Pain Management Protocols During Uterine Fibroid Embolisation: A Systematic Review of the Evidence.

BACKGROUND: Uterine fibroid embolisation (UFE) is an effective treatment for fibroids. There are varying analgesia protocols published to control procedure associated pain. We aimed to assess what protocols are most effective in controlling post-procedural pain. MATERIALS AND METHODS: A systematic review of the Embase and Medline databases was conducted according to PRISMA guidelines. Studies regarding analgesia protocols post-uterine fibroid embolisation with Visual Analogue Scale or Numerical Rating Scale pain scores were included. The mean maximal pain scores of patients post-procedure were evaluated. ANOVA and t tests were performed. RESULTS: We identified 26 studies (total 3353 patients), with a mean procedural success rate of > 87%. We stratified protocols into four groups. Mean pain scores were: opioids ± NSAIDs ± acetaminophen (4.84, SD = 1.56); opioids ± NSAIDs ± acetaminophen + nerve block (4.7, SD = 1.37); opioids ± NSAIDs ± acetaminophen + intrauterine artery drug administration (4.09, SD = 0.60); and opioids ± NSAIDs ± acetaminophen + other (5.30, SD = 1.13) without significant difference between groups (p = 0.71). Similarly, there was no difference (p = 0.057) between groups for time to discharge or side effects. CONCLUSIONS: There is no evidence to suggest that there is any superiority of one protocol above another in the published literature. Appropriate use of opioids ± NSAIDs ± acetaminophen alone appears to be sufficient to control pain post-UFE. However, due to large heterogeneity of the literature no firm conclusions can be reached, and further research is warranted. LEVEL OF EVIDENCE: Level 1, Systematic review.

Treatment of cerebral mucormycosis with drug therapy alone: A case report.

We report on an elderly male patient with headache and right-side weakness. Imaging studies revealed multiple space-occupying lesions in the parietal and occipital cerebral regions. Biopsy revealed broad aseptate ribbon-like structures branching at right angles, suggestive of mucormycosis. Improvement was observed after medical therapy with 20 weeks of liposomal amphotericin B (5 mg/kg/day) combined with posaconazole, followed by posaconazole (400 mg twice a day) alone for 1 month. The patient recovered without neurological deficits; however, multidrug-resistant bacteraemia and hospital-acquired pneumonia occurred, resulting in death. Nevertheless, our report shows that this lethal fungal infection can sometimes show favourable progress with drug therapy alone.

Miliary tuberculosis mimicking systemic lupus erythematosus flare.

A 26-year-old woman was diagnosed with and treated for systemic lupus erythematosus (SLE) in 2002. She was admitted 11 years later with nephrotic-range proteinuria and lupus nephritis and received two doses of rituximab after failing on steroids and mycophenolate mofetil. Four months later, she presented with fever and joint pain/swelling. Gram stains, joint aspirates, and blood culture all yielded negative results for bacteria. She was discharged after treatment for a possible flare of lupus, but two weeks later, she presented again with a cough and shortness of breath in addition to the flare symptoms. Synovial fluid Smears, and cultures yielded positive results for Mycobacterium tuberculosis; similarly, sputum polymerase chain reaction test and culture confirmed pulmonary tuberculosis. Tuberculosis is difficult to diagnose in SLE patients; it may present like or precipitate SLE flare. In this patient a presumed SLE flare turned out to be an aggressive miliary, disseminated tuberculosis.