Indomethacin Therapy Research Articles

Severe Hyperkalemia Caused by Short-term Indomethacin Therapy in a Patient with Primary Stabbing Headache

Severe Hyperkalemia Caused by Short-term Indomethacin Therapy in a Patient with Primary Stabbing Headache

The critical role of neuroimaging in hemicrania continua: Asystematic review and case series.

Hemicrania continua is a primary unilateral headache characterized by ipsilateral parasympathetic and sympathetic autonomic features. A key diagnostic criterion is its dramatic response to indomethacin treatment; however, various vascular or structural abnormalities have been reported to cause secondary hemicrania continua, presenting with clinical features similar to those of the primary headache presentation. We reviewed the literature to compile secondary hemicrania continua cases, highlighting the importance of imaging during the evaluation. Additionally, we also contributed our three cases to the existing studies. We conducted a review of articles from the PubMed and EMBASE databases that described reported cases of secondary hemicrania continua, covering the period from 1993 to 2021. Our review included detailed patient information, signs, and symptoms of hemicrania continua, as well as information on indomethacin usage and headache resolution (if pertinent). Secondary hemicrania continua can result from a remarkably diverse range of structural and vascular lesions, yet clinical reports on long-term follow-up are lacking. Notably, cases may exhibit a classical response to indomethacin, emphasizing the importance of neuroimaging in excluding secondary cases. Our search yielded 41 cases meeting our criteria. We excluded six cases that were not treated with indomethacin or were unresponsive to it. Additionally, we present three cases that highlight the necessity of neuroimaging in evaluating hemicrania continua, along with short- and long-term clinical outcomes following indomethacin and lesion-directed treatments. Case 1 presented with daily right-sided headaches and cranial autonomic symptoms. Her pain completely resolved with indomethacin use. Neuroimaging of the brain revealed a laterally directed saccular aneurysm of the right internal carotid artery. Case 2 presented with continuous left-sided unilateral headaches with superimposed exacerbations. She complained of left-sided photophobia with a dull sensation in the left ear. Her symptoms decreased after 2 weeks of indomethacin use. Neuroimaging of the head indicated a benign tumor with mass effect into the left lateral medulla and inferior cerebellar peduncle. Case 3 presented with a right side-locked headache with daily, severe superimposed exacerbations. She had photophobia in the right eye and a right-sided Horner's syndrome, along with tearing during her exacerbations. Neuroimaging of the brain revealed a pituitary tumor and her pain completely resolved with indomethacin. Hemicrania continua is a rare headache disorder that can be either primary or secondary. Importantly, response to indomethacin can still occur in secondary hemicrania continua. Thus, neuroimaging should be considered to rule out underlying structural etiology in all cases, regardless of their clinical responsiveness to indomethacin therapy.

Evaluation of gene expression level of genes FGF2 and CYP27b1 in male Wister rats treated with indomethacin

The biology department's animal house at Iraq's AL-Qadisiyah University hosted this study. It's part of Iraq's AL-Qadisiyah University, to demonstrate that the Kidney and Liver were subjected to oxidative stress from reactive oxygen species, which led to harmful consequences of the indomethacin medication on molecular level. 40 male Wister rats, aged (2 -3) months, weighing between 200 and 300 grams. Four groups of 10 rats. Control, 5 mg/kg, 7 mg/kg, and 10 mg/kg of indomethacin were given for 21 days to the groups. After the experiment, the animals were killed by hanging. After twenty-one days ,each of the study groups that received indomethacin therapy saw a statistically significant reduction (P <0.0 5), which was a decrease in the amount of the cyp27b1 gene, with the level of decrease being largest in the group that received treatment with ten milligrams per kilogram for 21 days. There was no difference (p>< 0.05) in the expression of the FGF2 gene between individuals in the untreated group and those who were given 5 mg, 7 milligrams, while 10 mg/kg of indomethacin showed significant increase. In conclusion indomethacin cause decrease in the level of cyp27b1gene, and cause increase expression in FGF2 gene

Neonatal acute kidney injury during indomethacin therapy: does it predict ductal closure?

Preterm newborns are at risk for patent ductus arteriosus, and non-steroidal anti-inflammatory drugs are often used to facilitate patent ductus arteriosus closure. Acute kidney injury is common in critically ill neonates and may be caused by non-steroidal anti-inflammatory drugs. We sought to describe the incidence of acute kidney injury among preterm infants receiving indomethacin and determine whether acute kidney injury during indomethacin therapy is associated with subsequent patent ductus arteriosus closure. Retrospective cohort including neonates < 33weeks gestational age, admitted to two level IIIb neonatal intensive care units between November 2016 and November 2019, who received indomethacin in the first 2 weeks of life. Acute kidney injury in the 7-day period after treatment was defined by neonatal modified Kidney Disease Improving Global Outcomes (KDIGO) criteria. Patent ductus arteriosus closure was defined clinically and/or via echocardiogram. Clinical characteristics were extracted from medical records. Association between acute kidney injury during treatment and successful closure of patent ductus arteriosus was evaluated using chi-square tests and logistic regression. One hundred fifty preterm infants were included; acute kidney injury occurred in 8% (all KDIGO Stage 1). Patent ductus arteriosus closed in 52.9% of the non-acute kidney injury group and 66.7% of the acute kidney injury group (p = 0.55). Serum creatinine was checked a mean of 3.1 times in the acute kidney injury group and 2.2 times in the non-acute kidney injury group. There was no difference in survival. We found no association between acute kidney injury during indomethacin therapy and patent ductus arteriosus closure. Paucity of serum creatinine values likely underdiagnosed acute kidney injury. Surveillance of kidney function during indomethacin therapy using more sensitive renal biomarkers may better identify infants who develop acute kidney injury in the context of non-steroidal anti-inflammatory drug use.

Endoscopic Excision of Hip Heterotopic Ossification, Plus Indomethacin and Radiation, Is Effective in Treating and Preventing Recurrence

To describe the clinical and patient-reported outcomes of heterotopic ossification (HO) excision as well as the results of a standardized HO prophylaxis protocol among a group of patients who previously underwent open or arthroscopic hip surgery. Patients who developed HO after index hip surgery and were subsequently treated with arthroscopic excision of HO and postoperative HO prophylaxis using 2 weeks of indomethacin and radiation were retrospectively identified. All patients were seen by a single surgeon and were treated with the same arthroscopic technique. Patients were also placed on a regimen of 2 weeks of indomethacin 50 mg and radiation therapy with 700 cGy in one fraction on the first postoperative day. Outcomes assessed included recurrence of HO and conversion to total hip arthroplasty by latest follow-up. Other outcomes included Modified Harris Hip Scores and Non-Arthritic Hip Scores, which were collected preoperatively and at 1-year and 2-year follow-up. There were 5 female and 9 male subjects, with an average age of 39 years (range 22-66) and average body mass index of 27.1 (19.1-37.5). Average follow-up time was 46 months (range 4-136). No patients had experienced HO recurrence by latest follow-up. Only 2 patients converted to total hip arthroplasty, one at 6 months and the other at 11 months postexcision. Average outcome scores improved by 2-year follow-up (average Modified Harris Hip Scores 52.8 improved to 86.5, average Non-Arthritic Hip Scores 49.4 improved to 83.8). Minimally invasive arthroscopic excision of HO and postoperative prophylaxis with combined indomethacin and radiation therapy effectively treats and prevents the recurrence of HO. Level IV, case series, therapeutic.

Histomorphological evaluation of the combined therapeutic potential of Carica papaya and Musa paradisiaca on indomethacin induced gastric injury

Background: Medicinal plants are often used for the preparation of remedies for the treatment of several ailments especially in rural areas. Objective: The study investigated the combined effect of Carica papaya (pawpaw) and Musa paradisiaca (plantain) leaves extract on the stomach walls of albino rats against indomethacin induced gastric ulceration. Materials and Methods: Twenty-five (n-25) albino rats were weighed and divided randomly into five groups. Each group consisted of five (n-5) rats. Group A served as negative control and received rat feeds and water ad libitum. Group B received feeds and a single dose of indomethacin (25 mg/kg body weight) via orogastric administration and organs were harvested 4 hours after administration. Group C rats were administered with Carica papaya leaf extract (250 mg/kg body weight) daily for 14 days. Group D was administered with Musa paradisiaca leaf extract (250 mg/kg body weight) for 14 days. Group E received combined extract of Carica papaya (250 mg/kg body weight) and Musa paradisiaca (250 mg/kg body weight) daily for 14 days. All the animals were allowed access to feed and water. The animals in groups C-E fasted for 24 hours and were administered with a single dose of indomethacin (25 mg/kg body weight). Four hours later, the animals were sacrificed under chloroform inhalation, organs harvested, processed and stained with haematoxylin and eosin for histomorphological evaluation. Result: The result of the study shows that the single dose of indomethacin caused gastric ulceration within 4 hours. Musa paradisiaca leaf extract ameliorated the effect of indomethacin on the stomach. Combination of Carica papaya and Musa paradisiaca leaves extract exacerbated the effect of indomethacin on gastrointestinal tract ulcers. Conclusion: The practice of using combined extract of Carica papaya and Musa paradisiaca should be avoided in ulcer patients or individuals on indomethacin therapy

Heterotopic ossification prophylaxis after acetabular fracture fixation using a posterior approach: a retrospective study at a level 1 trauma center

Background: Heterotopic ossification (HO) is a known complication of acetabular fracture repair. After surgery, standard methods for HO prevention involve observation, radiation therapy, or a course of nonsteroidal antiinflammatories (indomethacin). Methods: A retrospective chart review was performed to analyze the effectiveness of radiation and indomethacin as HO prophylaxis after acetabular fracture surgical repair. Data were analyzed from 117 patients who underwent stabilization of the acetabulum utilizing a posterior approach from 2016 to 2020. Patients were classified into three groups based on the postoperative therapy received: radiation therapy, indomethacin therapy, or no prophylaxis. Grade of HO for each patient was determined by examining pelvic radiographs using the Brooker classification system at the most recent follow-up. Incidence of total and severe HO was recorded for each group and compared. Demographics, follow-up time, injury severity, and other trauma characteristics also were reported. Statistics were calculated using a combination of analysis of the variance (ANOVA), chi square, and Kruskal-Wallis testing. Results: The indomethacin group was younger than the other two groups with a shorter average follow-up time. The radiation group demonstrated a lower incidence of severe and total HO compared to the control group. The indomethacin group had significantly less total HO than the control group. Conclusions: With a decreased incidence of severe HO in the radiation group compared to no prophylaxis, this study supports the utility of radiation therapy as HO prophylaxis following acetabular fracture repair using a posterior approach. It shows a trend indicating that indomethacin also may be useful. Level of Evidence: Level III.

Comparative Study between the Effect of Nifedipine, Ritodrine and Indomethacin Therapy on Doppler Indices of Fetal Umbilical and Middle Cerebral Arteries in Patients with Preterm Labour

Comparative Study between the Effect of Nifedipine, Ritodrine and Indomethacin Therapy on Doppler Indices of Fetal Umbilical and Middle Cerebral Arteries in Patients with Preterm Labour

Efficacy of Long-Term Indomethacin Therapy in Prolonging Pregnancy After Fetoscopic Laser Surgery for Twin-to-Twin Transfusion Syndrome: A Collaborative Cohort Study

(Abstracted from BJOG 2022;129:597–606) Approximately 10% to 15% of monochorionic diamniotic twin pregnancies are affected by twin-to-twin transfusion syndrome (TTTS). Fetoscopic laser surgery is recognized as the standard for treating such pregnancies.

Efficacy of long-term indomethacin therapy in prolonging pregnancy after fetoscopic laser surgery for twin-to-twin transfusion syndrome: a collaborative cohort study.

To evaluate the efficacy of long-term indomethacin therapy (LIT) in prolonging pregnancy and reducing spontaneous preterm birth (PTB) in patients undergoing fetoscopic laser surgery (FLS) for the management of twin-to-twin transfusion syndrome (TTTS). Retrospective cohort study of prospectively collected data. Collaborative multicentre study. Five hundred and fifty-seven consecutive TTTS cases that underwent FLS. Long-term indomethacin therapy was defined as indomethacin use for at least 48 hours. Log-binomial regression was used to estimate the relative risk of PTB in the LIT group compared with a non-LIT group. Cox regression was used to evaluate the association between LIT use and FLS-to-delivery survival. Gestational age (GA) at delivery. Among the 411 pregnancies included, a total of 180 patients (43.8%) received LIT after FLS and 231 patients (56.2%) did not. Median GA at fetal intervention did not differ between groups (20.4 weeks). Median GA at delivery was significantly higher in the LIT group (33.6 weeks) compared with the non-LIT group (31.1 weeks; P < 0.001). FLS-to-delivery interval was significantly longer in the LIT group (P < 0.001). The risks of PTB before 34, 32, 28 and 26 weeks of gestation were all significantly lower in the LIT group compared with the non-LIT group (relative risks 0.69, 0.51, 0.37 and 0.18, respectively). The number needed to treat with LIT to prevent one PTB before 32 weeks of gestation was four, and to prevent one PTB before 34 weeks was five. Long-term indomethacin after FLS for TTTS was found to be associated with prolongation of pregnancy and reduced risk for PTB. Long-term indomethacin used after fetoscopic laser surgery for twin-to-twin transfusion syndrome is effective in prolonging pregnancy and reducing the risk for preterm birth; especially extreme preterm birth.

Long‐term indomethacin therapy after laser surgery for TTTS. Worth the effort?

Fetal endoscopic surgery is a life-saving procedure for severe cases of TTTS. Over 25,000 cases of laser surgery for TTTS have been published since 1991, achieving survival rates of over 75% overall and 90% for at least one twin. However, preterm premature rupture of the membranes (PPROM) and birth before 32 weeks follow laser surgery in 20-50% of cases. This is due to the insult to the membranes caused by the trocar and the surgical procedure. Considerable efforts have been made for secondary prevention of PPROM, but despite more than 15 years of work in this field, clinical validation is lacking.

Effects and side effects of maternal administration of indomethacin for fetal tricuspid valve dysplasia

We report on the course of two fetuses with tricuspid valve dysplasia (TVD) who were treated with indomethacin. Case 1 presented at 24 weeks' gestation with severe tricuspid regurgitation (TR), retrograde flow in the arterial duct, no antegrade flow across the pulmonary valve and free pulmonary regurgitation (PR). There was cardiomegaly and fetal hydrops with ascites, skin edema and pleural effusion. The Simpson–Andrews–Sharland (SAS) prenatal severity score for TVD was 7, which predicted fetal demise. The SAS score ranges from 0 to 10, with no predicted survivors scoring ≥ 51. Case 2 presented at 16 weeks' gestation with moderate TR, antegrade flow across the pulmonary valve, progressing to functional pulmonary atresia by 21 weeks' gestation, and a SAS score of 4. At 33 + 5 weeks, there was evidence of further progression with increasing cardiomegaly (cardiothoracic ratio (CTR): 0.80), severe TR and PR and a SAS score of 8. Estimated fetal weight (EFW) dropped from 17th to 3rd centile, umbilical artery (UA) pulsatility index was > 95th centile and amniotic fluid index (AFI) was normal (8.9 cm). Maternal indomethacin (100 mg three times a day (TDS)) was commenced in both cases (Figure 1), leading to constriction/closure of the arterial duct, reduction in PR and antegrade flow across the pulmonary valve. In Case 1, by 26 weeks' gestation, fetal hydrops had completely resolved, indomethacin was replaced by ibuprofen (200 mg TDS) due to a more favorable side-effect profile. However, the arterial duct reopened and indomethacin was reintroduced. Following this, the arterial duct constricted, but oligohydramnios developed (AFI: 4.4 cm). At 30 weeks' gestation, there was faltering growth, EFW of 1.2 kg and anhydramnios. Indomethacin was stopped and the AFI normalized (17.1 cm), but cardiomegaly persisted with severe TR. Intrauterine death occurred at 31 + 6 weeks' gestation. In Case 2, following commencement of indomethacin, CTR reduced to 0.65 but oligohydramnios worsened (AFI: 4.2 cm). Indomethacin was stopped and AFI normalized. Indomethacin was restarted at a lower dose (50 mg TDS), but despite failure to constrict the arterial duct, oligohydramnios recurred (AFI: 1.5 cm) and therapy was ceased. The baby was delivered at 36 weeks' gestation due to absent end-diastolic UA flow, weighing 1.4 kg, and was stable without intervention at 1 year of age. Prenatally detected cases of TVD are often those at the most severe end of the spectrum, presenting with cardiomegaly secondary to severe TR1. Cardiomegaly leads to compression of the developing lung tissue, pulmonary hypoplasia and increased risk of postnatal demise. The fetal environment is disadvantageous for the fetus with TVD as the right ventricle (RV) faces systemic pressures and high pulmonary vascular resistance, worsening TR and subsequent right atrial dilatation, which in itself will exacerbate TR. Severe TR causes reduced antegrade flow across the pulmonary valve and reversal of flow in the arterial duct. This ‘steal’ from the systemic arterial circulation inhibits antegrade pulmonary blood flow and causes PR, which results in further volume loading of the RV. Furthermore, RV dilatation has an adverse effect on left ventricular geometry and function, causing additional fetal hemodynamic compromise2, explaining the high perinatal mortality of 45–71%3. Whilst there have been apparently favorable reports of indomethacin for a circular shunt in TVD2, 4, this treatment led to anhydramnios/oligohydramnios in both our cases. This may be due to pre-existing renal hypoperfusion secondary to poor ventricular-ventricular interaction and ductal steal. Furthermore, through its action on prostaglandins, indomethacin can lead to renal vasoconstriction and may cause oligohydramnios5. The potential benefits of ductal constriction for circular shunts need to be balanced against the risk of renal perfusion, necessitating close cardiac and fetal medicine supervision for affected fetuses. A prospective trial is needed to evaluate the risk-benefit ratio of this new treatment for fetal TVD. We acknowledge the contribution of Dr Wayne Tworetzky from the Children's Hospital in Boston, USA, whose group published the rationale for indomethacin therapy in this group of fetuses. Dr Tworetzky advised on the indomethacin and ibuprofen treatment used in the first case. Data available on request due to privacy/ethical restrictions

Long-Term Outcome of Indomethacin Treatment in Pediatric Patients with Paroxysmal Hemicrania-A Case Series.

Paroxysmal Hemicrania is a rare form of primary headache in children and adolescents, belonging to the group of trigeminal autonomic cephalalgias. Patients suffer from severe, short-lasting unilateral headaches accompanied by symptoms of the autonomic system on the same side of the head. The short duration of attacks distinguishes Paroxysmal Hemicrania from other trigeminal autonomic cephalalgias. Indomethacin is the treatment of choice, and its effectiveness provides a unique diagnostic criterion. However, the long-term outcomes in children are highly underreported. In this case-series, n = 8 patients diagnosed with Paroxysmal Hemicrania were contacted via telephone 3.1 to 10.7 years after initial presentation. A standardized interview was conducted. n = 6 patients were headache-free and no longer took indomethacin for 5.4 ± 3.4 years. The mean treatment period in these patients was 2.2 ± 1.9 years. Weaning attempts were undertaken after 1.7 ± 1.3 months; in n = 3 patients, more than one weaning attempt was necessary. n = 2 patients were still taking indomethacin (4.5 and 4.9 years, respectively). Both unsuccessfully tried to reduce the indomethacin treatment (two and six times, respectively). Adverse effects appeared in n = 6 (75%) patients and led to a discontinuation of therapy in n = 2 patients. Our long-term follow-up suggests that in a substantial proportion of pediatric patients, discontinuing indomethacin therapy is possible without the recurrence of Paroxysmal Hemicrania.

The future of Cochrane Neonatal

The future of Cochrane Neonatal

Do Indomethacin or Radiation for Heterotopic Ossification Prophylaxis Increase the Rates of Infection or Wound Complications After Acetabular Fracture Surgery?

To compare the rates of infection and wound complications in patients undergoing operative fixation (ORIF) of acetabular fractures receiving heterotopic ossification (HO) prophylaxis using indomethacin or external beam radiation therapy (XRT) versus no prophylaxis. Retrospective cohort. Level I trauma center. We reviewed 473 patients undergoing ORIF of acetabular fractures through posterior, combined, or extensile surgical approaches from 2012 to 2017, with a median follow-up of 13 months (0.5-77 months). Rates of infection and wound complications were stratified according to their HO prophylaxis method into three groups as indomethacin, XRT, and no prophylaxis. Overall, 167 patients (35.3%) received indomethacin, 104 patients (22.0%) received postoperative XRT, and 202 patients (42.7%) received no prophylactic treatment. There was no difference between the 3 groups for the risk of surgical site infection (P = 0.280). The XRT group had a significantly increased risk of noninfectious wound complications (20.2%) compared with the indomethacin group (6.6%, P = 0.002) and the no prophylaxis group (5.0%, P < 0.0001). Multivariate analysis revealed XRT remained a significant risk factor for noninfectious wound complications compared with no prophylaxis (odds ratio 5.39; 95% confidence interval 2.37-12.22; P < 0.0001). Although there is no difference between XRT, indomethacin, and no HO prophylaxis for the risk of surgical site infection, the use of XRT results in more than 5 times increased risk of noninfectious wound complications compared with no prophylaxis. This increased risk should be considered when contemplating XRT for HO prophylaxis in acetabular fracture patients. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Management of polyhydramnios pregnancy without risk factors: a case report

Introduction: Polyhydramnios is a condition in which the amount of amniotic fluid increases more than 2 litres. The causes of polyhydramnios are multifactorial, and most are idiopathic. Here we report challenging management of polyhydramnios case without apparent risk factors.&#x0D; Case: A 30-year-old woman G2P1001, 27-28 weeks of gestational age referred due to our tertiary health care center due to polyhydramnios. The patient chief complaint was progressively enlarged abdomen since a month ago. Her previous pregnancy, medical history and family history were unremarkable. The obstetric examination reflects the size of uterus equivalent to 36 weeks of gestational age. The fetomaternal ultrasound reveals a life, single fetus with normal heart rate and fetal movement, estimated fetal weight about 1057 grams, placenta corpus posterior grade I, Maximum Vertical Pocket 22.83 cm, no major congenital abnormalities were visible and bladder appears filled. Laboratory tests revealed blood glucose levels 90 mg/dl, Hb-A1c 5.2%, Ureum 27.30 mg/dl, Creatinine 3.39 mg/dl, and numerous leukocytes on urine sediment. Amnioreduction and fetal pulmonary maturation were conducted by Dexamethason protocol. Amnioreduction yield 1500 ml of clear, yellowish amniotic fluid. Regarding abnormality in renal function, diagnosis of Acute on Chronic Kidney Disease (ACKD were established by Internal medicine department, and the patients were given a series of ceftriaxone injection. The patient was planned for indomethacin therapy; however, Indomethacin was not available in Bali.&#x0D; Conclusion: Careful search for causes both from the maternal factor and fetal abnormalities can help to determine the prognosis of pregnancy. Ideally, amnioreduction, coupled with indomethacin therapy, are needed to reduce amniotic fluid, and serial monitoring of the amniotic fluid volume is required to prevent preterm labor.

Su1578 POST ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY PANCREATITIS PREVENTION USING TOPICAL EPINEPHRINE: A SYSTEMATIC REVIEW AND META-ANALYSIS

Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) is a common complication of endoscopic retrograde cholangiopancreatography (ERCP). Multiple drugs and techniques have been studied for the prevention of PEP. Topical epinephrine has recently been studied for the prevention of PEP and theoretically should work similarly as a PD stent. Topical epinephrine sprayed on the ampulla can reduce edema by arteriolar vasoconstriction and therefore improve pancreatic outflow. Evidence regarding the use of topical epinephrine in the prevention of PEP is inconsistent with some studies favoring their use while other studies did not show any benefit. We, therefore, conducted a systematic review and meta-analysis to delineate if topical epinephrine is useful in the prevention of PEP. A comprehensive literature review was conducted by searching multiple databases until August 2019, to identify all studies that evaluated the use of topical epinephrine alone or in conjunction with other agents for the prevention of PEP. The characteristics of the participants and outcome measurements (incidence of PEP) were analyzed. All analysis was conducted using Revman 5.3. Eight studies, including 6 randomized controlled trials (RCTs) and 2 observational studies with 4123 patients, were included in the meta-analysis. Our overall results included two types of studies. Some studies evaluated both topical epinephrine and rectal indomethacin therapy together and some studies compared topical epinephrine with placebo therapy. Five RCTs are of good quality while one was of fair quality. Both the observational studies were of good quality. Overall, there was no difference in the incidence of PEP in patients who underwent ERCP and were treated with epinephrine spray versus those who were not, OR=0.62 (CI 0.30-1.25) with heterogeneity (I2=72%). In a subgroup analysis, topical epinephrine, when compared to placebo significantly decreases the risk of PEP, OR=0.30 (0.16-0.55). However, in a subgroup analysis, addition of topical epinephrine to rectal indomethacin did not provide any additional advantage in decreasing the incidence of PEP, when compared to rectal indomethacin alone OR=1.15 (0.58-2.28). Topical epinephrine does not provide any additional advantage in combination with rectal indomethacin in the prevention of PEP in patients who underwent ERCP. However, topical epinephrine alone is associated with lower odds of PEP compared to placebo and can be considered if rectal indomethacin is unavailable or there is any contraindication to its use. It may also be considered as a suitable alternative to prophylactic pancreatic stenting. Future studies comparing topical epinephrine versus PD stenting can be considered to evaluate if topical epinephrine provides a similar advantage in decreasing PEP as compared to PD stenting.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Maternal low body mass index is a risk factor for fetal ductal constriction following indomethacin use among women undergoing fetal repair of spina bifida.

The objectives were to determine the prevalence of and to identify risk factors associated with constriction of the fetal ductus arteriosus (DA) following perioperative indomethacin use for fetal myelomeningocele (MMC) repair. Study design A retrospective chart review study included 100 consecutive fetuses who underwent fetal MMC repair between 2011 and 2018. All patients had fetal echocardiography (FE) on postoperative day (POD)#1 and 2 to detect constriction of the DA. All patients received indomethacin for tocolysis using a standardized protocol. Multivariate regression analysis was carried out to identify the predictors for fetal ductal constriction. Eighty patients met our study eligibility criteria. Median gestational age at time of surgery was 25 (24-25) weeks. Constriction of the DA was detected in 14 fetuses (17.5%). In five fetuses, this was observed on POD# 1, in seven on POD# 2, and in two on both days. The only independent risk factor for predicting DA constriction was maternal body mass index (BMI) <25 kg/m2 (P = .002). Indomethacin therapy following fetal MMC surgery requires careful daily FE surveillance. The association of DA constriction and low BMI suggests that BMI-based dosing of indomethacin may be recommended for perioperative tocolysis in fetal MMC surgery.

517: Low body-mass-index is a risk factor for fetal ductal constriction following indomethacin use for fetal-surgery

The objectives of the study were to determine the prevalence and to identify risk factors associated with constriction of the fetal ductus arteriosus (DA) following perioperative indomethacin use following fetal myelomeningocele (MMC) repair in a single large fetal center. A retrospective chart review study included 100 consecutive fetuses with normal preoperative echocardiography (FE) who underwent fetal MMC repair between December 2011 and December 2018. All patients had FE on postoperative day (POD) # 1 and 2 to detect constriction of the DA. All patients received indomethacin for tocolysis using a standardized protocol for 48 hours. The POD# 2 doses were withheld if ductal constriction was detected on POD# 1. Multivariate regression analysis was carried out to identify the predictors for fetal ductal constriction and to adjust for potential confounders. Data were expressed as median and interquartile range (IQR) or number and percentages. Eighty patients met our study eligibility criteria. The demographic characteristics of the study population are summarized in Table 1. Constriction of the DA was detected in 14 fetuses (17.5%). In 5 fetuses, this was observed on POD# 1, in 7 on POD# 2 and in 2 on both days. Multivariate regression analysis showed that the only independent risk factor for predicting constriction of the DA was maternal body mass index (BMI) < 25 Kg/m2 (p=0.002) (Table 2). All affected fetuses showed resolution of ductal constriction within a median of one day after indomethacin administration was stopped. In one case, constriction was particularly severe with partial reversal after 6 days and complete reversal after 15 days. Perioperative maternal indomethacin therapy following fetal MMC surgery requires careful daily fetal echocardiography due to the high incidence of fetal ductal constriction. The association of fetal DA constriction and low BMI warrants further investigation and suggests that BMI-based dosing of indomethacin may be recommended for perioperative tocolysis in fetal MMC surgery.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Nontraumatic avascular necrosis of the femoral head : Arthroscopic and navigation-supported core decompression.

The aim is to address core decompression and pathologies of the femoral head, treating them during the same procedure. Furthermore, radiation exposure will be reduced. Femoral head necrosis ARCO (Association Research Circulation Osseous) stagesI-III. Progressive femoral head necrosis as ARCO stagesIIIC-IV. Arthroscopically navigated core decompression of the femoral head using an established optoelectronic system with fluoro-free software module. First, hip joint arthroscopy was performed and further pathologies were treated. Second, core decompression was navigated by anavigation pointer and drill sleeve to reach the correct target point. After visualization, the procedure is repeated 3-5times. Limited weight bearing of the operated leg (20 kg) for 10-14days. Active or passive continuous motion machine for 4weeks. Adjuvant postoperative indomethacin therapy for 10days to reduce pain and bone marrow edema. From May 2018 to January 2019, 7patients (male = 4; 40 ± 9 years) underwent arthroscopically navigated core decompression with 2 (29%) and 5(71%) patients being classified as ARCOII andIII, respectively. Preoperatively, all patients reported load-dependent pain. In all cases, we could identify synovitis, which results in soft tissue release and synovectomy. Furthermore, 4 of 7patients had an additional labrum lesion, which is addressed by refixation or shrinking. Compared to the conventional technique, this fluoro-free navigation procedure allows more precise drilling. Moreover, additional pathologies, as found in all our cases, could be simultaneously addressed. The intraoperative radiation exposure for the patient and surgical team could also be reduced. Although arthroscopically assisted core decompression requires more preparation time, there are advantages over conventional surgery.