How safe and effective is prescribing oral isotretinoin to treat acne in patients on renal dialysis? A systematic review.

BACKGROUND: Patients on renal dialysis often develop severe acne. In spite of this, the literature remains scarce about the use of isotretinoin for the treatment of acne in this group of patients, and many clinicians remain apprehensive and hesitant to use it. AIM: To systematically review the literature surrounding the safety and efficacy of isotretinoin for the treatment of acne in patients on renal dialysis. METHODS: Four electronic databases (MEDLINE, Embase, CINAHL, Emcare) were systematically searched in March 2021. The search strategy incorporated the terms 'isotretinoin', 'renal', 'kidney', 'dialysis' and 'acne', along with terms closely related to these. Studies were considered eligible if they reported the use of isotretinoin for treatment of acne in patients with renal impairment or on renal dialysis, and if they had relevant implications to this topic. RESULTS: The search resulted in a total of 63 results. Using the PRISMA approach, 11 articles were deemed relevant to this review: 1 randomized single-blinded placebo-controlled trial, 2 case series, 2 retrospective studies and 6 case reports. Hence the level of evidence was mostly low (Grading of Recommendations, Assessment, Development and Evaluations level 3). CONCLUSION: This review of the literature suggests that low-dose isotretinoin (10-20 mg) can safely and successfully be used to treat severe acne in patients on renal dialysis, leading to a significant improvement in their quality of life. As the current literature on this topic is scarce, more studies would be beneficial to further establish the safe use of isotretinoin in patients on renal dialysis.

Randomized phase II placebo-controlled study to evaluate the efficacy of topical pure emu oil for joint pain related to adjuvant aromatase inhibitor use in postmenopausal women with early breast cancer: JUST (Joints Under Study).

PURPOSE: Aromatase inhibitors are standard of care in women with hormone receptor-positive early breast cancer. Published evidence demonstrates that adverse effects may have an impact on drug compliance, with arthralgias being one of the most commonly reported adverse effects. METHODS: Eligible patients were postmenopausal women who had experienced arthralgia following initiation of an aromatase inhibitor. Patients who experienced arthralgias following a minimum of a 3-month treatment on the aromatase inhibitor were randomized to emu oil or placebo oil. The primary endpoint was to assess for a reduction in pain as measured by a visual analogue score after 8 weeks of treatment. RESULTS: Seventy-three patients comprised the intent-to-treat population, and there was no statistically significant benefit with use of EO. However, there was a statistically significant improvement in pain (visual analogue score was -1.28; p < 0.001) and Brief Pain Inventory severity score -0.88 (p < 0.001), as well as functional interference (Brief Pain Inventory interference -1.10 (p < 0.001) for the entire population following an 8-week administration of EO or placebo oil. CONCLUSIONS: Arthralgias, as a result of aromatase inhibitor use, may be ameliorated by the use of topical oil massaged onto the joint. Further research into interventions for this common side effect is needed.

Cross-talk between macrophages and smooth muscle cells impairs collagen and metalloprotease synthesis and promotes angiogenesis.

Coronary atherosclerosis complicated by plaque disruption and thrombosis is a critical event in myocardial infarction and stroke, the major causes of cardiovascular death. In atherogenesis, macrophages (MAC) and smooth muscle cells (SMC) are key actors; they synthesize matrix components and numerous factors involved in the process. Here, we design experiments to investigate whether SMC-MAC communication induces changes in ECM protein composition and/or neo-angiogenesis. Cell to cell communication was achieved using trans-well chambers, where SMCs were grown in the upper chamber and differentiated MAC in the bottom chamber for 24 or 72h. We found that cross-talk between MAC and SMC during co-culture: (i) significantly decreased the expression of ECM proteins (collagen I, III, elastin) in SMC; (ii) increased the expression and activity of metalloprotease MMP-9 and expression of collagenase MMP-1, in both MAC and SMC; (iii) augmented the secretion of soluble VEGF in the conditioned media of cell co-culture and VEGF gene expression in both cell types, compared with control cells. Moreover, the conditioned media collected from MAC-SMC co-culture promoted endothelial cell tube formation in Matrigel, signifying an increased angiogenic effect. In addition, the MAC-SMC communication led to an increase in inflammatory IL-1ß and TLR-2, which could be responsible for cellular signaling. In conclusion, MAC-SMC communication affects factors and molecules that could alter ECM composition and neo-angiogenesis, features that could directly dictate the progression of atheroma towards the vulnerable plaque. Targeting the MAC-SMC cross-talk may represent a novel therapeutic strategy to slow-down or retard the plaque progression.

Customising the length of the Montgomery T-tube whilst retaining a bevelled edge.

BACKGROUND: The Montgomery T-tube is used in a number of conditions that require safe tracheal stenting. Specific lengths of T-tube limbs are occasionally needed in patients with complex airway anatomy or differing neck proportions; this requires customisation of the T-tube limbs. This is done either by pre-ordering customised T-tubes from the manufacturer (which needs to be planned ahead of time) or using a tube cutter in the operating theatre. However, the latter does not provide a 'factory like' bevelled edge when shortened, which increases the risk of mucosal trauma and granulation formation. OBJECTIVE: This paper reports a novel technique for customising the length of existing Montgomery T-tubes, with preservation of the bevelled edges. This technique can be easily performed with basic equipment available in operating theatres.

The use of Google Drive in clinical audit.

Audit is an important aspect of clinical governance and of the training of health-care professionals. Conventional methods of audit data collection can be time consuming and inefficient. This article suggests a novel technique of using Google Drive, with adherence to the Caldicott principles, to facilitate data collection in both local and multicentre audits.

Urethritis in men at the Genito-Urinary Medicine Clinic Kuala Lumpur Hospital.

The clinical features and aetiology of 100 consecutive symptomatic heterosexual male patients with urethritis were studied from March 1994 to August 1994 in the Genito-Urinary Medicine (GUM) Clinic, Kuala Lumpur Hospital. Gonococcal urethritis (GU) was found to be more common (53%) than non-gonococcal urethritis(47%). All patients with GU confirmed microbiologically had clinically evident urethral discharge. Almost half (41%) of the patients with GU developed post-gonococcal urethritis (PGU). The most common organism isolated in PGU was Ureaplasma urealyticum (37%) whilst only 4% had both Chlamydia trachomatis and Ureaplasma urealyticum. Of the 47% of patients with non-gonococcal urethritis (NGU), 50% had no microorganism isolated, 32% had Ureaplasma urealyticum, 7% Chlamydia trachomatis and 11% both Chlamydia trachomatis and Ureaplasma urealyticum.

A microbiological study of genital ulcers in Kuala Lumpur.

The microbial aetiology of genital ulcers was studied in 249 patients (241 men and 8 women) attending a Sexually Transmitted Disease Clinic in Kuala Lumpur, Malaysia. Herpes simplex virus type 2 was isolated in 48 (19.2%) patients, Haemophilus ducreyi from 22 (8.8%), Neisseria gonorrhoeae from seven (2.8%) and Chlamydia trachomatis from four (1.6%). Syphilis was diagnosed in 18 (7.2%) patients on the basis of dark field microscopy. Two (0.8%) patients were found to have both chancroid and syphilis and one (0.5%) had both gonorrhoea and syphilis. No organism was isolated in the remaining 151 (61.5%) patients. Overall, the accuracy of clinical diagnosis was 58% for single infection, 67% for herpes, 63% for syphilis, 47% for chancroid and 0% for lymphogranuloma venereum. Therefore, our study confirms the need for laboratory tests to diagnose accurately the aetiology of genital ulcer disease.

Lipid abnormalities in black renal patients.

Racial differences in lipoprotein (LP) and cardiovascular (CV) abnormalities have been noted in the general population and in the population of patients on dialysis. Few studies have investigated the interaction of race and LP and CV disturbances in other renal disease groups. We studied lipid profiles and risk ratios (total cholesterol (TC)/high density lipoprotein-cholesterol) (HDL-C) and apolipoprotein (apo) A-I/apo B (A-I/B)) and the influence of race across a spectrum of renal disease groups (normal renal function (NRD), nephrotic range proteinuria (NS), hemodialysis (HD), continuous ambulatory peritoneal dialysis (CAPD), post-transplant (TR), renal insufficiency (RI)). We also performed a longitudinal study of lipid profiles in patients with end stage renal disease (ESRD) and the relationship of these profiles to race and other variables. There was a general tendency towards a better CV risk profile for blacks than whites in all the groups. Blacks tended to have lower TC, higher HDL-C, lower TC/HDL-C, higher apo A-I, lower apo B, and higher A-I/B. We analyzed four yearly cross-sections of the HD and CAPD populations using ANOVA with adjustment for appropriate covariates. Whites had lower HDL-C and a higher TC/HDL-C risk ratio than blacks. HD patients had lower TC, TC/HDL-C, apo A-I, and apo B than CAPD patients, and women had higher TC than men. When lipid profiles were studied longitudinally by yearly intervals, no consistent significant changes were seen, but over two years, levels of apo B fell and A-I/B rose. Race had no significant effect on any of the longitudinal data.(ABSTRACT TRUNCATED AT 250 WORDS)

Medical nephrectomy: the use of metallic salts for treatment of end stage massive proteinuria and renal hypertension.

The first two cases outlined above with intractable massive proteinuria and uremia, were followed and treated with standard medical therapy and dialysis. After a period of study and demonstration of clinical deterioration both patients were given solutions containing sodium mercaptomerin. Within days there was a decline in urine protein excretion and a variable increase in serum protein concentration. The patients demonstrated an increase in blood pressure, which made hemodialysis treatment possible. No deleterious effects from the mercury salts were noted. These observations suggest that in selected cases nephrotoxic agents may be of value in decreasing massive proteinuria, and improving protein homeostasis in uremic patients. The ideal agent should be non-toxic to other organs and produce selective renal ablation (15). Although mercury is not the ideal agent, in these cases it did not produce observable side effects. This new method, applicable to dialysis patients with massive proteinuria, and of help in the control of uncontrollable hypertension in uremia, is an interesting new approach for our therapeutic armamentarium.

Non-A, non-B hepatitis: a new syndrome in uraemic patients.

One hundred patients on chronic haemodialysis were studied prospectively over one year for evidence of hepatitis and of infection with hepatitis A or B virus. Five patients developed transient elevations of SGPT, accompanied by a consistent pattern of clinical manifestations, including low-grade fever, anorexia, nausea, hepatomegaly, and hypotension during dialysis. None of these patients had a positive test for A or B virus infection. Non-A non-B hepatitis appears to cause a specific syndrome in uraemic patients, and its transmission in a dialysis unit seems unrelated to blood transfusions.

Metabolic changes in diabetic uremic patients on hemodialysis.

By studying the metabolic values of a nondiabetic and diabetic uremic population we demonstrated the following: 1. Insulin is higher in diabetic than nondiabetic uremic patients. A slight arteriovenous difference across the dialyzer membrane suggests that insulin is dialyzable in small amounts in man. 2. C-peptides are highest in nondiabetics, lower in maturity onset diabetics, and lowest in juvenile diabetics. 3. Growth hormone is higher in diabetics than nondiabetics, decreased in both groups during hemodialysis, and returns to pre-dialysis levels 2 hrs after the completion of dialysis treatment. 4. Plasma triglycerides are elevated in both popualtions during the fasting state anddrop during hemodialysis, rising slowly towards the end of hemodialysis. 5. The majority of diabetics on hemodialysis have low renin levels and do not respond to volume reduction. In the high renin diabetics and high and low renin nondiabetics the plasma renin levels rise in response to volume reduction during hemodialysis. Renin is not dialyzable in man. 6. Thyroid function tests show that diabetic and nondiabetic patients have measurements in the low normal range. Our results reveal significant information concerning metabolic changes which take place in diabetic and nondiabetic uremic patients on hemodialysis and helps to characterize these populations. This report may have implications in better understanding the nature of the problems encountered in these populations and in their management (Table III).

Medical nephrectomy. The use of metallic salts for the control of massive proteinuria in the nephrotic syndrome.

Two patients with intractable massive proteinuria and uremia were followed and treated with standard mecial therapy and dialysis. After a period of study and demonstration of clinical deterioration both patients were given solutions containing sodium mercaptomerin. Within days there was a decline in urine protein excretion and a variable increase in serum protein concentration. The patients demonstrated an increase in blood pressure, which made hemodialysis treatment possible. No deleterious effects from the mercury salts were noted. These observations suggest that in selected cases nephrotoxic agents may be of value in decreasing massive proteinuria, and improving protein homeostasis in uremic patients. Table I: Possible advantages of medical nephrectomy. 1. Reversal of hypotension and shock 2. Ability to perform hemodialysis 3. No anesthesia or surgical risk 4. No angiography related complications 5. Preservation of endocrine function of kidney. Possible advantages of medical nephrectomy (Table I), are: 1) Correction of proteinuria and hypotension; 2) Ability to perform hemodialysis; 3) No anesthesia or surgical risk; 4) No angiography related complications; and 5) Preservation of remaining endocrine function of the kidney, including erythropoietic and vitamin D action. The ideal agent should be non-toxic to other organs and produce selective renal ablation. Obviously mercury is not the ideal agent, although in these cases it did not produce observable side effects. It appears that this agent should be used with caution and only in patients with irreversible renal failure.

Eosinophilic meningitis (angiostrongylosis): a probable case.

A probable case of eosinophilic meningitis is described. This report is thought to be the first of a case of this disorder diagnosed in New South Wales, although infection probably occurred in Queensland. The life cycle of the parasite Angiostrongylus cantonensis is outlined briefly and the clinical manifestations of this disease are discussed. Treatment with thiabendazole seems to have been beneficial to this patient.