Update on gout and hyperuricemia

There have been recent advances in the understanding of underlying mechanisms and treatment of gout and chronic hyperuricemia, making this an important time to review the current state of the disease. The goal of this article is to provide a practical review of the current standard of care as well as discuss some new developments in the management. There is an increasing prevalence of gout and hyperuricemia worldwide. Gout confers a significant individual and societal burden and is often under‐treated. Appropriate diagnosis and treatment of acute gout should be followed by aggressive and goal‐oriented treatment of hyperuricemia and other risk factors. Allopurinol remains as a first‐line treatment for chronic hyperuricemia, but uricosuric agents may also be considered in some patients. Febuxostat, a non‐purine xanthine‐oxidase inhibitor, is a new agent approved for the treatment of hyperuricemia in patients with gout, which may be used when allopurinol is contraindicated. Gout and hyperuricemia appear to be independent risk factors for incident hypertension, renal disease and cardiovascular disease. Physicians should consider cardiovascular risk factors in patients with gout and treat them appropriately and aggressively.     

Malignant bone pain: Pathophysiology and treatments

Metastatic involvement of the bone is one of the most frequent causes of pain in cancer patients and represents one of the first signs of widespread neoplastic disease. The pain may originate directly from the bone, from nerve root compression, or from muscle spasms in the area of the lesions. The mechanism of metastatic bone pain is mainly somatic (nociceptive), even though, in some cases, neuropathic and visceral stimulations may overlap. The conventional symptomatic treatment of metastatic bone pain requires the use of multidisciplinary therapies, such as radiotherapy, in association with systemic treatment (hormonotherapy, chemotherapy, radioisotopes) with the support of analgesic therapy. Recently, studies have indicated the use of bisphosphonates in the treatment of pain and in the prevention of skeletal complications in patients with metastatic bone disease. In some patients, pharmacologic treatment, radiotherapy, and radioisotopes administered alone or in association are not able to manage pain adequately. The role of neuroinvasive techniques in treating metastatic bone pain is debated. The clinical conditions of the patient, his life expectancy, and quality of life must guide the physician in the choice of the best possible therapy.     

Allergic and Nonallergic Rhinitis: Update on Pathophysiology and Clinical Management

An understanding of the pathophysiology will dictate appropriate therapy for allergic and nonallergic rhinitis. Cholinergic pathways when stimulated produce typical secretions that can be identified by their grandular constituents so as to implicate neurologic stimulation. By contrast secretions typical of increased vascular permeability are found in allergic reactions and upper respiratory infections. In general it is worthwhile to treat early since the nose can be primed so as to produce symptoms at lower doses as the season continues. The mainstay of therapy continues to be antihistamines, which typically treat the sneezing, runny nose, and itchy eyes, nose and throat. The decongestants can ameliorate stuffy nose and systemic agents, such as phenylpropanolamine or pseudoephedrine, are preferred over the topical agents. Anti-inflammatory preparations such as Nasalcrom or steroid aerosols such as those containing belcomethasone, funisolide, budesonide, or Triamcinolone can prove very useful. If a neurologic mechanism or predominantly rhinorrhea symptoms are present, an anticholinergic such as a ipratropium might be the treatment of choice. Immunotherapy also is anti-inflammatory and blocks late phase allergic reactions, so the choices of medication based on pathogenic mechanisms represents sensible treatment options for rhinitis.     

Update on treatments for premature ejaculation

Current and upcoming treatment options for premature ejaculation (PE) are of global clinical interest. In 2008, the International Society for Sexual Medicine published an evidence-based definition for PE. While there are no US Food and Drug Administration-approved therapies for PE, the American Urological Association 2004 guidelines state the serotonergic antidepressants paroxetine, sertraline, fluoxetine and clomipramine and the topical lidocaine-prilocaine cream are effective treatment options. However, there are limitations associated with their use, which may be overcome by PE-specific therapies currently in development. Two agents that are in advanced stages of clinical development include: (i) dapoxetine, an on-demand short-acting selective serotonin reuptake inhibitor, and (ii) PSD502, a metered-dose aerosol containing lidocaine and prilocaine, also for on-demand treatment. Another on-demand agent in development is tramadol, a weak opioid that is currently approved for treating pain. Coupled with efficient diagnosis, it is hoped that these newer agents will improve the quality of life for patients who suffer from PE.     

Update on Chiari malformation: clinical manifestations,diagnosis, and treatments

The incidence of the Chiari I malformation is unknown; however, with increased diagnostic procedures, the diagnosis is becoming more common. In the past, Chiari I has been diagnosed in adulthood, but the condition is now being observed more frequently in pediatric clients. This article will review the clinical manifestations, diagnostic procedures, and treatment options available for Chiari type I (Chiari I) malformation. The nursing considerations for this condition are also discussed.     

Update on multiple sclerosis, its diagnosis and treatments

Abstract Multiple sclerosis (MS) is a central nervous system disorder, characterized by mononuclear cell inflammation, demyelination and often with extensive axonal injury. It was first described neuropathologically in the late 1800s. MS has an interesting geographical epidemiology, with a higher rate at latitudes further from the equator in both directions. Women outnumber males by about 2:1; this ratio has been increasing in recent years. Genome wide association studies have thus far identified over 50 genetic susceptibility loci, and these are rapidly expanding. Several environmental risk factors have been identified, including low serum vitamin D levels, exposure to Epstein-Barr virus and cigarette smoking. MS displays a heterogeneous disease course; most patients with the disease begin with a relapsing-remitting course, but often eventually develop steady disability progression. A small percentage of MS patients have a progressive course without clinical relapses. Several treatments are now available to decrease relapse rate and slow the accumulation of disability in patients with relapsing MS, but there is currently no effective treatment to slow the progressive forms of MS.     

Pathophysiology of Medication Overuse Headache—An Update

The pathogenesis of medication overuse headache is unclear. Clinical and preclinical studies have consistently demonstrated increased excitability of neurons in the cerebral cortex and trigeminal system after medication overuse. Cortical hyperexcitability may facilitate the development of cortical spreading depression, while increased excitability of trigeminal neurons may facilitate the process of peripheral and central sensitization. These changes may be secondary to the derangement of central, probably serotonin (5‐HT)‐, and perhaps endocannabinoid‐dependent or other, modulating systems. Increased expression of excitatory cortical 5‐HT_2A receptors may increase the susceptibility to developing cortical spreading depression, an analog of migraine aura. A reduction of diffuse noxious inhibitory controls may facilitate the process of central sensitization, activate the nociceptive facilitating system, or promote similar molecular mechanisms to those involved in kindling. Low 5‐HT levels also increase the expression and release of calcitonin gene‐related peptide from the trigeminal ganglion and sensitize trigeminal nociceptors. Thus, derangement of central modulation of the trigeminal system as a result of chronic medication use may increase sensitivity to pain perception and foster or reinforce medication overuse headache.     

Cytokines and the anorexia of infection: potential mechanisms and treatments

Anorexia during infection is thought to be mediated by immunoregulatory cytokines such as interleukins 1 and 6 and tumor necrosis factor. This article reviews the potential mechanisms of action by which these cytokines are thought to suppress food intake during infection and examines the proposition that blocking of cytokine activity might be one approach to improving food intake of the infected host.     

Hyperuricemia and gout: an update

Gout may be a primary or a secondary disorder. In both types of gout, overproduction or underexcretion of uric acid, or a combination of these abnormalities, may be the underlying mechanism. Controversy exists over the need for treatment of asymptomatic hyperuricemia. Treatment of tophi requires use of both uricosurics and allopurinol. A xanthine oxidase inhibitor is the drug of choice for patients with uric acid stones and for those with renal insufficiency.     

COVID‐19 and toxicity from potential treatments: Panacea or poison

Since December 2019, coronavirus disease (COVID‐19) has been increasingly spreading from its origin in Wuhan, China to many countries around the world eventuating in morbidity and mortality affecting millions of people. This pandemic has proven to be a challenge given that there is no immediate cure, no vaccine is currently available and medications or treatments being used are still undergoing clinical trials. There have already been examples of self‐medication and overdose. Clearly, there is a need to further define the efficacy of treatments used in the management of COVID‐19. This evidence needs to be backed by large randomised‐controlled clinical trials. In the meantime, there will no doubt be further off‐label use of these medications by patients and practitioners and possibly related toxicity.     

Herbs as old potential treatments for lymphedema management: A systematic review

IntroductionHerbs have been reported to be effective in reducing lymphedema burden. This paper aimed to review literature reporting on herbs for lymphedema treatment.MethodsA systematic review was performed using the PRISMA guideline. Clinical studies on herbal intervention and lymphedema were included. Evidence on the effectiveness of herbal interventions for desired outcomes including reduction of edema volume, other symptoms, quality of life and inflammation were collected and assessed in detail.ResultsIn all twenty studies were included in this review. Of these 14 studies were randomized clinical trials and the rest were prospective pilot studies. Herbal treatment was reported for breast cancer-related lymphedema in most studies and coumarin was the most reported herb that used for lymphedema management. Edema volume reduction (17 out of 20) and symptoms improvement (15 out of 20) were the outcomes reported in most studies.ConclusionPhytochemicals can be a promising pharmacotherapy for lymphedema management. However, further evidence is needed to establish definite effectiveness for the use of herbal remedies for lymphedema management.     

Constipation management in palliative care: treatments and the potential of independent nurse prescribing

Constipation is a common symptom in palliative care patients that can generate considerable suffering owing to both the inherent physical discomfort and the attendant psychological issues such as embarrassment. This article considers the management of constipation for palliative care patients, including the importance of the patient's own definition of their problem, the need for thorough and frequent assessment, established treatment options, and the challenges that nurses may face. It provides a simple algorithm to assist in the management process, and also looks at the current strength of the evidence base for two more recent therapies. Finally, it examines the potential of the independent nurse prescriber (INP) for constipation management in the UK, using a brief case study to illustrate a commonly experienced constipation management scenario for the INP in the community setting.     

Hyperuricemia and gout

Diagnosis of gout by crystal identification in synovial fluid is simple and defmitive. To treat gout effectively, the physician must determine whether overproduction or underexcretion of uric acid is the underlying mechanism. The acute attack is treated initially with antiinflammatory agents. After the acute phase is controlled, lifelong definitive therapy for hyperuricemia is begun.