Articles: treatment.
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The controversy over preemptive analgesia continues unabated, with studies both supporting and refuting its efficacy. The timing of an analgesic intervention and presence of a placebo control may have significant impact on the interpretation of results and may have led to the premature conclusion that preemptive analgesia is of limited clinical utility. A review of the recent literature using strict definitions of preemptive and preventive analgesia is required in order to clarify the broader issue of the benefits of perioperative analgesia. ⋯ Studies that used a preventive design had a greater likelihood of finding a beneficial effect. The application of preventive perioperative analgesia (not necessarily preincisional) is associated with a significant reduction in pain beyond the clinical duration of action of the analgesic agent, in particular for the N-methyl-D-aspartate antagonists. The classical definition of preemptive analgesia should be abandoned in favor of preventive analgesia. This will broaden the scope of inquiry from a narrow focus on preincisional versus postincisional interventions to one that aims to minimize postoperative pain and analgesic requirements by reducing peripheral and central sensitization arising from noxious preoperative, intraoperative and postoperative inputs.
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Airway remodeling is a summary term for the pathological changes that occur in airway structure in allergic or suppurative airway diseases. Characteristic changes of airway remodeling in asthma include goblet cell hyperplasia, deposition of collagens in the basement membrane zone, increased size and number of microvessels in the submucosa, hyperplasia and hypertrophy of airway smooth muscle, and hypertrophy of submucosal glands. Some of these changes, such as goblet cell hyperplasia and subepithelial collagen deposition, are present even in mild asthma; other changes such as increases in airway smooth muscle and gland volume appear to be more characteristic of severe asthma. ⋯ For this reason relatively little is known about the effects of current asthma treatments on airway remodeling. As mechanisms of airway remodeling are developed, it is hoped that novel therapeutic targets will be identified. Treatments specifically targeting mediators of remodeling hold promise as treatments that could modify disease progression in asthma.
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The selective cyclooxygenase-2 (COX-2) inhibitors celecoxib and rofecoxib were designed to have similar efficacy but less gastrointestinal toxicity than traditional nonsteroidal anti-inflammatory drugs (NSAIDs). Their efficacy has been demonstrated in the treatment of osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, postoperative dental pain and dysmenorrhea. ⋯ Nephrotoxicity and hyptertension remain concerns with COX-2 inhibitors, as they are with traditional NSAIDs. COX-2 inhibitors may be safe alternatives to traditional NSAIDs for patients with aspirin-sensitive asthma.
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Pediatr Crit Care Me · Jul 2002
Corticosteroids for the prevention of reintubation and postextubation stridor in pediatric patients: A meta-analysis.
To determine whether corticosteroids are effective in preventing or treating postextubation stridor and in reducing the need for subsequent reintubation of the trachea in critically ill infants and children. DESIGN: Meta-analysis of published randomized controlled trials. DATA SOURCES: References of each trial from a MEDLINE search were reviewed, and experts in the field were contacted. STUDY SELECTION: Any randomized controlled trial comparing the administration of corticosteroids with placebo on the prevalence of reintubation or postextubation stridor in infants or children receiving mechanical ventilation via an endotracheal tube in an intensive care unit. DATA EXTRACTION: Data extraction and methodologic quality assessment were assessed independently by two reviewers. DATA SYNTHESIS: Six controlled clinical trials met the criteria for inclusion; three trials pertain to neonates and three to children. Five trials examined the use of steroids for the prevention of reintubation (four of these evaluated postextubation stridor specifically); one trial examined the use of steroids to treat existing postextubation stridor in children. There was a nonsignificant trend toward a decreased rate of reintubation in all subjects when prophylactic steroids were used (n = 376, relative risk [RR] = 0.34, 95% confidence interval [CI] = 0.05-2.33). Prophylactic use of steroids reduced postextubation stridor in the pooled studies (n = 325, RR = 0.50, 95% CI = 0.28-0.88). In young children, there were significant reductions of postextubation stridor with preventive treatment (n = 216, RR = 0.53, 95% CI = 0.28-0.97), and a trend toward less stridor was observed in neonates (n = 109, RR = 0.42, 95% CI = 0.07-2.32). There was a nonsignificant trend toward a reduced reintubation rate when steroids were used to treat existing upper airway obstruction requiring reintubation (RR = 0.55, 95% CI = 0.17-1.78). Side effects were seldom reported and could not be evaluated. ⋯ Prophylactic administration of dexamethasone before elective extubation reduces the prevalence of postextubation stridor in neonates and children and may reduce the rate of reintubation.