A Comprehensive Review of the Adverse Effects of Systemic Corticosteroids

Ovarian Damage During chemotherapy in Autoimmune Diseases: Broad Health Implications beyond Fertility

Women with autoimmune diseases such as lupus, scleroderma, and vasculitis receiving cyclophosphamide for severe disease manifestations risk primary ovarian insufficiency(POI) due to gonadotoxicity of this therapy. In addition to loss of reproductive potential, POI is associated with increased risk of morbidity and mortality. Practitioners caring for women requiring gonadotoxic therapies should be familiar with long-term health implications of POI and strategies for ovarian preservation. Accumulating evidence supports the effectiveness of adjunctive gonadotropin releasing hormone analog (GnRH-a) for ovarian protection during gonadotoxic therapy in cancer and autoimmune populations. GnRH-a is less costly and invasive than assisted reproductive technologies used for achievement of future pregnancies, but is not Food and Drug Administration approved for ovarian preservation. This review focuses on POI comorbidities and strategies for mitigation of related sequelae, which can accumulate over decades of hypoesteogenism. These issues are arguably more pronounced for women with chronic autoimmune diseases, in whom superimposed POI further heightens risks of cardiovascular disease and osteoporosis. Therefore, even if future pregnancy is not desired, ovarian protection during gonadotoxic therapy should be a major goal of disease management.

Accessory carpal bone luxation in two gray wolves (Canis lupus)

Two sibling male castrated gray wolves (Canis lupus) developed acute onset right forelimb lameness, one at 8 and the other at 11 yr of age. In both cases, the right carpus was swollen, carpal hyperextension was notable, and the wolves exhibited significant intermittent lameness of the affected limb. Radiographs revealed right accessory carpal bone luxation in both cases, with type III fracture of the accessory carpal bone in one wolf. Although carpal bone luxation in domestic dogs is frequently treated surgically, conservative medical management resolved the lameness in both wolves with no further complications.

Betamethasone-enhanced vein graft conduit accelerates functional recovery in the rat sciatic nerve gap

PURPOSE

The objective of the study was to assess the effect of topically administered betamethasone on peripheral nerve regeneration and functional recovery after sciatic nerve transection in the rat.

MATERIALS AND METHODS

Forty-five healthy male white Wistar rats were divided into 3 experimental groups (n = 15), randomly. In the treatment group, a 10-mm sciatic nerve defect was bridged by use of an inside-out vein graft filled with 10 μL betamethasone (0.1 mg/kg) (IOVG/BETA group). In the control group, the vein was filled with phosphate-buffered saline solution alone (IOVG group). In the sham surgery group, the sciatic nerve was exposed with no further deleterious manipulations (SHAM group). Each group was subdivided into 3 subgroups of 5 animals each, and the regenerated nerve fibers were studied 4, 8, and 12 weeks after surgery.

RESULTS

Functional study confirmed faster recovery of regenerated axons in the IOVG/BETA group than in the IOVG group (P < .05). Gastrocnemius muscle mass in the IOVG/BETA group was found to be significantly greater than that in the IOVG group (P < .05). Morphometric indices of the regenerated fibers showed that the number and diameter of the myelinated fibers were significantly higher in the IOVG/BETA group than in the control group (P < .05). By use of immunohistochemistry, the location of reactions to S-100 in IOVG/BETA was clearly more positive than that in the IOVG group.

CONCLUSIONS

When loaded in a vein graft, betamethasone resulted in improvement of functional recovery and quantitative morphometric indices of sciatic nerve. Topical application of this readily available agent offers the benefit of cost savings, as well as avoiding the complications associated with systemic administration.

What rhinologists and allergists should know about the medico-legal implications of corticosteroid use: a review of the literature

BACKGROUND

Corticosteroids are a mainstay of treatment in the management of sinonasal inflammatory disease. Despite their common use, many practitioners are not well versed in their potential complications or the medico-legal ramifications of their use. The objectives of this review were to outline the existing data of the medico-legal implications of oral steroids.

METHODS

An OVID database search of the terms "corticosteroids OR adrenal cortex hormones" AND "medico-legal OR malpractice OR jurisprudence OR expert testimony OR informed consent" was performed. This search was then narrowed to English language articles and the titles and abstracts were searched for relevance.

RESULTS

The OVID search identified 178 articles. This search was then narrowed, resulting in 9 articles that were relevant and included in the current review. Five articles involved database reviews of litigation associated with medications. Steroids were found to be a common medication associated with litigation and the cost of the litigation involving steroid use can be very high. Common themes associated with the litigation include poor communication and lack of informed consent regarding steroid use. Several additional articles addressed single cases and many addressed lawsuit prevention.

CONCLUSION

Lawsuits associated with steroids are disproportionately costly and most of the allegations stem from a lack of informed consent over the use of steroids. Open dialogue with patients is the key to informed consent. Ideally, clinicians should discuss the rationale for steroid use, and the risks, expected benefits, and alternatives of the steroid therapy. Document this discussion and consider providing educational material for the patient to read and review.

Early postoperative care following endoscopic sinus surgery: an evidence-based review with recommendations

BACKGROUND

Early postoperative care following endoscopic sinus surgery (ESS) has been suggested to minimize avoidable complications and optimize long-term outcomes. Several postoperative care strategies have been proposed but a formal comprehensive evaluation of the evidence has never been performed. The purpose of this article is to provide an evidence-based approach to early postoperative care following ESS.

METHODS

A systematic review of the literature was performed and the Clinical Practice Guideline Manual, Conference on Guideline Standardization (COGS), and the Appraisal of Guidelines and Research Evaluation (AGREE) instrument recommendations were followed. Study inclusion criteria were: adult population >18 years old; chronic rhinosinusitis (CRS) based on published diagnostic criteria; ESS following failed medical therapy; primary study objective was to evaluate an ESS early postoperative care strategy; and clearly defined primary clinical end-point.

RESULTS

This review identified and evaluated the literature on 7 early postoperative care strategies following ESS: saline irrigations, sinus cavity debridements, systemic steroids, topical steroids, oral antibiotics, topical decongestants, and drug-eluting spacers/stents.

CONCLUSION

Based on the available evidence, use of nasal saline irrigation, sinus cavity debridement, and standard topical nasal steroid spray are recommended early postoperative care interventions. Postoperative antibiotic, systemic steroid, nonstandard topical nasal steroid solution, and/or drug-eluting spacers/stents are options in postoperative management. These evidence-based recommendations should not necessarily be applied to all postoperative patients and clinical judgment, in addition to evidence, is critical to determining the most appropriate care.

Ligand-independent phosphorylation of the glucocorticoid receptor integrates cellular stress pathways with nuclear receptor signaling

Glucocorticoids are stress hormones that maintain homeostasis through gene regulation mediated by nuclear receptors. We have discovered that other cellular stressors are integrated with glucocorticoid signaling through a new hormone-independent phosphorylation site, Ser134, on the human glucocorticoid receptor (GR). Ser134 phosphorylation is induced by a variety of stress-activating stimuli in a p38 mitogen-activated protein kinase (MAPK)-dependent manner. Cells expressing a mutant glucocorticoid receptor incapable of phosphorylation at Ser134 (S134A-GR) had significantly altered hormone-dependent genome-wide transcriptional responses and associated hormone-mediated cellular functions. The phosphorylation of Ser134 significantly increased the association of the GR with the zeta isoform of the 14-3-3 class of signaling proteins (14-3-3zeta) on chromatin promoter regions, resulting in a blunted hormone-dependent transcriptional response of select genes. These data argue that the phosphorylation of Ser134 acts as a molecular sensor on the GR, monitoring the level of cellular stress to redirect glucocorticoid-regulated signaling through altered 14-3-3zeta cofactor binding and promoter recruitment. This posttranslational modification allows prior cellular stress signals to dictate the transcriptional response to glucocorticoids.

Medical malpractice and corticosteroid use

OBJECTIVE

To analyze malpractice litigation trends related to the administration of corticosteroids and the reported complications.

STUDY DESIGN

Retrospective.

SETTING

Tertiary medical center.

SUBJECTS AND METHODS

The WESTLAW database was reviewed from March 1996 to November 2008. Data were compiled on the demographics of the defendant, plaintiff, expert witness specialty, allegation, complication, indication for steroids, verdict, and judgment.

RESULTS

Eighty-three cases met inclusion criteria and were selected for review. The most common conditions for which steroids were prescribed were pain (23%), asthma or another pulmonary condition (20%), a dermatologic condition (18%), a nondermatologic autoimmune condition (17%), and allergies (6%). Allegation of negligent use was the most common reason for a suit being filed (65%), followed by lack of proper informed consent (36%), failure to diagnose or misdiagnosis (22%), multiple allegations (25%), and wrongful death (4%). Verdicts for the defendant predominated (59%), whereas 24 cases (29%) were found for the plaintiff, and 10 cases (12%) settled out of court. The range of monetary awards was from $25,000 to $8.1 million. Complications reported were often multiple and included avascular necrosis (39%), mood changes (16%), visual complaints (14%), and infectious complications (14%). Three cases involved otolaryngologists.

CONCLUSION

Although other specialties were more often involved in suits, otolaryngologists frequently prescribe corticosteroids and must be diligent in explaining potential side effects of steroids. The informed consent process, documentation, and close monitoring of patients are critical to avoid potential litigation.

[Consensus on diagnosis and treatment of sudden hearing loss. Asociación Madrileña de ORL]

Idiopathic sudden sensorineural hearing loss is an unexplained unilateral hearing loss with onset over a period of less than 72 hours, without other known otological diseases. We present a consensus on the diagnosis, treatment and follow-up of this disease, designed by AMORL, after a systematic review of the literature from 1966 to June 2010. Diagnosis of sudden sensorineural hearing loss is based on mandatory otoscopy, acoumetry, tonal audiometry, speech audiometry, and tympanometry. After clinical diagnosis is settled, and before treatment is started, a full analysis should be done and an MRI should be requested later. Treatment is based on systemic corticosteroids (orally in most cases), helped by intratympanic doses as rescue after treatment failures. Follow-up should be done at day 7, with tonal and speech audiometries, and regularly at 15, 30, and 90 days after start of therapy, and after 12 months. By consensus, results after treatment should be reported as absolute dBs recovered in pure tonal audiometry, as improvement in the recovery rate in unilateral cases, and as improvement in speech audiometry.