Combined therapy with early initiation of infliximab following drainage of perianal fistulising Crohn’s disease: a retrospective cohort study

Background Recent studies have confirmed that combined surgery and anti-TNF therapy could improve outcomes in patients with perianal fistulising Crohn’s disease (PFCD). However, the optimal timing for infliximab infusion after surgical intervention is uncertain. We aimed to determine the long-term efficacy of early initiation of infliximab following surgery among PFCD patients. Methods We performed a retrospective cohort study of PFCD patients who received combined infliximab and surgical treatment between 2010 and 2018 at a tertiary referral hospital. Patients were grouped according to the time interval between surgery and infliximab infusion, with < 6 weeks into early infliximab induction group and > 6 weeks into delayed infliximab induction group. The primary outcome was to compare surgical re-intervention between early and delayed infliximab induction groups. The secondary outcomes were fistula healing and predictors associated with these outcomes of early infliximab induction approach. Results One hundred and seventeen patients were included (73 in early infliximab induction, 44 in delayed infliximab induction). The median interval between surgery and infliximab initiation was 9.0 (IQR 5.5–17.0) days in early infliximab induction group and 188.0 (IQR 102.25–455.75) days in delayed infliximab induction group. After followed-up for a median of 36 months, 61.6% of patients in early infliximab induction group and 65.9% in delayed infliximab induction group attained fistula healing (p = 0.643). The cumulative re-intervention rate was 23%, 32%, 34% in early infliximab induction group and 16%, 25%, 25% in delayed infliximab induction group, at 1, 2, and 3 years respectively (p = 0.235). Presence of abscess at baseline (HR = 5.283; 95% CI, 1.61–17.335; p = 0.006) and infliximab maintenance therapy > 3 infusions (HR = 3.691; 95% CI, 1.233–11.051; p = 0.02) were associated with re-intervention in early infliximab induction group. Presence of abscess at baseline also negatively influenced fistula healing (HR = 3.429, 95% CI, 1.216–9.668; p = 0.02). Conclusion Although no clear benefit was shown compared with delayed infliximab induction group, early initiation of infliximab after surgery could achieve promising results for PFCD patients. Before infliximab infusion, durable drainage is required for patients with concomitant abscess or prolonged infliximab maintenance therapy.

Long-term safety and effectiveness of mycophenolate mofetil in adults with lupus nephritis: a real-world study in Japan

ABSTRACT Objectives To assess the safety and effectiveness of mycophenolate mofetil (MMF) in Japanese adults with lupus nephritis (LN) in real-world clinical practice. Methods This multicentre, prospective, post-marketing surveillance study investigated the effectiveness and safety of MMF, as induction or maintenance therapy, in LN patients. Primary endpoints were adverse drug reactions (ADRs), changes in renal function from baseline, and relapse rate (RR) after 6 months in the maintenance group, estimated using the Kaplan–Meier method. Complete remission (CR) and partial remission (PR) were estimated by renal measurements. Results Overall, 112 patients were enrolled in the induction group and 340 in the maintenance group. Of these 452 patients, 418 were evaluable for safety and 396 for effectiveness. Eighty-three patients (19.85%) experienced ADRs, most commonly herpes zoster (3.34%) and diarrhoea (3.11%). Serious ADRs occurring in more than three patients were cytomegalovirus infections (1.43%), acute pyelonephritis (0.71%), and herpes zoster (0.71%). One patient died from herpes zoster disseminated. CR and PR were 19.54% and 44.82%, respectively, in the induction group, and 40.62% and 66.16%, respectively, in the maintenance group. RR in the maintenance group was 0.70%. Conclusions The tolerability of MMF is in line with that reported in other studies. Since the average dose of MMF was &lt;1.5 g/day, research into the optimal dose for achieving effectiveness is required.

Study of comparison of maternal and fetal outcomes in spontaneous labour and induced labour

Background: There has been consistent proportionate increase in the cases of induction of labor, but both maternal and neonatal effects of it remain poorly analysed previously. The present study was undertaken with the objective of comparison of maternal and fetal outcomes between groups of patients undergoing induction of labor and those having spontaneous labor.Methods: In this comparative prevalence study, the participants selected by predefined criteria were divided into 2 groups on the basis of progression of labor. They were spontaneous labor (group A) and induction of labor (group B). All the participants were assessed for various relevant maternal and neonatal outcomes and valid comparisons drawn.Results: A total of 1300 participants were studied. Proportion of patients requiring caesarean section was significantly higher in induction group (39.17%) against the spontaneous labor group (15.37%), with fetal distress being the commonest indication in both groups. The commonest complication noted was postpartum hemorrhage (PPH) (2.96% in group A and 1.98% in group B, p<0.05). Mean birth weight of babies was 2.76±0.42 kgs in spontaneous labor group and 2.68±0.48 kgs in induction of labor group (p>0.05). Incidences of NICU admissions and neonatal deaths were significantly higher in induction of labor group.Conclusions: Induction of labor should be employed judiciously by assessing the maternal and fetal condition and confirming relevant indication and should only be done if continuation of pregnancy is relatively more hazardous to either mother or baby.

Randomized clinical trial of active induction versus expectant management in premature rupture of the membranes at term

Immediate induction of labour in cases of pregnancy with PROM used to be a standard practice to avoid potential complications but induced labour is likely to be associated with increased risks of fetal and maternal complications due to oligohydramnios like cord compression and high rate of operative delivery. Purpose of this study is to determine in case the practice of actively inducing labour in women with PROM at term is preferable than expectant management for 12 hours and also to study the maternal and neonatal outcome. A total of 150 pregnant women were randomized into two groups who are between 18-35 years, at term gestation (37-40 weeks) having PROM irrespective of gravida. Women were immediately induced by Tab. Misoprostol(25microgrmas) in immediate induction group. Women who presented with PROM were observed for 12hrs from time of PROM without any intervention to accelerate the labour in conservative management group. An observation between the two groups of patients would be made with respect to maternal and fetal outcome. We observed that there was statistically insignificant increase in duration of labour and increased rate of caesarean section in expectant group. Maternal complications in both groups were found to be insignificant. However, women who were managed expectantly developed more puerperal pyrexia, wound infection and prolonged hospitalization than women who were managed with induction method. There was no statistically significant difference in the perinatal complications.

123 Use of The Induction Mobile Application in A Busy General Surgery Department

Introduction Contacting other hospital professionals, or accessing local guidelines is a common task for surgeons, which is usually facilitated by inefficient switchboard and intranet systems. Induction is a mobile application which includes crowd-sourced hospital directories and local guidelines, which could theoretically expedite these tasks. To assess this, we undertook a QIP within the General Surgery department using a bespoke Induction group. Method A private Induction group was created with the features mentioned above. We audited Induction against local trust processes (Switchboard and Intranet Trust Guidelines). We estimated cost saving using the 2019 junior doctor pay-scales. We also surveyed our department to evaluate their experiences using the application with a Likert scale. Results The timesaving from using Induction compared to current methods was on average 9.93 hours/week accumulated by 16 staff members, giving an estimated cost saving of £10,636.54/year. In a qualitative analysis, respondents rated Induction 4.8/5 for speed and 3.4/5 for completeness of directory, compared to 1.5/5 and 4.5/5 respectively for switchboard. Regarding accessing clinical guidelines, respondents rated the app as ‘easier’ and ‘quicker’ than the intranet. Conclusions We have demonstrated significant time and cost-savings using Induction compared to standard practices. Our QIP provides a replicable model to increase efficiency in surgery departments.

Women’s childbirth experiences in the Swedish Post-term Induction Study (SWEPIS): a multicentre, randomised, controlled trial

ObjectiveTo compare childbirth experiences in women randomly assigned to either induction of labour at 41 weeks or to expectant management until 42 weeks, in the Swedish Post-term Induction Study.DesignA register-based, multicentre, randomised, controlled, superiority trial.SettingWomen were recruited at 14 hospitals in Sweden, 2016–2018.ParticipantsWomen with an uncomplicated singleton pregnancy were recruited at 41 gestational weeks.InterventionsThe women were randomly assigned to induction of labour at 41 weeks (induction group, n=1381) or expectant management until 42 weeks (expectant management group, n=1379).Outcome measuresAs main outcome, women’s childbirth experiences were measured using the Childbirth Experience Questionnaire version 2 (CEQ2), in 656 women, 3 months after the birth at three hospitals. As exploratory outcome, overall childbirth experience was measured in 1457 women using a Visual Analogue Scale (VAS 1–10) within 3 days after delivery at the remaining eleven hospitals.ResultsThe total response rate was 77% (2113/2760). There were no significant differences in childbirth experience measured with CEQ2 between the groups (induction group, n=354; expectant management group, n=302) in the subscales: own capacity (2.8 vs 2.7, p=0.09), perceived safety (3.3 vs 3.2, p=0.06) and professional support (3.6 vs 3.5, p=0.38) or in the total CEQ2 score (3.3 vs 3.2, p=0.07), respectively. Women in the induction group scored higher in the subscale participation (3.6 vs 3.4, p=0.02), although with a small effect size (0.19). No significant difference was observed in overall childbirth experience according to VAS (8.0 (n=735) vs 8.1 (n=735), p=0.22).ConclusionsThere were no differences in childbirth experience, according to CEQ2 or overall childbirth experience assessed with VAS, between women randomly assigned to induction of labour at 41 weeks or expectant management until 42 weeks. Overall, women rated their childbirth experiences high.Trial registration numberISRCTN26113652.

Management of labor after external cephalic version

ObjectivesCurrent literature evaluating the role of induction of labor (IOL) following successful external cephalic version (ECV) attempt as compared to expectant management is limited. We aim to assess the risk of cesarean delivery in those undergoing immediate IOL following successful ECV as compared to those who were expectantly managed.MethodsA retrospective cohort study of successful external cephalic versions. The study group included 57 women that were induced after procedure in the lack of maternal or fetal indications for induction of labor. These women were compared to 341 expectantly managed women. Maternal and fetal characteristics and outcomes were compared.ResultsGestation age at delivery was higher among the expectant management group (401/7 vs. 384/7, median, p=0.002) as compared to the induction group. Cesarean delivery rates were similar between both groups (28 [8.2%] vs. 3 [5.3%], p=0.44). In a multivariate logistic regression analysis, only nulliparity was significantly associated with cesarean delivery (adjusted odds ratio 3.42, confidence interval 1.61–7.24, p=0.001). No correlation was found between the version-to-delivery interval and the risk for cesarean delivery.ConclusionsInduction of labor after successful ECV was not shown to influence cesarean delivery rates. As immediate IOL may result in higher rate of early-term deliveries, and in light of the lack of clinical benefit, we advocate against elective IOL following successful ECV.

CATALASE 1 GENE EXPRESSION (CAT-1) IN HYPERGLICEMIA INDUCED TESTIS, AS AN ANTIOXIDANT THERAPY INDICATORS

Objective: This study aims to analyze the effects of hyperglycemia status on the function of testicular spermatology, especially CAT-1. Material & Methods: This study was an experimental pre-clinical study. Twenty-seven rats were divided into 3 groups: normal, 2 weeks, and 4 weeks hyperglycemia. The hyperglycemic state in the Wistar rats was induced by Streptozotocin (STZ). All data were collected and analyzed with SPSS 20.0. At two and four weeks, testicular tissue was extracted and it will be processed using the Total RNA Mini Kit FavorPrepTM then quantitative PCR was performed using the SYBR® Fast qPCR Kit. Results: CAT-1 gene expression in the hyperglycemia induction group increased when induced for 2 weeks and again after 4 weeks compared to controls (18.88 ± 4.7 and 21.45 ± 5.52 vs 10.83 ± 3.4). However only induction after 2 weeks was statistically significant (p= 0.021). Conclusion: CAT-1 (Catalase) gene expression has increased in testicular tissue under conditions of hyperglycemia.

COMPARISION OF VARIOUS DOSES OF INTRAVENOUSLY ADMINISTERED DEXMEDETOMIDINE WITH FENTANYL ON HAEMODYNAMICS TO INTUBATION IN PATIENTS UNDERGOING SURGERY UNDER GENERAL ANESTHESIA

Background: During general anesthesia , direct laryngoscopy and intubation results in a profound sympathoadrenal response which leads to tachycardia , hypertension and in predisposed individuals may lead to myocardial ischemia and arrhythmias. Various drugs such as opioids, lignocaine, propofol, beta blockers, alpha agonists have been used to minimize these adverse responses. Methods: 90 patients ASA1, ASA2 scheduled to undergo elective and emergency surgery under general anaesthesia were enrolled in double blind prospective randomized controlled trial. ey were randomly allocated to one of the following groups. Group A received 2 micro gram/kg fentanyl intravenously10 minutes before induction. Group B received 2 micro gram/kg fentanyl and 0.5 microgram/kg dexmedetomidine intravenously 10 mins prior to induction. Group C received 2 mico gram/kg fentanyl and 1 microgram/kg dexmedetomidine i.v. 10 minutes prior to induction. Results: Both study groups(B & C) were comparable with respect to there heart rate at base line, 1 minute,2.5 minutes, 5 and 10 minutes after administration of the study drug. Group C(Dexmedetomidine 1 g) demonstrated a greater suppression of chronotropic response to intubation as compared together two groups. Both the groups (B & C) were comparable to their SBP at base line 5 and 10minutes Group C demonstrated a better suppression of the pressor response to intubation compared to other two groups