Compression Neuropathies of the Upper Extremity: A Review

Compressive neuropathies of the forearm are common and involve structures innervated by the median, ulnar, and radial nerves. A thorough patient history, occupational history, and physical examination can aid diagnosis. Electromyography, X-ray, and Magnetic Resonance Imaging may prove useful in select syndromes. Generally, first line therapy of all compressive neuropathies consists of activity modification, rest, splinting, and non-steroidal anti-inflammatory drugs. Many patients experience improvement with conservative measures. For those lacking adequate response, steroid injections may improve symptoms. Surgical release is the last line therapy and has varied outcomes depending on the compression. Carpal Tunnel syndrome (CTS) is the most common, followed by ulnar tunnel syndrome. Open and endoscopic CTS release appear to have similar outcomes. Endoscopic release appears to incur decreased cost baring a low rate of complications, although this is debated in the literature. Additional syndromes of median nerve compression include pronator syndrome (PS), anterior interosseous syndrome, and ligament of Struthers syndrome. Ulnar nerve compressive neuropathies include cubital tunnel syndrome and Guyon’s canal. Radial nerve compressive neuropathies include radial tunnel syndrome and Wartenberg’s syndrome. The goal of this review is to provide all clinicians with guidance on diagnosis and treatment of commonly encountered compressive neuropathies of the forearm.

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Nonopioid, Multimodal Analgesia as First-line Therapy After Otolaryngology Operations: Primer on Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

Otolaryngology ◽

10.1177/0194599820947013 ◽

2020 ◽

pp. 019459982094701

Author(s):

John D. Cramer ◽

Michael L. Barnett ◽

Samantha Anne ◽

Brian T. Bateman ◽

Richard M. Rosenfeld ◽

...

Keyword(s):

Postoperative Pain ◽

Multimodal Analgesia ◽

Cochrane Library ◽

First Line ◽

Opioid Prescribing ◽

First Line Therapy ◽

Line Therapy ◽

Inflammatory Drugs ◽

Anti Inflammatory ◽

Effective Analgesia

Objective To offer pragmatic, evidence-informed advice on nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line therapy after surgery. This companion to the American Academy of Otolaryngology–Head & Neck Surgery (AAO-HNS) clinical practice guideline (CPG), “Opioid Prescribing for Analgesia After Common Otolaryngology Operations,” presents data on potency, bleeding risk, and adverse effects for ibuprofen, naproxen, ketorolac, meloxicam, and celecoxib. Data Sources National Guidelines Clearinghouse, CMA Infobase, National Library of Guidelines, NICE, SIGN, New Zealand Guidelines Group, Australian National Health and Medical, Research Council, TRIP database, PubMed, Guidelines International Network, Cochrane Library, EMBASE, CINAHL, BIOSIS Previews, ISI Web of Science, AHRQ, and HSTAT. Review Methods AAO-HNS opioid CPG literature search strategy, supplemented by PubMed/MEDLINE searches on NSAIDs, emphasizing systematic reviews and randomized controlled trials. Conclusion NSAIDs provide highly effective analgesia for postoperative pain, particularly when combined with acetaminophen. Inconsistent use of nonopioid regimens arises from common misconceptions that NSAIDs are less potent analgesics than opioids and have an unacceptable risk of bleeding. To the contrary, multimodal analgesia (combining 500 mg acetaminophen and 200 mg ibuprofen) is significantly more effective analgesia than opioid regimens (15 mg oxycodone with acetaminophen). Furthermore, selective cyclooxygenase-2 inhibition reliably circumvents antiplatelet effects. Implications for Practice The combination of NSAIDs and acetaminophen provides more effective postoperative pain control with greater safety than opioid-based regimens. The AAO-HNS opioid prescribing CPG therefore prioritizes multimodal, nonopioid analgesia as first-line therapy, recommending that opioids be reserved for severe or refractory pain. This state-of-the-art review provides strategies for safely incorporating NSAIDs into acute postoperative pain regimens.

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Avoidance of futile treatment and adverse events by using angiogenesis-specific imaging for early detection of disease progression in patients with first-line metastatic renal cell carcinoma.

Journal of Clinical Oncology ◽

10.1200/jco.2012.30.34_suppl.134 ◽

2012 ◽

Vol 30 (34_suppl) ◽

pp. 134-134

Author(s):

Stephen K. Gruschkus ◽

Carolyn Bodnar ◽

Amol Dhamane ◽

Manan Shah

Keyword(s):

Renal Cell Carcinoma ◽

Early Detection ◽

Cell Carcinoma ◽

Metastatic Renal Cell Carcinoma ◽

Renal Cell ◽

First Line ◽

Early Detection Of Disease ◽

First Line Therapy ◽

Line Therapy ◽

Patients Experience

134 Background: Although sunitinib is effective first-line therapy (1LT) for metastatic renal cell carcinoma (mRCC), ~20% of patients experience rapid progressive disease (PD). Traditional RECIST monitoring often does not detect PD until 90 days after 1LT initiation. Investigational angiogenesis-specific imaging (AI) may identify PD as early as 14 days post-1LT initiation, thus allowing a switch to a potentially more effective second-line therapy and avoiding unnecessary risk of AEs. This study’s goal was to quantify the potential reduction in futile 1LT length, AEs, and costs by using AI for early detection of PD. Methods: Decision modeling with a 90-day horizon evaluated a comparator arm using RECIST monitoring at 90 days and an intervention arm using AI at 14 days. Sunitinib costs were $21,250 for the comparator arm and $13,282 for the intervention arm. RECIST costs were $619 and AI costs were tested as a breakeven analysis. A literature review quantified AE rates associated with 1LT sunitinib and claims data were used to determine costs. Early PD detection was estimated based on a 20% rapid PD rate. Results: For AI sensitivity of 50% to predict rapid PD, a 38-day reduction in futile 1LT could be achieved per PD patient by using AI vs. RECIST (AI sensitivity of 75%/100% yielded 57/76 fewer days). The potential number of AEs avoided through early PD identification is shown below. Costs saved per 1,000 mRCC patients were $684,566 for AEs and $3,187,400 for futile 1LT. Based on these results, $3,872 per mRCC patient would be freed up for AI. Conclusions: Continuing 1LT after PD brings unnecessary risk of AEs and delays potentially effective 2nd-line therapy. Results of this study indicate that early PD identification using AI may improve quality of care by minimizing duration of futile 1LT and avoiding unnecessary AEs. [Table: see text]

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Frontiers in Gastroenterology

Journal of Pharmacy Practice ◽

10.1106/9v9t-paul-w05m ◽

2002 ◽

Vol 15 (3) ◽

pp. 241-249

Author(s):

Joseph Reilly ◽

Edmund J. Bini

Keyword(s):

Pegylated Interferon ◽

The United States ◽

Published Data ◽

First Line ◽

Ulcer Disease ◽

First Line Therapy ◽

Line Therapy ◽

Inflammatory Drugs ◽

Irritable Bowel ◽

Bleeding Ulcers

There have been a number of exciting advancements and changes in the gastroenterology field over the last few years. A new mesalamine formulation, balsalazide disodium, is now available for the treatment of ulcerative colitis (UC). Balsalazide may be utilized as first line therapy for patients with UC, or patients who are intolerant to other mesalamine preparations. In the area of irritable bowel syndrome, alosetron was removed from the market after reports that it was associated with severe constipation and death, although a causal relationship could not be established. Published data examines the risk of certain medications and the development of reflux disease and esophageal adenocarcinoma. Also, new proton pump inhibitors (PPIs) are available, esomeprazole, as well as alternate methods of administration for others. The first intravenous PPI, pantoprazole, is available in the United States, although currently there is a paucity of data regarding its efficacy. Peptic ulcer disease is also discussed, including Helicobacter pylori resistance, nonsteroidal anti-inflammatory drugs, and the treatment of bleeding ulcers. With pegylated interferon, progress in the treatment of hepatitis C offers promise for many patients. This review will highlight many recent changes in gastroenterology an offer a perspective on how disease management has changed.

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Chronic mandible inflammation as the first symptom of chronic recurrent multifocal osteomyelitis (CRMO) – a case report

Nowa Stomatologia ◽

10.25121/ns.2018.23.2.72 ◽

2018 ◽

Vol 23 (2) ◽

Author(s):

Ewa Krasuska-Sławińska ◽

Paulina Piekarska ◽

Piotr Gietka ◽

Anna Wieteska-Klimczak ◽

Mirela Wadecka ◽

...

Keyword(s):

Clinical Symptoms ◽

Chronic Recurrent Multifocal Osteomyelitis ◽

Unknown Aetiology ◽

First Line ◽

First Line Therapy ◽

Line Therapy ◽

Soft Tissue Swelling ◽

Multifocal Osteomyelitis ◽

Inflammatory Drugs ◽

Mild Fever

Chronic recurrent multifocal osteitis (CRMO) is a rare disease of an unknown aetiology, occurring mainly in children aged 4-14 years. It is characterised by recurring episodes of osteitis, with no detectable cause, lasting from several months up to a few years. It usually affects the metaphysis of long bones. Primary lesions in the form of isolated focuses rarely occur in the mandible. The clinical symptoms of CRMO include ostealgia, soft tissue swelling (oedema), skin reddening, and mild fever. The diagnosis is difficult. It involves numerous laboratory and radiological investigations. In order to exclude infectious and neoplastic aetiology, it is advisable to perform a tissue biopsy. The disease is long-lasting with exacerbations and remissions. The prognosis is uncertain. Non-steroidal anti-inflammatory drugs and empirical antibiotic therapy are a recommended first-line therapy; if no improvement is observed, corticosteroids should be used. The analysed case concerns a 10-year-old boy with mandible inflammation as the first symptom of chronic recurrent multifocal osteitis (CRMO). Mandibular lesions may be the first symptom of chronic recurrent multifocal osteitis. The non-specific onset and variable clinical picture delay the diagnosis. Early diagnosis enables early treatment, which prevents complications.

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Corticosteroids for Acute and Recurrent Idiopathic Pericarditis: Unexpected Evidences

Cardiology Research and Practice ◽

10.1155/2019/1348364 ◽

2019 ◽

Vol 2019 ◽

pp. 1-7

Author(s):

Antonio Perrone ◽

Anna Castrovilli ◽

Giuseppina Piazzolla ◽

Sabina Savino ◽

Alessia D’Introno ◽

...

Keyword(s):

Recurrence Rate ◽

Low Dose ◽

Common Disease ◽

High Dose ◽

Efficacy And Safety ◽

Emergency Room Visits ◽

First Line ◽

First Line Therapy ◽

Line Therapy ◽

Inflammatory Drugs

Pericarditis is a common disease, often postviral or “idiopathic,” diagnosed in about 5% of emergency room visits for non-ischemic chest pain. Although pericarditis often occurs as a benign and self-limiting disease, it may present recurrences. The first-line therapy includes aspirin/nonsteroidal anti-inflammatory drugs (ASA/NSAIDs) plus colchicine. Steroids especially at high-dose have been associated with a higher recurrence rate. In this retrospective study, we evaluated efficacy and safety of ASA/NSAIDs and prednisone in the treatment of acute or recurrent idiopathic pericarditis (colchicine was off-label in the period of the study). The cohort included 276 patients diagnosed with acute idiopathic pericarditis. Mean age was 45.4 ± 12.7 years, and males were significantly higher in number and younger than females. Sixty-one patients (22.1%) were treated with prednisone and 215 with ASA/NSAIDs (77.9%). 171 patients experienced at least one recurrence (62%). No difference in recurrence rate was observed (p=0.257) between the groups treated with prednisone (55.7%) vs. ASA/NSAIDs (63.7%). The recurrences were treated with steroids at low doses and very gradual tapering, and the dose reduction was slower as the number of relapses was higher. Steroids alone were administered to about 80% of patients, while in the remaining 20% of cases, they were associated with ASA/NSDAIDs or colchicine. Approximately 90% of patients had a very favorable course, that is no more than 2 relapses and no patients presented serious side effects. Steroids at low dose, did not act, surprisingly, as an independent risk factor for recurrences and therefore may be considered a successful and safe treatment for acute and recurrent idiopathic pericarditis.

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