Prevention Of Recurrent Attacks Research Articles

Early versus late initiation of infliximab for refractory uveitis in a cohort of Egyptian BD patients

Introduction Behçet’s syndrome is a multisystem inflammatory disease characterized by recurrent oral aphthous ulcers, genital ulcers, skin lesions, and uveitis. Ocular involvement, occurring roughly in 50% of patients, is one of the most feared complications of Behçet’s syndrome. Recurrent severe uveitis leads to irreversible severe vision loss. Purpose The main goals in the management of patients with Behçet’s uveitis are rapid resolution of intraocular inflammation, prevention of recurrent attacks, and achievement of complete remission and preservation of vision. Corticosteroids are generally used for the treatment of acute episodes of inflammation. According to the updated EULAR recommendations for the management of BS ‘any patient with BS and inflammatory eye disease affecting the posterior segment should be on a treatment regime such as azathioprine, cyclosporine-A, interferon alpha or monoclonal tumor necrosis factor alpha antagonists. Methods Infliximab has been increasingly used in the treatment of Behçet’s syndrome patients with uveitis when they are refractory to conventional immunosuppressive therapy. However, there is no consensus on the best time to start anti- tumor necrosis factor alpha therapy. In our study we evaluated the outcome of early initiation of infliximab for refractory uveitis in cohort of Egyptian Behçet’s syndrome patients. Conclusion Early administration of Intravenous Infliximab therapy for severe sight-threatening uveitis and chorioretinitis in Egyptian Behçet’s syndrome patients has a favorable value regarding BCVA. Multidisciplinary approach in managing Behçet’s uveitis is mandatory to reach better functional visual outcome.

Long-term complications in acute porphyria.

New treatment options and low attack-related mortality have changed the life expectancy of patients with acute porphyria (AP) to that of the general population. Clinicians should therefore be aware of the long-term complications of AP, which typically include chronic neuropathy and encephalopathy, high blood pressure and porphyria-associated kidney disease. Patients have an increased risk of primary liver cancer (PLC), but no increased risk of non-hepatic cancers. Chronic pain occurs in patients with recurrent attacks, combined with chronic fatigue and nausea, leading to poor quality of life. Patients with sporadic attacks may also have chronic symptoms, which should be distinguished from mild recurrent attacks and treated appropriately. Sequels of acute polyneuropathy after an attack should be distinguished from ongoing chronic polyneuropathy, as the management is different. Overestimation of chronic neuropathy or encephalopathy caused by AP should be avoided, and other causes should be treated accordingly. Prevention of recurrent attacks is the best strategy for managing chronic comorbidities and should be actively accomplished. Hormonal interventions in female patients, or in severe cases, prophylactic givosiran or haematin, may be helpful before liver transplantation to prevent recurrent attacks. Regular monitoring can be personalised according to the patient's age, comorbidities and AP activity. Blood pressure, renal function and cardiovascular risk factors should be monitored annually in patients with previous symptoms. Appropriate medication and lifestyle management, including nutrition and hydration, are necessary to prevent complications. As PLC is common, especially in patients with acute intermittent porphyria, bi-annual surveillance after the age of 50 is important.

Acute hepatic porphyrias: Recommendations for diagnosis and management with real-world examples

Acute hepatic porphyria (AHP) is a group of four rare inherited diseases, each resulting from a deficiency in a distinct enzyme in the heme biosynthetic pathway. Characterized by acute neurovisceral symptoms that may mimic other medical and psychiatric conditions, lack of recognition of the disease often leads to a delay in diagnosis and initiation of effective treatment. Biochemical testing for pathway intermediates that accumulate when the disease is active forms the basis for screening and establishing a diagnosis. Subsequent genetic analysis identifies the pathogenic variant, supporting screening of family members and genetic counseling. Management of AHP involves avoidance of known exogenous and hormonal triggers, symptomatic treatment, and prevention of recurrent attacks. Here we describe six case studies from our own real-world experience to highlight current recommendations and challenges associated with the diagnosis and long-term management of the disease.

Behçet's Disease Uveitis.

Uveitis in Behçet's disease (BD) is frequent (40% of cases) and is a major cause of morbidity. The age of onset of uveitis is between 20 and 30 years. Ocular involvement includes anterior, posterior, or panuveitis. Uveitis may be the first sign of the disease in 20% of cases or it may appear 2 or 3 years after the first symptoms. Panuveitis is the most common presentation and is more commonly found in men. Bilateralization usually occurs on average 2 years after the first symptoms. The estimated risk of blindness at 5 years is 10-15%. BD uveitis has several ophthalmological features that distinguish it from other uveitis. The main goals in the management of patients are the rapid resolution of intraocular inflammation, the prevention of recurrent attacks, the achievement of complete remission, and the preservation of vision. Biologic therapies have changed the management of intraocular inflammation. The aim of this review is to provide an update to a previous article by our team on pathogenesis, diagnostic approaches, and the therapeutic strategy of BD uveitis.

Effectiveness of providing health education to caregivers of hospitalized children with asthma for the prevention of recurrent attacks: a quasi-randomized trial

Objective: To determine the effectiveness of health education intervention for caregivers of children with asthma, focused on preventing recurrent attacks and improving knowledge.Methods: A quasi-randomized trial of 177 caregivers of asthmatic children was conducted in government hospitals in a district of Sri Lanka. At the time of discharge from the hospital, a health education booklet was prepared and given to the caregivers in the intervention group, along with individual explanation and discussion. The caregivers’ knowledge of asthma and preventive practices was assessed. The primary outcome was the proportion of children with recurrent attacks of asthma who needed doctor visits during the three month post discharge period. The intention-to-treat principle was applied for data analysis.Results: In comparison to the control group, the intervention group had a 76% significant reduction in visits to the doctor for recurrent attacks (95% CI:45%-90%) and a 75% significant reduction in hospital admissions required for asthmatic children (95% CI:16%-93%) at the end of three months of intervention. The mean score of knowledge of asthma in the intervention group was 1.73 units higher at three months (p < 0.01) and 1.47 units higher at six months (p < 0.01) than the control group. The mean score of preventive practices for asthma in the intervention group was 1.25 units higher at three months (p = 0.02) and 1.15 units higher at six months (p < 0.01) versus the control group.Conclusion: Health education intervention significantly decreased doctor and hospital visits at three months. In addition, caregiver knowledge of asthma and preventive practices also improved.Trial Registration Number: SLCTR/2010/007

Dosha phenotype specific Ayurveda intervention ameliorates asthma symptoms through cytokine modulations: Results of whole system clinical trial

Ethnopharmacological relevanceOver the past few decades, there have been significant scientific advances leading to improved understanding of asthma as a disease and treatment providing immediate relief. However, prevention of recurrent attacks, exacerbations and disease cure remains a challenge. Ayurveda refers to bronchial asthma as Tamaka Swasa and it is well explained in Charaka Samhita. Management of asthma in Ayurveda includes removal of vitiated Kapha through Shodhana, Shamana procedures, herbal and herbomineral formulations in addition to advising a healthy lifestyle and diet. Several clinical trials on Ayurvedic formulations for treatment of asthma are reported, however, whole system management of asthma has rarely been studied in the manner in which it is actually being practiced. Ayurveda therapeutics provides Dosha specific approaches, which needs biological investigation. Aim of the studyThe objective of our study was to investigate lung functions and cytokine changes in Asthmatic individuals in response to Ayurvedic intervention. MethodsThe study design was approved by the Institutional Ethics Committee of Tilak Ayurveda Mahavidyalaya (TAMV) & Sheth Tarachand Ramnath Charitable Ayurveda Hospital and followed guidelines of the Declaration of Helsinki and Tokyo for humans. It was conducted as a whole system individualized pragmatic clinical trial and written consent of patients was collected before enrollment.One hundred and fifteen patients with mild-to-moderate asthma were divided into 2 sub-groups depending on their disease subsets and administered phenotype specific ayurvedic interventions. Seventy six asthma patients completed the treatment. Serum IgE levels, blood eosinophil counts, spirometry and blood cytokine levels were measured before the start of treatment and six months at the end of treatment. Age and sex matched healthy participants (n=69) were recruited in the study for comparison of cytokines levels. ResultsSignificant improvements in FEV1(% predicted) (p<0.0001) and FVC (% predicted) (p=0.0001) was observed in asthmatic patients who underwent Ayurvedic treatment. Circulating levels of IgE (p<0.03) and eosinophil numbers (p=0.001) reduced significantly in the asthmatics after Ayurvedic treatment. This was associated with significant reduction in levels of circulating cytokines. Levels of Th2, Th1 and inflammatory cytokines in the peripheral blood were higher than healthy control participants at baseline (p values <0.0001) and reduced significantly after ayurvedic intervention. ConclusionThis proof of concept study highlights the potential benefits and possible mechanism of Ayurvedic interventions in patients with mild-to-moderate asthma. The interventions significantly reduced IgE and eosinophil count, also improved lung function and reduced levels of circulating Th2 cytokines.

Meniere's disease.

Meniere's disease (MD) is a disorder of the inner ear that causes vertigo attacks, fluctuating hearing loss, tinnitus and aural fullness. The aetiology of MD is multifactorial. A characteristic sign of MD is endolymphatic hydrops (EH), a disorder in which excessive endolymph accumulates in the inner ear and causes damage to the ganglion cells. In most patients, the clinical symptoms of MD present after considerable accumulation of endolymph has occurred. However, some patients develop symptoms in the early stages of EH. The reason for the variability in the symptomatology is unknown and the relationship between EH and the clinical symptoms of MD requires further study. The diagnosis of MD is based on clinical symptoms but can be complemented with functional inner ear tests, including audiometry, vestibular-evoked myogenic potential testing, caloric testing, electrocochleography or head impulse tests. MRI has been optimized to directly visualize EH in the cochlea, vestibule and semicircular canals, and its use is shifting from the research setting to the clinic. The management of MD is mainly aimed at the relief of acute attacks of vertigo and the prevention of recurrent attacks. Therapeutic options are based on empirical evidence and include the management of risk factors and a conservative approach as the first line of treatment. When medical treatment is unable to suppress vertigo attacks, intratympanic gentamicin therapy or endolymphatic sac decompression surgery is usually considered. This Primer covers the pathophysiology, symptomatology, diagnosis, management, quality of life and prevention of MD.

A Study to Assess the Knowledge and Practice of Patients with Bronchial Asthma Regarding Prevention of Recurrent Attacks of Asthma

A Study to Assess the Knowledge and Practice of Patients with Bronchial Asthma Regarding Prevention of Recurrent Attacks of Asthma

Ocular Involvement of Behçet’s Syndrome: a Comprehensive Review

Behçet's syndrome (BS) is a vasculitis involving several organ systems including the eyes. Ocular involvement is one of the most disabling complications of BS, causing loss of vision that may progress to blindness if left untreated. The typical form of ocular involvement is a relapsing and remitting panuveitis and retinal vasculitis. Initial attacks may spontaneously improve and subsequently disappear in a few weeks but tend to recur if left untreated. Destructive and recurrent attacks, especially with posterior segment and retina involvement, may cause irreversible ocular structural changes and permanent damage in sensory retina, resulting in loss of vision. The risk of irreversible damage to ocular tissue which may result in loss of vision warrants early and intensive treatment especially in patients at high risk such as young men who tend to follow an aggressive disease course. The management strategy involves rapid suppression of inflammation during the attacks and prevention of recurrent attacks. Local and systemic measures including immunosuppressives, corticosteroids, and biologic agents are used for this purpose. Surgery may be required in selected cases. The prognosis of eye involvement has greatly improved over the last decades with the effective use of immunosuppressives.

Urinary Tract Infections in Children: A Changing Paradigm

Purpose: To review the changing paradigms in the diagnosis, investigation and management of Urinary Tract Infections (UTIs) in children beyond the neonatal period. Methods: A literature search was done using PUBMED, EBSCO host database and GOOGLE SCHOLAR of all articles including reviews and guidelines on UTIs in children for the last ten years. A total of 2725 articles including review articles and guidelines published over the last 10 years were searched and reviewed. Results: UTIs are the second most common cause of serious bacterial infections in early childhood, thus placing a huge financial burden on the health budget. Despite increasing resistance to several first-line antibiotics, appropriate antibiotic treatment has almost eliminated mortality. Early guidelines advocated aggressive treatment and extensive imaging studies, particularly for the detection of serious ureteric reflex and kidney scarring. Treatment in the acute episode is aimed at eradication of bacteriuria and alleviation of symptoms. Long-term goals include prevention of recurrent attacks of UTIs, kidney scarring and correction of urological lesions that may predispose to recurrent infections. Although there is increasing evidence to show that long-term antimicrobial prophylaxis may be associated with a reduced risk of recurrent infection in selected groups of patients, but not renal scarring, more studies are needed to confirm this. Surgical intervention is now restricted to cases with severe vesicoureteric reflux and failed medical management with endoscopic surgery being increasingly used in most centres compared to open surgery. Conclusion: Following extensive research, a more tangible approach to UTIs is advocated providing for more judicious use of resources with reduced harm from procedures, without affecting outcome. This review addresses the diagnosis, management and treatment of UTIs in children beyond the neonatal period.

Etiology of Hypokalemic Paralysis in Korea: Data from a Single Center

Recognizing the underlying causes of hypokalemic paralysis seems to be essential for the appropriate management of affected patients and their prevention of recurrent attacks. There is, however, a paucity of documented reports on the etiology of hypokalemic paralysis in Korea. We retrospectively analyzed 34 patients with acute flaccid weakness due to hypokalaemia who were admitted during the 5-year study period in order to determine the spectrum of hypokalemic paralysis in Korea and to identify the differences in clinical parameters all across the causes of hypokalemic paralysis. We divided those 34 patients into 3 groups; the 1st group, idiopathic hypokalemic periodic paralysis (HPP), the 2nd, thyrotoxic periodic paralysis (TPP), and the 3rd group, secondary hypokalemic paralysis (HP) without TPP. Seven of the patients (20.6%) were diagnosed as idiopathic HPP considered the sporadic form, and 27 patients (79.4%) as secondary HP. Among the patients diagnosed as secondary HP, 16 patients (47.1%) had TPP. Patients of secondary hypokalemic paralysis without TPP required a longer recovery time compared with those who had either idiopathic HPP or TPP. This is due to the fact that patients of secondary HP had a significantly negative total body potassium balance, whereas idiopathic HPP and TPP were only associated with intracellular shift of potassium. Most of the TPP patients included in our study had overt thyrotoxicosis while 3 patients had subclinical thyrotoxicosis. This study shows that TPP is the most common cause of hypokalemic paralysis in Korea. And we suggest that doctors should consider the presence of TPP in patients of hypokalemic paralysis even if they clinically appear to be euthyroid state.

Manifestations oculaires de la maladie de Behçet

Eye involvement in Behçet's disease (BD) is frequent and an important cause of morbidity. The mean age at onset of uveitis is between 20 and 30 years in male and 30 years in female patients. Ocular involvement includes anterior, posterior or panuveitis. Uveitis may be the presenting manifestation of the disease in 20% of cases or may appear 2 or 3 years after the disease onset. The estimated risk of blindness at 5 years ranges from 15 to 25%. The main goals in the management of patients with BD uveitis are the rapid control of intraocular inflammation, the prevention of recurrent attacks, the achievement of complete remission, and preservation of vision. The medical treatment of patients with severe uveitis relies on the use of systemically administered drugs, including corticosteroids and cytotoxic agents. Anti-TNF agents and interferon-alpha seem to be efficient and well-tolerated alternative therapeutic options. Controlled clinical trials are mandatory to define the place of these new immunomodulatory agents in the therapeutic strategy, and especially their use as first-line therapy.

Sigmoid Volvulus an Update

Sigmoid volvulus is the third most common cause of colonic obstruction in the United States after cancer and diverticulitis. Etiologic factors include anatomic variation, chronic constipation, neurologic disease, and megacolon. Management of sigmoid volvulus involves relief of obstruction and the prevention of recurrent attacks; the outcome depends on the population and selection of patients. Although volvulus is uncommon, it may be encountered during pregnancy and is a condition that poses significant risk to both mother and fetus requiring a management strategy that varies with each trimester.

Recurrent acute pancreatitis

Patients with recurrent acute pancreatitis should be treated with the same supportive and symptom-oriented measures as those with acute pancreatitis. The need for specific treatment depends on the cause of the pancreatitis. Patients should discontinue alcohol use, putative causative medications, and exposure to toxins or helminths in endemic areas. Metabolic abnormalities need to be corrected, and appropriate treatment should be initiated for associated infections, autoimmune diseases, vasculitis, and hypercoagulable states. For patients with gallstone pancreatitis, endoscopic retrograde cholangiopancreatography is indicated if biliary obstruction persists or if cholangitis is present. Elective cholecystectomy may be performed in appropriate patients; otherwise, consider biliary sphincterotomy and ursodeoxycholic acid for prevention of recurrent attacks. Transpapillary stenting or sphincterotomy of the minor papilla benefits some patients with pancreas divisum and no other explanation for recurrent pancreatitis. Surgical sphincteroplasty is reserved for those failing endoscopic treatment. Biliary sphincterotomy benefits more than 50% of patients with sphincter of Oddi dysfunction and recurrent acute pancreatitis. Some authors advocate pancreatic sphincter manometry and sphincterotomy for persistent pancreatic segment hypertension in patients who have recurrent pancreatitis after biliary sphincterotomy. In patients with pancreatic duct strictures, transpapillary stent placement serves as a short-term measure; most patients ultimately require surgery.

Prevention of recurrent attacks of pancreatitis in patients with cystic fibrosis: The role of endoscopic therapy

Prevention of recurrent attacks of pancreatitis in patients with cystic fibrosis: The role of endoscopic therapy

Valproate prevents the recurrence of absence status

We assessed the value of valproate in the prevention of recurrent attacks of absence status in 25 patients. Eighteen patients had primary generalized epilepsy with a mean frequency of attacks of absence status of 5.7 per year. After a mean follow-up period of 4.4 years, the attack frequency was reduced to 0.6 per year (p less than 0.0005); 14 patients had no recurrence, 3 had rare attacks with noncompliance, and 1 had an incomplete response probably due to gastrointestinal intolerance. Patients with evidence of generalized cerebral damage (n = 2) or with EEG evidence of focalization (n = 5) did not respond as favorably. Valproate is the drug of choice for the prevention of recurrence of absence status. Moreover, the response can be predicted on the basis of the electroclinical subtype of absence status.

Finnish Approach to the Treatment of Acute Otitis Media Report of the Finnish Consensus Conference

The theme of the first consensus conference to be held in Finland was the treatment of acute otitis media. The statements and recommendations accepted by the conference, which was organized according to the National Institutes of Health model, are presented in this report. On the basis of scientific knowledge, clinical experience, and conditions in Finland, the conference delegates concluded that penicillin V, in large doses, is still the drug of first choice in this disease. The importance of surgical drainage of the middle ear was stressed, as was the necessity of careful follow-up of the patient until the condition is completely healed. Decongestants were considered rather useless. In the prevention of recurrent attacks, adenoidectomy but not tonsillectomy was regarded as being of help, tympanostomy of probable benefit, antimicrobial (sulfonamide) prophylaxis worth considering in selected cases, but the effect of pneumococcal vaccination poor. The conference delegates agreed that uncomplicated acute otitis media should, as before, usually be treated by physicians taking care of children at the primary health care level.

A decade of progress in therapy of Adams-Stokes disease.

Isopropylarterenol is the most effective drug for treatment of acute syncopal attacks of Adams-Stokes disease and prevention of recurrent attacks. When syncope does not resolve quickly, closed-chest cardiac massage can be applied effectively whether the arrhythmia is due to ventricular arrest or fibrillation, affording time to determine the mechanism and organize appropriate therapy.Permanent electric pacemaking is now feasible, either with a portable pacemaker connected to an electrode catheter in contact with the endocardium of the right ventricle or with a subcutaneously implanted pacemaker connected to electrodes placed in the left ventricular myocardium.

Long-acting repository penicillin in prophylaxis of recurrent rheumatic fever.

The problem of prevention of recurrent attacks of rheumatic fever has always presented a great challenge to the responsible physician. Prior to the advent of chemotherapeutic and antibiotic agents, the avoidance of streptococcic disease and the general symptomatic care of the patient proved fruitless in attempting to prevent progressive cardiac damage in the patient who had had rheumatic fever. Tonsillectomy has not prevented recurrences of the disease, and now it is usually felt that patients with histories of rheumatic fever have the same indications for removal of the tonsils as do those who have not been afflicted with the disease. The strongest evidence for a direct relationship between rheumatic activity and antecedent streptococcic infection has been presented by prophylactic programs. The sulfonamides were used in the first direct approach to the prevention of recurrences by attempting to keep the throat free of beta hemolytic streptococci of Lancefield group A. Because