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There is limited evidence to inform the optimal timing of use for biologic disease-modifying antirheumatic drugs (DMARDs) in the perioperative period among patients with systemic rheumatic diseases. In a meta-analysis of cohort studies including over 7,300 patients on biologic DMARDs for systemic rheumatic diseases who were undergoing surgery, patients who continued biologics did not appear to be at an increased risk for surgical site infection or delayed wound healing. Stopping biologics prior to surgery, however, was associated with higher rates of disease flares (26% versus 7%). These findings are limited by the retrospective and heterogenous nature of the evidence. Our general approach to patients on biologic DMARDs undergoing elective surgery is to withhold the medication at the end of the dosing cycle if disease activity permits.

Laryngospasm during pediatric procedural sedation is rare but serious, and a better understanding of risk factors may help guide care. In the largest study to date, which included over 275,000 sedations in children performed outside of the operating room, the unadjusted prevalence of laryngospasm was 3.3 per 1,000 cases.1 On adjusted analysis, risk factors for laryngospasm included concurrent upper respiratory infection (odds ratio [OR] 3.9), airway procedures (OR 3.7), and, compared with propofol alone, use of propofol with ketamine (OR 2.5) or with dexmedetomidine (OR 2.1). Risks associated with ketamine and propofol as single agents were similar. These findings provide a strong rationale for appropriate airway expertise for all providers of pediatric sedation and identify important factors to consider when determining sedation regimens for children.

Combination pharmacotherapy is frequently used for patients with painful diabetic neuropathy that does not respond to initial monotherapy, despite limited data to support the efficacy of this practice. In a multicenter trial of 130 patients with painful diabetic neuropathy who were given initial monotherapy with amitriptyline, pregabalin, or duloxetine, those whose pain did not improve at six weeks were given a second agent from a different pharmacologic class. 2 At 16-week follow-up, combination strategies consisting of pregabalin added to amitriptyline, amitriptyline added to pregabalin, or pregabalin added to duloxetine all provided greater benefit than monotherapy, and each strategy provided similar (approximately 50%) pain reduction relative to baseline pain. These results support the strategy of combination pharmacotherapy for patients with painful diabetic neuropathy that does not respond to initial monotherapy.