Cultivate your medical knowledge with our curated collection of cutting-edge articles. Explore the latest research, insights, and breakthroughs in the field of healthcare in our dedicated medical topics section.

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Medical Topics

Postoperative neuropathic pain is one of the most dreadful complications following lumbar spine surgeries. Owing to the similarities in the pathophysiological and biochemical mechanisms underlying epilepsy and neuropathic pain, many antiepileptic drugs (AEDs) like pregabalin and gabapentin are being used in the treatment of post-operative neuropathic pain.It is important to mention that Gabapentin 900mg/day led to the lowest VAS score (Pain score) and was the best in its opioid sparing effect followed by other concentrations&nbsp; of Gabapentin (1200mg, 600mg, and 300mg) &amp; Pregabalins (150mg &amp; 75mg), respectively with no significant differences in adverse events in spine Surgeries.
Reference:&nbsp; Garg RN, Vaje S, Patil H, Bajaj S. A prospective and observational study to assess the efficacy of pregabalin versus gabapentin in relieving early post operative neuropathic pain with respect to clinical and functional outcomes in patients undergoing open lumbar discectomy surgery. International Journal of Research in Orthopaedics. 2023;10(1):57–63. doi:10.18203/issn.2455-4510.intjresorthop20234039&nbsp;
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Management of Perioperative Pain Control After Spine Surgery

Postoperative pain is influenced by various factors, including the duration and site of the operation, the amount of manipulation involved, and the individualized perception of pain. More than two-thirds of patients who undergo total joint arthroplasty experience severe postoperative pain. Many patients suffer from extreme pain after total knee arthroplasty (TKA) and total hip arthroplasty (THA), especially in the first 2 weeks. Enhanced pain control after arthroplasty is related to shorter rehabilitation time, decreased complications, and improved patient satisfaction. The number of joint arthroplasty surgeries have increased worldwide, with more than one million arthroplasties performed each year in the United States. Considering the increased number of arthroplasty cases, it seems necessary to identify the latest approaches for postoperative pain control. Duloxetine, a selective serotonin and norepinephrine reuptake inhibitor (SNRI), has been approved for treating depression,
anxiety, and post-traumatic stress disorders by the US Food and Drug Administration (FDA). It has also been
approved to treat diabetic neuropathic pain and fibromyalgia. Several studies has shown the role of duloxetine in reducing the pain caused by knee and hip osteoarthritis, two systematic reviews and meta-analyses have confirmed duloxetine’s analgesic and opioid-sparing role postoperatively. In conclusion, Duloxetine 30mg/60mg shows moderate opioid sparing effects and statistically significant reduction in pain scores with no significant difference in the prevalence of side effects versus Placebo.
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Reference: Azimi A, Hooshmand E, Mafi AA, Tabatabaei F-S. Effect of duloxetine on opioid consumption and pain after total knee and hip arthroplasty: A systematic review and meta-analysis of randomized clinical trials. Pain Medicine. 2023;24(9):1035–45. doi:10.1093/pm/pnad045&nbsp;
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Medicines and Opioids Consumption Effect on Post-operative Pain

Postoperative pain control is a critical component of comprehensive postsurgical patient care, as it affects patient satisfaction and operative outcomes and can result in pathophysiologic neural alterations that evolve into chronic pain syndromes. Tissue trauma resulting from surgery is thought to lead to both central and peripheral nerve sensitization, resulting in an activity-dependent increase in spinal neurons excitation and a decreased threshold of nociceptive afferents, respectively.&nbsp;
Historically, opioids have been the preferred drug of choice for the management of postoperative pain following joint arthroplasty. However, when used in excess, opioids can lead to deleterious side effects and have the potential for both addiction and abuse. These risks are particularly important in orthopaedics given that orthopaedic surgeons are highest prescribers amongst all surgeons.
Considering the concerns surrounding excessive opioid use, multimodal analgesic regimens utilizing a combination of opioid and nonopioid analgesic drugs targeting different sites within the central and peripheral nervous system have emerged as the new standard in managing postoperative pain. Among commonly used interventions, such as acetaminophen and nonsteroidal anti-inflammatory drugs, there is a growing body of evidence suggesting that duloxetine is used in the management of postoperative pain. The 60mg concentration of Duloxetine significantly reduced pain at rest and at movement as well as opioid consumption at 48 and 72hrs after Knee or Hip Replacement operations.
Reference: Jones IA, Talehakimi A, Murphy LS, Wang JC, Piple AS, Christ AB, et al. Duloxetine for postoperative pain control following knee or hip replacement: A systematic review and meta-analysis. Arthroplasty Today. 2023 Apr;20:101097. doi:10.1016/j.artd.2023.101097&nbsp;
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Post-operative Pain Control after Knee Replacement

Chronic sciatica (CS), like most neuropathic pain states, is often resistant to simple treatment regimens. Chronic sciatica is sciatica lasting longer than 3 months. Neuropathic pain states are typically managed by super-adding anticonvulsant drugs onto simple drug regimens. The drugs most used are gabapentin (GBP) or pregabalin (PGB). Chronic sciatica has therefore been increasingly treated with super-added GBP or PGB. GBP led to superior Visual analog pain intensity scale reduction with fewer and less sever adverse events than PGB. In addition to this, it is important to mention that GBP should be commenced before PGBs to permit optimal crossover of medicines.
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Reference:
Robertson K, Marshman L, Plummer D, Downs E. Effect of Gabapentin vs Pregabalin on Pain Intensity in Adults With Chronic Sciatica. JAMA Neurology. 2019;76(1):28.
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Trends in Pain Management of Chronic Sciatica

In patients with both chronic liver disease and type 2 diabetes who consistently followed their treatment regimen, GLP-1 agonists could lead to a reduced risk of major adverse liver outcomes (MALO). The impact of glucagon-like peptide-1 receptor (GLP1) agonists on hard clinical outcomes in patients with chronic liver diseases of any cause and concurrent type 2 diabetes is uncertain, despite their potential for resolving metabolic dysfunction-associated steatohepatitis. GLP1 agonists could potentially serve as a treatment option to lower the risk of MALO in patients with type 2 diabetes and any form of chronic liver disease who adhere to the treatment regimen over time. However, confirmation of these findings would require validation through randomized clinical trials.&nbsp;
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Reference: Wester A, Shang Y, Toresson Grip E, et alGlucagon-like peptide-1 receptor agonists and risk of major adverse liver outcomes in patients with chronic liver disease and type 2 diabetesGut Published Online First: 22 January 2024. doi: 10.1136/gutjnl-2023-330962.&nbsp;

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GLP-1 Agonists Reduce Risk for Severe Liver Disease

SGLT2 inhibitors were linked to a reduced likelihood of composite anemia outcomes, particularly instances of anemia events.&nbsp;
This retrospective cohort study, indicated that using SGLT2 inhibitors was associated with a 19% reduced risk of composite anemia outcomes compared to the use of GLP-1 RA.&nbsp;
The results remained consistent across various SGLT2 inhibitors, implying a class-wide effect of anemia benefits associated with SGLT2 inhibitors.&nbsp;
These main findings were supported by alterations in hematological laboratory parameters, revealing significant distinctions between the SGLT2 inhibitor and GLP-1 RA groups over the three-year monitoring period.&nbsp;
The similarity in glycemic control and kidney function changes observed in both the SGLT2 inhibitor and GLP-1 RA groups suggest that mechanisms possibly responsible for the decreased incidence of anemia with SGLT2 inhibitor use are likely independent of these factors.&nbsp;
SGLT2 inhibitors may be considered as an adjunct therapy to mitigate the occurrence of mitigate the occurrence of anemia in patients with type 2 diabetes and chronic kidney disease.&nbsp;
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Reference: Hu J, et al. Use of SGLT2 Inhibitors vs GLP-1 RAs and Anemia in Patients With Diabetes and CKD. JAMA Netw Open. 2024;7(3):e240946.&nbsp;

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Diabetes Treatment and Risk of Anemia in Patients with Diabetes and CKD 

Metformin for type 2 diabetes mellitus (T2DM) patients is linked to a decreased risk of experiencing severe diabetic nephropathy and major cardiovascular events.&nbsp;
For T2DM patients with compromised kidney functions, maintaining metformin therapy is connected to reduced risk of major kidney and cardiovascular events compared with non-metformin user or discontinued user.&nbsp;
Metformin usage among T2DM patients, regardless of their renal functions variation, consistently shows a lower risk of severe diabetic nephropathy (DN), major adverse cardiovascular events (MACE), and major adverse kidney events (MAKE) compared with the control cohort.&nbsp;
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Reference: Yongjin Yi, et al. Impact of metformin on cardiovascular and kidney outcome based on kidney function status in type 2 diabetic patients: a multicentric, retrospective cohort study. Sci Rep 14, 2081 (2024).&nbsp;

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Impact of Metformin on Cardiovascular and Kidney Outcomes in Type 2 Diabetic Patients 

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Updated Vaccination Recommendations for People with Multiple Sclerosis

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MS
Multiple Sclerosis
CNS
Cognitive Impairment

A New Framework for Cognitive Impairment in MS: 5 Phenotypes Based on Severity and Domain

The evolving understanding of multiple sclerosis (MS) continues to reshape our approach to its diagnosis and management. A landmark article by Giovannoni and colleagues, published in Therapeutic Advances in Neurological Disorders, introduces the concept of "smouldering MS", positing it as the fundamental driver of disease progression. Below, we distill the key insights and clinical implications.
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Understanding Smouldering MS
Smouldering MS is characterized by persistent disease activity, independent of clinical relapses or visible MRI lesions. The authors propose that this chronic, underlying pathology may be the "real MS," responsible for long-term disability and progressive neurodegeneration.
Key Features Include:
<ul style="margin-top: 0in;" type="disc">
<li>Chronic Active Lesions: Also called "rim lesions," these slowly expanding lesions show sustained demyelination and axonal injury.</li>
<li>Diffuse Inflammation: Microglial and astrocytic activation in both gray and white matter drives progressive damage.</li>
<li>Cortical Demyelination: Subtle cortical damage, associated with cognitive and physical decline, is often missed on conventional MRI.</li>
<li>Accelerated Brain Atrophy: Smouldering MS is linked to faster brain volume loss, a key marker of neurodegeneration.</li>
</ul>
This paradigm challenges traditional notions that focus primarily on relapsing-remitting MS (RRMS) and emphasizes the importance of identifying smouldering disease activity early.
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Diagnostic and Monitoring Challenges
Traditional MRI metrics such as gadolinium-enhancing lesions and T2 lesion count may not adequately capture smouldering MS. Instead, the authors advocate for advanced imaging techniques and biomarkers to assess:
<ul style="margin-top: 0in;" type="disc">
<li class="MsoNormal" style="mso-list: l2 level1 lfo2; tab-stops: list .5in;">Chronic lesion activity: Better captured by techniques like susceptibility-weighted imaging (SWI).</li>
<li class="MsoNormal" style="mso-list: l2 level1 lfo2; tab-stops: list .5in;">Diffuse neurodegeneration: Measured through cortical atrophy and brain volume loss.</li>
<li class="MsoNormal" style="mso-list: l2 level1 lfo2; tab-stops: list .5in;">Microglial activation: Potentially detectable with PET imaging or other emerging modalities.</li>
</ul>
Neurologists should remain vigilant for subtle signs of progression that might not correlate with clinical relapses.
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Therapeutic Implications
Smouldering MS necessitates a paradigm shift in treatment approaches:
<ol style="margin-top: 0in;" start="1" type="1">
<li class="MsoNormal" style="mso-list: l1 level1 lfo3; tab-stops: list .5in;">Early and Aggressive Intervention Delaying treatment risks missing the window to address the insidious damage associated with smouldering MS. Starting therapy early, even in clinically silent phases, may mitigate long-term disability.</li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo3; tab-stops: list .5in;">Neuroprotective Strategies Therapies with potential neuroprotective effects, such as sphingosine-1-phosphate (S1P) receptor modulators (e.g., fingolimod), could play a critical role in targeting smouldering disease mechanisms.</li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo3; tab-stops: list .5in;">Emerging Treatments Research into agents promoting remyelination, axonal repair, and microglial modulation is essential to address this unmet need.</li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo3; tab-stops: list .5in;">Redefining Treatment Goals Beyond controlling inflammation, therapies should aim to reduce brain atrophy and slow neurodegeneration, which better reflect smouldering activity.</li>
</ol>
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Key Takeaways for Clinical Practice
<ul style="margin-top: 0in;" type="disc">
<li class="MsoNormal" style="mso-list: l0 level1 lfo4; tab-stops: list .5in;">Adopt a Broader Lens: Monitor for neurodegeneration and subtle signs of progression, even in the absence of clinical relapses.</li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo4; tab-stops: list .5in;">Refine Treatment Selection: Consider therapies with neuroprotective and disease-modifying potential to address smouldering MS.</li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo4; tab-stops: list .5in;">Communicate with Patients: Educate patients about the importance of long-term, proactive management to prevent silent progression.</li>
</ul>
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For the full article, visit: <a href="https://doi.org/10.1177/17562864211066751">Ther Adv Neurol Disord. 2022 Jan 25;15:17562864211066751</a>.

Medical Topics

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