Pegloticase and the patient with treatment-failure gout.

Gout is an inflammatory arthritis characterized by sudden, painful inflammation. Gout can affect any joint in an asymmetric distribution. Gouty attacks may be isolated or can be followed by years of recurrent flares. Over time, elevated serum urate levels and tophaceous deposits can lead to deformity and disability from underlying bony erosion. The concept of 'treatment-failure gout' describes a unique population that has been either unable to tolerate allopurinol or who have not experienced normalization of serum urate levels on allopurinol. It is estimated that approximately 1-1.5% of the estimated 3-8 million people with gout in the USA have treatment-failure gout. Pegloticase is an US FDA-approved intravenous medication that is a mammalian recombinant uricase conjugated to monomethoxy polyethylene glycol. Two recent Phase III trials have found pegloticase to be effective in the management of treatment-failure gout. These studies also highlight safety concerns regarding the drug's immunogenicity.

Obstetric outcomes in women with multiple sclerosis and epilepsy.

OBJECTIVE: To estimate the national occurrence of pregnancies in women with multiple sclerosis (MS) and epilepsy and to compare these pregnancy outcomes cross-sectionally with those in women with pregestational diabetes mellitus (DM) and the general obstetric population. METHODS: We studied the 2003-2006 Nationwide Inpatient Sample, of the Healthcare Cost and Utilization Project, to estimate the number of deliveries in women with MS, epilepsy, DM, and the general obstetric population. Pregnancy outcomes included length of hospital stay, hypertensive disorders including preeclampsia (HTN), premature rupture of membranes (PROM), intrauterine growth restriction (IUGR), and cesarean delivery. Multivariable regression analyses used maternal age and race/ethnicity as covariates. RESULTS: Of an estimated 18.8 million deliveries, 10,055 occurred in women with MS, 4,730 with epilepsy, and 187,239 with DM. MS was associated with mildly increased odds of antenatal hospitalization (odds ratio [OR] 1.3, 95% confidence interval [CI] 1.2-1.5), IUGR (OR 1.7, 95% CI 1.2-2.4), and cesarean delivery (OR 1.3, 95% CI 1.1-1.4). Similarly, epilepsy was associated with increased rates of antenatal hospitalization (OR 3.0, 95% CI 2.6-3.5), IUGR (OR 1.9, 95% CI 1.2-3.3), and cesarean delivery (OR 1.5, 95% CI 1.3-1.9). HTN and PROM were not increased in either group. DM was associated with an increased risk of all adverse outcomes. Length of stay was modestly increased in all groups compared with controls. CONCLUSION: In this large national database study of pregnancy outcomes in women with multiple sclerosis and epilepsy, rates of intrauterine growth restriction and cesarean delivery were only marginally higher than the general obstetric population without increases in other adverse outcomes.

Bloody nipple discharge in an infant and a proposed diagnostic approach.

Bloody nipple discharge is a rare finding in infants and is associated most often with benign mammary duct ectasia. The rarity of this symptom in infants and its association with breast carcinoma in adults can lead to unnecessary investigation and treatment. Here we describe a 4-month-old boy with bilateral bloody nipple discharge that resolved spontaneously without treatment by 6 months of age. Furthermore, we propose a strategic method for the evaluation of such infants.