Need For Rescue Medication Research Articles

All-trans retinoic acid plus high-dose dexamethasone as first-line treatment for patients with newly diagnosed immune thrombocytopenia: a multicentre, open-label, randomised, controlled, phase 2 trial

High-dose dexamethasone is the standard initial treatment for patients with immune thrombocytopenia, but many patients still relapse and require further treatments. All-trans retinoic acid has been shown to exert immunomodulatory effects and promote thrombopoiesis, and so we aimed to assess the activity and safety of all-trans retinoic acid plus high-dose dexamethasone as a first-line treatment for newly diagnosed patients with immune thrombocytopenia. This multicentre, open-label, randomised, controlled, phase 2 trial was done at six different tertiary medical centres in China. Eligible participants were adults (aged >18 years) with treatment-naive, newly diagnosed, primary immune thrombocytopenia who had either a platelet count of less than 30 × 109 platelets per L or a platelet count of less than 50 × 109 platelets per L and clinically significant bleeding. We randomly assigned (1:1) participants to receive either all-trans retinoic acid (10 mg orally twice daily for 12 weeks) plus high-dose dexamethasone (40 mg/day intravenously for 4 consecutive days) or high-dose dexamethasone alone using a central, web-based randomisation system. If patients did not respond by day 14, the 4-day course of dexamethasone was repeated. The primary endpoint was 6-month sustained response, defined as the maintenance of a platelet count of at least 30 × 109 platelets per L and at least 2-times higher than the baseline count and the absence of bleeding, with no need for rescue medication at this time. The primary endpoint was analysed by intention-to-treat and safety was assessed in all participants who received at least one dose of the study drug. This trial is registered with ClinicalTrials.gov, NCT04217148, and is now completed. Between Jan 1, 2020, and June 30, 2020, 132 patients were randomly assigned to either all-trans retinoic acid plus high-dose dexamethasone (n=66) or high-dose dexamethasone alone (n=66). Three patients did not receive their allocated treatment, leaving 129 in the safety analysis set. At 6 months, a significantly higher proportion of participants in the all-trans retinoic acid plus high-dose dexamethasone group (45 [68%] of 66) than in the high-dose dexamethasone monotherapy group (27 [41%] of 66) had a sustained response (OR 3·095, 95% CI 1·516-6·318; p=0·0017). The most common adverse events were dry skin (31 [48%] of 64 patients), headaches (12 [19%]), and insomnia (12 [19%]) in the combination group, and insomnia (ten [15%] of 65 patients) and anxiety or mood disorders (eight [12%]) in the monotherapy group. Both treatments were well tolerated and no grade 4 or worse adverse events occurred. There were no treatment-related deaths. The combination of all-trans retinoic acid and high-dose dexamethasone was safe and active in newly diagnosed patients with primary immune thrombocytopenia, providing a sustained response. This regimen represents a potential first-line treatment in this setting, but further studies are needed to validate its efficacy and safety. The Beijing Municipal Science and Technology Commission, the National Natural Science Foundation of China, the Beijing Natural Science Foundation, the National Key Research and Development Program of China, and the Foundation for Innovative Research Groups of the National Natural Science Foundation of China.

New insights in mite immunotherapy - sublingual tablets.

Sublingual tablet immunotherapy has been demonstrated to be effective for allergies induced by exposure to grass, ragweed, specific trees (Japanese Cedar; birch homologous tree mix), and house dust mites (HDM). This review provides both an overview of the evidence-based clinical studies that address the use of the HDM SLIT-tablet for the treatment of HDM-induced allergic rhinitis/conjunctivitis and its appropriate use in carefully selected asthmatic patients and provides the clinician with practical management considerations. Solid evidence-based clinical studies have shown that the HDM SLIT-tablet is both well tolerated in patients with mild-to-moderate asthma and has demonstrated a meaningful improvement in exacerbations, need for rescue medication, quality of life, and asthma control. The HDM SLIT-tablet provides the allergy specialist with a well-tolerated treatment that has established superior safety to subcutaneous injection therapy, which can be administered easily as a sublingual dissolvable tablet, and which provides the opportunity to address one of the more difficult aspects in the management of an inducer of perennial allergic disease - that of persistent airway inflammation and allergic asthma.

Rapid Agitation Control With Ketamine in the Emergency Department: A Blinded, Randomized Controlled Trial

We hypothesized that the use of intramuscular ketamine would result in a clinically relevant shorter time to target sedation. We conducted a randomized clinical trial comparing the rapidity of onset, level of sedation, and adverse effect profile of ketamine compared to a combination of midazolam and haloperidol for behavioral control of emergency department patients with severe psychomotor agitation. We included patients with severe psychomotor agitation measured by a Richmond Agitation Score (RASS) ≥+3. Patients in the ketamine group were treated with a 5 mg/kg intramuscular injection. Patients in the midazolam and haloperidol group were treated with a single intramuscular injection of 5 mg midazolam and 5 mg haloperidol. The primary outcome was the time, in minutes, from study medication administration to adequate sedation, defined as RASS ≤-1. Secondary outcomes included the need for rescue medications and serious adverse events. Between June 30, 2018, and March 13, 2020, we screened 308 patients and enrolled 80. The median time to sedation was 14.7 minutes for midazolam and haloperidol versus 5.8 minutes for ketamine (difference 8.8 minutes [95% confidence interval (CI) 3.0 to 14.5]). Adjusted Cox proportional model analysis favored the ketamine arm (hazard ratio 2.43, 95% CI 1.43 to 4.12). Five (12.5%) patients in the ketamine arm and 2 (5.0%) patients in the midazolam and haloperidol arm experienced serious adverse events (difference 7.5% [95% CI -4.8% to 19.8%]). In ED patients with severe agitation, intramuscular ketamine provided significantly shorter time to adequate sedation than a combination of intramuscular midazolam and haloperidol.

Comparison of efficacy and safety of bromelain with diclofenac sodium in the management of postoperative pain and swelling following mandibular third molar surgery

AimThe present study aimed to evaluate and compare the efficacy and safety of oral bromelain, a natural enzyme complex with oral diclofenac sodium in managing pain and swelling after mandibular third molar surgery. Materials and methodsA total of 40 patients were randomly divided into two groups, the bromelain group (n = 20) and the diclofenac sodium group (n = 20). Patients received either bromelain, 500 mg twice daily or diclofenac sodium, 50 mg thrice daily for five days after the surgical extraction of impacted third molars. Swelling and trismus were evaluated pre-operatively (day0) and on postoperative days 1, 2, and 7, pain on postoperative days 1, 2, and 7,also, the need for rescue medication and adverse effects were evaluated in both groups. ResultsThere was no difference between the bromelain and diclofenac groups in VAS pain scores (day1 = 35.1 vs 33.4, p = 0.829; day2 = 22 vs 22.4, p = 0.694; day7 = 13 vs 14.3, p = 0.678). There was no difference between the groups in swelling (day0 = 270.8 vs 266.5, p = 0.256; day1 = 279.2 vs 272.8, p = 0.167; day2 = 277.3 vs 271.4, p = 0.151; day7 = 269.2 vs 266.1, p = 0.440), trismus (day0 = 50.5 vs 48.9, p = 0.542; day1 = 29.6 vs 31.7, p = 0.839; day2 = 31.7 vs 32.6, p = 0.882; day7 = 41.1 vs 37.6, p = 0.273) and the number of rescue medications (1.6vs1.9, p = 0.956). Patients in both the groups did not report any severe or serious adverse effects. ConclusionsBromelain was comparable to diclofenac in the management of postoperative pain, swelling and trismus following impacted mandibular third molar surgery.

Antiemetic Efficacy of Palonosetron Compared with the Combination of Ondansetron and Dexamethasone for Prevention of Postoperative Nausea and Vomiting in Patients Undergoing Laparoscopic Gynaecological Surgery.

For the prevention of PONV, we evaluated the efficacy of palonosetron compared with ondansetron along with dexamethasone in patients undergoing laparoscopic gynaecological surgery. A total of 84 adults, posted for elective laparoscopic surgeries under general anaesthesia were included in the study. The patients were randomly allocated to two groups (n = 42 each). Immediately after induction, patients in the first group (group I) received 4 mg ondansetron with 8 mg dexamethasone, and patients in the second group (group II) received 0.075 mg palonosetron. Any incidences of nausea and/or vomiting, the requirement of rescue antiemetic, and side effects were recorded. In group I, 66.67% of the patients had an Apfel score of 2, and 33.33% of the patients had a score of 3. In group II, 85.71% of patients had an Apfel score of 2, and 14.29% of the patients had a score of 3. At 1, 4, and 8 hours, the incidence of PONV was comparable in both groups. At 24 hours there was a significant difference in the incidence of PONV in the group treated with ondansetron with dexamethasone combination (4/42) when compared to the palonosetron group (0/42). The overall incidence of PONV was significantly higher in group I (23.81%: ondansetron and dexamethasone combination) than in group II (7.14%: palonosetron). The need for rescue medication in group I was significantly high. Conclusion: Palonosetron was more efficacious compared to the combination of ondansetron and dexamethasone for preventing PONV for laparoscopic gynaecological surgery.

Implementation of a risk-stratified approach to prevent postoperative nausea and vomiting in an institution with high baseline rates of prophylaxis.

Background and Aims:Although a risk-adjusted approach to preventing postoperative nausea and vomiting (PONV) is generally recommended, the successful implementation of such practice without mandated protocols remains elusive. To date, such a strategy has never been adapted to curb high baseline rates of prophylaxis.Material and Methods:We conducted an observational study on a cohort of patients undergoing elective surgery before and after the implementation of a quality improvement initiative including a risk-stratified approach to prevent PONV. The primary outcome was the number of prophylactic interventions administered. Secondary outcome included the repetition of ineffective medications and the need for rescue medication in the post-anesthesia care unit (PACU).Results:A total of 636 patients were included; 325 patients during the control period and 311 after the intervention. The educational program failed to reduce the amount of prophylactic antiemetics administered (2.0 vs. 2.6, P < 0.001) and the repeat administration of ineffective medications for rescue (16% vs. 20%, P = 0.15). More patients in the intervention group required rescue medication compared to the control group (16.9% vs. 9.7%; P = 0.04).Conclusion:Implementation of best practices to combat PONV remains elusive. Our results indicate that difficulties in changing provider behavior also apply to institutions with high prophylactic antiemetic administration rates.

Intravenous Sodium Valproate Versus Dexamethasone Evaluation for Migraine Headache Pain Control in Acute Setting: A Randomized, Controlled, Double-Blind Study

Introduction: Migraine is a common disease in the emergency department (ED), which is capable of imposing limitations on people’s activity and imposing a high cost on the government. There are a lot of common treatments for migraine. In numerous studies, sodium valproate is included, among other treatments. This Study designed for efficacy evaluation of Sodium Valproate versus Dexamethasone in acute migraine headache pain control. Method: A controlled clinical trial has been established for ED patients with compliant of acute migraine headaches. 108 patients were included and categorized into two groups based on a randomized schedule: one with 1200 mg sodium valproate and another with 8 mg dexamethasone in 150 mL normal saline, which was IV infused in 10 minutes. As a primary outcome, pain visual analog scale (VAS) score was determined and compared on arrival and minutes 30, 60 and 120 after intervention, and as a secondary outcome, the percentage of rescue from headache through medication and sustainability of freedom and relief from headache were determined and compared between the two groups. Results: The mean decline of pain VAS score (0–10) in the sodium valproate group was 2.33 SD (1.74) and 3.49 SD (2.56), and in the dexamethasone group, it was 2.20 SD (1.86) and 3.30 SD (2.45) in the first and second hours after intervention, respectively. In each group, they are statistically significant (P &lt; 0.05), even though there was no statistically significant difference between the two groups of study (P &gt; 0.05). In terms of need for rescue medication, in the sodium valproate group, 30/54 (55.6%) people and in the dexamethasone group, 33/54 (61.1%) people used the medication; however, there were no statistically significant differences found between the two groups (P &gt; 0.05). Conclusion: Probably it can be concluded that there is no statistically significant difference between the efficacy of 1200 mg IV sodium valproate compared and 8 mg IV dexamethasone in reducing acute migraine headache Keywords: Sodium valproate, dexamethasone, acute migraine, pain control.

Comparison between intravenous and intrathecal clonidine for postoperative analgesia of patients submitted to laparoscopic cholecystectomy: randomized clinical trial

Introduction and objectivesAlpha2 adrenergic agonists, such as clonidine, are used as adjuvants during anesthesia due to their analgesic, sedative, and cardiovascular effects. The objective of the present study was to compare the effect of clonidine administered intravenously and intrathecally on the postoperative pain score of patients undergoing laparoscopic cholecystectomy, according to the route of administration and postoperative opioid consumption. MethodsThis randomized clinical trial, blind to patients and evaluator, assessed 60 patients, candidates for elective laparoscopic cholecystectomy under standardized general anesthesia techniques. Patients were randomly allocated into three groups (20 in each group): Control Group (CG), Intrathecal Clonidine Group (ITCG), and Intravenous Clonidine Group (IVCG). The primary outcome was the comparison of pain, Blood Pressure (BP) and Heart Rate (HR) scores among groups. The secondary outcome was report of adverse effects such as bradycardia, hypotension and sedation, and the need for rescue medication. ResultsThe mean age was 37.2 ± 8.2 years, and the mean body mass was 28.3 ± 3.6 kg.m-2. Regarding HR (p = 0.003) and pain (p = 0.027), patients in ITCG and CG showed a different profile over time, with CG showing higher consumption of morphine as rescue medication (p = 0.005). ConclusionThe administration of intrathecal and intravenous clonidine in low doses can reduce hemodynamic parameters and decrease postoperative requirement of analgesics. Further studies should investigate the ideal dose and method.

Analgesics for Dental Implants: A Systematic Review.

Postsurgical pain is commonly associated with dental and oral surgery, and the use of analgesics has been investigated in the management of postoperative pain. This systematic review summarizes available evidence on analgesics used to manage dental implant surgery postoperative pain, to identify best therapeutic protocols and knowledge gap. A comprehensive search was conducted including MEDLINE/Pubmed, EMBASE, SCOPUS, clinicaltrials.gov, and the Cochrane Database of Systematic Reviews through May 2020. Only randomized controlled trials were included. PRISMA guidelines were followed, and risk of bias was appraised using Cochrane RoB2 tool. Eleven trials (762 patients overall) were included. Some aspects limited the feasibility of a meaningful meta-analysis; thus, a narrative synthesis was conducted. Risk of bias was low in four studies and high in two studies, while five studies raised some concerns due to the randomization process. Analgesic use seemed to be associated with improved postoperative outcomes (pain, patient’s satisfaction, and need for rescue medication) when compared to placebo. Overall, this review suggests that the administration of analgesics may provide some advantages in the management of postoperative outcomes after dental implant placement, while indications about the best analgesics cannot be provided.

Anti-Inflammatory Effectiveness of Oral Dexamethasone 4 mg on Mandibular Third Molar Surgeries: A Split-Mouth Randomized Clinical Trial

This study aimed to evaluate the anti-inflammatory effect of oral dexamethasone 4mg in a single dose preemptively administered to reduce pain, swelling, and trismus following mandibular third molar surgeries. A split-mouth randomized clinical trial was performed including 22 participants undergoing surgical removal of bilateral and symmetrically positioned third molars. A total of 44 teeth were allocated by simple randomization to either the test or nonintervention/control side. Oral dexamethasone 4mg was administered on the test side an hour before the surgery. All of the participants were unaware of the medication studied, and only 1 surgeon, blinded to the medication intake, performed all of the procedures. Anti-inflammatory effect was evaluated using the clinical parameters of mouth opening, swelling, and rescue analgesic medication intake to control pain. The statistical analysis was blinded to the allocation groups, and a significance value P<.05 was adopted for all the tests. Dexamethasone reduced the mean of rescue analgesic medication intake by 5 times (P=.002). Facial swelling was lower on the test side by 72h postsurgery in comparison with the control side (P=.036). No significant difference in mouth opening was found between the groups. Preemptive use of oral dexamethasone 4mg proved to be effective in controlling pain and reducing the need for rescue medication and had a beneficial effect in reducing swelling during a short postoperative period.

Low-dose Ketamine For Acute Pain Control in the Emergency Department: A Systematic Review and Meta-analysis.

There has been increased interest in the use of low-dose ketamine (LDK) as an alternative analgesic for the management of acute pain in the emergency department (ED). The objective of this systematic review was to compare the analgesic effectiveness and safety profile of LDK and morphine for acute pain management in the ED. Electronic searches of Medline and EMBASE were conducted and reference lists were hand-searched. Randomized controlled trials (RCTs) comparing LDK to morphine for acute pain control in the ED were included. Two reviewers independently screened abstracts, assessed quality of the studies, and extracted data. Data were pooled using random-effects models and reported as mean differences and risk ratios (RRs) with 95% confidence intervals (CIs). We used the Grading of Recommendations Assessment, Development and Evaluation approach to assess the certainty of the evidence. Eight RCTs were included with a total of 1,191 patients (LDK=598, morphine=593). There was no significant difference in reported mean pain scores between LDK and morphine within the first 60minutes after analgesia administration and a slight difference in pain scores favoring morphine at 60 to 120minutes. The need for rescue medication was also similar between groups (RR=1.26, 95% CI= 0.50 to 3.16), as was the proportion of patients who experienced nausea (RR=0.97, 95% CI= 0.63 to 1.49) and hypoxia (RR=0.38, 95% CI= 0.10 to 1.41). All outcomes were judged to have low certainty in the evidence. Low-dose ketamine and morphine had similar analgesic effectiveness within 60minutes of administration with comparable safety profiles, suggesting that LDK is an effective alternative analgesic for acute pain control in the ED.

Efficacy and Safety of Ibuprofen Plus Paracetamol in a Fixed-Dose Combination for Acute Postoperative Pain in Adults: Meta-Analysis and a Trial Sequential Analysis.

Ibuprofen and paracetamol (acetaminophen) are very commonly used for analgesia and pain. In 2020, the US FDA gave its first approval of a fixed-dose combination (FDC) of the two drugs in the same tablet for postoperative pain. There has been no quantitative, summative analysis of the FDC effect size measures against postoperative pain in adults. Similar analyses exist, but only in pediatric patients. This was the first meta-analysis to compare the efficacy and safety outcomes of the ibuprofen/paracetamol FDC against placebo, administered postoperatively, for moderate to severe pain relief in adults. The MEDLINE, EMBASE, and Cochrane CENTRAL databases, in addition to the grey literature, were searched for clinical trials until April 2020, to identify comparative literature studies of the ibuprofen/paracetamol FDC in acute postoperative pain in adults. No restrictions on doses, formulations (oral, intravenous), and underlying type of surgery were applied. Independent reviewers performed the study selection, data extraction, and the risk-of-bias and quality-of-evidence assessments based on the Cochrane criteria. The outcome measures of interest in the meta-analysis were ≥ 50% pain relief , need for rescue medications, and occurrence of adverse drug events. Statistical analyses using a random-effects model were performed, at a statistical significance of p < 0.05. The RevMan software was used for analysis. A trial sequential analysis (TSA) was conducted to assess how precise and conclusive the meta-analysis outcomes are. Seven double-blind, randomized controlled trials with 2947 participants were included. The FDC dose was at three different levels: 75-100mg ibuprofen/250mg paracetamol, 150-200mg ibuprofen/500mg paracetamol (FDA-approved dose level), and 292.5-400mg ibuprofen/975-1000mg paracetamol. The ≥ 50% pain relief outcome was more achieved with the FDC compared to placebo (risk ratio [RR] 2.60, 95% confidence interval [CI] 2.11-3.20, p < 0.00001), as was the reduced need for rescue medications (RR 0.51, 95% CI 0.37-0.71, p < 0.0001). While inconclusive based on TSA, the FDC was at the highest doses at least as well tolerated as placebo regarding the occurrence of adverse events, including severe, common, and treatment-related adverse events, as well as those that lead to discontinuation, but it was also significantly associated with lower rates of headache and nausea. Subgroup analyses confirmed that the efficacy and safety of the FDC were maintained regardless of doses and formulations. The sensitivity analysis confirmed outcomes against potential publication bias and identified sources of heterogeneity in analyses. The ibuprofen plus paracetamol FDC is conclusively an effective analgesic against placebo in acute postoperative, moderate to severe pain in adults. It is also superiorly well tolerated, including at the higher dose of 292.5-400mg ibuprofen/975-1000mg paracetamol; however, safety outcomes were inconclusive. Future studies need to confirm the safety of FDC and itsbenefits against other marketed analgesics in postoperative pain.

Characteristics of COPD patients treated with single‑inhaler triple therapy inreal-life clinical practice.

Inflammation associated with chronic obstructive pulmonary disease (COPD) causes narrowing of the airways and destruction of the lung parenchyma. The triple therapy (ICS+LABA+LAMA) may improve lung function, patient‑reported outcomes, and exacerbation risk in a specified subset of GOLD group D patients. A better understanding of the factors leading to the single‑inhaler triple therapy (SITT) prescription in real-life scenario is still an unmet need. We assessed the characteristics of 838 GOLD group D patients treated with SITT and way of how those patients had been routinely managed before in their outpatient settings. The cross-sectional observational survey was based on an assessment of routine practice patterns and retrospective collection of anonymous medical data. Severe and very severe forms of airflow obstruction were experienced by 52 % and 34% of patients, respectively. The mean number of exacerbations during the 12‑month period antecedent to SITT prescription was 2.01. Before starting SITT, various combinations of COPD medications were prescribed: LABA (95 %), followed by ICS and LAMA. Compared to patients with 0-1 exacerbation, the patients with ≥2 exacerbations had higher levels of mMRC and CAT scores (2.47 vs 2.69 and 16.02 vs 19.31, respectively, both p <0.001), worse treatment adherence and higher need for rescue medication (4.7 vs 3.9 units, p=0.0011). The driver for switching the treatment to SITT was an expected improvement in lung function followed by reduction in dyspnoea and number of exacerbations. Despite current treatment, the burden of COPD remains significant in GOLD group D patients. The lung function, symptoms burden and exacerbation history are among the most important factors involved in the decision for stepping up to SITT with potential roles of both bronchodilator and anti-inflammatory components (Tab. 2, Fig. 9, Ref. 66).

Efficacy of Antiemetic Regimens for Prevention and Treatment of Chemotherapy-Induced Nausea and Vomiting in Patients of Breast Cancer Receiving Highly Emetogenic Chemotherapy

Abstract Background: Chemotherapy is fraught with serious and troublesome adverse effects, of which nausea and vomiting appears earliest and is the most disturbing. Therefore, this study was planned to investigate the antiemetic drug regimens used for chemotherapy-induced nausea vomiting (CINV) in patients with breast cancer receiving highly emetogenic chemotherapy (HEC). Subjects and Methods: An observational follow-up study was conducted to assess the efficacy of antiemetic regimens in breast cancer patients receiving HEC. A total of 71 newly diagnosed patients with breast cancer were included in the study. Patients were assessed for nausea by the visual analog scale, and a history of emetic episodes and need for rescue medication were recorded at 0 h, 6 h, 24 h, 48 h, and 120 h post-chemotherapy till three cycles. Results: The patients were prescribed a combination of ondansetron and dexamethasone (n = 23, n = 17, and n = 13 in first, second, and third cycle, respectively) or a combination of aprepitant, ondansetron, and dexamethasone (n = 48, n = 54 and n = 56 in the first, second, and third cycle, respectively). The intensity of nausea was higher for the patients who were prescribed ondansetron and dexamethasone regimen as compared to patients prescribed aprepitant additionally. Complete response, i.e., no emesis and no rescue medication, was higher in triple-drug regimen (52% vs. 0.4%, 63% vs. 17.6%, and 69% vs. 23% in three cycles, respectively). Conclusion: The control of CINV was better with a combination of aprepitant, ondansetron, and dexamethasone as compared to a regimen without aprepitant.

Effect of St. John's wort oil and olive oil on the postoperative complications after third molar surgery: randomized, double-blind clinical trial.

This multicenter study aimed to evaluate the effects of St. John's wort oil and virgin olive oil on the postoperative complications and compare this with chlorhexidine gluconate plus benzydamine hydrochloride mouthwash after the removal of impacted third molar. A total of 90 patients in need of impacted third molar surgery were included in this study. All included patients were randomly divided into 3 groups. The patients in group 1 received St. John's wort oil; the patients in group 2 received virgin olive oil, and those in group 3 received mouthwash containing chlorhexidine gluconate plus benzydamine hydrochloride. The self-reported pain and difficulty during jaw function, trismus, facial swelling, number of analgesics used during first postoperative week, and postoperative periodontal condition including plaque accumulation, bleeding on probing, and periodontal pocket depth were compared between the groups. No significant differences were found regarding the study variables. The data of the present study supports that the use of essential oils provides efficient alternative to the gold standard chlorhexidine gluconate mouthwash in reducing postoperative complications and improving healing process without adverse effects after surgical removal of impacted third molars. The use of essential oils showed similar results as the chlorhexidine gluconate mouthwash regarding swelling, mouth opening, pain, need for rescue medication, infectious complications (i.e., alveolar osteitis), and periodontal healing. Therefore, essential oils can be an alternative to routine mouthwashes to ensure oral hygiene after impacted third molar surgery.

A sport cream (Harpago-Boswellia-ginger-escin) for localized neck/shoulder pain.

Neck/shoulder, sudden pain, or muscular pain (not associated to structural or bone/joints components), due to fascial or muscular strain is common in active subjects, in non-professional athletes and sports performers. The aim of this supplement registry was the evaluation of a cream based on natural, active ingredients for topical application in supporting the improvement of pain and improving head/neck mobility, possibly minimizing the use of systemic drugs. The cream includes standardized active ingredients of natural origin as an extract of Harpagophytum procumbes, an extract from Boswellia serrata, a CO2 extract of ginger and escin. Subjects were divided into three groups, all using the standard management (SM) in combination with the Sport Cream or in addition to Flector (diclofenac) patch. The groups were comparable and homogeneous at the baseline. No side effects or skin tolerability issues were observed with the Sport Cream nor with the SM or diclofenac patches. Subjects receiving sport cream + SM reported a significant improvement in pain, stiffness, altered mobility and altered working capacity, with a reduced need for rescue medication (diclofenac) compared to subjects in the other two groups. Finally, subjects receiving sport cream + SM reported a more remarkable decrease in skin temperature in the affected area associated to an improvement in clinical symptoms.

Allergen Immunotherapy for Local Respiratory Allergy.

Local respiratory allergy (LRA) is an eosinophilic phenotype of chronic airway disease. Three entities have been described within the LRA spectrum: local allergic rhinitis (LAR) and local allergic asthma (LAA) in non-atopic patients, and dual allergic rhinitis (DAR) in atopic patients (coexistence of LAR and allergic rhinitis). In this article, we aim to review the current evidence on the therapeutic options for LRA. No controlled study has assessed the effect of standard therapy (oral antihistamines, intranasal or inhaled corticosteroids, bronchodilators) in LRA subjects. Three randomized clinical trials and one observational study demonstrated that allergen immunotherapy (AIT) is able to control nasal and ocular symptoms, decrease the need for rescue medication, and improve quality of life in LAR individuals. Nasal or inhaled steroids can be expected to improve eosinophilic inflammation in LRA patients but cannot change the natural course of the disease. Moreover, the long-term and disease-modifying effects of AIT in LRA subjects need to be investigated.

The use of 3 selected lactobacillary strains in vaginal probiotic gel for the treatment of acute Candida vaginitis: a proof-of-concept study.

In vitro studies suggest that certain probiotic bacterial strains have potential activity against opportunistic infections such as Candida. There are few in vivo trials using probiotics as a single treatment for acute Candida vulvovaginitis (CV). In this open-label, proof-of-concept study, selected Lactobacillus strains were tested in women with acute Candida vaginitis. Twenty women diagnosed with proven, symptomatic CV were instructed to administer a vaginal probiotic gel with L. plantarum YUN-V2.0, L. pentosus YUN-V1.0 and L. rhamnosus YUN-S1.0 for 10 consecutive days. Vaginal rinsing fluid, vaginal culture swab and vaginal smear for fresh wet-mount microscopy were collected before and 7, 14 and 28days after start of treatment. On average, participating women were 39years old and had an history of 5 vaginal infections of which 95% was CV. Nine women (45%) completed the study without the need of rescue medication. Women who needed rescue treatment experienced twice as much Candida infections in the past. A negative correlation was found between the clinical composite score and the time to use rescue medication (R2 = 0.127). Seventy-four per cent of participants found the study gel comfortable to use, and 42% of all women would use the tested gel again for this indication. Forty-five per cent of women were treated successfully for acute CV with a novel vaginal gel containing 3 selected Lactobacillus strains. Patients needing rescue treatment were suffering from more severe and long-standing disease. These results warrant for further testing of this new product, especially of its potential in cases with mild to moderate severity, as an adjuvant to antimycotics or as a preventive measure in women with recurrent vulvovaginal candidosis.

The analgesic efficacy of IV acetaminophen for acute postoperative pain in C-section patients: a randomized, double-blind, placebo-controlled study

Background The rate of cesarean delivery is on the rise in the USA. Satisfactory postoperative analgesia remains a top priority for cesarean delivery. Multimodal analgesia with a reduction in opioid consumption and improvement in patient satisfaction is a goal for anesthesiologists caring for this patient population. Our study sought to assess whether IV acetaminophen in four divided doses over 24 h decreased pain scores and opioid requirements in patients undergoing cesarean delivery with neuraxial anesthesia. Methods 66 patients undergoing elective cesarean delivery under spinal anesthesia with hyperbaric bupivacaine 12 mg, fentanyl 10 µg, and preservative-free morphine 150 µg were randomized to receive either IV acetaminophen or IV placebo for four consecutive doses in the first 24 h postoperatively. The need for rescue medication using morphine equivalence, pain scores, patient satisfaction, and side effects were assessed by a blinded researcher in the first 24 and 48 h postoperatively. Results There was no difference in opioid requirements in the acetaminophen versus placebo group, 44.32 ± 23 mg versus 47.59 ± 28 mg (p = .607), respectively at 24 h. There was also no difference at 48 h, 57.95 ± 20 mg versus 56.59 ± 22 mg (p = .795). Postoperative pain scores, patient satisfaction, and adverse events were similar in both groups as well. Conclusions The results of this study failed to demonstrate any additional benefits of administering multiple doses of IV acetaminophen for treating postoperative pain in patients who have undergone CS surgery and receiving intra-thecal morphine as part of their anesthesia and analgesia. Trial Registry number NCT02069184

Local Infiltration Analgesia with Ropivacaine Improves Postoperative Pain Control in Ankle Fracture Patients: A Retrospective Cohort Study.

Purpose The study aimed at investigating the effect of local infiltration analgesia (LIA) with ropivacaine on postoperative analgesia for patients undergoing ankle fracture surgery. Methods Consecutive patients were retrospectively included and analysed according to their medical records from July 2014 to August 2018 in a tertiary hospital. Inclusion criteria were patients undergoing open reduction and internal fixation (ORIF) for ankle fractures under general anaesthesia. Moreover, patients should have received intravenous patient-controlled analgesia (iPCA) or LIA + iPCA for postoperative pain relief. The primary outcome indicator was visual analogue scale (VAS) from 8 hours to 48 hours after surgery. Secondary outcomes included postoperative opioid requirement, need for rescue medication, opioid-related adverse effects, and wound complications. Results In total, 89 consecutive patients were included in the study. There were 48 males and 41 females. The average age was 44.6 ± 7.0 years, and VAS scores were significantly lower in the LIA + iPCA group at 8 hours after surgery (1.51 ± 0.58 cm vs 4.77 ± 1.83 cm, p < 0.001). The time to first tramadol consumption was longer (580 ± 60.9 minutes vs 281 ± 86.4 minutes, p < 0.001). The time to first tramadol consumption was longer (580 ± 60.9 minutes vs 281 ± 86.4 minutes, p < 0.001). The time to first tramadol consumption was longer (580 ± 60.9 minutes vs 281 ± 86.4 minutes, p < 0.001). The time to first tramadol consumption was longer (580 ± 60.9 minutes vs 281 ± 86.4 minutes, p < 0.001). The time to first tramadol consumption was longer (580 ± 60.9 minutes vs 281 ± 86.4 minutes, Conclusions The retrospective cohort study indicates that LIA with ropivacaine can provide better early postoperative pain management with a reduction of VAS scores for ankle fracture surgery. Patients receiving wound infiltration also experience decreased opioid consumption, a lower rate of analgesia-related side effects, and comparable wound complication rate.