P–302 Levonorgestrel-releasing intrauterine device (LNG-IUD) for symptomatic endometriosis following surgery: a Cochrane systematic review

Study question Does levonorgestrel-releasing intrauterine device (LNG-IUD) improve post-operative outcomes for endometriosis when compared to other systemic hormonal treatments or no additional treatment? Summary answer We are uncertain whether LNG-IUD has an impact on dysmenorrhoea when compared to no postoperative treatment or post-operative GnRH agonists (GnRH-a). What is known already Endometriosis is a condition characterised by the presence of ectopic deposits of endometrial-like tissue outside the uterus, usually in the pelvis; inducing a chronic inflammatory response which can lead to pelvic pain and infertility. Various treatment options exist including surgical treatment, ovarian suppression therapy, or a combination of these strategies. The impact of laparoscopic treatment on overall pain is uncertain and a significant proportion of women will require further surgery. Therefore, adjuvant medical therapies such as LNG-IUD have been considered to reduce treatment failure and recurrence of symptoms. Study design, size, duration A Cochrane systematic review and meta-analysis was performed. Electronic searches of the Cochrane Gynaecology and Fertility Specialised Register of Controlled Trials, CENTRAL, MEDLINE, EMBASE, PsycINFO, CINAHL and Epistemonikos were conducted to January 2021 for relevant randomised controlled trials (RCTs). Two independent authors screened studies and extracted data. Risk ratios (RR) were calculated for dichotomous data and standardised mean differences (SMD) for continuous data, with 95% confidence intervals (CI). Heterogeneity was examined via the I² statistic. Participants/materials, setting, methods Participants: women undergoing surgical treatment for endometriosis without hysterectomy Intervention: LNG-IUD insertion within three months of surgery Comparison: No postoperative treatment, placebo IUD or any other systemic treatment Primary outcome: overall pain Secondary outcomes: improvement of the most troublesome symptom, dysmenorrhoea, quality of life, satisfaction with treatment and adverse events. Primary analysis was conducted on data per woman randomised. Main results and the role of chance Four RCTs were included, with a total of 157 women. Five studies are awaiting classification and one is an ongoing study. We corresponded with original study authors to clarify missing outcome data. No studies reported on overall pain or improvement in the most troublesome symptom. We await study author clarification on quality of life and treatment satisfaction data. We are uncertain whether LNG-IUD improves dysmenorrhoea compared to no postoperative treatment at 12 months. Data on this outcome were reported on by 2 RCTs, but were expressed as median and inter-quartile range and so meta-analysis was not possible (RCT 1: delta of median visual analog scale (VAS) 81 versus 50, p = 0.006, n = 55; RCT 2: fall in VAS by 50 (35–65) p = 0.012 versus 30 (25– 40), p = 0.021, n = 40). We are uncertain whether compared to post-operative GnRH-a, LNG-IUD affects rates of dysmenorrhoea at 6 months (VAS SMD 0.79, 95% CI –0.08 to 1.67, p = 0.08, one RCT, n = 22, very low quality evidence). Various adverse events with LNG-IUD were reported including irregular bleeding and weight gain. However, due to a lack of raw data and comparable studies, we were unable to undertake meta-analysis. Limitations, reasons for caution The major limitation of this systematic review was that there were insufficient studies reporting on our prespecified outcomes, including our primary outcome. In addition, the included studies were not all of high quality with limited long-term follow-up. Wider implications of the findings: This systematic review highlights the paucity of RCTs reporting outcomes included in the new core outcome set for endometriosis research. Further high-quality RCTs are needed to assess postoperative adjuvant hormonal therapy and these should prioritise investigating key endometriosis outcomes such as overall pain, quality of life and treatment satisfaction. Trial registration number Not applicable

Calcified Right Ventricular Fibroma in an Adult: A Case Report

Background: Cardiac fibromas are rare benign tumors of the heart composed of fibroblasts and collagen. They are common among children and adolescents but are rarely present in adults. Case presentation: We here report the case of a fifty-seven-year-old man who complaining of a 2-year history of chest tightness at rest. Transthoracic echocardiography detected a severe calcified mass protruding outside the right ventricular anterior wall near the apex. The patient was referred for tumor resection. The calcified mass was determined to be a cardiac fibroma with postoperative histopathological examination. The patient experienced an unremarkable post-operative recovery and was discharged 8 days later. Subsequent follow-up has shown complete freedom from his troublesome symptom. Conclusions: Preoperative diagnosis with various imaging modalities and early surgery are the keys to improve prognosis of patients with cardiac fibromas.

Internal biliary diversion to avoid liver transplantation in an adult with intractable pruritus due to idiopathic intrahepatic cholestasis

Background Cholestasis is due to the obstruction at any level of the excretory pathway of bile. One particularly troublesome symptom of cholestasis is pruritus which leads to a profound effect on a patient’s quality of life. In children with progressive familial intrahepatic cholestasis (PFIC), medical treatment often fails. An alternative surgical procedure using biliary diversion offers significant relief for intractable pruritus in non-responders. Case presentation A 43-year-old male presented with a history of persistent jaundice and intractable pruritus for a 2-month duration. His liver enzymes were markedly elevated. However, his liver synthetic function was preserved. After extensive evaluation, a cause for cholestasis was not identified. A multi-disciplinary decision was to consider liver transplantation, but as his liver synthetic functions were remarkably preserved and the intractable pruritus was the sole indication for a transplantation, it was finally decided that internal biliary diversion should be done for symptomatic relief. His pruritus dramatically improved at 6 weeks post-operative. His liver enzymes and bilirubin levels also decreased compared to his pre-operative status. Currently, his liver functions are being closely monitored. Conclusion Though it is not used in adults, the experience of biliary diversion in children with PFIC shows that there is a considerable improvement of symptoms and postpone the need for a transplant. In our patient, liver function and bilirubin as expected did not show a major improvement. But the dramatic improvement of the symptoms gave us the time to postpone the liver transplantation. A biliary diversion is a reasonable option that needs to be considered even in adults with refectory pruritus due to cholestasis.

An Evidence-Based Review of Antitussive Herbs Containing Essential Oils in Traditional Persian Medicine

Background: Cough is one of the most common medical symptoms for which medical advice is sought. Although cough is a protective reflex responsible for clearing the airways from secretions and foreign bodies, it can be a troublesome symptom that causes discomfort to patients. Due to the increasing interest in herbal remedies in the both developed and developing countries, in the current study, we aimed to overview medicinal herbs containing essential oils used as antitussive agents according to the Traditional Persian Medicine [TPM] textbooks. We summarized the relevant scientific evidence on their possible pharmacological actions. Methods: To collect the evidence for treatment of cough or “seaal” [cough in ancient books] from TPM sources, five main medicinal Persian manuscripts were studied. The antitussive herbs were listed and their scientific names were identified and authenticated in accordance with botanical reference books. ScienceDirect and PubMed online databases were searched for related mechanisms of action of the reported medicinal plants. Results: The number of 49 herbs containing essential oils were recommended in TPM for the treatment of cough; 21 of them had at least one known mechanism of action for cough suppression in the scientific literature. According to this review, most of the cited medicinal plants were assessed for either nitric oxide inhibitory or antitussive/expectorant activities. Conclusion: In addition to advantageous effects of antitussive herbs noted by TPM, the present review highlighted some recent evidence-based data on these promising candidates that could be used as an outline for future research on their medicinal use.

Prevalence of uremic pruritus in chronic kidney patients undergoing maintenance hemodialysis at Kathmandu Medical College Teaching Hospital

Background: Uremic pruritus is a common and troublesome symptom of chronic kidney disease. It is one of the dominant dermatological manifestations of chronic kidney disease which affects the quality of life of patients.Objective: To assess the prevalence and severity of uremic pruritus in chronic kidney disease patients undergoing maintenance hemodialysis.Methodology: A prospective cross-sectional study was done over three months among chronic kidney patients undergoing maintenance hemodialysis to show the association of mineral bone disorders with uremic pruritus. Patients complaining of pruritus were taken as cases and then pruritus was quantified using a Visual Analogue Scale.Results: 144 patients participated in this study, out of which 41 (28.47%) were females. Mean age was 54.97±9.75 years and 68.06% patients were on dialysis. Uremic pruritus was seen in 80 patients (55.56%), amongst them 23 patients (28.75 %) had severe pruritus as measured by Visual Analogue Scale. Uremic pruritus was more frequent and more severe in patients having higher serum phosphorus levels (p =0.004).Conclusion: This study further substantiates the need of adequate control of phosphorus levels in hemodialysis patients to reduce complications like uremic pruritus.Journal of Kathmandu Medical College, Vol. 5, No. 4, Issue 18, Oct.-Dec., 2016, Page: 124-127

Other Levodopa-Responsive Problems: Anxiety, Insomnia, and Pain

Carbidopa/levodopa is well recognized to effectively treat movement (“motor”) problems in DLB and PDD, as well as in typical Parkinson’s disease. However, symptoms responding to levodopa also include anxiety and insomnia. Moreover, pain control may improve with optimized levodopa dosages. The role for carbidopa/levodopa in treating these symptoms cannot be overemphasized; quality of life may markedly improve with optimized dosage. Anxiety is a normal part of the human existence. It is normal to become nervous before a school test or speaking before a large audience. In fact, some of us are especially nervous or anxious as part of our normal makeup. However, newly developing anxiety is a frequent component of DLB, PDD, and Parkinson’s disease. In the context of these disorders, anxiety may occasionally be the most troublesome symptom, even bordering on panic. The good news is that this is often treatable with carbidopa/ levodopa. The usual anxiety everyone experiences, or the excessive anxiety of nervous people, does not respond to levodopa. Certain anxiety is normal, such as during family crises and arguments. If a person has been nervous all of their life, levodopa will not be the solution; such anxiety is not due to brain dopamine deficiency. However, anxiety that develops after, or a little before the onset of DLB, PDD, or Parkinson’s disease is different. If recently, small issues have provoked panic and this is not a lifelong pattern, levodopa therapy may prove helpful. The anxiety experienced by those with DLB or PDD may occasionally reach crisis proportions. Emergency room physicians are familiar with older adults being brought in by concerned family members because “mom is in a panic.” Sometimes a Valium-like drug is prescribed to establish a quick response. Medications from the Valium class are termed benzodiazepines and include such agents as alprazolam (Xanax), lorazepam (Ativan), clonazepam (Klonopin), as well as Valium itself (diazepam). Benzodiazepines are very sedating, which is beneficial in the emergency room to relax the nervous person; however, ongoing sedation is not acceptable on a long-term basis. Moreover, these drugs contribute to imbalance (fall risk) and tend to impair thinking.

Do cannabis-based medicinal extracts have general or specific effects on symptoms in multiple sclerosis? A double-blind, randomized, placebo-controlled study on 160 patients

The objective was to determine whether a cannabis-based medicinal extract (CBME) benefits a range of symptoms due to multiple sclerosis (MS). A parallel group, double-blind, randomized, placebo-controlled study was undertaken in three centres, recruiting 160 outpatients with MS experiencing significant problems from at least one of the following: spasticity, spasms, bladder problems, tremor or pain. The interventions were oromucosal sprays of matched placebo, or whole plant CBME containing equal amounts of delta-9- tetrahydrocannabinol (THC) and cannabidiol (CBD) at a dose of 2.5- 120 mg of each daily, in divided doses. The primary outcome measure was a Visual Analogue Scale (VAS) score for each patient’s most troublesome symptom. Additional measures included VAS scores of other symptoms, and measures of disability, cognition, mood, sleep and fatigue. Following CBME the primary symptom score reduced from mean (SE) 74.36 (11.1) to 48.89 (22.0) following CBME and from 74.31 (12.5) to 54.79 (26.3) following placebo [ns]. Spasticity VAS scores were significantly reduced by CBME (Sativex) in comparison with placebo (P- 0.001). There were no significant adverse effects on cognition or mood and intoxication was generally mild.