Tumour necrosis factor inhibitors and serious infections in reproductive-age women and their offspring: a narrative review.

Tumour necrosis factor inhibitors (TNFi) are commonly used to treat patients with chronic inflammatory diseases, and function by inhibiting the pro-inflammatory cytokine tumour necrosis factor-α (TNF-α). Although beneficial in reducing disease activity, they are associated with an increased risk of serious infections. Data on the risk of serious infections associated with TNFi use during the reproductive years, particularly in pregnancy, are limited. For pregnant women, there is an additional risk of immunosuppression in the offspring as TNFi can be actively transported across the placenta, which increases in the second and third trimesters. Several studies have explored the risk of serious infections with TNFi exposure in non-pregnant and pregnant patients and offspring exposed in utero, indicating an increased risk in non-pregnant patients and a potentially increased risk in pregnant patients. The studies on TNFi-exposed offspring showed conflicting results between in utero TNFi exposure and serious infections during the offspring's first year. Further research is needed to understand differential risks based on TNFi subtypes. Guidelines conditionally recommend the rotavirus vaccine before 6 months of age for offspring exposed to TNFi in utero, but more data are needed to support these recommendations because of limited evidence. This narrative review provides an overview of the risk in non-pregnant patients and summarizes evidence on how pregnancy can increase vulnerability to certain infections and how TNFi may influence this susceptibility. This review focuses on the evidence regarding the risk of serious infections in pregnant patients exposed to TNFi and the risk of infections in their offspring.

Challenges to optimal rheumatology care: a patient-centered focus group study.

OBJECTIVE: To assess challenges to optimal rheumatology care from the perspective of patients served by our institution's rheumatology division. DESIGN SETTING AND PARTICIPANTS: Focus group study of adult rheumatic disease patients who attend clinics at a university teaching hospital in Montreal, Canada. INTERVENTIONS: Individuals participated in 1-h focus group discussions concerning their experiences and beliefs regarding rheumatology care. Sessions were recorded and transcripts generated. A thematic analysis approach was used by two individual analyzers. MAIN OUTCOME MEASURES AND RESULTS: Eighteen patients participated in three focus groups (group one = 8 patients; group two = 5; group three = 5). Eleven patients had systemic lupus erythematosus, 6 had rheumatoid arthritis, and 1 patient had psoriatic arthritis. The average age (standard deviation) was 51.2 (14.0) years, disease duration 23.5 (14.5) years, and in the majority had at least a high school education. All participants were female and 72.2% were Caucasian. Three main themes emerged: theme 1 identified patients' needs for information and support, at diagnosis and throughout the disease trajectory; theme 2 identified barriers to accessing health care: theme 3 identified patients' beliefs regarding improvements needed to optimize their experiences throughout the disease course. CONCLUSIONS: Our focus group study not only clarified the needs of rheumatology patients with chronic inflammatory disease, and identified barriers to optimal rheumatology care, but also was a source of recommendations that might improve patient experiences in seeking health care in a rheumatology setting. Limitations include the fact that our participants were all female, and mostly were middle aged, Caucasian and well educated. Regardless, the findings can help inform efforts to improve rheumatology care. Key Points • Our focus group study clarified the needs of chronic inflammatory rheumatic disease, and identified barriers to optimal rheumatology care. • Despite some potential limitations, our work provides recommendations that could improve patient experiences when seeking health care in a rheumatology setting.

Neurodevelopmental disorders in children born to mothers with systemic lupus erythematosus.

Children born to women with systemic lupus erythematosus seem to have a potentially increased risk of neurodevelopmental disorders compared to children born to healthy women. Recent experimental data suggest in utero exposure to maternal antibodies and cytokines as important risk factors for neurodevelopmental disorders. Interestingly, women with systemic lupus erythematosus display high levels of autoantibodies and cytokines, which have been shown, in animal models, to alter fetal brain development and induce behavioral anomalies in offspring. Furthermore, subjects with systemic lupus erythematosus and neurodevelopmental disorders share a common genetic predisposition, which could impair the fetal immune response to in utero immunologic insults. Moreover, systemic lupus erythematosus pregnancies are at increased risk of adverse obstetrical outcomes and medication exposures, which have been implicated as potential risk factors for neurodevelopmental disorders. In this article, we review the current state of knowledge on neurodevelopmental disorders and their potential determinants in systemic lupus erythematosus offspring.

Comparison between ultrasound-guided transversus abdominis plane and conventional ilioinguinal/iliohypogastric nerve blocks for day-case open inguinal hernia repair.

BACKGROUND: Transversus abdominis plane (TAP) block has been reported to provide effective analgesia after lower abdominal surgery, but there are few data comparing ilioinguinal/iliohypogastric nerve (IHN) block with ultrasound-guided TAP block in patients undergoing inguinal hernia repair. METHODS: Two hundred and seventy-three patients undergoing day-case open inguinal hernia repair with a mesh were randomly allocated to receive either ultrasound-guided TAP block or blind IHN block with levobupivacaine 0.5%, before surgery. Patients were monitored for visual analogue scale (VAS) scores at rest (in the post-anaesthesia care unit, and at 4 and 12 h) and at rest and during movement (at 24, 48 h, 3 and 6 months). Pain at 6 months was also assessed using the DN4 questionnaire for neuropathic pain. RESULTS: Median VAS pain scores at rest were lower in the ultrasound-guided TAP group at 4 h (11 vs 15, P=0.04), at 12 h (20 vs 30, P=0.0014), and at 24 h (29 vs 33, P=0.013). Pain after the first 24 h, at 3 and 6 months after surgery, and DN4 scores were similar in both groups (P=NS). The proportion of patients with VAS >40 mm on movement at 6 months was comparable {18.2% [95% CI (12.2-26.1%)] vs 22.4% (15.8-30.6%) in the TAP and IHN groups, respectively, P=0.8}. Postoperative morphine requirements were lower during the first 24 h in the TAP block group (P=0.03). CONCLUSIONS: Ultrasound-guided TAP block provided better pain control than 'blind' IHN block after inguinal hernia repair but did not prevent the occurrence of chronic pain.

[Vascular clamping in hepatic surgery]. / Les clampages vasculaires en chirurgie hépatique.

Outcome of hepatectomy procedures depends greatly on proper control of intraoperative bleeding. We detail here the different techniques for vascular clamping, discussing their different indications. Four parameters can be used to define clamping: the zone of application: separate control of arterial or glisson pedicles and portal veins (pedicles, selective hilar, suprahilar and intrahilar clamps), suprahepatic veins or vena cava; selectivity: partial or total clamp of hepatic blood supply; duration, continuous or intermittent; association measures to favor tolerance to ischemia (cooling, preservation fluid) or to limit downstream consequences (extracorporal circulation, derivation). The optimal clamp depends on the localization of the lesion and its relations with the great vessels, presence of liver disease, and the patient's general and cardiovascular status as well as the experience of the operator and the anesthesist. The goal is to use clamp as sparingly as possible, favoring selective clamps to avoid ischemia.

Congenital acute lymphoblastic leukemia with chromosomal abnormalities including a translocation (1;4;22).

Cytogenetic studies in a patient with inborn ALL demonstrated identical and complex abnormalities in all the cells, indicating a monoclonal origin. These abnormalities included, among others, a translocation (1;4;22).