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

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Overview
The National Institute for Health and Care Excellence (NICE) has released updated guidance (NG226) on the diagnosis and management of osteoarthritis (OA) in individuals aged 16 and over. 
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&nbsp;Diagnosis: A Clinical Approach
NICE now recommends that imaging is not required to diagnose OA if the following features are present:
<ul style="margin-top: 0in;" type="disc">
<li class="MsoNormal" style="mso-list: l3 level1 lfo1; tab-stops: list .5in;">Age ≥45 years</li>
<li class="MsoNormal" style="mso-list: l3 level1 lfo1; tab-stops: list .5in;">Activity-related joint pain</li>
<li class="MsoNormal" style="mso-list: l3 level1 lfo1; tab-stops: list .5in;">No morning joint stiffness or morning stiffness lasting ≤30 minutes</li>
</ul>
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Core Treatment Strategies
The guideline reinforces the importance of non-pharmacological interventions as the foundation of OA care:
<ol style="margin-top: 0in;" start="1" type="1">
<li class="MsoNormal" style="mso-list: l2 level1 lfo2; tab-stops: list .5in;">Patient Education Encourage understanding of OA </li>
<li class="MsoNormal" style="mso-list: l2 level1 lfo2; tab-stops: list .5in;">Exercise therapy For all people with osteoarthritis, offer therapeutic exercise tailored to their needs (for example, local muscle strengthening, general aerobic fitness).</li>
<li class="MsoNormal" style="mso-list: l2 level1 lfo2; tab-stops: list .5in;">Weight management For individuals with overweight or obesity, support weight loss to alleviate symptoms and improve function.</li>
</ol>
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Pharmacological Management
If Pharmacological treatments are needed to manage Osteoarthritis, use them:
*alongside non-pharmacological treatments and to support therapeutic exercise
*at the lowest effective dose for the shortest possible time.
<ul style="margin-top: 0in;" type="disc">
<li class="MsoNormal" style="mso-list: l0 level1 lfo3; tab-stops: list .5in;">Start with topical NSAIDs; if ineffective, consider an &nbsp;oral NSAID with a Proton pump inhibitor.</li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo3; tab-stops: list .5in;">Paracetamol and opioids are not routinely recommended due to limited efficacy and risk of harm.</li>
</ul>
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Intra-articular and Surgical Options
<ul style="margin-top: 0in;" type="disc">
<li class="MsoNormal" style="mso-list: l4 level1 lfo4; tab-stops: list .5in;">Corticosteroid injections when other pharmacological treatments are ineffective.</li>
<li class="MsoNormal" style="mso-list: l4 level1 lfo4; tab-stops: list .5in;">Referral for joint replacement surgery should be considered when conservative management fails, and &nbsp;when pain or functional limitations are impacting quality of Life.</li>
</ul>
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Interventions Not Recommended
The guideline advises against the use of:
<ul style="margin-top: 0in;" type="disc">
<li class="MsoNormal" style="mso-list: l1 level1 lfo5; tab-stops: list .5in;">Glucosamine products</li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo5; tab-stops: list .5in;">Acupuncture</li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo5; tab-stops: list .5in;">Electrotherapy (e.g., TENS)</li>
</ul>
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Full guideline available at NICE: <a href="https://www.nice.org.uk/guidance/ng226">https://www.nice.org.uk/guidance/ng226</a>
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NICE Osteoarthritis Guideline (NG226) published on 19 October 2022

Post-spinal surgery pain remains a significant challenge despite advances in minimally invasive techniques. This pain, often severe and neuropathic, can lead to chronic pain and diminishees quality of life. While multimodal analgesia offers a comprehensive approach, limitations exist with current options like opioids. Duloxetine, an SNRI with demonstrated analgesic effect, may be an effective treatment option for postoperative pain following spine surgery. This systematic review evaluates the efficacy and safety of duloxetine in managing acute and chronic pain following spine surgery.
 Study Characteristics, Results, Discussion, and Conclusion
Study Characteristics
Seven studies (five RCTs, one pilot trial, and one retrospective observational study) comprising 487 participants were analyzed. All studies were published since 2015, with most after 2017. Duloxetine dosages ranged from 20-60mg, with varying administration schedules (single dose pre-operatively, pre- and post-operatively, or daily for three months). Various spinal surgery types were included. Numeric rating scale (NRS),Verbal numeric scale, brief pain inventory, visual analogue scale (VAS), Pain catastrophizing scale and McGill Pain Questionnaire (MPQ) were used to determine postoperative pain in included studies. Some of the studies included evaluated pain 48 hours and others studied&nbsp; 12 weeks after surgery.
Results
<ul style="margin-top: 0in;" type="disc">
<li class="MsoNormal">RCTs: One RCT showed significantly lower pain scores with duloxetine/etoricoxib combination versus placebo, etoricoxib alone, and duloxetine alone. Another found similar pain score reductions with duloxetine and pregabalin, both superior to placebo. One study showed significantly lower pain scores with duloxetine/opioid versus placebo/opioid at 4- and 12-weeks post-surgery. Two RCTs found no significant difference between duloxetine and control (diazepam or placebo).</li>
<li class="MsoNormal">Pilot Study: Duloxetine significantly improved the affective component of pain as measured by the McGill Pain Questionnaire (MPQ).</li>
<li class="MsoNormal">Retrospective Study: 79.2% of patients (19/24) experienced a ≥2-point NRS pain score reduction with duloxetine. All patients (9/9) with postsurgical chronic pain responded positively. Mean NRS pain scores decreased significantly in responders (6.22 to 2.78).</li>
<li class="MsoNormal">Opioid Consumption: Studies concluded that there is a significant reduction in opioid consumption in patients receiving duloxetine.</li>
<li class="MsoNormal">Adverse Events: Studies concluded that Duloxetine was well tolerated without serious adverse events</li>
</ul>
Discussion
Results regarding duloxetine's efficacy for post-spinal surgery pain are mixed. While some studies demonstrated significant pain reduction, others did not. Thus, it is crucial to recognize the potential limitations within individual studies and the variability in methodologies.
&nbsp;To establish duloxetine’s efficacy and safety conclusively, future RCTs should systematically compare it with other oral medications such as nonsteroidal anti-inflammatory drugs, assess its long-term safety profile, and determine the optimal dosage regimen.
Conclusion
The findings suggest that duloxetine holds promise as an effective component and an alternative to opioids for postoperative pain management following spinal surgery.
 References: <a href="https://pmc.ncbi.nlm.nih.gov/articles/PMC10793159/pdf/main.pdf">- The eﬀect of duloxetine on postoperative pain and opium consumption in</a>
<span style="font-size: 12.0pt; line-height: 115%; font-family: 'Aptos',sans-serif; mso-ascii-theme-font: minor-latin; mso-fareast-font-family: Aptos; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin; mso-bidi-font-family: Arial; mso-bidi-theme-font: minor-bidi; mso-ansi-language: EN-US; mso-fareast-language: EN-US; mso-bidi-language: AR-SA;"><a href="https://pmc.ncbi.nlm.nih.gov/articles/PMC10793159/pdf/main.pdf">spine surgery: A systematic review -North American Pain society journal</a>

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The eﬀect of duloxetine on postoperative pain and opium consumption in spine surgery: A systematic review 

Osteoarthritis (OA) is a progressive joint disorder characterized by cartilage degradation, inflammation, and chronic pain, significantly impacting quality of life. In their paper, Farinelli et al. explore a wide range of pain management options—spanning from traditional to emerging therapies—while highlighting the limitations and future directions of OA treatment.
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Conventional Pharmacologic Treatments:
<ul style="margin-top: 0in;" type="disc">
<li class="MsoNormal" style="mso-list: l2 level1 lfo1; tab-stops: list .5in;">NSAIDs (Non-Steroidal Anti-Inflammatory Drugs): Commonly used to alleviate pain and inflammation, but can cause gastrointestinal, renal, and cardiovascular side effects.</li>
<li class="MsoNormal" style="mso-list: l2 level1 lfo1; tab-stops: list .5in;">Acetaminophen: Often recommended for mild OA pain, although its efficacy is limited.</li>
<li class="MsoNormal" style="mso-list: l2 level1 lfo1; tab-stops: list .5in;">Opioids: Used for severe pain, though associated with dependency and adverse effects, making them less favourable for long-term use.</li>
<li class="MsoNormal" style="mso-list: l2 level1 lfo1; tab-stops: list .5in;">Topical agents: Such as capsaicin and diclofenac, may be useful for localized pain with fewer systemic effects.</li>
<li class="MsoNormal" style="mso-list: l2 level1 lfo1; tab-stops: list .5in;">Intra-articular injections:</li>
<ul style="margin-top: 0in;" type="circle">
<li class="MsoNormal" style="mso-list: l2 level2 lfo1; tab-stops: list 1.0in;">Corticosteroids: Provide short-term relief, especially in inflammatory OA flares.</li>
<li class="MsoNormal" style="mso-list: l2 level2 lfo1; tab-stops: list 1.0in;">Hyaluronic acid: Offers lubrication and potential anti-inflammatory effects but with variable results in studies.</li>
</ul>
</ul>
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Non-Pharmacologic Approaches:
<ul style="margin-top: 0in;" type="disc">
<li class="MsoNormal" style="mso-list: l0 level1 lfo2; tab-stops: list .5in;">Physical therapy and exercise: Recommended to improve joint function, muscle strength, and overall mobility.</li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo2; tab-stops: list .5in;">Weight management: Particularly important for knee OA, as excess weight increases joint stress.</li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo2; tab-stops: list .5in;">Patient education and self-management programs: Empower patients to take an active role in managing their condition.</li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo2; tab-stops: list .5in;">: Alternative management: such as aquatic exercise, walking aids, and tibiofemoral bracing</li>
</ul>
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Emerging and Future Therapies:
·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Platelet-rich plasma (PRP): PRP holds promise in alleviating pain, enhancing knee functionality, and improving the quality of life.&nbsp; More favorable outcomes are observed in younger patients and cases of mild OA
·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Mesenchymal Stem Cell Therapy: To date, bone marrow mesenchymal stem cells (BM-MSCs) are considered the gold standard of bone and cartilage tissue engineering. These cells can migrate from subchondral bone to damaged sites, differentiate into chondrocytes and osteoblasts, and integrate with new tissues and surrounding tissues.
·&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Innovation in Osteoarthritis Therapy: Nanotechnology (including liposomes, micelles, and carbon nano allotropes) finds widespread application across diverse industries and in the field of medicine. Research has reported a crucial purpose of nanotechnology in treating OA through the development of drug delivery approaches. 
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<ul style="margin-top: 0in;" type="disc">
<li class="MsoNormal" style="mso-list: l1 level1 lfo3; tab-stops: list .5in;">Personalized medicine: Future strategies may tailor pain management based on genetic, metabolic, and biomechanical factors.</li>
</ul>
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Conclusion: Despite the availability of multiple treatment strategies, no single approach fully addresses OA pain due to its complex and multifactorial nature. Multimodal and individualized strategies combining pharmacologic and non-pharmacologic interventions offer the best outcomes. Future research focused on molecular mechanisms and regenerative solutions is crucial for achieving more effective and personalized pain relief.
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For more information, click the link: <a href="https://pmc.ncbi.nlm.nih.gov/articles/PMC11048725/?utm_source=chatgpt.com">https://pmc.ncbi.nlm.nih.gov/articles/PMC11048725</a>

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Pain Management Strategies in Osteoarthritis

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Management of Osteoarthritis of the Hip:
Evidence-Based Clinical Practice Guideline
The American Academy of Orthopaedic Surgeons Board of Directors


Management of Osteoarthritis of the Hip: Evidence-Based Clinical Practice Guideline

Introduction:
Knee arthroscopy is a common orthopedic procedure, but surgical site infections (SSIs), though infrequent, can significantly impact patient outcomes. This newsletter summarizes the findings of a recent systematic review and meta-analysis that investigated risk factors for SSI following knee arthroscopy.
. The studies were published between 1992 and 2022 and conducted across three continents. The Newcastle-Ottawa Scale (NOS) was used to assess the methodological quality of included studies.
Key Findings:
The meta-analysis identified several patient-related and surgery-related risk factors associated with increased risk of SSI after knee arthroscopy.
Patient-Related Risk Factors:
<ul style="margin-top: 0in;" type="disc">
<li class="MsoNormal" style="mso-list: l2 level1 lfo1; tab-stops: list .5in;">Obesity (BMI ≥30 kg/m ²): Obese patients had a 1.27-times higher risk of infection (95% CI, 1.08-1.49).</li>
<li class="MsoNormal" style="mso-list: l2 level1 lfo1; tab-stops: list .5in;">Male Sex: Male patients demonstrated a 1.52-times greater infection risk (95% CI, 1.32-1.75).</li>
<li class="MsoNormal" style="mso-list: l2 level1 lfo1; tab-stops: list .5in;">Diabetes: Patients with diabetes had a 1.71-times increased risk (95% CI, 1.36-2.14).</li>
<li class="MsoNormal" style="mso-list: l2 level1 lfo1; tab-stops: list .5in;">Tobacco Use: Tobacco users experienced a 1.65-times elevated risk (95% CI, 1.38-1.97).</li>
<li class="MsoNormal" style="mso-list: l2 level1 lfo1; tab-stops: list .5in;">Preoperative Steroid Use: A history of steroid use significantly increased the risk of infection, with a 3.41-fold increase (95% CI, 2.10-5.54).</li>
</ul>
Surgery-Related Risk Factors:
<ul style="margin-top: 0in;" type="disc">
<li class="MsoNormal" style="mso-list: l1 level1 lfo2; tab-stops: list .5in;">High Procedure Complexity: Procedures requiring an auxiliary incision or extended operative time were associated with a 2.02-times higher risk (95% CI, 1.69-2.43).</li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo2; tab-stops: list .5in;">Autograft Use for Cruciate Ligament Reconstruction: The use of autografts was associated with a 2.66-times higher risk of infection compared to allografts (95% CI, 1.84-3.86).</li>
</ul>
Factors Not Significantly Associated with Infection:
<ul style="margin-top: 0in;" type="disc">
<li class="MsoNormal" style="mso-list: l0 level1 lfo3; tab-stops: list .5in;">Age (&gt;50 years): No significant association was found between age and infection risk.</li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo3; tab-stops: list .5in;">Antibiotic Prophylaxis: The study found no significant association between antibiotic prophylaxis and infection.</li>
</ul>
Clinical Implications:
These findings provide valuable insights for orthopedic HCPs. Assessment of these risk factors can facilitate early identification of patients at increased risk of SSI following knee arthroscopy. This allows for optimization of perioperative strategies, enhanced postoperative care, and improved patient outcomes. However, it is important to remember that these are correlational findings, and further research is needed to establish causal relationships and explore the interplay of multiple risk factors.
References: <a href="https://www.journalofhospitalinfection.com/article/S0195-6701(24)00234-2/abstract">Risk factors for infection in patients undergoing knee arthroscopy: a systematic review and meta-analysis</a>
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Risk Factors for Infection After Knee Arthroscopy

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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ADA 2025 Guidelines: Navigating the New Diagnostic Algorithm for MASLD 

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ADA 2025 Guidelines- Management of MASLD:

ADA 2025 Guidelines- Management of MASLD

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Metabolic Dysfunction–Associated Steatotic Liver Disease (MASLD) in People with Diabetes: The Need for Screening and Early Intervention. A Consensus Report of the American Diabetes Association 

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Dapagliflozin plus calorie restriction for remission of type 2 diabetes: multicentre, double blind, randomised, placebo-controlled trial

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Impact of sodium‒glucose cotransporter‐2 inhibitors in patients with recent versus previous myocardial infarction: a systematic review and meta-analysis 

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The Modern Role of Basal Insulin in Advancing Therapy in People With Type 2 Diabetes 

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<p class="Paragraph SCXW218006624 BCX0" style="-webkit-user-drag: none; -webkit-tap-highlight-color: transparent; margin: 0px 0px 10.6667px; padding: 0px; user-select: text; overflow-wrap: break-word; white-space-collapse: preserve; vertical-align: baseline; font-kerning: none; background-color: transparent; color: windowtext;"><span class="TextRun SCXW218006624 BCX0" lang="EN-US" style="-webkit-user-drag: none; -webkit-tap-highlight-color: transparent; margin: 0px; padding: 0px; user-select: text; font-variant-ligatures: none !important; font-size: 12pt; line-height: 20.85px; font-family: Aptos, Aptos_EmbeddedFont, Aptos_MSFontService, sans-serif;" xml:lang="EN-US" data-contrast="auto">Higher A1c variability, assessed over a 4-year period, was associated with a substantially increased risk for subsequent mortality outcomes in patients with type 1 diabetes (T1D) and those with type 2 diabetes (T2D), regardless of average A1c levels <span class="EOP SCXW218006624 BCX0" style="-webkit-user-drag: none; -webkit-tap-highlight-color: transparent; margin: 0px; padding: 0px; user-select: text; font-size: 12pt; line-height: 20.85px; font-family: Aptos, Aptos_EmbeddedFont, Aptos_MSFontService, sans-serif;" data-ccp-props="{}">&nbsp;
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<p class="Paragraph SCXW218006624 BCX0" style="-webkit-user-drag: none; -webkit-tap-highlight-color: transparent; margin: 0px 0px 10.6667px; padding: 0px; user-select: text; overflow-wrap: break-word; white-space-collapse: preserve; vertical-align: baseline; font-kerning: none; background-color: transparent; color: windowtext;"><span class="EOP SCXW218006624 BCX0" style="-webkit-user-drag: none; -webkit-tap-highlight-color: transparent; margin: 0px; padding: 0px; user-select: text; font-size: 12pt; line-height: 20.85px; font-family: Aptos, Aptos_EmbeddedFont, Aptos_MSFontService, sans-serif;" data-ccp-props="{}">&nbsp;
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<div class="OutlineElement Ltr SCXW218006624 BCX0" style="-webkit-user-drag: none; -webkit-tap-highlight-color: transparent; margin: 0px; padding: 0px; user-select: text; clear: both; cursor: text; overflow: visible; position: relative; direction: ltr; font-family: 'Segoe UI', 'Segoe UI Web', Arial, Verdana, sans-serif; font-size: 12px; background-color: #ffffff;">
<p class="Paragraph SCXW218006624 BCX0" style="-webkit-user-drag: none; -webkit-tap-highlight-color: transparent; margin: 0px 0px 10.6667px; padding: 0px; user-select: text; overflow-wrap: break-word; white-space-collapse: preserve; vertical-align: baseline; font-kerning: none; background-color: transparent; color: windowtext;"><span class="TextRun SCXW218006624 BCX0" lang="EN-US" style="-webkit-user-drag: none; -webkit-tap-highlight-color: transparent; margin: 0px; padding: 0px; user-select: text; font-variant-ligatures: none !important; font-size: 12pt; line-height: 20.85px; font-family: Aptos, Aptos_EmbeddedFont, Aptos_MSFontService, sans-serif;" xml:lang="EN-US" data-contrast="auto">Variability measures were generally higher in T2D, with 38% of patients with T2D vs 33% of those with T1D having an A1c variability score ≥ 50.<span class="EOP SCXW218006624 BCX0" style="-webkit-user-drag: none; -webkit-tap-highlight-color: transparent; margin: 0px; padding: 0px; user-select: text; font-size: 12pt; line-height: 20.85px; font-family: Aptos, Aptos_EmbeddedFont, Aptos_MSFontService, sans-serif;" data-ccp-props="{}">&nbsp;
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<div class="OutlineElement Ltr SCXW218006624 BCX0" style="-webkit-user-drag: none; -webkit-tap-highlight-color: transparent; margin: 0px; padding: 0px; user-select: text; clear: both; cursor: text; overflow: visible; position: relative; direction: ltr; font-family: 'Segoe UI', 'Segoe UI Web', Arial, Verdana, sans-serif; font-size: 12px; background-color: #ffffff;">
<p class="Paragraph SCXW218006624 BCX0" style="-webkit-user-drag: none; -webkit-tap-highlight-color: transparent; margin: 0px 0px 10.6667px; padding: 0px; user-select: text; overflow-wrap: break-word; white-space-collapse: preserve; vertical-align: baseline; font-kerning: none; background-color: transparent; color: windowtext;"><span class="TextRun SCXW218006624 BCX0" lang="EN-US" style="-webkit-user-drag: none; -webkit-tap-highlight-color: transparent; margin: 0px; padding: 0px; user-select: text; font-variant-ligatures: none !important; font-size: 12pt; line-height: 20.85px; font-family: Aptos, Aptos_EmbeddedFont, Aptos_MSFontService, sans-serif;" xml:lang="EN-US" data-contrast="auto">Predictors of high A1c variability were younger age, obesity, comorbidities, and residence in deprived areas for both T1D and T2D, whereas non-White ethnicity was a predictor of high variability only in T1D.<span class="EOP SCXW218006624 BCX0" style="-webkit-user-drag: none; -webkit-tap-highlight-color: transparent; margin: 0px; padding: 0px; user-select: text; font-size: 12pt; line-height: 20.85px; font-family: Aptos, Aptos_EmbeddedFont, Aptos_MSFontService, sans-serif;" data-ccp-props="{}">&nbsp;
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<div class="OutlineElement Ltr SCXW218006624 BCX0" style="-webkit-user-drag: none; -webkit-tap-highlight-color: transparent; margin: 0px; padding: 0px; user-select: text; clear: both; cursor: text; overflow: visible; position: relative; direction: ltr; font-family: 'Segoe UI', 'Segoe UI Web', Arial, Verdana, sans-serif; font-size: 12px; background-color: #ffffff;">
<p class="Paragraph SCXW218006624 BCX0" style="-webkit-user-drag: none; -webkit-tap-highlight-color: transparent; margin: 0px 0px 10.6667px; padding: 0px; user-select: text; overflow-wrap: break-word; white-space-collapse: preserve; vertical-align: baseline; font-kerning: none; background-color: transparent; color: windowtext;"><span class="TextRun SCXW218006624 BCX0" lang="EN-US" style="-webkit-user-drag: none; -webkit-tap-highlight-color: transparent; margin: 0px; padding: 0px; user-select: text; font-variant-ligatures: none !important; font-size: 12pt; line-height: 20.85px; font-family: Aptos, Aptos_EmbeddedFont, Aptos_MSFontService, sans-serif;" xml:lang="EN-US" data-contrast="auto">A higher vs lower A1c variability score (≥ 80 vs &lt; 20) was associated with nearly a threefold increase in mortality risk for patients with T1D and a twofold increased risk for those with T2D (hazard ratio [HR] for T1D, 2.78; 95% CI, 2.15-3.60; HR for T2D, 1.91; 95% CI, 1.83-1.99).<span class="EOP SCXW218006624 BCX0" style="-webkit-user-drag: none; -webkit-tap-highlight-color: transparent; margin: 0px; padding: 0px; user-select: text; font-size: 12pt; line-height: 20.85px; font-family: Aptos, Aptos_EmbeddedFont, Aptos_MSFontService, sans-serif;" data-ccp-props="{}">&nbsp;
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<div class="OutlineElement Ltr SCXW218006624 BCX0" style="-webkit-user-drag: none; -webkit-tap-highlight-color: transparent; margin: 0px; padding: 0px; user-select: text; clear: both; cursor: text; overflow: visible; position: relative; direction: ltr; font-family: 'Segoe UI', 'Segoe UI Web', Arial, Verdana, sans-serif; font-size: 12px; background-color: #ffffff;">
<p class="Paragraph SCXW218006624 BCX0" style="-webkit-user-drag: none; -webkit-tap-highlight-color: transparent; margin: 0px 0px 10.6667px; padding: 0px; user-select: text; overflow-wrap: break-word; white-space-collapse: preserve; vertical-align: baseline; font-kerning: none; background-color: transparent; color: windowtext;"><span class="TextRun SCXW218006624 BCX0" lang="EN-US" style="-webkit-user-drag: none; -webkit-tap-highlight-color: transparent; margin: 0px; padding: 0px; user-select: text; font-variant-ligatures: none !important; font-size: 12pt; line-height: 20.85px; font-family: Aptos, Aptos_EmbeddedFont, Aptos_MSFontService, sans-serif;" xml:lang="EN-US" data-contrast="auto">The impact of average A1c levels on mortality was less pronounced than that of A1c variability, as evidenced by higher population attributable fractions for variability (A1c variability score ≥ 20) than for average A1c levels in both T1D and T2D.<span class="LineBreakBlob BlobObject DragDrop SCXW218006624 BCX0" style="-webkit-user-drag: none; -webkit-tap-highlight-color: transparent; margin: 0px; padding: 0px; user-select: text; font-size: 12pt; line-height: 20.85px; font-family: WordVisiCarriageReturn_MSFontService, Aptos, Aptos_EmbeddedFont, Aptos_MSFontService, sans-serif;">&nbsp; <span class="LineBreakBlob BlobObject DragDrop SCXW218006624 BCX0" style="-webkit-user-drag: none; -webkit-tap-highlight-color: transparent; margin: 0px; padding: 0px; user-select: text; font-size: 12pt; line-height: 20.85px; font-family: WordVisiCarriageReturn_MSFontService, Aptos, Aptos_EmbeddedFont, Aptos_MSFontService, sans-serif;">&nbsp; <a class="Hyperlink SCXW218006624 BCX0" style="-webkit-user-drag: none; -webkit-tap-highlight-color: transparent; margin: 0px; padding: 0px; user-select: text; text-decoration-line: none;" href="https://www.sciencedirect.com/science/article/pii/S0168822725002438" target="_blank" rel="noreferrer noopener"><span class="TextRun Underlined SCXW218006624 BCX0" lang="EN-US" style="-webkit-user-drag: none; -webkit-tap-highlight-color: transparent; margin: 0px; padding: 0px; user-select: text; color: #467886; font-size: 12pt; text-decoration-line: underline; line-height: 20.85px; font-family: Aptos, Aptos_EmbeddedFont, Aptos_MSFontService, sans-serif; font-weight: bold; font-variant-ligatures: none !important;" xml:lang="EN-US" data-contrast="none">HbA1c variability and all-cause mortality in type 1 and type 2 diabetes: A population-based cohort study using electronic health records - Diabetes Research and Clinical Practice</a><span class="EOP SCXW218006624 BCX0" style="-webkit-user-drag: none; -webkit-tap-highlight-color: transparent; margin: 0px; padding: 0px; user-select: text; font-size: 12pt; line-height: 20.85px; font-family: Aptos, Aptos_EmbeddedFont, Aptos_MSFontService, sans-serif;" data-ccp-props="{}">&nbsp;
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HbA1c variability and all-cause mortality in type 1 and type 2 diabetes: A population-based cohort study using electronic health records

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The Association Between Hemoglobin A1c and Complications Among Individuals With Diabetes and Severe Chronic Kidney Disease 

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Semaglutide and Cardiovascular Outcomes in Obesity without Diabetes | New England Journal of Medicine 

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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>.

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Smouldering MS: The fundamental driver of disease progression

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Newsletter: Unveiling the Enigma of CD20-Positive CD8 T Cells 

Unveiling the Enigma of CD20-Positive CD8 T Cells 

<h3 class="MsoNormal" style="text-align: center;" align="center">Migraine: The Hidden Burden Across the Globe Insights from the OVERCOME (International) Study</h3>

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Migraine: The Hidden Burden Across the Globe
Insights from the OVERCOME (International) Study

Migraine: The Hidden Burden Across the Globe Insights from the OVERCOME (International) Study

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Sleep Under Siege: Understanding the Impact of Sleep Disturbances in Older Adults During and After the Pandemic 

The Impact of Trauma on Long-Term Mental Health: A Call for Follow-Up Care
Recent research sheds light on the significant and long-lasting mental health challenges faced by trauma patients.
A study by Lai Kin Yaw et al., published in JAMA Network Open, reveals that new mental health conditions often develop in patients after traumatic injuries, with these conditions being linked to increased risks of trauma readmissions, suicides, and all-cause mortality.
Key Findings:
<ul style="margin-top: 0in;" type="disc">
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;">Prevalence of Mental Health Conditions Post-Trauma: Among 29,191 adult trauma patients, 11.3% developed new mental health conditions after their trauma admission. The conditions primarily included drug dependence in 8.2%, neurotic disorders (including PTSD) in 5.4%, anxiety disorders, and mood disorders.  </li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;">Long-Term Impact: Developing a new mental health condition was associated with:</li>
<ul style="margin-top: 0in;" type="circle">
<li class="MsoNormal" style="mso-list: l0 level2 lfo1; tab-stops: list 1.0in;">Increased trauma readmissions: Patients with new-onset mental health conditions were 30% more likely to experience repeated trauma admissions.</li>
<li class="MsoNormal" style="mso-list: l0 level2 lfo1; tab-stops: list 1.0in;">Higher risk of suicide: There was a 3.14-fold increase in the likelihood of suicide by hanging or drug overdose.</li>
<li class="MsoNormal" style="mso-list: l0 level2 lfo1; tab-stops: list 1.0in;">Elevated all-cause mortality: These patients were 24% more likely to die from any cause, emphasizing the severe impact of mental health deterioration following trauma.</li>
</ul>
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;">Vulnerable Subgroups: Certain factors were found to increase the risk of developing mental health issues after trauma, including:</li>
<ul style="margin-top: 0in;" type="circle">
<li class="MsoNormal" style="mso-list: l0 level2 lfo1; tab-stops: list 1.0in;">Younger age</li>
<li class="MsoNormal" style="mso-list: l0 level2 lfo1; tab-stops: list 1.0in;">Unemployment</li>
<li class="MsoNormal" style="mso-list: l0 level2 lfo1; tab-stops: list 1.0in;">Single or divorced status</li>
<li class="MsoNormal" style="mso-list: l0 level2 lfo1; tab-stops: list 1.0in;">Indigenous ethnicity</li>
<li class="MsoNormal" style="mso-list: l0 level2 lfo1; tab-stops: list 1.0in;">Lower socioeconomic status</li>
<li class="MsoNormal" style="mso-list: l0 level2 lfo1; tab-stops: list 1.0in;">Traumatic brain injury</li>
</ul>
</ul>
Clinical Implications:
This study underscores the critical need for mental health follow-up in trauma patients, especially those from vulnerable subgroups. Given the high incidence of new mental health conditions following trauma and their association with adverse long-term outcomes, mental health care should be considered an essential component of trauma recovery.
Recommendations for Healthcare Providers:
<ol style="margin-top: 0in;" start="1" type="1">
<li class="MsoNormal" style="mso-list: l1 level1 lfo2; tab-stops: list .5in;">Early Identification: Screen for emerging mental health conditions during hospital stays and post-discharge.</li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo2; tab-stops: list .5in;">Targeted Interventions: Focus on high-risk groups such as younger patients, those with lower socioeconomic status, and individuals with traumatic brain injuries.</li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo2; tab-stops: list .5in;">Long-Term Monitoring: Offer regular follow-ups for mental health assessments, considering the multiphasic trajectory of trauma recovery.</li>
</ol>
Takeaway for Practice:
Mental health conditions after trauma are not isolated to PTSD but also include drug dependence and mood disorders. Addressing these conditions promptly can improve long-term health outcomes and reduce the risk of further trauma, suicide, and premature death.
For optimal recovery, clinicians should integrate mental health care into the treatment plan for trauma patients.
For More Information:
We encourage you to review the full study for more insights on managing post-trauma mental health and its long-term effects: Yaw, L.K., Burrell, M., Ho, K.M. "Long-Term Outcomes and Determinants of New-Onset Mental Health Conditions After Trauma." JAMA Network Open, March 2025.
<a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2831185">https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2831185</a>

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The Impact of Trauma on Long-Term Mental Health: A Call for Follow-Up Care

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clinical summary of the Canadian Pain Society's (CPS) revised consensus statement on the pharmacologic management of neuropathic pain.

Clinical summary of the Canadian Pain Society's (CPS) revised consensus statement on the pharmacologic management of neuropathic pain.

Real-World Impact of DOAC Switching in NVAF Patients
Atrial fibrillation (AF) is a common heart rhythm disorder linked to increased stroke risk, especially in its non-valvular form (NVAF). DOACs (e.g., apixaban, rivaroxaban) are now standard for stroke prevention in NVAF, replacing older treatments like warfarin. However, switching between DOACs is frequent in practice, raising questions about its impact on stroke/systemic embolism (SE) and major bleeding (MB) risk. This real-world study examines those risks in NVAF patients switching between apixaban and rivaroxaban compared to those continuing their initial DOAC. This US claims database study analyzed privately insured NVAF patients who initiated apixaban or rivaroxaban between 2013 and 2021. Patients were classified as "switchers" or "continuers" (assigned a pseudo-switch date). Propensity score matching (PSM) balanced baseline characteristics between groups. Outcomes (stroke/SE and major bleeding) were compared using Cox proportional hazards models, with a sensitivity analysis conducted on standard-dose patients. The results showed that: Switching from apixaban to rivaroxaban significantly increased the risks of both stroke/SE (HR 1.99) and major bleeding (HR 1.80), with incidence rates of 1.53 vs. 0.75 and 4.59 vs. 2.44 per 100 person-years, respectively. Conversely, switching from rivaroxaban to apixaban did not significantly change stroke/SE risk (HR 0.74) but significantly&nbsp;reduced&nbsp;major bleeding risk (HR 0.49), with corresponding incidence rates of 0.61 vs. 0.78 and 2.01 vs. 3.89. These findings held true in a sensitivity analysis of standard-dose patients. This study demonstrates that switching from apixaban to rivaroxaban increases stroke/SE and bleeding risks, while switching from rivaroxaban to apixaban may&nbsp;lower&nbsp;bleeding risk without increasing stroke/SE risk. These findings, consistent even among standard-dose patients, can inform clinical decision-making regarding DOAC switches in NVAF. Further research is needed to understand the motivations behind these switches.  
Reference: <a href="https://pdfs.semanticscholar.org/b1fb/8e8d21e4dc003744e8b2d6cd8b173be80513.pdf#:~:text=We%20aimed%20to%20evaluate%20stroke%2Fsystemic%20em-bolism%20%28SE%29%20and,patients%20continuing%20or%20switching%20to%20different%20oral%20anticoagulants.">Deitelzweig S, Kang A, Jiang J, Gao C, Luo X, Nipun Atreja, et al. Clinical Impact of Switching or Continuation of Apixaban or Rivaroxaban among Patients with Non-Valvular Atrial Fibrillation. Journal of Clinical Medicine. 2024 Feb 14;13(4):1073–3.</a>  
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Real-World Impact of DOAC Switching in NVAF Patients

<h1 class="MsoNormal">Guidelines Comparison The 2024 ESC guidelines introduce a simplified, three-tiered system:</h1>
Non-elevated: &lt;120/70 mmHg (no drug treatment recommended)
Elevated: 120-139/70-89 mmHg (drug treatment considered based on CVD risk and follow-up BP)
Hypertension: ≥140/90 mmHg (prompt treatment recommended for all)
The ESC avoids terms like "normal" or "optimal" because even in the lowest BP range, CVD risk still increases with rising BP. They retain the traditional ≥140/90 mmHg threshold for hypertension as this is where treatment clearly shows net benefit. The "elevated" category acknowledges that treatment can benefit higher-risk individuals even below this traditional threshold, based on recent trial data.
Here's a summary comparison:
<table class="MsoTable15Plain3" style="border-collapse: collapse; mso-yfti-tbllook: 1184; mso-padding-alt: 0in 5.4pt 0in 5.4pt;" border="0" cellspacing="0" cellpadding="0">
<tbody>
<tr style="mso-yfti-irow: -1; mso-yfti-firstrow: yes; mso-yfti-lastfirstrow: yes;">
<td style="border: none; border-bottom: solid #7F7F7F 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themetint: 128; mso-border-bottom-alt: solid #7F7F7F .5pt; padding: 0in 5.4pt 0in 5.4pt;" valign="top">
Feature
</td>
<td style="border: none; border-bottom: solid #7F7F7F 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themetint: 128; mso-border-bottom-alt: solid #7F7F7F .5pt; padding: 0in 5.4pt 0in 5.4pt;" valign="top">
ESC 2024
</td>
<td style="border: none; border-bottom: solid #7F7F7F 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themetint: 128; mso-border-bottom-alt: solid #7F7F7F .5pt; padding: 0in 5.4pt 0in 5.4pt;" valign="top">
ESH 2023
</td>
<td style="border: none; border-bottom: solid #7F7F7F 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themetint: 128; mso-border-bottom-alt: solid #7F7F7F .5pt; padding: 0in 5.4pt 0in 5.4pt;" valign="top">
ACC/AHA 2017
</td>
</tr>
<tr style="mso-yfti-irow: 0;">
<td style="border: none; border-right: solid #7F7F7F 1.0pt; mso-border-right-themecolor: text1; mso-border-right-themetint: 128; mso-border-right-alt: solid #7F7F7F .5pt; background: #F2F2F2; mso-background-themecolor: background1; mso-background-themeshade: 242; padding: 0in 5.4pt 0in 5.4pt;" valign="top">
BP Classification
</td>
<td style="background: #F2F2F2; mso-background-themecolor: background1; mso-background-themeshade: 242; padding: 0in 5.4pt 0in 5.4pt;" valign="top">
3 tiers: Non-elevated, Elevated, Hypertension
</td>
<td style="background: #F2F2F2; mso-background-themecolor: background1; mso-background-themeshade: 242; padding: 0in 5.4pt 0in 5.4pt;" valign="top">
6 tiers: Optimal, Normal, High-normal, Grade 1-3 Hypertension
</td>
<td style="background: #F2F2F2; mso-background-themecolor: background1; mso-background-themeshade: 242; padding: 0in 5.4pt 0in 5.4pt;" valign="top">
4 tiers: Normal, Elevated, Hypertension Stage 1-2
</td>
</tr>
<tr style="mso-yfti-irow: 1;">
<td style="border: none; border-right: solid #7F7F7F 1.0pt; mso-border-right-themecolor: text1; mso-border-right-themetint: 128; mso-border-right-alt: solid #7F7F7F .5pt; padding: 0in 5.4pt 0in 5.4pt;" valign="top">
Hypertension Threshold
</td>
<td style="padding: 0in 5.4pt 0in 5.4pt;" valign="top">
≥140/90 mmHg
</td>
<td style="padding: 0in 5.4pt 0in 5.4pt;" valign="top">
≥140/90 mmHg (but treatment at ≥160 mmHg for &gt;80 years old)
</td>
<td style="padding: 0in 5.4pt 0in 5.4pt;" valign="top">
≈130/80 mmHg (for high-risk individuals)
</td>
</tr>
<tr style="mso-yfti-irow: 2;">
<td style="border: none; border-right: solid #7F7F7F 1.0pt; mso-border-right-themecolor: text1; mso-border-right-themetint: 128; mso-border-right-alt: solid #7F7F7F .5pt; background: #F2F2F2; mso-background-themecolor: background1; mso-background-themeshade: 242; padding: 0in 5.4pt 0in 5.4pt;" valign="top">
Staging Based on Complications
</td>
<td style="background: #F2F2F2; mso-background-themecolor: background1; mso-background-themeshade: 242; padding: 0in 5.4pt 0in 5.4pt;" valign="top">
No
</td>
<td style="background: #F2F2F2; mso-background-themecolor: background1; mso-background-themeshade: 242; padding: 0in 5.4pt 0in 5.4pt;" valign="top">
Yes
</td>
<td style="background: #F2F2F2; mso-background-themecolor: background1; mso-background-themeshade: 242; padding: 0in 5.4pt 0in 5.4pt;" valign="top">
No
</td>
</tr>
<tr style="mso-yfti-irow: 3; mso-yfti-lastrow: yes;">
<td style="border: none; border-right: solid #7F7F7F 1.0pt; mso-border-right-themecolor: text1; mso-border-right-themetint: 128; mso-border-right-alt: solid #7F7F7F .5pt; padding: 0in 5.4pt 0in 5.4pt;" valign="top">
Rationale
</td>
<td style="padding: 0in 5.4pt 0in 5.4pt;" valign="top">
Simplified for treatment decisions; acknowledges risk continuum
</td>
<td style="padding: 0in 5.4pt 0in 5.4pt;" valign="top">
Detailed classification and staging for prognosis
</td>
<td style="padding: 0in 5.4pt 0in 5.4pt;" valign="top">
Lower threshold reflecting earlier trial data in high-risk individuals
&nbsp;
</td>
</tr>
</tbody>
</table>
The ESC 2024 guidelines prioritize simplicity and treatment decisions, while the ESH 2023 guidelines provide a more prognostic classification. The ACC/AHA 2017 guidelines represent an earlier approach with a lower hypertension threshold based on then-available data.
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Comparison of Resistant Hypertension Guidelines (ESC 2024, ESH 2023, ACC/AHA 2017)
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<tbody>
<tr style="mso-yfti-irow: -1; mso-yfti-firstrow: yes; mso-yfti-lastfirstrow: yes;">
<td style="border: none; border-bottom: solid #7F7F7F 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themetint: 128; mso-border-bottom-alt: solid #7F7F7F .5pt; padding: 0in 5.4pt 0in 5.4pt;" valign="top">
Feature
</td>
<td style="border: none; border-bottom: solid #7F7F7F 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themetint: 128; mso-border-bottom-alt: solid #7F7F7F .5pt; padding: 0in 5.4pt 0in 5.4pt;" valign="top">
ESC 2024
</td>
<td style="border: none; border-bottom: solid #7F7F7F 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themetint: 128; mso-border-bottom-alt: solid #7F7F7F .5pt; padding: 0in 5.4pt 0in 5.4pt;" valign="top">
ESH 2023
</td>
<td style="border: none; border-bottom: solid #7F7F7F 1.0pt; mso-border-bottom-themecolor: text1; mso-border-bottom-themetint: 128; mso-border-bottom-alt: solid #7F7F7F .5pt; padding: 0in 5.4pt 0in 5.4pt;" valign="top">
ACC/AHA 2017
</td>
</tr>
<tr style="mso-yfti-irow: 0;">
<td style="border: none; border-right: solid #7F7F7F 1.0pt; mso-border-right-themecolor: text1; mso-border-right-themetint: 128; mso-border-right-alt: solid #7F7F7F .5pt; background: #F2F2F2; mso-background-themecolor: background1; mso-background-themeshade: 242; padding: 0in 5.4pt 0in 5.4pt;" valign="top">
Spironolactone
</td>
<td style="background: #F2F2F2; mso-background-themecolor: background1; mso-background-themeshade: 242; padding: 0in 5.4pt 0in 5.4pt;" valign="top">
Class IIa
</td>
<td style="background: #F2F2F2; mso-background-themecolor: background1; mso-background-themeshade: 242; padding: 0in 5.4pt 0in 5.4pt;" valign="top">
Class II
</td>
<td style="background: #F2F2F2; mso-background-themecolor: background1; mso-background-themeshade: 242; padding: 0in 5.4pt 0in 5.4pt;" valign="top">
Favored, no formal recommendation
</td>
</tr>
<tr style="mso-yfti-irow: 1; mso-yfti-lastrow: yes;">
<td style="border: none; border-right: solid #7F7F7F 1.0pt; mso-border-right-themecolor: text1; mso-border-right-themetint: 128; mso-border-right-alt: solid #7F7F7F .5pt; padding: 0in 5.4pt 0in 5.4pt;" valign="top">
Renal Denervation
</td>
<td style="padding: 0in 5.4pt 0in 5.4pt;" valign="top">
Consider if: Performed at experienced center after risk/benefit discussion and multidisciplinary assessment Class IIb) Do not use if: eGFR &lt; 40 mL/min/1.73m² (Class III)
</td>
<td style="padding: 0in 5.4pt 0in 5.4pt;" valign="top">
Consider if eGFR &gt; 40 mL/min/1.73m² (Class II)
</td>
<td style="padding: 0in 5.4pt 0in 5.4pt;" valign="top">
Not addressed
</td>
</tr>
</tbody>
</table>
 Reference:
<a href="https://www.ahajournals.org/doi/full/10.1161/HYPERTENSIONAHA.124.24173?rfr_dat=cr_pub++0pubmed&amp;url_ver=Z39.88-2003&amp;rfr_id=ori%3Arid%3Acrossref.org">McCarthy CP, Bruno RM, Rahimi K, Touyz RM, McEvoy JW. What Is New and Different in the 2024 European Society of Cardiology Guidelines for the Management of Elevated Blood Pressure and Hypertension? Hypertension. 2024 Dec 31.</a>
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Cardiology Guidelines Comparison

The European Society of Cardiology (ESC) has released the 2024 Guidelines for the Management of Elevated Blood Pressure and Hypertension, introducing updated recommendations to enhance patient outcomes and optimize clinical practice.
&nbsp;Key Updates:
<ul style="margin-top: 0in;" type="disc">
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;">Revised Blood Pressure Targets: Stricter control recommendations based on patient age and cardiovascular risk.</li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;">Early Combination Therapy: Dual or triple therapy is now emphasized as first-line treatment for better efficacy.</li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;">Lifestyle Modifications: Stronger reinforcement of diet, exercise, and sodium reduction in hypertension management.</li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;">Advanced Blood Pressure Monitoring: Greater focus on home and ambulatory monitoring for accurate diagnosis and treatment adjustments.</li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;">Special Population Considerations: Tailored treatment approaches for elderly patients, individuals with diabetes, and pregnant women.</li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;">Comprehensive Cardiovascular Risk Management: Hypertension treatment is now integrated into broader cardiovascular disease prevention strategies.  </li>
</ul>
For further details, refer to the full 2024 ESC Guidelines on Hypertension: &nbsp;<a href="https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Elevated-Blood-Pressure-and-Hypertension" target="_new">ESC 2024 Hypertension Guidelines</a>
Reference: European Society of Cardiology. 2024 ESC Guidelines for the management of elevated blood pressure and hypertension. Eur Heart J. 2024. Available from: <a href="https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Elevated-Blood-Pressure-and-Hypertension" target="_new">https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Elevated-Blood-Pressure-and-Hypertension</a>

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2024 ESC Guidelines for the Management of Hypertension – Key Updates

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2024 ESC Guidelines for the Management of Atrial Fibrillation – Key Updates 

The European Society of Cardiology (ESC) has released the 2023 Focused Update to the 2021 Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure. This update integrates the latest clinical evidence to enhance patient care and optimize treatment strategies.
&nbsp;Key Updates:
<ul style="margin-top: 0in;" type="disc">
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;">Refined Heart Failure Classification: Emphasizing Heart Failure with Improved Ejection Fraction (HFimpEF) as a distinct category.</li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;">Updated Pharmacological Recommendations: Stronger endorsement of SGLT2 inhibitors as foundational therapy for all heart failure patients, regardless of ejection fraction.</li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;">Personalized Treatment Strategies: Tailored therapeutic approaches based on biomarkers, imaging, and genetic considerations.</li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;">Enhanced Use of Implantable Devices: Expanded indications for implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy (CRT) in selected patients.</li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;">Acute Heart Failure Management: Revised recommendations for diuretic strategies, vasodilators, and inotropic support to improve acute-phase treatment.</li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;">Focus on Comorbidities: Updated guidance on managing iron deficiency, kidney disease, and diabetes in heart failure patients.</li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;">Telemedicine and Remote Monitoring: Encouragement of digital health solutions for early intervention and long-term management.</li>
</ul>
For further details, refer to the full 2023 ESC Focused Update on Heart Failure: <a href="https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Focused-Update-on-Heart-Failure-Guidelines">&nbsp;ESC 2023 Heart Failure Guidelines Update</a>
Reference: European Society of Cardiology. 2023 Focused Update of the 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2023. Available from:<a href="file:///C:/Users/nader.nokrachi/Downloads/%20https:/www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Focused-Update-on-Heart-Failure-Guidelines%20"> https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Focused-Update-on-Heart-Failure-Guidelines</a> 
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2023 Focused Update of the ESC Guidelines for the Diagnosis and Treatment of Acute and Chronic Heart Failure – Key Updates

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Cognitive Impairment in Major Depressive Disorder (MDD) 

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European Glaucoma Society – Terminology and Guidelines for Glaucoma (5th Edition)
Newsletter Summary


European Glaucoma Society – Terminology and Guidelines for Glaucoma (5th Edition) Newsletter Summary

Purpose
The ESSENCE-2 Open-Label Extension (OLE) study aimed to assess the long-term safety, tolerability, and efficacy of a novel water-free, no preserved cyclosporine 0.1% ophthalmic solution (marketed as VEVYE®) in patients with dry eye disease (DED). ​
<div class="MsoNormal" style="text-align: center;" align="center"><hr align="center" size="2" width="100%"></div>
Study Design
<ul style="margin-top: 0in;" type="disc">
<li class="MsoNormal" style="mso-list: l1 level1 lfo1; tab-stops: list .5in;">Type: Phase 3, prospective, multicentre, open-label clinical study.</li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo1; tab-stops: list .5in;">Participants: 202 patients who completed the ESSENCE-2 trial.</li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo1; tab-stops: list .5in;">Treatment: Patients administered one drop of cyclosporine 0.1% solution in each eye twice daily for 52 weeks.</li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo1; tab-stops: list .5in;">Assessments:</li>
<ul style="margin-top: 0in;" type="circle">
<li class="MsoNormal" style="mso-list: l1 level2 lfo1; tab-stops: list 1.0in;">Primary Safety Endpoints: Ocular and nonocular adverse events (AEs).</li>
<li class="MsoNormal" style="mso-list: l1 level2 lfo1; tab-stops: list 1.0in;">Secondary Safety Endpoints: Visual acuity, bio microscopy, intraocular pressure, and dilated fundoscopy.</li>
<li class="MsoNormal" style="mso-list: l1 level2 lfo1; tab-stops: list 1.0in;">Efficacy Endpoints: Total corneal fluorescein staining (tCFS) score (NEI Scale), ocular symptoms (visual analogue scale), and Schirmer tear test. ​</li>
</ul>
</ul>
<div class="MsoNormal" style="text-align: center;" align="center"><hr align="center" size="2" width="100%"></div>
Key Findings
<ul style="margin-top: 0in;" type="disc">
<li class="MsoNormal" style="mso-list: l0 level1 lfo2; tab-stops: list .5in;">Completion Rate: 175 patients (86.6%) completed the 52-week study.</li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo2; tab-stops: list .5in;">Safety:</li>
<ul style="margin-top: 0in;" type="circle">
<li class="MsoNormal" style="mso-list: l0 level2 lfo2; tab-stops: list 1.0in;">55 patients (27.5%) reported 74 ocular treatment-emergent adverse events (TEAEs).</li>
<li class="MsoNormal" style="mso-list: l0 level2 lfo2; tab-stops: list 1.0in;">The most common ocular AE was instillation site pain (6.5%), all cases were mild.</li>
</ul>
<li class="MsoNormal" style="mso-list: l0 level1 lfo2; tab-stops: list .5in;">Efficacy:</li>
<ul style="margin-top: 0in;" type="circle">
<li class="MsoNormal" style="mso-list: l0 level2 lfo2; tab-stops: list 1.0in;">Statistically significant improvements in all prespecified efficacy endpoints compared with baseline at each visit.</li>
<li class="MsoNormal" style="mso-list: l0 level2 lfo2; tab-stops: list 1.0in;">Corneal staining improvements were observed early and stabilized over time.</li>
<li class="MsoNormal" style="mso-list: l0 level2 lfo2; tab-stops: list 1.0in;">Tear production showed continuous improvement.</li>
<li class="MsoNormal" style="mso-list: l0 level2 lfo2; tab-stops: list 1.0in;">Symptom improvement followed these effects, with scores reaching a minimum after one year of treatment. ​</li>
</ul>
</ul>
<div class="MsoNormal" style="text-align: center;" align="center"><hr align="center" size="2" width="100%"></div>
Conclusion
The water-free cyclosporine 0.1% ophthalmic solution was found to be safe and well-tolerated over long-term use. The study demonstrated sustained efficacy over one year in both signs and symptoms of DED, providing insights into the healing dynamics in patients with predominantly inflammatory DED. ​
<div class="MsoNormal" style="text-align: center;" align="center"><hr align="center" size="2" width="100%"></div>
Access to Full Study
For more detailed information, you can access the full study here: &nbsp;<a href="https://pubmed.ncbi.nlm.nih.gov/38771801/" target="_new">PubMed – ESSENCE-2 OLE Study</a>
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Newsletter Summary: Long-Term Safety and Efficacy of Water-Free Cyclosporine 0.1% Ophthalmic Solution for Dry Eye Disease (ESSENCE-2 OLE Study)

Purpose
To evaluate the efficacy and safety of a water-free cyclosporine 0.1% ophthalmic solution (CyclASol) compared with vehicle in treating moderate to severe dry eye disease (DED).
Methods
Design: Phase 3, multicenter, double-masked, randomized controlled trial
Setting: Conducted at 27 clinical sites in the United States
Population: Adults (≥18 years) with moderate to severe DED and specific signs (e.g., total corneal fluorescein staining score ≥4)
Intervention:
Patients were randomized 1:1 to either: Cyclosporine 0.1% solution (n = 369) &amp; Vehicle (placebo) (n = 186)
Dosing: One drop per eye, twice daily for 29 days
Follow-up visits: Day 15 ± 2 and Day 29 ± 2 and nearly 200 participants had the opportunity to enroll in a 1-year extension study, to be reported separately
&nbsp;
Endpoints
Co–Primary Endpoints:
<ol style="margin-top: 0in;" start="1" type="1">
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;">Change from baseline in total corneal fluorescein staining (tCFS) at Day 29</li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;">Change from baseline in eye dryness score (EDS) at Day 29</li>
</ol>
Secondary Endpoints:
Change in Ocular Surface Disease Index (OSDI) score
Tear film breakup time
Visual analog scale for dryness
Ocular discomfort and photophobia
&nbsp;
&nbsp;
Results
&nbsp;Total corneal fluorescein staining significantly improved in the Cyclosporine group compared to vehicle at Day 29
Mean difference: −0.58 units (95% CI, −0.84 to −0.32); P &lt; .001
Eye dryness score improvement showed a numerical trend, but did not reach statistical significance at Day 29
OSDI score and other symptom-based measures showed favorable changes in the treatment group
Safety: The treatment was well tolerated, with no serious treatment-related ocular adverse events
&nbsp;
&nbsp;
Additional Context
A compromised ocular surface due to DED may affect refractive accuracy before surgeries (e.g., LASIK, cataract) and impair postoperative outcomes
&nbsp;No single “gold standard” exists for DED management; a staged approach based on clinical severity is commonly followed
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Conclusion
The water-free cyclosporine 0.1% solution demonstrated significant efficacy in improving ocular surface integrity in patients with moderate to severe DED over 29 days. Though symptom relief trends were noted, significant symptom-based endpoint improvement was not consistently achieved. The solution was found to be safe and well tolerated.
<div class="MsoNormal" style="text-align: center;" align="center"><hr align="center" size="2" width="100%"></div>
To access the full publication: <a href="https://jamanetwork.com/journals/jamasurgery/fullarticle/2805045">Read the full article on JAMA Ophthalmology</a>
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Efficacy and Safety of a Water-Free Topical Cyclosporine, 0.1%, Solution for the Treatment of Moderate to Severe Dry Eye Disease (ESSENCE-2 Randomized Clinical Trial)", 
published in JAMA Ophthalmology

Efficacy and Safety of a Water-Free Topical Cyclosporine, 0.1%, Solution for the Treatment of Moderate to Severe Dry Eye Disease (ESSENCE-2 Randomized Clinical Trial)",  published in JAMA Ophthalmology

"Immediate vs Delayed Postpartum Insertion of Long-Acting Reversible Contraception Methods: Meta-Analysis of Randomized Controlled Trials" published in the American Journal of Obstetrics and Gynecology in September 2024
Purpose
To compare the effectiveness and safety of immediate postpartum insertion (before hospital discharge) versus delayed insertion (typically ≥6 weeks postpartum) of long-acting reversible contraception (LARC) methods—including intrauterine devices (IUDs) and implants.
<div class="MsoNormal" style="text-align: center;" align="center"><hr align="center" size="2" width="100%"></div>
Methods
<ul style="margin-top: 0in;" type="disc">
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;">A systematic review and meta-analysis of 17 randomized controlled trials.</li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;">Included studies that compared immediate vs delayed LARC insertion in postpartum individuals.</li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;">Primary outcomes: Subsequent pregnancy rates and LARC utilization at 6 months.</li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;">Secondary outcomes: Expulsion, continuation, removal, breastfeeding outcomes, and adverse events.</li>
</ul>
<div class="MsoNormal" style="text-align: center;" align="center"><hr align="center" size="2" width="100%"></div>
Results
<ul style="margin-top: 0in;" type="disc">
<li class="MsoNormal" style="mso-list: l1 level1 lfo2; tab-stops: list .5in;">Subsequent Pregnancy: Immediate LARC insertion significantly reduced the risk of pregnancy compared to delayed insertion. RR = 0.16 (95% CI: 0.04–0.71; P = .02).</li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo2; tab-stops: list .5in;">LARC Use at 6 Months: Women in the immediate group were more likely to be using LARC at 6 months. RR = 1.23 (95% CI: 1.09–1.37; P &lt; .01).</li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo2; tab-stops: list .5in;">Breastfeeding Outcomes: No significant difference between groups for any breastfeeding or exclusive breastfeeding.</li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo2; tab-stops: list .5in;">Expulsion Rates: Immediate insertion was associated with a higher IUD expulsion rate. However, no differences in adverse events such as pelvic inflammatory disease, uterine perforation, or hospital readmission were observed.</li>
</ul>
<div class="MsoNormal" style="text-align: center;" align="center"><hr align="center" size="2" width="100%"></div>
Conclusion
Immediate postpartum LARC insertion is a safe and effective strategy that:
<ul style="margin-top: 0in;" type="disc">
<li class="MsoNormal" style="mso-list: l2 level1 lfo3; tab-stops: list .5in;">Increases contraceptive use at 6 months</li>
<li class="MsoNormal" style="mso-list: l2 level1 lfo3; tab-stops: list .5in;">Reduces risk of subsequent pregnancy</li>
<li class="MsoNormal" style="mso-list: l2 level1 lfo3; tab-stops: list .5in;">Does not negatively impact breastfeeding</li>
</ul>
Although expulsion rates are higher, they are not linked to serious adverse outcomes. This supports immediate postpartum LARC insertion as a beneficial option for postpartum contraceptive planning For further details, you can access the full article here: <a href="https://www.sciencedirect.com/science/article/abs/pii/S0002937824009311" target="_new">ScienceDirect Link</a>
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Immediate vs Delayed Postpartum Insertion of Long-Acting Reversible Contraception Methods: Meta-Analysis of Randomized Controlled Trials

Antioxidants and Fertility in Women with Ovarian Aging
Introduction:
Ovarian aging is a major contributor to female subfertility, characterized by a decline in both oocyte quantity and quality. This newsletter summarizes a recent systematic review and meta-analysis investigating the impact of antioxidant supplementation on fertility in women with ovarian aging.
Study Details:
Shang et al. conducted a systematic review and meta-analysis of 20 randomized controlled trials (RCTs), including 2617 participants. The studies evaluated various antioxidants, doses, and treatment durations in women with ovarian aging undergoing in vitro fertilization (IVF). The primary outcomes were live birth rate and clinical pregnancy rate.
Key Findings:
<ul style="margin-top: 0in;" type="disc">
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;">Clinical Pregnancy Rate: Antioxidant supplementation was associated with a statistically significant increase in clinical pregnancy rate (OR 1.55, 95% CI 1.18-2.04).</li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;">Live Birth Rate: No significant difference in live birth rate was observed between antioxidant and control groups (OR 1.05, 95% CI 0.80-1.37).</li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;">Miscarriage Rate: Antioxidants did not significantly impact miscarriage rates (OR 0.80, 95% CI 0.44-1.44).</li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;">Oocyte and Embryo Quality: Antioxidants were associated with a significant increase in the number of retrieved oocytes and high-quality embryos. However, no significant improvement was seen in the number of mature (MII) oocytes.</li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;">Gonadotropin Dose: Antioxidant treatment significantly reduced the required dose of gonadotropin during ovarian stimulation.</li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;">Adverse Events: No significant association between antioxidants and adverse events was observed.  </li>
</ul>
Subgroup Analysis Highlights:
<ul style="margin-top: 0in;" type="disc">
<li class="MsoNormal" style="mso-list: l1 level1 lfo2; tab-stops: list .5in;">Coenzyme Q10 (CoQ10): CoQ10 demonstrated the most promising results, particularly for clinical pregnancy rates. A dose of 30 mg/day for 3 months before controlled ovarian stimulation appeared to be the most effective regimen, especially in women with diminished ovarian reserve and those under 35 years old.</li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo2; tab-stops: list .5in;">Melatonin: Melatonin showed potential benefits for embryo quality, particularly at lower doses (&lt;5 mg/day).</li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo2; tab-stops: list .5in;">Dose-Dependent Effect: Subgroup analyses suggested a trend towards greater improvements with lower doses of antioxidants.</li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo2; tab-stops: list .5in;">Ovarian Aging Population: Antioxidants demonstrated greater benefits in women over 35 with diminished ovarian reserve.</li>
</ul>
Clinical Implications:
This meta-analysis suggests that antioxidant supplementation may be a valuable complementary therapy for women with ovarian aging undergoing IVF. CoQ10, in particular, warrants consideration, especially at a dose of 30 mg/day for 3 months before ovarian stimulation. While promising, these findings should be interpreted cautiously due to the limitations of included studies and the need for further research, particularly on live birth rates and long-term outcomes. Further investigation is needed to confirm the optimal antioxidant type, dosage, and treatment duration for different patient subgroups. Reference:  
<a href="https://pmc.ncbi.nlm.nih.gov/articles/PMC11345374/">Antioxidants and Fertility in Women with Ovarian Aging- Advances in Nutrition.</a>
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Antioxidants and Fertility in Women with Ovarian Aging

Key Takeaways for Healthcare Professionals:
<ul style="margin-top: 0in;" type="disc">
<li class="MsoNormal" style="mso-list: l1 level1 lfo1; tab-stops: list .5in;">Higher Prevalence: POI is more common than previously thought, affecting 3.5% of women under 40.</li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo1; tab-stops: list .5in;">Simplified Diagnosis: Only one elevated FSH level &gt;25 IU/L (along with amenorrhea/irregular cycles) is now required for POI diagnosis. AMH can be useful in cases of diagnostic uncertainty, but is not a primary diagnostic test.</li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo1; tab-stops: list .5in;">Genetic Testing Recommended: Chromosomal analysis and FMR1 premutation testing are recommended for all women with non-iatrogenic POI. Additional genetic testing (e.g., next-generation sequencing) may be offered where available and after genetic counseling.</li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo1; tab-stops: list .5in;">Hormone Therapy (HT) Essential: HT is recommended until the usual age of menopause for primary prevention of long-term health risks, regardless of the presence of estrogen deficiency symptoms.</li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo1; tab-stops: list .5in;">HT Dosing: A daily dose containing no less than 2 mg oral estradiol or 100 µg transdermal estradiol (or equivalent) is suggested to optimize bone health.</li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo1; tab-stops: list .5in;">Combined Oral Contraceptive (COC): If the COC is used, a continuous or extended regimen is recommended.</li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo1; tab-stops: list .5in;">Testosterone Therapy: Can be considered for hypoactive sexual desire disorder in POI after excluding other causes.</li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo1; tab-stops: list .5in;">Lifestyle: Encourage healthy lifestyle (diet, exercise, smoking cessation, weight management) to optimize overall health.</li>
<li class="MsoNormal" style="mso-list: l1 level1 lfo1; tab-stops: list .5in;">Personalized Care: Address the psychological impact of POI diagnosis with compassionate communication and shared decision-making. Refer to support groups and mental health resources as needed.</li>
</ul>
Main Changes from the 2015 Guideline:
<ul style="margin-top: 0in;" type="disc">
<li class="MsoNormal" style="mso-list: l0 level1 lfo2; tab-stops: list .5in;">Simplified diagnostic criteria for POI (one FSH measurement).</li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo2; tab-stops: list .5in;">Updated guidance on genetic testing.</li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo2; tab-stops: list .5in;">Clarified estrogen doses and regimens for HT.</li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo2; tab-stops: list .5in;">Recommendations on COC use.</li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo2; tab-stops: list .5in;">Updated guidance on testosterone therapy.</li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo2; tab-stops: list .5in;">Emphasis on personalized care and the psychological impact of diagnosis.</li>
</ul>
References: <a href="https://www.fertstert.org/article/S0015-0282(24)02385-9/pdf">Evidence-based guideline: Premature Ovarian Insufficiency-ASRM</a>
&nbsp;

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Updated Guideline on Premature Ovarian Insufficiency (POI)

A recent single-center, prospective study evaluated the efficacy of nebulized budesonide and ambroxol hydrochloride, combined with intravenous amoxicillin-clavulanate, in treating community-acquired pneumonia (CAP) in 56 children under 6 years old. The study, conducted at the Affiliated Maternity and Child Health Care Hospital of Nantong University, examined the impact of this combined therapy on various microbial strains, clinical symptoms, and inflammatory markers.
Key Findings:
<ul style="margin-top: 0in;" type="disc">
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;">Younger children, especially infants under one year, presented with a higher incidence of multiple pathogen infections and more severe clinical manifestations like dyspnea. The most common pathogens were Streptococcus pneumoniae, Haemophilus influenzae, and Mycoplasma.</li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;">The combination therapy demonstrated significant clinical improvement across all age groups and against various pathogens. Improvements were observed in fever, cough, lung rales, and radiological findings. CRP and PCT levels also returned to normal, with statistically significant improvements in CRP for children aged 1-3 years.</li>
<li class="MsoNormal" style="mso-list: l0 level1 lfo1; tab-stops: list .5in;">Nebulized budesonide and ambroxol hydrochloride appear to offer a promising therapeutic option for pediatric CAP, especially in younger children with severe presentations.</li>
</ul>
Study Details:
Children received intravenous amoxicillin-clavulanate along with nebulized budesonide (1 mg twice daily) and ambroxol hydrochloride (0.5 mg twice daily) for one week. Clinical symptoms, laboratory markers (WBC, CRP, PCT), and radiological findings were assessed throughout the study.
Clinical Implications:
This study suggests that nebulized budesonide and ambroxol hydrochloride, as an adjunct to standard antibiotic therapy, may be beneficial in managing pediatric CAP. While promising, these findings are based on a single-center study with a limited sample size. Larger, multicenter randomized controlled trials are needed to confirm these results and evaluate long-term outcomes.
Reference: <a href="https://jhpn.biomedcentral.com/articles/10.1186/s41043-024-00621-4">The efficacy of nebulized budesonide and ambroxol hydrochloride in treating pediatric community-acquired pneumonia and their impact on clinical characteristics and inflammatory markers</a>
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Nebulized Budesonide/Ambroxol Shows Promise in Pediatric CAP

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