Localized peripheral neuropathic pain: topical treatment with lidocaine 700 mg medicated plaster in routine clinical practice

Aim: To provide real-world evidence for the effectiveness and tolerability of lidocaine 700 mg medicated plaster (LMP) in localized peripheral neuropathic pain (l-PNP) treatment compared with first-line oral medications (OM). Patients & methods: This was a noninterventional, retrospective 6-month cohort study in patients refractory to at least one recommended OM, using anonymized medical care data from the German Pain eRegistry. Treatment groups were matched by propensity scoring, considering seven predefined confounding factors. The primary effectiveness end point was the absolute change in average pain intensity index from baseline at weeks 4, 12 and 24 of treatment and over the treatment period. Results: A total of 3081 datasets were retained per treatment group. LMP provided superior pain reductions and significantly greater improvements in pain-related impairments of daily living and quality of life with significantly better tolerability (p < 0.001 for all parameters) than OM. Conclusion: These real-world data confirm the effectiveness and good tolerability of LMP for l-PNP treatment under routine medical care.

Gastrointestinal Bleeding During Direct Oral Anticoagulants Therapy in Patients With Nonvalvular Atrial Fibrillation and Risk of Polypharmacy

Although concomitant medications have been raised as a factor affecting hemorrhage during direct oral anticoagulants (DOACs) therapy, details remain unelucidated. This study was conducted to clarify the relationship between concomitant medications with possible pharmacokinetic interactions and number of concomitant medications, and bleeding and embolism in patients with nonvalvular atrial fibrillation on DOACs. The subjects were 1,010 patients prescribed DOACs between April 2011 and June 2018. The study investigated their course between the first prescription and December 2018, including the presence or absence of clinically relevant bleeding, gastrointestinal bleeding (GIB), and major cardiovascular and cerebrovascular events (MACCE). Impacts of medications were evaluated by the general linear model with inverse probability-weighted propensity score. The observation period was 2,272 patient-years. The rate of bleeding was 4.7%/year, GIB was 2.8%/year, and MACCE was 2.0%/year. Taking 10 or more oral medications concurrently was a significant risk for GIB (hazard ratio, 2.046 [1.188–3.526]; p = 0.010). Nonsteroidal anti-inflammatory drugs (NSAIDs) was the only significant risk for GIB. Clinicians should be aware of gastrointestinal bleeding when using DOACs with patients taking more than 10 medications and/or NSAIDs.

Surgery and Catheter Ablation for Atrial Fibrillation: History, Current Practice, and Future Directions

Atrial fibrillation (AF) is the most common of all cardiac arrhythmias, affecting roughly 1% of the general population in the Western world. The incidence of AF is predicted to double by 2050. Most patients with AF are treated with oral medications and only approximately 4% of AF patients are treated with interventional techniques, including catheter ablation and surgical ablation. The increasing prevalence and the morbidity/mortality associated with AF warrants a more aggressive approach to its treatment. It is the purpose of this invited editorial to describe the past, present, and anticipated future directions of the interventional therapy of AF, and to crystallize the problems that remain.

AstraZeneca ChAdOx1-S COVID-19 Vaccine Can Be Safely Administered in Patients with EDTA Allergy

Background: Immediate hypersensitivity reactions to COVID-19 vaccines have been postulated to be linked to their excipients, such as polyethylene glycol (PEG) in Pfizer Comirnaty, or polysorbate 80 and ethylenediaminetetracetic acid (EDTA) in AstraZeneca ChAdOx1-S [recombinant] (Vaxzevria). These excipients are potentially found in a range of other products, including injectable and oral medications as well as intravenous radiocontrast media (RCM) and various cosmetic products.Currently patients with proven excipient allergy may be advised to avoid a COVID-19 vaccine containing that excipient and/or potentially cross-reactive excipients. We present two cases of previously confirmed EDTA anaphylaxis, who had negative Vaxzevria vaccine in-vivo testing and subsequently tolerated the vaccine.Case 1: A patient with history of anaphylaxis to RCM and local anaesthetics (LA) had positive intradermal test (IDT) to EDTA nine years earlier. Skin testing to Vaxzeria vaccine (up to 1:10 IDT), Comirnaty vaccine (up to 1:10 IDT) and EDTA 0.3mg/mL IDT were negative. However, following EDTA 3mg/ml IDT, he developed immediate generalised urticaria without anaphylaxis. Basophil activation testing was negative to disodium EDTA, Vaxzevria and Cominarty vaccines. Given the negative in-vitro and in-vivo testing to Vaxzevria vaccine, he proceeded to Vaxzevria immunisation and tolerated both doses.Case 2: A patient with history of anaphylaxis to RCM had positive skin testing to EDTA and RCM containing EDTA six years earlier. Following referral to COVID19 vaccine clinic, Vaxzevria vaccine (1:10 IDT) and Cominarty vaccine (1:10 IDT) were negative whilst EDTA was positive at 0.3mg/mL IDT. He subsequently tolerated both Vaxzevria vaccinations.Conclusion: Excipient allergy does not necessarily preclude a patient from receiving a vaccine containing that excipient. Allergy testing can help identify excipient-allergic patients who may still tolerate vaccination, which is important in situations where COVID-19 vaccination options are limited.

Expert opinion on current and emerging treatment options in androgenetic alopecia and telogen effluvium: an Indian perspective

<p class="abstract">The diagnosis and management of hair loss needs an organized and systematic approach for recognizing pattern of hair loss and identification of hair loss etiology. Early and specific diagnosis is essential to initiate appropriate treatment in the early phases of hair loss. Topical minoxidil and oral finasteride are the only approved drugs for androgenetic alopecia (AGA). Various other treatment options are widely used but have limited clinical evidence. Similarly, there are no specific treatments recommended for telogen effluvium (TE). However, the treatment may become challenging with increasing availability of new formulations and drugs with no substantial evidence to support them. Multiple focused group discussions were conducted among Indian dermatologists to gain expert opinion on appropriate management of AGA and TE in the current scenario. This article summarizes the consensus clinical viewpoints for topical and oral medications, role of nutritional supplements, and other adjunctive therapies in managing AGA and TE. The panel highlighted that the choice of treatment for AGA and TE depends on the individual hair loss pattern and response to medications. A brief discussion on the use of shampoos and procedures has also been highlighted. </p>

Manual Therapy Interventions for Adhesive Capsulitis: A Review

Adhesive Capsulitis is a debilitating condition which causes the capsule of the Gleno-humeral joint to get thickened and contracted progressively. The prevalence of the disease is much higher in the middle aged and elderly community. It is characterized by pain in the shoulder, and advance towards the restriction of the active and passive glenohumeral motions and thereby obstructing the overall functional activities of the daily living. The effectiveness of various non-operative methods in the treatment of Adhesive Capsulitis has been demonstrated in the literature. Corticosteroid injections and the oral medications are known to be alleviating the pain levels and the inflammatory reactions but not the mobility of the affected joint. Joint mobilization techniques, electrotherapeutic modalities and other manual treatment methods are also found to be effective. In summary, this review focuses on the pathophysiology of the adhesive capsulitis, stages of the condition progress and various manual therapy interventions. Keywords: Gleno-humeral joint, frozen shoulder, rehabilitation, active and passive movements, functional activities.

Which Emergent Medication Should I Give Next? Repeated Use of Emergent Medications to Treat Acute Agitation

Agitation is a common symptom encountered among patients treated in psychiatric emergency settings. While there are many guidelines available for initial management of the acutely agitated patient, there is a notable dearth of guidelines that delineate recommended approaches to the acutely agitated patient in whom an initial medication intervention has failed. This manuscript aims to fill this gap by examining evidence available in the literature and providing clinical algorithms suggested by the authors for sequential medication administration in patients with persistent acute agitation in psychiatric emergency settings. We discuss risk factors for medication-related adverse events and provide options for patients who are able to take oral medications and for patients who require parenteral intervention. We conclude with a discussion of the current need for well-designed studies that examine sequential medication options in patients with persistent acute agitation.

The impact of curative treatment on hyperglycemia in patients with Cushing syndrome

Context Hyperglycemia is a common complication of Cushing syndrome (CS). Objective We aimed to determine the impact of curative procedure on hyperglycemia and its management in patients with CS. Design Retrospective longitudinal cohort study, 2000-2019. Setting Referral center. Patients Adults with endogenous CS and hyperglycemia. Main outcome measure Hemoglobin A1c (HbA1c), intensity of hyperglycemia therapy, improvement of hyperglycemia. Results In 174 patients with CS (pituitary in 106, ectopic in 25, adrenal in 43), baseline median HbA1c was 6.9% (range 4.9-13.1), with 41 (24%) patients not on any therapy for hyperglycemia, 93 (52%) on oral medications, and 64 (37%) on insulin (median daily units of 58, range 10-360). Following CS remission, at the end of follow up (median 10.5 months), 37 (21%) patients demonstrated resolution of hyperglycemia, 82 (47%) demonstrated improvement, and 55 (32%) had no change or worsening in hyperglycemia. At the end of follow up, HbA1c decreased by 0.84% (p &lt; 0.0001) and daily insulin dose decreased by a mean of 30 units, p &lt; 0.0001. Biochemical hypercortisolism severity score (severe vs moderate/mild: Odds ratio (OR) of 2.4 (95%CI of 1.1-4.9)), and CS subtype (nonadrenal vs adrenal: OR of 2.9 (95%CI 1.3-6.4)), but not type of hyperglycemia (diabetes vs prediabetes: OR of 2.1 (0.9-4.9)) were associated with hyperglycemia improvement at the end of follow up. Conclusion Two thirds of patients with CS and hyperglycemia demonstrate resolution or improvement of hyperglycemia after a curative procedure. Close monitoring during CS recovery is needed to assure appropriate therapy modification.