Background: Chronic urticaria, in many cases, has an unsatisfactory response to antihistamines. The current recommendations in urticaria do not mention the dose and duration for methotrexate. Aims: This study aims to systematically review the use/efficacy of methotrexate in chronic urticaria. Methods: A systematic search in four databases, that is, PubMed/Medline, Cochrane central, Google Scholar and Clinicaltrials.gov was done to identify studies on the use of methotrexate in chronic urticaria using key words “methotrexate [MeSH terms]” and “urticaria” or “urticaria, chronic” or “urticaria, chronic spontaneous.” Results: Nine articles (study participants 127), including three randomized control trials, one prospective interventional trial without control, three retrospective reviews and two case reports, were identified and finally included in the systematic review. There was a paucity of literature and the three randomized control trials did not show any benefit of methotrexate over antihistamines alone. However, in studies where steroid-dependent cases were given methotrexate, marked benefit was reported with steroid-sparing effect, particularly on methotrexate dose escalation. Limitations: Due to a paucity of published literature on methotrexate in urticaria, a meta-analysis could not be done. Conclusion: In chronic recalcitrant or steroid-dependent cases, methotrexate may be a therapeutic agent of interest; however, current evidence does not point to any added advantage in efficacy over antihistamines. More evidence based on larger, well-executed randomized control trials is needed in the future to get more definitive answers.

PURPOSE: Chronic Obstructive Pulmonary Disease (COPD) is currently the fourth leading cause of death worldwide and its prevalence is expected to rise further. Sepsis is a life-threatening condition defined by organ dysfunction caused by a dysregulated host response to infection. Patients with COPD have been reported to be at a higher risk of developing sepsis due to the use of corticosteroids, underlying comorbidities, and possibly impaired barrier function. Hence in our study, we used the nationally representative database to outline the trends, impact and predictors of poor outcomes due to sepsis among COPD hospitalizations. METHODS:We identified adult hospitalizations due to primary diagnosis of COPD by using International Classification of Diseases (9th/10th Editions) Clinical Modification (ICD-9-CM/ICD-10-CM) from the Nationwide Inpatient Sample (NIS) for the years 2007-2018. Sepsis was identified as the presence of codes in secondary fields. We identified comorbidities by Elixhauser comorbidity software supplied by HCUP. Primary outcomes of interest were in-hospital mortality and discharge to facilities. We utilized the Cochran Armitage trend test to analyze the trends of outcomes and multivariable survey logistic regression models to estimate the impact of sepsis.RESULTS: Out of a total 6,940,615 hospitalizations due to primary diagnosis of COPD, 64,748 (0.93%) were complicated with sepsis. Among the patients who developed sepsis, 31% were discharged to facilities and 19% died during the hospitalization. After adjusting with confounding factors, sepsis was associated with significantly higher in-hospital mortality (OR 4.9; 95% CI 4.5-5.3; p<0.01) and discharge to facilities (OR 2.2; 95% CI 2.1 -2.3; p<0.01). In trend analysis, adjusted odds of in-hospital mortality remained stable (aOR 6.1 in 2007 to aOR 5.3 in 2018; ptrend:0.31) and discharge to facilities increased (aOR 2.2 in 2007 to aOR 2.6 in 2018; ptrend:0.02). Among those who developed sepsis, increasing age, Caucasians (OR 1.2; 95% CI 1.1 -1.4; p<0.01), northeast region (OR 1.4; 95% CI 1.2 -1.7; p<0.01), DIC (OR 3.7; 95% CI 2.2 -6.1; p<0.01), pneumococcal infection (OR 1.2; 95% CI 1.1 -1.4; p<0.01), CHF (OR 1.2; 95% CI 1.1 -1.3 p<0.01) and Renal failure (OR 1.4 95% CI 1.2 -1.5 p<0.01) were also associated with in-hospital mortality. CONCLUSIONS:In this nationally representative study, we observed that sepsis was associated with significantly high mortality among COPD hospitalizations and remained stable over the past decade. We were also able to delineate several factors which were significantly associated with in-hospital mortality.CLINICAL IMPLICATIONS: Our study highlights the need for better risk stratification in patients with COPD developing sepsis to improve the outcomes. Further studies are warranted to consider factoring some of the modifiable factors into account and to ameliorate the outcomes of sepsis during COPD hospitalizations.

Background and Aims: Anesthesia in obese patients is difficult due to associated comorbidities and altered physiology. Desflurane and sevoflurane have a low fat-blood solubility coefficient and are better suited in these patients to achieve a rapid emergence. We studied BIS guided drug titration to compare the postoperative recovery characteristics and cognitive function of desflurane versus sevoflurane in obese patients undergoing laparoscopic abdominal surgeries. Material and Methods: After institutional ethics committee approval and written informed consent, sixty obese patients (BMI ≥30 kg/m 2 ) were randomized to receive either BIS guided desflurane or sevoflurane. Recovery was assessed by time taken for eye opening on verbal command, sustained head lift for 5 s, and extubation and orientation to time, place, and person after discontinuation of volatile anesthetic agent. For cognitive function, time taken to complete Mini mental state examination (MMSE) score to baseline was compared in both study groups. Results: Difference of time taken for eye opening on verbal command, sustained head lift for 5 s, and extubation and orientation to time, place, and person was not significant between both anesthetic groups. Patients in sevoflurane group took significantly ( P -value = 0.001) less time (40.07 ± 13 min) to achieve preoperative MMSE score than desflurane group (51.2 ± 11.7 min). Conclusion: Both desflurane and sevoflurane have similar recovery profile in obese patients when anesthetic concentration is carefully titrated. Reversal of cognitive function is significantly earlier in obese patients anesthetized with sevoflurane.

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