Management of Lateral Epicondylitis Using Transdermal Nitroglycerin: A Systematic Review.

Lateral epicondylitis (LE), also known as tennis elbow, is an overuse tendinopathy originating from the forearm extensor tendons of the elbow. An emerging therapy for the treatment of LE is the use of transdermal nitroglycerin (NTG) patches for pain relief and improved function. The aim of this systematic review was to assess the current literature on the effect of a transdermal NTG patch for the treatment of LE. A literature search using MEDLINE, EMBASE, SportDiscus, and the Cochrane Database of Systematic Reviews was conducted. Studies selected for inclusion were those in which patients were clinically diagnosed with LE, RCTs, observational studies, and only articles published in English. Studies were excluded if they involved patients <18 years of age or involved patients with a potential alternative source of elbow pain such as previous surgery to the elbow, a previous history of dislocation, fracture of the elbow or tendon rupture, or a referred pain source such as cervical radiculopathy or peripheral nerve involvement. Studies were also excluded if they involved patients who were already prescribed topical NTG for any other indication (i.e., angina), and if the studies had no measurement of symptom relief or measurement or functional scoring. The initial search strategy yielded 69 articles, out of which four met the eligibility criteria and were included in this systematic review. The studies showed improvement in elbow pain in the short-term and mid-term (up to six months), while one study that followed participants for a five-year duration post-treatment, showed no benefit. Three studies used an effective NTG dose of 1.25mg/24h and one study used an effective dose of 1.44mg/24h. Topical NTG was more effective when combined with a tendon rehabilitation program. The most commonly reported side effects of topical NTG were headaches and dermatitis. Overall, the current literature demonstrates that the use of NTG patches for LE improves short- and mid-term pain as well as elbow function. However, more studies are required to fully understand the effect of topical NTG on LE, particularly the effective dose range and the long-term benefits.

Ethical diversity and the role of conscience in clinical medicine.

In a climate of plurality about the concept of what is "good," one of the most daunting challenges facing contemporary medicine is the provision of medical care within the mosaic of ethical diversity. Juxtaposed with escalating scientific knowledge and clinical prowess has been the concomitant erosion of unity of thought in medical ethics. With innumerable technologies now available in the armamentarium of healthcare, combined with escalating realities of financial constraints, cultural differences, moral divergence, and ideological divides among stakeholders, medical professionals and their patients are increasingly faced with ethical quandaries when making medical decisions. Amidst the plurality of values, ethical collision arises when the values of individual health professionals are dissonant with the expressed requests of patients, the common practice amongst colleagues, or the directives from regulatory and political authorities. In addition, concern is increasing among some medical practitioners due to mounting attempts by certain groups to curtail freedom of independent conscience-by preventing medical professionals from doing what to them is apparently good, or by compelling practitioners to do what they, in conscience, deem to be evil. This paper and the case study presented will explore issues related to freedom of conscience and consider practical approaches to ethical collision in clinical medicine.