Systemic Anti-inflammatory Medications Research Articles

Operative treatment of the rheumatic shoulder

The duration and severity of rheumatic diseases of the shoulder correlate with symptom frequency, structural changes and associated functional limitations. The multifactorial character of the underlying rheumatic disease requires a multimodal therapeutic concept including interaction of surgical and non-surgical disciplines. In addition to basic systemic anti-inflammatory medication, injections targeting the synovial tissue by corticoid instillation and glenohumeral radiosynoviorthesis (with an intact rotator cuff) are further options. Operative interventions on rheumatic shoulders can be characterized as disease-modifying, protective, reconstructive or palliative, depending on the stage. Combining minimally invasive arthroscopic surgical techniques with modern basic therapy has the potential to shift the indications for operative interventions towards an earlier stage of disease without favoring or propagating structural alterations which have already occurred. In cases of severe joint destruction with loss of the rotator cuff, reverse shoulder arthroplasty can be an appropriate option.

CLINICAL CHALLENGE: SYSTEMIC RHIZOPUS MICROSPORUS INFECTION WITH RENAL CAVITATION IN A GREY SEAL (HALICHOERUS GRYPUS)

A 22-yr-old, intact female grey seal (Halichoerus grypus) (wt: 155 kg) had limited prior medical history other than persistent perionychitis of the right pedal flipper. Four years before the current presentation, this problem had been resolved completely by skeletal amputation of the right pedal digit 3 distal phalanx. During that same year, and progressive over the following 3 yr, the seal developed cataracts and keratopathy including corneal vascularization, pigmentation, and edema. It was elected to perform cataract removal, corneal debridement, and placement of subconjunctival cyclosporine implants (Lux Biosciences Inc., Jersey City, New Jersey 07302, USA; lot# 47614, 0.75 inch). Postoperative treatment (Fig. 1) was initiated with systemic broadspectrum antibiotics, anti-inflammatory and antifungal medications, gastroprotectants, and topical ophthalmic care that included antibiotics and anti-inflammatory medications. After 6 mo of treatment, no substantial improvement to the seal’s ophthalmic status was noted. The corneal hyperpigmentation OU had recurred and a stromal abscess OD had developed. Additionally, the seal presented with non-

Successful Long-term Use of Oral Isotretinoin for the Management of Morbihan Disease

BACKGROUND Morbihan disease (MD) is characterized by persistent erythema and solid edema of the upper two-thirds of the face. It is generally regarded as a late-stage complication of rosacea, although its etiology is poorly understood. The standard therapeutic management includes systemic anti-inflammatory medications; however, the clinical response, if any, is often unsatisfactory. We review the current challenges and a promising new option for the treatment of MD. OBSERVATIONS Five cases of MD were treated with long-term (>6 months; mean, 16 months) oral isotretinoin, with documented nonrecurrence. The mean sustained daily dose was 60 mg/d (range, 40-80 mg/d), and the mean cumulative dose was approximately 285 mg/kg (range, 170-491 mg/kg). The total treatment period ranged from 10 to 24 months, with a mean disease-free follow-up period of 9 months (range, 1-24 months). A substantial clinical improvement was not noted until 6 months of treatment in all 5 cases. CONCLUSIONS We report 5 cases of MD that were successfully treated with long-term oral isotretinoin, with lasting results. Further research is required to better understand the pathogenesis of MD and isotretinoin's mechanism of action in this condition.

Successful Clinical Management of Temporary Blindness In A Horse: A Case Report

Abstrac: Treatment of progressive blindness of both the eyes was attempted in field condition in horse. In this study, a case of equine was presented and since there was constraint of proper diagnosis and treatment, how the case was successfully managed in field condition was projected. After a careful examination, the treatment protocol included Injections of streptopencillin 2.5 g daily twice intramuscularly along with multivitamin injection Hivit daily once for one week and Inj. Melonex was given 10 ml intramuscularly daily for one week was given. The topical and systemic anti-inflammatory medications i.e. Genticyn- HC drops locally and betnesol eye ointment 0.1% w/w (Glaxo) was used 2-3 times a day. With this we could successfully treat the case within a week period. Keyword: Leopard; Immobilization; Xylazine-ketamine; Atepamezole I. Introduction: Uveitis is an immune-mediated disease. Impairment of the normal blood-aqueous barrier in the iris and ciliary body vasculature owing to inflammation is the underlying cause of the clinical signs (Kern, 1987). Uveitis unfortunately is often misdiagnosed as something less severe or in some cases it is totally ignored. It is important that uveitis be diagnosed correctly because lack of or incorrect treatment can have serious consequences (Nelson, 1995). Case presentation: A male horse of age six yrs was brought to veterinary hospital Deorania District Bareilly, with the history of development of progressive blindness of both the eyes. There was no associated history of trauma or accident. Rectal temperature was found to be 103 0 F and the heart rate was 45 per minute. It was reported that the horse was not taking feed properly for the past one week. Due to the limited facilities available in the field only the animal’s faecal examination could be done which was found to be negative for any parasitic ova. II. Clinical examination and treatment On examination of eye carefully it was found that animal had blepherospasms, epiphora, corneal edema, and fibrin clots in the anterior chamber with miosis. Which are the typical signs of acute uveitis. The animal was carefully examined for the reflexes. It was found that animal was having his bilateral vision compromised. The pupillary reflex was found to be present but the animal was unable to walk straight due to blindness. Injections of streptopencillin 2.5 g daily twice was administered intramuscularly along with multivitamin injection Hivit daily once for one week and Inj. melonex was given 10 ml intramuscularly daily for one week. Although diagnosis of the causative agent in this case could not be made due to inadequate facilities but the fact that acute uveitis may be caused due to leptospira infection, which is one of the most common ocular diseases in horses characterized by episodes of active inflammation followed by varying periods of quiescence led us to take a decision on treating the case symptomatically. The topical and systemic anti-inflammatory medications i.e. Genticyn- HC drops locally and betnesol eye ointment 0.1% w/w (Glaxo) was used 2-3 times a day. Injections of meloxicam 15 ml intravenously was given for one week had solved the problem of pain and inflammation and also the corneal edema. Atropine ointment was also used locally which paralyses the iris sphincter and cilliary body musculature. These effects reduce the muscle spasms but along with it a regular history of the defecation was taken to monitor the gut motility which is affected by atropine applied topically also. Injection dexamethasone 10 ml (4mg/ ml) was also given initially for a period of four days intramuscularly. Amazingly it was found that the animal slowly recovered from the compromised vision and started to have a near normal vision within a week period. The treatment was continued for a period of one more week after a gap of another four days.

What Is New After 40 Years of Glaucoma Implants

Forty years ago, Molteno introduced the prototype of the present day long tube implant. Since then, modifications in size and shape and introduction of valve system have taken place. Aqueous has been shown to contain proinflammatory substances that have been shown to influence the thickness of the bleb wall, and the hypertensive phase has been seen with the implants. The effect of the aqueous may be modified by the use of systemic antiinflammatory medication or by surgical modification, namely supra-Tenon insertion of the implant. Recent studies have shown that tube implantation is as efficacious as trabeculectomy in patients who were either pseudophakic or earlier had failed filters. Newer nontube implants, such as the Express shunt, have been introduced along with others, such as the gold micro shunt implant and the iStent, presently in clinical trials.

Intravitreal Steroid Slow-Release Device Replacing Repeated Intravitreal Triamcinolone Injections for Sympathetic Ophthalmia

To report on the intraocular use of a steroid slow-release device in an attempt to avoid multiple intraocular triamcinolone injections in chronic sympathetic ophthalmia. A 47-year-old patient with sympathetic ophthalmia had received 17 intravitreal triamcinolone injections to suppress the uveitis, to increase intraocular pressure, and to reduce systemic anti-inflammatory medication. To avoid the frequent reinjections combined with the temporary reduction in vision and potential risk of infection and a recurrence of sympathetic ophthalmia, a slow-release device of 2.1-mg fluocinolone acetonide was intravitreally implanted. During the follow-up of 11 months after the procedure, intraocular pressure stabilized at 12 to 18 mmHg and visual acuity at 0.40 to 0.50. The systemic immunosuppressive therapy was stopped, and consequently, the insulin treatment could be halted. Despite the limitations of a single case report, the results suggest that an intravitreal slow-release device of fluocinolone may be an alternative to repeatedly administered intravitreal triamcinolone injection for the long-term treatment of sympathetic ophthalmia. The intraocular slow-release application of steroids has enabled patients to live free from diabetic treatment and immunosuppressive medication after 21 years of systemic immunosuppressive therapy with secondary Cushing disease including diabetes mellitusand arterial hypertension.

Combined Fluocinolone Acetonide Intraocular Delivery System Insertion, Phacoemulsification, and Intraocular Lens Implantation for Severe Uveitis

To determine whether a three-year fluocinolone acetonide sustained drug delivery system can be implanted safely at the same time that phacoemulsification and intraocular lens (IOL) implantation are performed for a visually significant cataract in eyes with uveitis. Retrospective, single-center case series. All consecutive patients treated from April 1998 through September 2006 at an academic clinical practice with intermediate uveitis, posterior uveitis, or panuveitis requiring immunosuppressive therapy, periocular corticosteroid injections, or both. Phacoemulsification, IOL implantation, and fluocinolone acetonide implant insertion were performed during a single surgical session. The main outcome measures were preoperative and postoperative ocular inflammation, visual acuity (VA), intraoperative complications, anti-inflammatory medication use, IOP, and postoperative adverse events. Twenty-four eyes of 21 patients were studied. Mean follow-up duration was 27 months (range, six to 60 months). No patients had intraoperative complications. The mean Snellen VA at baseline was 20/316, which improved significantly to 20/75 at 12 months. The average number of recurrences in the 12 months before implantation was 2.2 episodes per eye. Only one eye experienced a recurrence at seven months after implantation. Topical corticosteroids, posterior sub-Tenon capsule injections, and systemic anti-inflammatory medications were reduced significantly at 12 months. Average IOP was unchanged after surgery compared with preoperative IOP; 15% underwent glaucoma filtering surgery. A fluocinolone acetonide implant insertion can be combined safely with phacoemulsification plus IOL implantation during the same surgical session in eyes with uveitis. VA generally was improved, uveitis recurrences decreased, and the need for immunosuppression decreased. The most common side effect was increased IOP.

Severe acute inflammatory reaction (SAIR) of the fetlock joint after intraarticular hyaluronate injection in a horse

Hyaluronate (HA) was administered by intra-articular injection to a 13-year-old Haflinger mare for treatment of metacarpophalangeal osteoarthritis. Ten hours after the injection, a severe inflammatory reaction developed in the treated joint. While awaiting results of synovial fluid analysis, treatment for iatrogenic infectious arthritis was initiated, but the analysis did not confirm sepsis. Clinical signs improved significantly following systemic non-steroidal anti-inflammatory medication and the horse was discharged three days later. Following an intravenous hyaluronate injection, four days after discharge, the synovitis recurred. Synovial fluid analysis did not show any abnormalities, but the clinical signs were severe. The severe acute inflammatory reaction required systemic non-steroidal anti-inflammatory and intra-articular corticosteroid treatment in order to resolve the problem.

Indication and effect of immunosuppression in patients with scleritis

The value of immunosuppressive drugs for the therapy of scleritis patients is unclear. The authors investigated the indications and effects of immunosuppression in a group of patients with scleral inflammation. Retrospective study of patients treated for scleritis (n = 87) or episcleritis (n = 18). The demographic factors, clinical symptoms, visual outcome, course of inflammation, ocular complications resulting from inflammation, topical and systemic antiinflammatory medication, and associated systemic diseases were analysed. Only one patient with episcleritis, but 37 with scleritis presented with ocular complications (P = 0.003). The vision was impaired in 15 patients with scleritis, but not in episcleritis patients (P = 0.022). In the group of patients with episcleritis, only those with frequent relapses required more than topical antiinflammatory drugs, especially systemic non-steroidals. In contrast, systemic therapy was indicated in all of the scleritis patients. Ocular complications were found more often in patients with necrotising (n = 7/10) or posterior scleritis (n = 10/11) than in those with diffuse (9/39) or nodular (11/27) scleritis. Compared with the other patients, associated systemic autoimmune diseases were more common in patients with necrotising scleritis (P = 0.03). The need for immunosuppression was associated with vision-threatening complications (glaucoma, uveitis, peripheral ulcerative keratitis) (P < 0.01), systemic autoimmune disease, and necrotising and posterior form of scleritis (P < 0.01). Quiescence of scleritis was obtained in 59 of the scleritis patients, and improvement of inflammation was achieved in further 21. In 26 patients, scleritis did not improve with systemic steroid or non-steroidal treatment, but with immunosuppression. Scleritis is often associated with life-threatening systemic diseases and vision-threatening ocular complications. In patients with severe scleritis, especially with the posterior and necrotising form, improvement can often be achieved with immunosuppression.

Systemic use of anti-inflammatory medications and age-related maculopathy: the Blue Mountains Eye Study

Purpose To assess whether an association exists between systemic use of anti-inflammatory medications at baseline and the prevalence or incidence of either late or early age-related maculopathy (ARM) in a population-based cohort. Methods 3654 participants of the Blue Mountains Eye Study baseline examination (1992–94) were followed during 1997–99. Use of anti-inflammatory medication was recorded during the baseline interview. After excluding 543 persons who died since baseline, 2334 (75% of the surviving participants) attended 5-year follow-up examinations. Retinal photographs taken during both examinations were graded using the Wisconsin Age-Related Maculopathy Grading System. Prevalence refers to the proportion of participants having ARM at baseline. Incidence refers to the proportion of participants without ARM at baseline who developed it over the 5-year period. Known ARM risk factors were adjusted for when assessing the relationship between use of anti-inflammatory medications and ARM. Results At baseline, 1010 (27.6%) of 3654 participants were current users of non-steroidal anti-inflammatory drugs (NSAIDs), 514 (14.1%) were past users and 1282 (35.1%) were ever users. The corresponding numbers of subjects reporting current, past or ever use of corticosteroids (including inhaled steroids) were 225 (6.2%), 519 (14.2) and 564 (15.4), respectively. Late ARM was present in 72 participants (2.0%) and early ARM was present in 171 participants (4.9%) at the baseline examination. During the follow-up period, 25 participants (1.1%) developed incident late ARM and 192 (8.7%) developed incident early ARM. After adjusting for age, sex, family history of ARM and smoking, no significant associations were evident for the use of NSAIDs or corticosteroids and the prevalence of either late or early ARM. There were also no associations found between use of these medications at baseline and the 5-year incidence of either late or early ARM. Conclusions No association was found between use of systemic anti-inflammatory medications and either the cross-sectional prevalence or longitudinal incidence of ARM in this population.

Laser-Facilitated arthrodesis of the distal tarsal joints

Abstract Arthritis of the distal tarsal joints is a common cause of lameness in performance horses. Clinical signs of distal tarsal arthritis are variable and may include gait abnormalities typical for tarsal lameness, including accentuated elevation of the affected limb, shortened cranial phase of the stride, and decreased arc of the foot. Affected horses frequently resent palpation of the lumbar and gluteal musculature. The lameness is usually increased after a hind limb flexion test. This condition is most commonly treated with intra-articular injections of sodium hyaluronate and corticosteroids in conjunction with controlled exercise and systemic nonsteroidal anti-inflammatory medication. Horses that are refractory to this form of treatment have traditionally been treated by cunean tenectomy with inconsistent results. Various surgical techniques have been used to achieve arthrodesis of these joints in an effort to eliminate the lameness associated with arthritic changes in these joints. Laser-assisted arthrodesis offers a minimally invasive surgical procedure with a relatively short convalescent period that eliminates the clinical signs of lameness in a high number of cases.

Lens-induced uveitis.

has been described in humans and many animal species. Traumatic rupture of the lens capsule may result in vision-threatening intraocular inflammation that is poorly responsive to medical management. Phthisis bulbi, persistent uveitis or glaucoma often occurs in these eyes. Surgical removal of the lens material is generally indicated shortly after the injury in an effort to preserve vision. Leaking of lens proteins through an intact lens capsule may result in a lympho-plasmacytic anterior uveitis. This is most commonly associated with the presence of a hypermature cataract. The presence of lens-induced uveitis prior to cataract surgery significantly reduces the success rate of cataract surgery. Small amounts of circulating lens proteins maintain a normal T-cell tolerance for lens proteins. Lens-induced uveitis develops when a breakdown occurs of this normal T-cell tolerance. Immune complexes play an important role in the tissue damage associated with the ensuing inflammation. Other factors associated with the tissue damage include hydroxyl radicals, nitroxide radicals, and hydrogen peroxide and arachidonic acid metabolites. Treatment consists of topical and systemic anti-inflammatory medications, mydriatic agents, and glaucoma medications when indicated. Experimental pharmacological agents include dual cyclooxygenase/lipoxygenase inhibitors, interleukin-1 blockers, antioxidants and hydroxyl radical scavengers.

Fluocinolone acetonide sustained drug delivery device to treat severe uveitis

Purpose Uveitis is often a chronic disease requiring long-term medical therapy. In this report, we describe a pilot safety and efficacy trial of a novel sustained drug delivery system containing fluocinolone acetonide to treat patients with severe uveitis. Design Prospective, noncomparative, interventional case series Participants Patients with severe uveitis. Methods Sustained drug delivery devices designed to release fluocinolone acetonide for at least 2.5 years were implanted through the pars plana into the vitreous cavity of seven eyes of five patients. All patients had severe uveitis not well controlled with, or intolerant to, repeated periocular corticosteroid injections, systemic corticosteroids, nonsteroidal immunosuppressive agents, or a combination thereof at the time of device implantation. Before device implantation, patients underwent complete evaluation including history, ophthalmologic examination, fluorescein angiography, visual field testing, and electroretinography. After surgery, patients were reexamined at 1 week, 2 weeks, 4 weeks, and at 1- to 3-month intervals. Visual fields, electroretinograms, and fluorescein angiography were repeated at 3- to 6-month intervals. Main outcome measures Preoperative and postoperative visual acuity, ocular inflammation, anti-inflammatory medication use, and intraocular pressure. Results Patients had a diagnosis of Behçet’s syndrome (two eyes), or idiopathic panuveitis (five eyes, including two with necrotizing retinitis, two with progressive chorioretinitis, and one with iridocyclitis and intermediate uveitis). Patients were observed an average of 10 months (range, 5–19 months). All eyes had stabilized or improved visual acuity after device implantation, and four of seven eyes had an improvement of three lines or more. The mean initial visual acuity, measured by Snellen chart, was 20/207, and the mean final visual acuity was 20/57 ( P = 0.02). After surgery, at the final visit, no eye had clinically detectable inflammation, and all seven eyes had a marked reduction in systemic, topical, and periocular anti-inflammatory medication use. Four eyes had increased intraocular pressure 6 weeks to 6 months after device implantation. Intraocular pressure has been controlled on topical medications. No patient experienced intraoperative complications. Conclusions A fluocinolone acetonide sustained drug delivery device is a promising new therapy for the treatment of severe uveitis. Intraocular pressure must be carefully monitored long after device implantation. Based on these data, a randomized study of a larger group of patients is warranted.

Septic bursitis

Nine cases of septic bursitis are presented, and the literature on the subjectcomprehensively reviewed, with an emphasis on the clinical manifestations of septic bursitis in various anatomic locations. Physical activities associated with increased susceptibility to septic bursitis and systemic conditions that increase the severity of septic bursitis are catalogued. Analysis of the microbiology of cases reported in the literature demonstrates that greater than 80% of cases of septic bursitis are caused by Staphylococcus aureus and other gram-positive organisms. However, a wide variety of gram-negative microorganisms, fungi, and other infectious agents have been reported to cause septic bursitis and may lead to complications in diagnosis and treatment. The nine cases reported here demonstrate the potential severity of septic bursitis and emphasize that significant systemic complications may result from this common musculoskeletal infection. Indications for hospitalization and/or intravenous antibiotic therapy for septic bursitis include the presence of fulminant local infection, evidence for systemic toxicity, or infection in an immunocompromised patient. Patients who fail to respond to intravenous antibiotics and percutaneous aspiration of the bursa may require surgical drainage or bursectomy by one of several methods that have been proposed. There is some recent evidence that intrabursal corticosteroid injection for therapy of nonseptic subcutaneous bursitis may be more effective than systemic antiinflammatory medication or simple bursa aspiration.