. 2007;254(11):1518-23. https://doi.org/10.1007/s00415-007-0561-4 for a patient with ADEM and iatrogenic Cushing’s secondary to long-term high dose corticosteroid therapy.

Avoiding prostate bed radiation for the PSMA-PET detected nodal recurrence patient post prostatectomy

BackgroundNodal only recurrence post radical prostatectomy (RP) is increasingly recognised in the PSMA scan era. Management is controversial with a curative approach usually incorporating prostate bed and nodal irradiation (PB + NRT) in combination with long-term hormonal therapy. It is unknown whether omitting prostate-bed irradiation (PBRT) is safe in a subgroup of these patients. PurposeTo document the outcomes for pelvic nodal only salvage radiation therapy (NRT) plus concurrent androgen deprivation therapy (ADT) for patients with PSMA PET documented nodal relapses. Methods and materialsEligible patients included PSMA PET documented nodal only relapses post RP who received NRT with or without PBRT at Royal North Shore Hospital (NSCC), Gosford Hospital (CCCC) or Genesis Care (GC) between January 2015 and December 2021. Baseline demographics, surgical pathology, radiation details, ADT use and outcomes were documented. ResultsForty-six patients were identified, 22 in the PB + NRT cohort and 24 in the NRT cohort. Compared to the PBRT + NRT group, the NRT cohort had lower stage disease (pT2 = 7 (29 %), pT3a = 15 (63 %), pT3b = 1 (4 %) vs pT2 = 0, pT3a = 10 (45 %), pT3b = 12 (55 %)) (p=<0.001) and lower rates of R1 resection (0 % vs 63.6 % (n = 14)) (p < 0.001) respectively. The median follow-up from radiotherapy was 3.9 years.Four-year biochemical failure- free survival (BFFS) was 64 % in the NRT group vs 67 % in the PB + NRT group. Of the ten (41.6 %) failures in the NRT group, 1 (4 %) was a biochemical failure only, 2 (8 %) recurred in the PB and received further salvage treatment, 4 (17 %) had nodal failure outside the pelvis and 3 (13 %) had distant metastases.One patient (4 %) in the NRT group recorded late grade ≥2 GU toxicity compared with 7 (32 %) in the PB + NRT. No patients in the NRT group recorded late grade ≥2 GI toxicity compared with 2 (9 %) in the PB + NRT cohort. ConclusionThis study provides early evidence for the feasibility of PBRT sparing to avoid local toxicity. Most patients in this cohort failed distantly. This data suggests that for selected men PB-avoidance may be considered given informed consent.