Administration Of Nonsteroidal Anti-inflammatory Drugs Research Articles

Effect of postoperative non-steroidal anti-inflammatory drugs on anastomotic leakage after pancreaticoduodenectomy.

BackgroundAlthough the association between an increase in anastomotic leakage (AL) and non-steroidal anti-inflammatory drugs (NSAIDs) has been reported in gastrointestinal surgeries, this issue has rarely been addressed for pancreaticoduodenectomy (PD). We aimed to investigate the association between postoperative NSAIDs administration and clinically relevant AL (CR-AL) following PD.MethodsWe retrospectively evaluated 2,163 consecutive patients who underwent PD between 2007 and 2019. The patients were divided into two groups; patients who received and did not receive NSAIDs by postoperative day (POD) 5. We conducted a propensity score analysis using inverse probability of treatment weighting (IPTW) to adjust the baseline differences between both groups. We compared the occurrence of CR-AL and other postoperative outcomes before and after IPTW. Further, we used the multivariable binary logistic regression method for a sensitivity analysis for CR-AL.ResultsA total of 2,136 patients were included in the analysis. Of these, 222 (10.4%) received NSAIDs by POD 5. The overall occurrence rate of CR-AL was 14.9%. After IPTW, postoperative NSAIDs were significantly associated with CR-AL (odds ratio [OR]: 1.24, 95% CI [1.05, 1.47], P = 0.012), prolonged postoperative hospitalization (OR: 1.31, 95% CI [1.14, 1.50], P < 0.001), and unplanned readmission within 30 days postoperatively (OR 1.48: 95% CI [1.15, 1.91], P = 0.002). However, this association was not consistent in the sensitivity analysis.ConclusionsPostoperative NSAIDs use was significantly associated with an increase in CR-AL incidence following PD. However, sensitivity analysis failed to show its association, which precludes a firm conclusion of its detrimental effect.

A Study of Antiulcer Activity in Cynodon dactylon Leaves Extract on Albino Rats

Peptic ulcer is a chronic, non-malignant inflammatory disease characterized by ulceration in the upper gastro-intestinal tract (stomach and duodenum) where parietal cells are found. The aetiology of gastric ulceration is multifactorial and not clearly defined, but some predisposing factors have been implicated. This includes duration of starvation, nature of food ingested, bile reflux, lessened mucosal resistance, alteration of gastric mucosal blood flow, disruption of gastric mucosal barrier by stress, decrease in alkaline mucosal bicarbonate and mucus secretion, over dosage and or prolonged administration of non-steroidal anti-inflammatory drugs. Among numerous species of plants growing in India, Durva or taxonomically the Cynodon dactylon occupies a key position in ethno medicinal practices and traditional medical knowledge systems (Ayurveda, Unani, Nepalese, and Chinese). Durva consists of dried whole plant of Cynodon dactylon (Linn.) Pers. (Family: Poaceae), an elegant, tenacious, perennial, creeping grass growing throughout the country. In our present study, the mature green leaves of Cynodon dactylon belongs to family Poaceae were collected from in and around area of Thanjavur District, Tamil Nadu, South India. The plant was identified with the help of Manual of Tamil Nadu and Karnatic flora with standard references. From this study, it is clear that C. dactylon leaf extract has significant anti-ulcer activity in animal models. The extract is non-toxic even at relatively high concentrations. The anti-ulcer activity is probably due to the presence of flavonoids.

Effect of pre-operative administration of ibuprofen in children undergoing extraction for reducing post-operative pain: a double-blind randomised controlled clinical trial.

Introduction Administration of non-steroidal anti-inflammatory drugs (NSAIDs) before tooth extraction may reduce post-surgical pain, but there is a lack of research.Aims To compare pain and anxiety in paediatric tooth extraction patients receiving a pre-operative NSAID vs placebo.Design Randomised, double-blind, placebo-controlled clinical trial.Setting Princess Nourah bint Abdulrahman University's dental clinic in Riyadh, Saudi Arabia.Materials and methods Eligible paediatric tooth extraction patients were randomised to group A, which received NSAID pre-operatively, or group B, which received the placebo.Interventions A research coordinator measured participants before extraction, and then 3 hours and 24 hours post-extraction.Main outcome methods The Wong-Baker FACES scale and the Modified Child Dental Anxiety Scale (faces).Results There were 56 participants (28 in each group). Pain and anxiety scores were not statistically significantly different between the two groups before or 24 hours post-extraction. However, group A had significantly lower pain (-1.3151, p = 0.0063) and anxiety scores (-0.6071, p = 0.0081) compared to group B three hours post-extraction.Discussion Pre-operative administration of NSAIDs in paediatric dental patients was associated with significantly lower post-extraction pain and anxiety.Conclusions Clinicians should consider making NSAID administration before paediatric tooth extraction part of their clinical protocol.

Post-operative pain management in dental implant surgery: a systematic review and meta-analysis of randomized clinical trials.

To evaluate the clinical efficacy of various analgesic medications in mitigating orofacial pain following dental implant surgery. A systematic search was conducted to identify randomized controlled clinical trials (RCTs). The primary outcomes examined were post-operative pain (POP) and consumption of rescue analgesics following implant placement; secondary outcomes included adverse effects, post-operative inflammation, infection, swelling, bleeding, patient satisfaction, and quality of life. Random effects meta-analysis was conducted for risk ratios of dichotomous data. Nine RCTs fulfilled the eligibility criteria. Individual studies and meta-analysis of two studies indicated that nonsteroidal anti-inflammatory drugs (NSAIDs) significantly reduced POP and consumption of rescue analgesics after dental implant placement compared to placebo. Transdermal administration of NSAIDs may be superior to the oral route as it was similarly effective for POP control and resulted in fewer side effects. Glucocorticoids administered as primary analgesics or NSAID adjuvants resulted in comparable pain sensation compared to NSAIDs alone. Caffeine-containing analgesics were reported as acceptable and effective for the treatment of POP and swelling when compared to codeine adjuvants. With regard to analgesic dosing schedules, pain modulation may be most critical during the first 72 h following dental implant placement. Risk of bias assessment indicated an overall low risk of bias across the included trials. Within the limitations of this review, POP following implant surgery may be effectively treated with the short-term use of analgesic medications. However, given the heterogeneity in the available RCTs, there is insufficient evidence to recommend an analgesic regimen following dental implant surgery. Short-term use of analgesic medications may be sufficient for post-operative pain management in dental implant surgery. Ultimately, the clinician's analgesic prescription should be directed by a patient's medical history, in order to increase the success of pain management in a short period of time and decrease potential adverse effects. CRD42018099324.

Tension pneumoperitoneum secondary to duodenal perforation presumptively due to the administration of meloxicam in a cat

AbstractA 4‐year‐old neutered domestic cat was presented with a history of vomiting, anorexia, lethargy and severe abdominal distension. The cat was hypothermic and hypotensive. It had received a week course of meloxicam. Abdominal radiographies revealed the presence of a very large volume of peritoneal gas associated loss in peritoneal serosal detail and gastric dilatation. The presumptive diagnosis was tension pneumoperitoneum and peritonitis caused, most likely, by a gastrointestinal perforation. Exploratory laparotomy confirmed the presence of a duodenum perforation. At the end of the surgery, the cat suffered a cardiorespiratory arrest and died. Unfortunately, the post‐mortem examination was not allowed. Spontaneous pneumoperitoneum is a rare condition reported in cats. The incidence of non‐steroidal anti‐inflammatory drugs (NSAIDs) induced by gastroduodenal perforation in cats has been reported in a few cases. In the cat reported here, the authors suspect that duodenal perforation was secondary to NSAID administration.

Endoscopic changes in patients diagnosed with acute pancreatitis.

There have been long debates on the introduction of proton pump inhibitors into acute pancreatitis therapy as standard treatment. The aim of the study was to assess endoscopic lesions of the upper gastrointestinal tract in patients hospitalized for acute pancreatitis. We carried out a prospective analysis of patients hospitalized in one surgical center who had an upper gastrointestinal tract endoscopic examination performed during the first 48 hours of hospitalization. We performed analysis of basic descriptive statistics along with the Shapiro-Wilk Test, logistic order regression analysis, One-Way Analysis of Variance, and Student's t-test for independent trials. From January 2016 to December 2019, 476 patients were hospitalized because of acute pancreatitis. The upper gastrointestinal tract endoscopic examination was performed in 85 patients (N.) in the first 48 hours. From the examined group 45 patients (52.94%) developed mild acute pancreatitis, 28 (32.94%) moderate pancreatitis, and 12 (14.12%) severe pancreatitis. Lesions in the endoscopic imaging were observed in 80 patients (94.12%). A very high percentage of patients hospitalized for acute pancreatitis present lesions in the endoscopic imaging of the upper gastrointestinal tract. The standard treatment of AP is the administration of non-steroidal anti-inflammatory drugs, which themselves can cause gastric and duodenal mucosal defects. All these factors indicate the need for standard use of proton pump inhibitors in patients hospitalized for acute pancreatitis.

Алгоритмы персонализированного назначения нестероидных противовоспалительных средств пациентам с синдромом хронической тазовой боли на основе фармакогенетического тестирования

Алгоритмы персонализированного назначения нестероидных противовоспалительных средств пациентам с синдромом хронической тазовой боли на основе фармакогенетического тестирования

Aggressive fluid hydration plus non-steroidal anti-inflammatory drugs versus non-steroidal anti-inflammatory drugs alone for post-endoscopic retrograde cholangiopancreatography pancreatitis (FLUYT): a multicentre, open-label, randomised, controlled trial

Pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP). Prophylactic rectal administration of non-steroidal anti-inflammatory drugs (NSAIDs) is considered as standard of care to reduce the risk of post-ERCP pancreatitis. It has been suggested that aggressive hydration might further reduce this risk. Guidelines already recommend aggressive hydration in patients who are unable to receive rectal NSAIDs, although it is laborious and time consuming. We aimed to evaluate the added value of aggressive hydration in patients receiving prophylactic rectal NSAIDs. FLUYT, a multicentre, open-label, randomised, controlled trial done across 22 Dutch hospitals, included patients aged between 18 and 85 years with moderate to high risk of post-ERCP pancreatitis. Patients were randomly assigned (1:1) by a web-based module with varying block sizes to a combination of aggressive hydration and rectal NSAIDs (100 mg diclofenac or indomethacin; aggressive hydration group) or rectal NSAIDs (100 mg diclofenac or indomethacin) alone (control group). Randomisation was stratified according to treatment centre. Aggressive hydration comprised 20 mL/kg intravenous Ringer's lactate solution within 60 min from the start of ERCP, followed by 3 mL/kg per h for 8 h. The control group received normal intravenous saline with a maximum of 1·5 mL/kg per h and 3 L per 24 h. The primary endpoint was post-ERCP pancreatitis and was analysed on a modified intention-to-treat basis (including all patients who underwent randomisation and an ERCP and for whom data regarding the primary outcome were available). The trial is registered with the ISRCTN registry, ISRCTN13659155. Between June 5, 2015, and June 6, 2019, 826 patients were randomly assigned, of whom 388 in the aggressive hydration group and 425 in the control group were included in the modified intention-to-treat analysis. Post-ERCP pancreatitis occurred in 30 (8%) patients in the aggressive hydration group and in 39 (9%) patients in the control group (relative risk 0·84, 95% CI 0·53-1·33, p=0·53). There were no differences in serious adverse events, including hydration-related complications (relative risk 0·99, 95% CI 0·59-1·64; p=1·00), ERCP-related complications (0·90, 0·62-1·31; p=0·62), intensive care unit admission (0·37, 0·07-1·80; p=0·22), and 30-day mortality (0·95, 0·50-1·83; p=1·00). Aggressive periprocedural hydration did not reduce the incidence of post-ERCP pancreatitis in patients with moderate to high risk of developing this complication who routinely received prophylactic rectal NSAIDs. Therefore, the burden of laborious and time-consuming aggressive periprocedural hydration to further reduce the risk of post-ERCP pancreatitis is not justified. Netherlands Organisation for Health Research and Development and Radboud University Medical Center.

Prescription pattern of non-steroidal anti-inflammatory drugs (NSAIDs) among community patients with musculoskeletal and co-morbid conditions: A crosssectional study from an Iraqi province

Purpose: To determine the pattern of prescription of non-steroidal anti-inflammatory drugs (NSAIDs) and proton pump inhibitors (PPIs) co-prescription with NSAIDs in a sample of patients suffering from musculoskeletal disorders with and without co-morbid cardiovascular (CV) disease conditions in Baghdad Province, Iraq.Methods: A descriptive, cross-sectional study was conducted using a structured questionnaire to assess the clinical characteristics of patients that used NSAIDs alone or with PPIs for the treatment of different musculoskeletal disorders with and without co-morbid cardiovascular (CV) disease conditions.Results: A total of 102 participants were enrolled in the study. More than half of the participants had comorbid disease conditions (53.9 %), particularly hypertension (47.1 %). Nearly a quarter of the participants with CV disease conditions used non-selective NSAIDs (25.5 %). The majority of NSAIDs intake were orally administered for more than one month (79.4 %). Physicians were the major source for patient education about the risk of NSAIDs-associated complications according to 59.6 % of the participants. The majority of participants reported non-adherence to the prescribed PPIs (86.5 %). There was a statistically significant difference between the participants that used NSAIDs alone, and those with PPI co-prescription within the age group of 31 - 60 years (p &lt; 0.0001) and for a duration of more than one month for NSAIDs administration (p &lt; 0.0001).Conclusion: There is improper use of NSAIDs, particularly the non-selective agents, among patients with co-morbid cardiovascular disease conditions, as well as poor medication adherence and improper co-prescription of PPIs. This requires periodic revision for long-term intake of NSAIDs, while applying more care to high-risk patients regarding co-prescription of NSAIDs with PPIs.&#x0D; Keywords: Cardiovascular, Co-morbidity, Gastrointestinal complications, NSAIDs, Proton-pump inhibitors

Effects of hydroalcoholic extract of Berberis integerrima on the clinical signs, hs-CRP, TNFα, and ESR in active rheumatoid arthritis patients

AimTo evaluate the effects of Barberry (Berberis integerrima) on clinical signs and inflammatory factors in patients with Rheumatoid arthritis (RA). MethodA total of 70 patients with active RA in a double-blind, placebo-controlled clinical trial (IRCT 201409249472N7) were randomly allocated to intervention and control groups. All the patients consumed 1500 mg of barberry extract and 1500 mg Hydroxypropyl methylcellulose (HPMC) each day respectively for three months. Clinical signs and serum levels of high-sensitivity C-reactive protein (hs-CRP), Tumor necrosis factor alpha (TNFα), and erythrocyte sedimentation rate (ESR) were measured before and after the intervention. ResultsThe results showed that consumption of the extract of Berberis integerrima resulted in a significant decrease in Visual Analog Scale (VAS), morning stiffness, number of tender joints, Disease Activity Score 28 (DAS28), Global Physician Assessment (GPA), serum levels of ESR, TNFα (p < 0.001), and hs-CRP (p < 0.01) in intervention group compared to the control group. Changes in the number of inflamed joints, the necessity for the administration of non-steroidal anti-inflammatory drugs (NSAIDs) (p = 0.02), and glucocorticoids (p < 0.001) were significant only in the intervention group. ConclusionBarberry can improve clinical signs and inflammatory factors in RA patients and may be useful in their treatment approaches.

Emerging evidence that adaptive bone formation inhibition by non-steroidal anti-inflammatory drugs increases stress fracture risk.

There is mounting evidence suggesting that the commonly used analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), may inhibit new bone formation with physical training and increase risk of stress fractures in physically active populations. Stress fractures are thought to occur when bones are subjected to repetitive mechanical loading, which can lead to a cycle of tissue microdamage, repair, and continued mechanical loading until fracture. Adaptive bone formation, particularly on the periosteal surface of long bones, is a concurrent adaptive response of bone to heightened mechanical loading that can improve the fatigue resistance of the skeletal structure, and therefore may play a critical role in offsetting the risk of stress fracture. Reports from animal studies suggest that NSAID administration may suppress this important adaptive response to mechanical loading. These observations have implications for populations such as endurance athletes and military recruits who are at risk of stress fracture and whose use of NSAIDs is widespread. However, results from human trials evaluating exercise and bone adaptation with NSAID consumption have been less conclusive. In this review, we identify knowledge gaps that must be addressed to further support NSAID-related guidelines intended for at-risk populations and individuals.

Childhood\u2010onset systemic lupus erythematosus with trisomy X and the increased risk for bone complications: a case report

BackgroundSystemic lupus erythematosus is a multi-organ inflammatory autoimmune disease; immune complexes are part of the pathogenesis, but not entirely responsible. Trisomy X is the most common female chromosomal abnormality and the role of an additional X chromosome in the development of systemic lupus erythematosus is well recognized. However, the potential complications and optimal management of childhood lupus with trisomy X remain unclear. Herein, we describe a case of childhood-onset systemic lupus erythematosus associated with severe bone complications presumably secondary to trisomy X.Case presentationA 16-year-old Japanese girl was diagnosed with childhood-onset systemic lupus erythematosus and trisomy X. A chromosomal abnormality (47, XXX) was incidentally identified on bone marrow examination initially done to determine the cause of pancytopenia. She had a persistent headache, fever for six days, diffuse hair loss, mucosal ulcers, butterfly eruptions, and palmar erythema. Furthermore, thrombocytopenia, anemia, and erythrocyte fragmentation were detected, suggesting secondary thrombotic microangiopathy. She was initially treated with intravenous methylprednisolone pulse therapy and prescribed monthly cyclophosphamide for severe disease activity, prednisolone, mycophenolate mofetil, and hydroxychloroquine as remission maintenance drugs. She developed generalized extremity pain that had been worsening throughout the disease. Extremity magnetic resonance imaging performed 12 months after the treatment onset revealed multifocal avascular necrosis, and dual-energy X-ray absorptiometry revealed further decreased bone mineral density. High plasma levels of factor VIII were detected by additional tests for coagulation functions, and we suspected the possibility that factor VIII might cause avascular necrosis due to thrombosis. Currently, she is being treated with prednisolone and MMF for SLE. However, her extremity pain has not been managed effectively even under the administration of non-steroidal anti-inflammatory drugs and pregabalin.ConclusionsAn additional X chromosome has been reported to be associated with factor VIII and osteoporosis. Additionally, elevated plasma levels of FVIII is the risk factors for thrombosis, which leads to the risk of avascular necrosis. Patients with systemic lupus erythematosus complicated by trisomy X might be at a higher risk of avascular necrosis and osteoporosis that can also manifest in childhood systemic lupus erythematosus.

Angiotensin-Converting Enzyme Inhibitor/Receptor Blocker, Diuretic, or Nonsteroidal Anti-inflammatory Drug Use After Major Surgery and Acute Kidney Injury: A Case-Control Study

BackgroundAcute kidney injury (AKI) is common after surgery and associated with increased mortality, costs, and lengths of hospitalization. We examined associations between angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB), diuretic, or nonsteroidal anti-inflammatory drug (NSAID) use after major surgery and AKI. Materials and methodsWe conducted a nested case-control study of patients who underwent major cardiac, thoracic, general, or vascular surgery in Calgary, Alberta, Canada. Cases with AKI were matched on age, gender, and surgery type with up to five controls without AKI within 30-d after surgery. Adjusted odds ratios (ORs) for AKI were determined based on postoperative administration of ACEIs/ARBs, diuretics, or NSAIDs. ResultsAmong 33,648 patients in the cohort, 2911 cases with AKI were matched to 9309 controls without AKI. Postoperative diuretic [OR = 1.96; 95% confidence interval (CI) = 1.68-2.29], but not ACEI/ARB (OR = 0.83; 95% CI = 0.72-0.95) or NSAID (OR = 1.12; 95% CI = 0.96-1.31), use was independently associated with higher odds of AKI (including stages 1 and 2/3 AKI) after all types of major surgery. There were increased adjusted odds of AKI 1 to 5 d after first exposure to diuretics and 1 d after first exposure to NSAIDs (but not after later exposures). Relationships between ACEI/ARB use and AKI varied by surgery type (p-interaction = 0.004), with lower odds of AKI observed among ACEI/ARB use after cardiac surgery (OR = 0.70; 95% CI = 0.57-0.81), but no difference after other major surgeries. ConclusionsPostoperative administration of diuretics and NSAIDs was associated with increased odds of AKI after major surgery. These findings characterize potentially modifiable medication exposures associated with AKI after surgery.

Incidence and Predictive Risk Factors of Postoperative Urinary Retention After Primary Total Knee Arthroplasty

BackgroundPostoperative urinary retention (POUR) after total knee arthroplasty (TKA) may cause urologic injury and delay patient discharge. This study measures the incidence of POUR and identifies predictive risk factors. MethodsTwo-hundred seventy-one consecutive patients undergoing primary unilateral TKA were prospectively enrolled. Bladder scans were performed in the postanesthesia care unit (PACU) and every four hours thereafter. POUR was defined as >400cc with inability to void and was treated with catheterization. Patient demographics, urologic history, operative data, perioperative medications, and bladder scanner volumes were investigated with the univariate and multivariate logistic regression analysis. ResultsFifty-five patients (20%) developed POUR. Compared with non-POUR patients, PACU bladder scan volumes were greater in patients who developed POUR (344cc vs 120cc, P < .001). POUR patients had lower BMI (27.8 vs 29.4, P = .03), longer operative duration (83.9 vs 76.0 minutes, P = .002), and lower ASA scores (2.2 vs 2.4, P = .02). Total intravenous fluid was equivalent between groups (1134cc vs 1185cc, P = .41). POUR patients received less narcotics measured by morphine milligram equivalents (16.1 vs 23.9, P < .001). Fifteen variables including spinal type (bupivacaine and ropivacaine) and paralytic use were not predictive of POUR. Potentially predictive variables included anesthetic types administered (spinal, general, regional, and combination) and perioperative administration of nonsteroidal anti-inflammatory drugs (NSAIDs), glycopyrrolate, and muscle relaxants. The multivariate analysis showed that NSAIDs (P = .05) and glycopyrrolate (P = .04) were significant predictors. ConclusionA significant percentage of patients develop POUR after TKA. Select patient demographics and PACU bladder scanning may identify those at risk. Appropriate pain control and judicious use of perioperative NSAIDs and glycopyrrolate may help minimize the risk of POUR.

Naproxen for Post-Operative Pain.

Post-operative pain is a common type of acute pain that can require therapeutic intervention. Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used to manage post-operative pain and help reduce or eliminate the use of opioids. Current pain management guidelines recommend administration of NSAIDs as first line therapy to all post-operative surgical patients, unless contraindicated, as one method to minimize opioid use. This article is based on previously conducted studies and does not contain any studies with human participants or animals performed by the author. Literature for controlled trials involving naproxen in a peri-procedural setting was included. Comprehensive meta-analyses and individual clinical trial reports were summarized. Naproxen was shown to have significant efficacy in treating pain following different surgical interventions, eliminating, or reducing the use of rescue opioids in many trials. Importantly, naproxen did not demonstrate an increased rate of bleeding or other adverse events in this elevated-risk population. As a generally safe and effective medication, clinical consideration should be given to naproxen when developing any comprehensive, patient-specific, pain management plan.

163 Impact of a standardized post-cesarean analgesia regimen on postpartum opioid use

To determine if implementation of a standardized postoperative analgesic regimen decreases opioid use following cesarean birth. A standardized postoperative analgesia protocol was implemented in June 2018. It included scheduled acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) with opioids for breakthrough pain. There was no prior standardized protocol. A before-and-after study design was used to compare oral morphine milligram equivalents (MME) for nine months prior to and after this protocol was implemented, excluding the two month period of protocol rollout. Women with opioid use disorder or postoperative intubation were excluded. The primary outcome was the cumulative MME used in the first 72 hours postoperatively. Total MME dose at 12, 24, and 48 hours were also compared. Of 2340 women who underwent cesarean birth during the study period (7/1/17 – 4/30/19), 2001 women met inclusion criteria (914 before 4/10/18 (pre-protocol) and 1087 after 6/17/18 (post-protocol)). Baseline characteristics of the two groups were similar, including maternal body mass index (BMI), planned versus unplanned cesarean birth, and type of intraoperative anesthesia used. The cumulative opioid dose in the first 72 hours postoperatively was 216.3+/-84.3 MME prior to implementation compared to 171.5+/-91.5 MME following implementation (p<0.001). The average cumulative MME use was higher in the pre-protocol group compared to post-protocol at all time periods: 12 hours (57.3+/-23.8 vs 48.6+/-26.2 MME, p<0.001), 24 hours (98.1+/-34.1 vs 82.1+/-38.8 MME, p<0.001), and 48 hours (165.8+/-58.3 vs 134.9+/-66.2 MME, p<0.001). The average pain scores were lower in the pre-protocol group (3 vs 3.3, p<0.001). Scheduled administration of acetaminophen and NSAIDs following cesarean birth significantly decreased the cumulative dose of opioids used in the first 72 hours postoperatively by 20.7%. While the impact of this change is less than a full enhanced recovery after surgery protocol, this simple change resulted in an MME decrease that equates to 5-6 less doses of oral opioids.

Comparative efficacy and safety of different regimens of ranibizumab for neovascular age-related macular degeneration: a network meta-analysis of randomised controlled trials

ObjectiveTo give a comprehensive efficacy and safety ranking of different therapeutic regimens of ranibizumab for neovascular age-related macular degeneration (nAMD).DesignA systematic review and network meta-analysis.MethodsThe PubMed, Embase, Cochrane Central Register...

Beyond the guidelines management of juvenile idiopathic arthritis: a case report of a girl with polyarticular disease refractory to multiple treatment options and Leri Weill syndrome

BackgroundThe last two decades brought new treatment options and high quality guidelines into the paediatric rheumatologic practice. Nevertheless, a number of patients still present a diagnostic and therapeutic challenge due to combination of vague symptoms and unresponsiveness to available treatment modalities.Case presentationWe report a case of sixteen years old girl suffering from polyarticular type of juvenile idiopathic arthritis refractory to multiple treatment options. She first presented at the age of 4 with swelling and contractures of both knees. Her symptoms were initially unresponsive to nonsteroidal anti-inflammatory drugs and progressed despite treatment with intraarticular and systemic glucocorticoids and methotrexate. Throughout the years, she received several biologics together with continuous administration of nonsteroidal anti-inflammatory drugs and disease modifying anti-rheumatic drugs as well as intraarticular and systemic glucocorticoids in disease flares. However, none of this options provided a permanent remission, so various other modalities, as well as other possible diagnoses were constantly being considered. Eventually she became dependent on a daily dose of systemic glucocorticoids. In 2018, the treatment with Janus kinase inhibitor tofacitinib was initiated, which led to gradual amelioration of musculoskeletal symptoms, improvement of inflammatory markers and overall well-being, as well as to the weaning of systemic glucocorticoids. As the swelling of the wrists subsided for the first time in many years, Madelung’s deformity was noticed, first clinically, and later radiographically as well. Genetic analysis revealed short-stature homeobox gene deficiency and confirmed the diagnosis of Leri Weill syndrome.ConclusionsThis case report emphasizes the need for reporting refractory, complicated cases from everyday clinical practice in order to build-up the overall knowledge and share experience which is complementary to available guidelines. Individual reports of difficult to treat cases, especially when additional diagnoses are involved, can be helpful for physicians treating patients with common rheumatological diseases such as juvenile idiopathic arthritis.

Hyaluronan-Loaded Liposomal Dexamethasone-Diclofenac Nanoparticles for Local Osteoarthritis Treatment.

Osteoarthritis (OA) remains one of the common degenerative joint diseases and a major cause of pain and disability in older adult individuals. Oral administration of non-steroidal anti-inflammatory drugs (NSAIDs) (such as diclofenac, DIC) or intra-articular injected gluco-corticosteroids (such as dexamethasone, DEX) were the conventional treatment strategies for OA to reduce joint pain. Current limitations for both drugs including severe adverse effects with risks of toxicity were noted. The aim of the present study was to generate a novel OA treatment formulation hyaluronic acid (HA)-Liposomal (Lipo)-DIC/DEX to combat joint pain. The formulation was prepared by constructing DIC with DEX-loaded nanostructured lipid carriers Lipo-DIC/DEX mixed with hyaluronic acid (HA) for prolonged OA application. The prepared Lipo-DIC/DEX nanoparticles revealed the size as 103.6 ± 0.3 nm on average, zeta potential as −22.3 ± 4.6 mV, the entrapment efficiency of 90.5 ± 5.6%, and the DIC and DEX content was 22.5 ± 4.1 and 2.5 ± 0.6%, respectively. Evidence indicated that HA-Lipo-DIC/DEX could reach the effective working concentration in 4 h and sustained the drug-releasing time for at least 168 h. No significant toxicities but increased cell numbers were observed when HA-Lipo-DIC/DEX co-cultured with articular chondrocytes cells. Using live-animal In vivo imaging system (IVIS), intra-articular injection of each HA-Lipo-DIC/DEX sufficed to reduce knee joint inflammation in OA mice over a time span of four weeks. Single-dose injection could reduce the inflammation volume down to 77.5 ± 5.1% from initial over that time span. Our results provided the novel drug-releasing formulation with safety and efficiency which could be a promising system for osteoarthritis pain control.

Clinical characteristics of temporomandibular disorders presenting posterior open bite – A report of 12 cases

Background/purposeThere is a paucity of comprehensive information about posterior open bite (POB) in patients with temporomandibular disorders (TMD) because of its rare prevalence. The purpose of this study was to investigate the etiologies, clinical characteristics, and treatment outcomes of patients with TMD presenting POB. Materials and methodsThis study includes a careful review of medical records and imaging findings of 12 patients with TMD (seven men and five women, 50.9 ± 19.2 years, 15–72 years) complaining of POB. ResultsIn total, 11 had unilateral POB, whereas 1 had bilateral POB. In 11 patients, POB was caused by inflammatory disorders of temporomandibular joint (TMJ). In the remaining one patient, TMJ medial disc displacement (MDD) was responsible for POB. Of 11 patients with inflammatory conditions of TMJ, four patients had unilateral TMJ internal derangement (ID), two had bilateral TMJ ID, and one had rheumatism. POB was resolved in 10 of 11 patients with TMJ inflammation following the administration of non-steroidal anti-inflammatory drugs and self-management instructions. Prosthodontic treatment was needed in one patient to resolve POB. POB was resolved in the patient with TMJ MDD after stabilization splint therapy. ConclusionPOB in patients with TMD was mostly caused by inflammatory disorders of TMJ. TMJ MDD could also be a reason. Although almost all POB was resolved by conservative treatments including medications, the possibility of prosthodontic, orthodontic, or surgical treatments also must be considered.